Showing papers in "Laryngoscope in 2014"

Olfactory training is helpful in postinfectious olfactory loss: A randomized, controlled, multicenter study

Abstract: Objectives/Hypothesis: The aim of this study was to evaluate the effects of olfactory training (OT) on olfactory function in patients with persistent postinfectious olfactory dysfunction (PIOD). Study Design: Randomized, single-blind, controlled, multicenter crossover study. Methods: Twelve tertiary university medical centers participated. Investigations were performed at three visits (base- line, after 18 weeks, and after 36 weeks), including only subjects with PIOD of <24-months duration. At each visit, partici- pants received detailed assessment of olfactory function. Seventy subjects trained with high concentrations of four odors for 18 weeks; the other half (n 5 74) trained with low concentrations of odors. For the following 18 weeks this regimen was switched. Results: After 18 weeks, olfactory function improved in the high-training group in 18 of 70 participants (26%), whereas only 11/74 improved in the low-training group (15%). In subjects with a duration of olfactory dysfunction of <12 months, olfactory function improved in 15/24 participants (63%) of the high-training group and in 6/31 participants (19%) of the low-training group (P 5.03). Conclusions: OT improves PIOD, and the use of odors at higher concentrations is beneficial to improvement. OT is a safe procedure and appears to be particularly useful in patients who start OT within 12 months after the onset of the disor- der. OT is the first successful therapy regime in patients with PIOD.

Impact of electrode design and surgical approach on scalar location and cochlear implant outcomes.

Abstract: Objectives/Hypothesis Three surgical approaches: cochleostomy (C), round window (RW), and extended round window (ERW); and two electrodes types: lateral wall (LW) and perimodiolar (PM), account for the vast majority of cochlear implantations. The goal of this study was to analyze the relationship between surgical approach and electrode type with final intracochlear position of the electrode array and subsequent hearing outcomes. Study Design Comparative longitudinal study. Methods One hundred postlingually implanted adult patients were enrolled in the study. From the postoperative scan, intracochlear electrode location was determined and using rigid registration, transformed back to the preoperative computed tomography which had intracochlear anatomy (scala tympani and scala vestibuli) specified using a statistical shape model based on 10 microCT scans of human cadaveric cochleae. Likelihood ratio chi-square statistics were used to evaluate for differences in electrode placement with respect to surgical approach (C, RW, ERW) and type of electrode (LW, PM). Results Electrode placement completely within the scala tympani (ST) was more common for LW than were PM designs (89% vs. 58%; P < 0.001). RW and ERW approaches were associated with lower rates of electrode placement outside the ST than was the cochleostomy approach (9%, 16%, and 63%, respectively; P < 0.001). This pattern held true regardless of whether the implant was LW or PM. When examining electrode placement and hearing outcome, those with electrode residing completely within the ST had better consonant-nucleus-consonant word scores than did patients with any number of electrodes located outside the ST (P = 0.045). Conclusion These data suggest that RW and ERW approaches and LW electrodes are associated with an increased likelihood of successful ST placement. Furthermore, electrode position entirely within the ST confers superior audiological outcomes. Level Of Evidence 2b. Laryngoscope, 124:S1–S7, 2014

GJB2-associated hearing loss: systematic review of worldwide prevalence, genotype, and auditory phenotype

Abstract: Objectives/Hypothesis To perform a systematic review of GJB2-associated hearing loss to describe genotype distributions and auditory phenotype. Data Sources 230 primary studies identified from Pubmed. Review Methods Pubmed was searched systematically to screen broadly for any study reporting on genotype and carrier frequencies for biallelic GJB2-associated hearing loss in defined populations around the world. Genotype and audiometric data were extracted and subjected to meta-analysis to determine genotype distributions, carrier frequencies, rates of asymmetric or progressive hearing loss, and imaging abnormalities. Results A total of 216 articles comprising over 43,000 hearing-loss probands were included. The prevalence of biallelic GJB2-associated hearing loss was consistent across most of the 63 countries examined, with different mutations being predominant in different countries. Common mutations were found in greater than 3% of the general population worldwide. Meta-analysis of 48 case-control studies demonstrated a two-fold higher carrier frequency among hearing-impaired individuals compared to normal-hearing controls for truncating alleles, but not V37I. Progression, asymmetry, and imaging abnormalities were present in 14% to 19% of individuals with GJB2-associated hearing loss. Conclusion GJB2 mutations are highly prevalent around the world. The multiple predominant mutations present in different populations attest to the importance of this gene for normal cochlear function and suggests an evolutionary heterozygote advantage. The unusually high carrier rate for truncating mutations among hearing-impaired individuals is consistent with either the presence of complementary mutations or a carrier phenotype. The significant rate of asymmetry and progression highlights the importance of diagnostic workup and close follow-up for this highly variable condition. Laryngoscope, 124:E34–E53, 2014

A systematic review of transoral robotic surgery and radiotherapy for early oropharynx cancer: a systematic review.

Abstract: Objectives/Hypothesis To demonstrate the comparative effectiveness of transoral robotic surgery (TORS) to intensity modulated radiotherapy (IMRT) for early T-stage oropharyngeal cancer. Data Sources The search included MEDLINE, EMBASE, CENTRAL, PsychInfo, CINAHL, and bibliographies of relevant studies through September 2012. Methods Studies included patients treated for early T-stage oropharynx cancer with TORS or IMRT. Study retrieval and data extraction were conducted in duplicate and resolved by consensus. Treatment- specific details, as well as recurrence, survival, and adverse events, were collected. Methodologic quality for each study was appraised. Results Twenty case series, including eight IMRT studies (1,287 patients) and 12 TORS studies (772 patients), were included. Patients receiving definitive IMRT also received chemotherapy (43%) or neck dissections for persistent disease (30%), whereas patients receiving TORS required adjuvant radiotherapy (26%) or chemoradiotherapy (41%). Two-year overall survival estimates ranged from 84% to 96% for IMRT and from 82% to 94% for TORS. Adverse events for IMRT included esophageal stenosis (4.8%), osteoradionecrosis (2.6%), and gastrostomy tubes (43%)—and adverse events for TORS included hemorrhage (2.4%), fistula (2.5%), and gastrostomy tubes at the time of surgery (1.4%) or during adjuvant treatment (30%). Tracheostomy tubes were needed in 12% of patients at the time of surgery, but most were decannulated prior to discharge. Conclusion This review suggests that survival estimates are similar between the two modalities and that the differences lie in adverse events. Laryngoscope, 124:2096–2102, 2014

The prevalence of voice problems among adults in the United States

Abstract: Objectives/Hypothesis Determine the prevalence of voice problems and types of voice disorders among adults in the United States. Study Design Cross-sectional analysis of a national health survey. Methods The 2012 National Health Interview Survey was analyzed, identifying adult cases reporting a voice problem in the preceding 12 months. In addition to demographic data, specific data regarding visits to healthcare professionals for voice problems, diagnoses given, and severity of the voice problem were analyzed. The relationship between voice problems and lost workdays was investigated. Results An estimated 17.9 ± 0.5 million adults (mean age, 49.1 years; 62.9% ± 1.2% female) reported a voice problem (7.6% ± 0.2%). Overall, 10.0% ± 0.1% saw a healthcare professional for their voice problem, and 40.3% ± 1.8% were given a diagnosis. Females were more likely than males to report a voice problem (9.3% ± 0.3% vs. 5.9% ± 0.3%, P < .001). Overall, 22% and 11% reported their voice problem to be a moderate or a big/very big problem, respectively. Infectious laryngitis was the most common diagnosis mentioned (685,000 ± 86,000 cases, 17.8% ± 2.0%). Gastroesophageal reflux disease was mentioned in 308,000 ± 54,000 cases (8.0% ± 1.4%). The mean number of days affected with the voice problem in the past year was 56.2 ± 2.6 days. Respondents with a voice problem reported 7.4 ± 0.9 lost workdays in the past year versus 3.4 ± 0.1 lost workdays for those without (contrast, +4.0 lost workdays; P < .001). Conclusions Voice problems affect one in 13 adults annually. A relative minority seek healthcare for their voice problem, even though the self-reported subjective impact of the voice problem is significant. Level of Evidence 4 Laryngoscope 124:2359–2362, 2014

Etiology, diagnosis, and management of facial palsy: 2000 patients at a facial nerve center

Abstract: Objectives/Hypothesis To evaluate the range and incidence of facial palsy etiologies in cases presenting to a tertiary facial nerve center, and to review the broad and evolving spectrum of diagnostic and management approaches to the condition Study Design Retrospective chart review Methods Records of patients referred for facial weakness between 2003 and 2013 were reviewed for cases of facial palsy Cases of muscle dysfunction and primary hemifacial spasm were excluded The remainder were analyzed by age, sex, and diagnosis Diagnostic and treatment strategies were reviewed Results There were 1,989 records that met inclusion criteria Bell's palsy accounted for 38% of cases, acoustic neuroma resections 10%, cancer 7%, iatrogenic injuries 7%, varicella zoster 7%, benign lesions 5%, congenital palsy 5%, Lyme disease 4%, and other causes 17% Sixty-one percent of patients were female Mean age at presentation was 445 years (±186 years) Diagnoses were revealed primarily by history, though serial physical examinations, radiography, and hematologic testing also contributed Management strategies included observation, physical therapy, pharmacological therapy, chemodenervation, facial nerve exploration, decompression, repair, and the full array of static and dynamic surgical interventions Conclusions Bell's palsy remains the most common facial palsy; females present more often for evaluation Comprehensive diagnostic investigation is mandatory in atypical cases, and thorough management must be multidisciplinary The algorithms presented herein outline a single center's approach to the facial palsy patient, providing a framework that clinicians caring for these patients may adapt to their specific settings Level of Evidence 2b Laryngoscope, 124:E283–E293, 2014

Drug-induced sleep endoscopy in sleep-disordered breathing: report on 1,249 cases.

Abstract: Objectives/Hypothesis To describe upper airway (UA) collapse patterns during drug-induced sleep endoscopy (DISE) in a large cohort of patients with sleep-disordered breathing (SDB) and to assess associations with anthropometric and polysomnographic parameters. Study Design Observational study. Methods A total of 1,249 patients [age 47 ± 10 y; apnea–hypopnea index (AHI) 18.9 ± 15.3/h; body mass index (BMI) 27.2 ± 3.7 kg/m2] underwent polysomnography and DISE. DISE findings were categorized to the following UA levels: palate, oropharynx, tongue base, and hypopharynx. The degree of collapse was reported as complete, partial, or none. The pattern of the obstruction was described as anteroposterior, lateral, or concentric. Associations between DISE findings and anthropometric and polysomnographic parameters were analyzed. Results Palatal collapse was seen most frequently (81%). Multilevel collapse was noted in 68.2% of all patients. The most frequently observed multilevel collapse pattern was a combination of palatal and tongue base collapse (25.5%). Palatal collapse was seen most frequently (81%). The prevalence of complete collapse, multilevel collapse, and hypopharyngeal collapse increased with increasing severity of obstructive sleep apnea (OSA). Multilevel and complete collapse were more prevalent in obese patients and in those with more severe OSA. Both higher BMI and AHI values were associated with a higher probability of complete concentric palatal collapse. Conclusion The current study provides an overview of UA collapse patterns in a large cohort of SDB patients who underwent DISE. The associations found in this study may indicate that UA collapse patterns observed during DISE cannot be fully explained by selected baseline polysomnographic and anthropometric characteristics. Level of Evidence 4. Laryngoscope, 124:797–802, 2014

Continuous vagal IONM prevents recurrent laryngeal nerve paralysis by revealing initial EMG changes of impending neuropraxic injury: a prospective, multicenter study

Abstract: Objectives/Hypothesis Existing intraoperative neuromonitoring (IONM) formats stimulate the recurrent laryngeal nerve (RLN) intermittently, exposing it to risk for injury in between stimulations. We report electrophysiologic parameters of continuous vagal monitoring, utilizing a novel real-time IONM format, and relate these parameters to intraoperative surgical maneuvers that delineate nascent adverse but reversible electrophysiologic parameters to prevent nerve injury. These results are correlated with postoperative vocal cord functional outcome. Study Design Prospective multicenter tertiary study. Method Evoked vagal nerve waveform amplitude and latency changes during 102 thyroidectomies were recorded. Adverse electrophysiologic response was categorized into 1-concordant amplitude reduction and latency increase events (combined events) and 2-loss of signal (LOS). Surgical maneuvers were modified when adverse electrophysiologic findings were noted. All patients underwent preoperative and postoperative laryngoscopy; intraoperative electrophysiologic findings were correlated with postoperative laryngeal function. Results Continuous vagal monitoring did not result in stimulation-evoked nerve injury or intraoperative adverse cardiac, pulmonary, or gastrointestinal effects. Both intraoperative combined events and LOS were associated with development of vocal cord paralysis (VCP) (P = 0.001 and P >0.001 respectively). Combined events had a positive predictive value (PPV) of 33%, negative predictive value (NPV) of 97%, and were reversible in 73%. LOS had a PPV of 83%, NPV of 98%, and was reversible in only 17%. Milder combined events and isolated amplitude or latency changes were not associated with VCP. Conclusions Continuous vagal monitoring is safe and provides real-time RLN evaluation during surgical maneuvers. Combined events and LOS, both easily identifiable intraoperatively, are related to the development of VCP. A combined event represents a largely reversible electrophysiologic change when the associated surgical maneuver is aborted. If allowed to continue, it can advance to LOS (which typically is significantly less reversible) and to postoperative VCP. Continuous vagal monitoring has utility in identifying real-time adverse concordant amplitude and latency changes (combined events), which can prompt modification of the associated surgical maneuver and may prevent RLN paralysis during thyroidectomy. Level of Evidence 4. Laryngoscope, 124:1498–1505, 2014

Productivity costs in patients with refractory chronic rhinosinusitis.

Abstract: Objectives/Hypothesis Disease-specific reductions in patient productivity can lead to substantial economic losses to society. The purpose of this study was to: 1) define the annual productivity cost for a patient with refractory chronic rhinosinusitis (CRS) and 2) evaluate the relationship between degree of productivity cost and CRS-specific characteristics. Study Design Prospective, multi-institutional, observational cohort study. Methods The human capital approach was used to define productivity costs. Annual absenteeism, presenteeism, and lost leisure time was quantified to define annual lost productive time (LPT). LPT was monetized using the annual daily wage rates obtained from the 2012 U.S. National Census and the 2013 U.S. Department of Labor statistics. Results A total of 55 patients with refractory CRS were enrolled. The mean work days lost related to absenteeism and presenteeism were 24.6 and 38.8 days per year, respectively. A total of 21.2 household days were lost per year related to daily sinus care requirements. The overall annual productivity cost was $10,077.07 per patient with refractory CRS. Productivity costs increased with worsening disease-specific QoL (r = 0.440; p = 0.001). Conclusion Results from this study have demonstrated that the annual productivity cost associated with refractory CRS is $10,077.07 per patient. This substantial cost to society provides a strong incentive to optimize current treatment protocols and continue evaluating novel clinical interventions to reduce this cost. Level of Evidence N/A. Laryngoscope, 124:2007–2012, 2014

Epidemiology of sinonasal squamous cell carcinoma: A comprehensive analysis of 4994 patients

Abstract: Objectives/Hypothesis To examine the incidence and survival of patients with sinonasal squamous cell carcinoma (SNSCC) between the years of 1973 and 2009 using the Surveillance, Epidemiology, and End Result (SEER) database. Study Design Retrospective cohort study using a national database. Methods The SEER registry was utilized to calculate incidence and survival trends for patients with SNSCC between 1973 and 2009. Patient data were then analyzed according to age, sex, and race. Results A total of 4,994 cases of SNSCC were identified, composed of 64.44% males and 35.56% females. Incidence trend analysis revealed a significant decrease in yearly rates from 1973 to 2009 for the overall population, females, whites, blacks, and “others” (P .05) were found when comparing survival between the last three decades. Differences in long-term survival were noted between whites, blacks, and “others,” with whites displaying the highest 20-year survival. Males and females were found to have similar long-term survival curves, with 20-year survival of 30.68% and 26.35%, respectively. Conclusions The overall incidence of SNSCC is declining. However, survival has not significantly improved in the last 3 decades. Race seems to influence the overall survival of this tumor. Future studies need to be conducted to investigate these dynamic trends related to SNSCC. Level of Evidence 2b. Laryngoscope, 124:76–83, 2014

Modification of the lund-kennedy endoscopic scoring system improves its reliability and correlation with patient-reported outcome measures

Abstract: Objectives/Hypothesis To compare three existing endoscopic scoring systems and a newly proposed modified scoring system for the assessment of patients with chronic rhinosinusitis (CRS). Study Design Blinded, prospective cohort study. Methods CRS patients completed two patient-reported outcome measures (PROMs)—the visual analogue scale (VAS) symptom score and the Sino-Nasal Outcome Test-22 (SNOT-22)—and then underwent a standardized, recorded sinonasal endoscopy. Videos were scored by three blinded rhinologists using three scoring systems: the Lund-Kennedy (LK) endoscopic score; the Discharge, Inflammation, Polyp (DIP) score; and the Perioperative Sinonasal Endoscopic score. The videos were further scored using a modified Lund-Kennedy (MLK) endoscopic scoring system, which retains the LK subscores of polyps, edema, and discharge but eliminates the scoring of scarring and crusting. The systems were compared for test-retest and inter-rater reliability as well as for their correlation with PROMs. Results One hundred two CRS patients were enrolled. The MLK system showed the highest inter-rater and test-retest reliability of all scoring systems. All systems except for the DIP correlated with total VAS scores. The MLK was the only system that correlated with the symptom subscore of the SNOT-22 in both unoperated and postoperative patients. Conclusions Modification of the LK system by excluding the subscores of scarring and crusting improves its reliability and its correlation with PROMs. In addition, the MLK system retains the familiarity of the widely used LK system and is applicable to any patient irrespective of surgical status. The MLK system may be a more suitable and reliable endoscopic scoring system for clinical practice and outcomes research. Level of Evidence 4 Laryngoscope 124:2216–2223, 2014

Complications of primary and revision functional endoscopic sinus surgery for chronic rhinosinusitis

Abstract: Objectives/Hypothesis The goal of this study was to determine the incidence of major complications following primary and revision functional endoscopic sinus surgery (FESS). In addition, this study aimed to determine factors associated with the occurrence of complications including patient and provider characteristics and the use of image guidance system (IGS) technology. Study Design Retrospective cohort analysis of California and Florida all-payer databases from 2005 to 2008. Methods The rates of major surgical complications (skull base, orbital, and hemorrhagic) after primary and revision FESS were calculated, and bivariate analyses were performed to investigate relationships of complications with demographic and clinical characteristics. A multivariate model was used to determine risk factors for the occurrence of major complications. Results Among 78,944 primary FESS cases, 288 major complications were identified representing a complication rate of 0.36% (95% CI 0.32%–0.40%). The major complication rate following revision cases (n = 19; 0.46%) and primary cases (n = 288; 0.36%) was similar (OR = 1.26; 95% CI 0.79–2.00). Multivariate analysis showed that patients who were >40 years old, had a primary payer of Medicaid, had surgery involving the frontal sinus, or had image guidance during surgery were at higher risk for major complications. Conclusion The rate of major complications (0.36%) associated with primary FESS is lower than earlier reports. The rate of major complications following revision FESS (0.46%) was found to be similar to primary cases. IGS, insurance status, age, and extent of surgery were found to be associated with an increased risk of major complications following FESS. Level of Evidence 2C. Laryngoscope, 124:838–845, 2014

Spontaneous cerebrospinal fluid leak repair: a five-year prospective evaluation.

Abstract: Objectives/Hypothesis Mounting evidence indicates the majority of spontaneous cerebrospinal fluid (CSF) leaks are associated with intracranial hypertension. The objectives of the current study were to assess outcomes regarding spontaneous CSF leaks focusing on premorbid factors, surgical technique, and management of intracranial pressure. Study Design Prospective cohort. Methods Prospective evaluation of patients with spontaneous CSF leaks was performed. Data regarding demographics, nature of presentation, body mass index (BMI), location and size of defect, intracranial pressure, clinical follow-up, and complications were collected. Results Over 5 years, 46 patients (average age, 51 years) with 56 spontaneous CSF leaks were treated by a single otolaryngologist. Twenty-one subjects presented with recurrence of their CSF leak following previous endoscopic and/or open approaches by other physicians. Obesity was present in 78% of individuals (average BMI, 35.6). Fifty-two CSF leaks (93%) were successfully repaired at first attempt. With secondary repair, all CSF leaks were closed at last clinical follow-up (average, 93 weeks). Three patients developed late failures (>2 months), with one recurrence at a distinct location from the primary site at 8 months postprocedure (associated with ventriculoperitoneal shunt failure). Opening pressures via lumbar puncture averaged 24.3 ± 8.3 cm H20, which increased significantly to 32.3 ± 9.0 cm H20 (P < .0001) following closure of the skull base defect(s). Management of intracranial hypertension included acetazolamide (n = 23) or permanent CSF diversion (n = 19, including five revisions of failed preexisting shunts). Conclusions Although spontaneous CSF leaks have the highest recurrence rate of any etiology, prospective evaluation demonstrates high success rates with control of intracranial hypertension. Level of Evidence 4. Laryngoscope, 124:70–75, 2014

Preventing pharyngo-cutaneous fistula in total laryngectomy: a systematic review and meta-analysis.

Abstract: Objectives/Hypothesis Concurrent chemoradiotherapy is the gold-standard nonsurgical organ-preservation treatment for advanced laryngeal carcinoma. Total laryngectomy (TL) is increasingly reserved for surgical salvage. Salvage surgery is associated with more complications than primary surgery. A systematic review and meta-analysis was undertaken to establish the impact of organ preservation protocols on pharyngo-cutaneous fistula incidence following TL, and to synthesize evidence on the role of “onlay” prophylactic tissue flaps in reducing this complication in salvage TL. Data Sources The English language literature (January 1, 2000, to September 1, 2013) was searched, using PUBMED and EMBASE databases, for the terms “laryngectomy” and “fistula.” Of 522 studies identified from database searches, 33 were included in the quantitative synthesis. Review Methods Studies reporting fistula incidence following primary TL (PTL), salvage TL (STL), and STL with “onlay” flap-reinforced pharyngeal closure were included. Data were extracted by the first author (M.S.). Meta-analysis of fistula incidence was performed. Results PTL fistula incidence is 14.3% (95% CI 11.7–17.0), STL 27.6% (23.4–31.8), and STL with flap-reinforced closure 10.3% (4.6–15.9). Chemoradiotherapy is associated with a pooled fistula incidence of 34.1% (22.6–45.6), compared to 22.8% (18.3–27.4) for radiotherapy alone. Relative risk of fistula is 0.566 (0.374–0.856, P = 0.001) for STL with flap-reinforced closure compared to STL alone. The number needed to treat (NNT) to prevent one fistula is 6.05. Conclusion Prophylactic flaps used in an “onlay” technique reduce fistula incidence in STL. Chemoradiotherapy increases fistula incidence more than radiotherapy alone. Prophylactic flaps should be offered in salvage cases after failed chemoradiation protocols. Level of Evidence 3A.Laryngoscope, 124:1150–1163, 2014

Rates of revision and device failure in cochlear implant surgery: A 30-year experience

Abstract: Objectives/Hypothesis To characterize revision cochlear implant surgery and quantify rates of revision and device failure. Study Design Retrospective review of 235 cases of revision cochlear implant surgery performed at the Sydney Cochlear Implant Center over a period of 30 years, between January 1982 and June 2011. Methods Patient demographics and characteristics of revision surgery were retrospectively extracted from a centralized database. Analyses of overall and cumulative rates were performed. Results During the study period, 2,827 primary cochlear implantations were performed in 2,311 patients, with 201 primary implants in 191 patients of this cohort (109 children and 82 adults) undergoing 235 revision surgeries. The most common indication for revision surgery was device failure (57.8%), followed by migration/extrusion (23.4%), infection/wound complication (17.0%), and poor outcome/secondary pathology (6.4%). The majority of revision surgeries were reimplantations. Overall revision and device failure rates were 8.3% and 4.8%, respectively. The cumulative revision rate for primary implants at all ages increased linearly by 1% per year. The cumulative revision rate was significantly higher in children, and decreased with more recently performed implantations and with newer generations of implants. Conclusions The cumulative revision rate for primary implants suggests an ongoing linear relationship between the time of postprimary implantation and the need for revision surgery. We have formed an evidence base that characterizes the nature and frequency of revision surgery in a high-volume setting, allowing clinicians to effectively counsel prospective patients and clinics to understand the burden of revision surgery and device failure. Level of Evidence 4 Laryngoscope 124:2393–2399, 2014

Mammary analogue secretory carcinoma: Update on a new diagnosis of salivary gland malignancy

Abstract: Objectives/Hypothesis To review the known histopathologic findings and clinical behavior of mammary analogue secretory carcinoma (MASC). Data Sources PubMed. Review Methods Literature search using the terms “Mammary analogue secretory carcinoma,” “Mammary analog secretory carcinoma,” and “MASC” to identify all relevant publications. Results MASC is an unusual and rare malignant salivary gland tumor first described in 2010. It shares histologic, immunohistochemical, and genetic features with secretory carcinoma of the breast. The clinical behavior of MASC ranges from slowly growing tumors that infrequently recur after surgical resection to aggressive tumors that cause widespread metastasis and death. Many cases of MASC were discovered in archived cases previously classified as acinic cell carcinoma, mucoepidermoid carcinoma, and adenocarcinoma not otherwise specified. Conclusion MASC is a newly recognized variant of salivary gland malignancy. Further research is needed to better delineate its overall prevalence and to define an appropriate treatment algorithm for this new clinical entity. Level of Evidence NA. Laryngoscope, 124:188–195, 2014

Incremental health care utilization and costs for acute otitis media in children

Abstract: Objectives/Hypothesis Determine the incremental health care costs associated with the diagnosis and treatment of acute otitis media (AOM) in children. Study Design Cross-sectional analysis of a national health-care cost database. Methods Pediatric patients (age < 18 years) were examined from the 2009 Medical Expenditure Panel Survey. From the linked medical conditions file, cases with a diagnosis of AOM were extracted, along with comorbid conditions. Ambulatory visit rates, prescription refills, and ambulatory health care costs were then compared between children with and without a diagnosis of AOM, adjusting for age, sex, region, race, ethnicity, insurance coverage, and Charlson comorbidity Index. Results A total of 8.7 ± 0.4 million children were diagnosed with AOM (10.7 ± 0.4% annually, mean age 5.3 years, 51.3% male) among 81.5 ± 2.3 million children sampled (mean age 8.9 years, 51.3% male). Children with AOM manifested an additional +2.0 office visits, +0.2 emergency department visits, and +1.6 prescription fills (all P <0.001) per year versus those without AOM, adjusting for demographics and medical comorbidities. Similarly, AOM was associated with an incremental increase in outpatient health care costs of $314 per child annually (P <0.001) and an increase of $17 in patient medication costs (P <0.001), but was not associated with an increase in total prescription expenses ($13, P = 0.766). Conclusions The diagnosis of AOM confers a significant incremental health-care utilization burden on both patients and the health care system. With its high prevalence across the United States, pediatric AOM accounts for approximately $2.88 billion in added health care expense annually and is a significant health-care utilization concern. Level of Evidence 2C. Laryngoscope, 124:301–305, 2014

Minimally invasive image‐guided cochlear implantation surgery: First report of clinical implementation

Abstract: OBJECTIVE Minimally-invasive image-guided approach to cochlear implantation (CI) involves drilling a narrow, linear tunnel to the cochlea. Reported herein is the first clinical implementation of this approach.

Management of acute blunt and penetrating external laryngeal trauma.

Abstract: Objectives/Hypothesis Improve the care of acute external laryngeal trauma by reviewing controversies and the evolution of treatment. Data Source Internet-based search engines, civilian and military databases, and manual search of references from these sources over the past 90 years. Review Methods Utilizing the above-mentioned sources, electronic and manual searches of primary topics such as laryngeal trauma or injury, emergency tracheotomy, airway trauma, intubation versus tracheotomy, cricothyrotomy, esophageal trauma, and emergent management of airway injuries in civilian and combat zones. Citations were reviewed, selected reports analyzed, and the most relevant articles referenced. Results Optimal treatment of acute laryngeal trauma includes early identification of injuries utilizing a directed history and physical examination. Timely management of the wounded airway is essential. The choice of intubation, tracheotomy, or cricothyrotomy must be individualized. Computed tomography (CT) may assist in differentiating patients who can be observed versus those who require surgical exploration. In selected patients, laryngeal electromyography and stroboscopy may also be useful. Surgery should begin with direct laryngoscopy and rigid esophagoscopy to evaluate the hard and soft tissues of the larynx, and to visualize the pharynx and esophagus. Minor endolaryngeal lacerations and abrasions may be observed, whereas more significant injuries require primary closure via a thyrotomy. Laryngeal skeletal fractures should be reduced and fixated. Endolaryngeal stenting is reversed for massive mucosal trauma, comminuted fractures, and traumatic anterior commissure disruption. Conclusions Acute external injury to the larynx is both life threatening and a potential long-term management challenge. Although a rare injury, sufficient experience now exists to recommend specific treatments, and to preserve voice and airway function. Laryngoscope, 124:233–244, 2014

Analysis of the readability of patient education materials from surgical subspecialties.

Abstract: Objectives/Hypothesis Patients are increasingly using the Internet as a source of information on medical conditions. Because the average American adult reads at a 7th- to 8th-grade level, the National Institutes of Health recommend that patient education material be written between a 4th- and 6th-grade level. In this study, we assess and compare the readability of patient education materials on major surgical subspecialty Web sites relative to otolaryngology. Study Design Descriptive and correlational design. Methods Patient education materials from 14 major surgical subspecialty Web sites (American Society of Colon and Rectal Surgeons, American Association of Endocrine Surgeons, American Society of General Surgeons, American Society for Metabolic and Bariatric Surgery, American Association of Neurological Surgeons, American Congress of Obstetricians and Gynecologists, American Academy of Ophthalmology, American Academy of Orthopedic Surgeons, American Academy of Otolaryngology–Head and Neck Surgery, American Pediatric Surgical Association, American Society of Plastic Surgeons, Society for Thoracic Surgeons, and American Urological Association) were downloaded and assessed for their level of readability using 10 widely accepted readability scales. Results The readability level of patient education material from all surgical subspecialties was uniformly too high. Average readability levels across all subspecialties ranged from the 10th- to 15th-grade level. Conclusions Otolaryngology and other surgical subspecialties Web sites have patient education material written at an education level that the average American may not be able to understand. To reach a broader population of patients, it might be necessary to rewrite patient education material at a more appropriate level. Level of Evidence N/A. Laryngoscope, 124:405–412, 2014

Beyond the nasoseptal flap: Outcomes and pearls with secondary flaps in endoscopic endonasal skull base reconstruction

Abstract: Objectives/Hypothesis Endoscopic endonasal skull base surgery defects require effective reconstruction. Although the nasoseptal flap (NSF) has become our institution's workhorse for large skull base defects with cerebrospinal fluid (CSF) leaks, situations where it is unavailable require secondary flaps. Clinical outcomes, pearls and pitfalls, and an algorithm will be presented for these secondary flaps. Study Design Clinical case series. Methods Medical records of all endoscopic endonasal skull base surgeries at a tertiary care academic medical center were reviewed for skull base defect type, reconstruction method, CSF leak rate, and flap necrosis rate. Results Of 330 flaps for reconstructing endoscopic endonasal skull base defects, secondary flaps were used in 34 cases (10%). These included 16 endoscopic-assisted pericranial flaps, seven tunneled temporoparietal fascia flaps, three inferior turbinate flaps, two middle turbinate flaps, two anterior lateral nasal wall flaps, two palatal flaps, one occipital flap, and one facial artery buccinator flap. There were 19 anterior cranial fossa defects, 10 clival defects, three sellar defects, and one frontal and one lateral orbit/middle fossa defect. Twenty-five of the 34 cases (73.5%) had either prior or postoperative radiation therapy. The most common pathology was sinonasal cancer, with 16 cases (47.1%). The postoperative CSF leak rate was 3.6% due to one middle turbinate flap necrosis. Conclusions Secondary flaps for skull base reconstruction can be harvested with minimally invasive techniques and demonstrate excellent success rates (97%) that are comparable to that of the NSF (>95%). Multiple flaps for complex skull base defects should be in the armamentarium of comprehensive skull base surgery centers. Level of Evidence 4. Laryngoscope, 124:846–852, 2014

Thermal effects of endoscopy in a human temporal bone model: Implications for endoscopic ear surgery

Abstract: Objectives/Hypothesis Although the theoretical risk of elevated temperatures during endoscopic ear surgery has been reported previously, neither temperature change nor heat distribution associated with the endoscope has been quantified. In this study, we measure temperature changes during rigid middle ear endoscopy in a human temporal bone model and investigate whether suction can act as a significant cooling mechanism. Study Design Human temporal bone model of endoscopic middle ear surgery. Methods Fresh human temporal bones were maintained at body temperature (∼36°C). Temperature fluctuations were measured as a function of 1) distance between the tip of a 3-mm 0° Hopkins rod and round window membrane, and 2) intensity of the light source. Infrared imaging determined the thermal gradient. For suction, a 20-Fr suction catheter was utilized. Results We found: 1) an endoscope maximally powered by a xenon or light-emitting diode light source resulted in a rapid temperature elevation up to 46°C within 0.5 to 1 mm from the tip of the endoscope within 30 to 124 seconds, 2) elevated temperatures occurred up to 8 mm from the endoscope tip; and 3) temperature decreased rapidly within 20 to 88 seconds of turning off the light source or applying suction. Conclusions Our findings have direct implications for avoiding excessive temperature elevation in endoscopic ear surgery. We recommend: 1) using submaximal light intensity, 2) frequent repositioning of the endoscope, and 3) removing the endoscope to allow tissue cooling. Use of suction provides rapid cooling of the middle ear space and may be incorporated in the design of new instrumentation for prolonged dissection. Level of Evidence NA Laryngoscope, 124:E332–E339, 2014

Preliminary data on two voice therapy interventions in the treatment of presbyphonia

Abstract: Objectives/Hypothesis Presbyphonia is common among elderly individuals, yet few studies have evaluated behavioral treatment approaches for presbyphonia. The primary aim of this study was to assess the short-term efficacy of two types of voice therapy—vocal function exercises (VFE) and phonation resistance training exercise (PhoRTE) therapy—in the treatment of presbyphonia. The secondary aim was to determine if differences in adherence and treatment satisfaction existed between the two therapy approaches. Study Design Prospective, randomized, controlled. Methods Preliminary data from 16 elderly participants with presbyphonia randomly assigned to VFE, PhoRTE, or a no-treatment control group (CTL) were analyzed. Before and after a 4-week intervention period, participants completed the Voice-Related Quality of Life (V-RQOL) questionnaire and a perceived phonatory effort (PPE) task. Additionally, participants receiving treatment completed weekly practice logs and a posttreatment satisfaction questionnaire. Results Preliminary data revealed VFE and PhoRTE groups demonstrated a significant improvement in V-RQOL scores. However, only PhoRTE demonstrated a significant reduction in PPE, as suggested by the study's causal model. The CTL group did not demonstrate significant changes. Numerically, VFE registered slightly greater adherence to home practice recommendations than did PhoRTE, but PhoRTE perceived greater treatment satisfaction than VFE. Conclusions Findings provide new evidence regarding the efficacy of voice therapy exercises in the treatment of age-related dysphonia and suggest PhoRTE therapy as another treatment method for improved voice-related quality of life and reduced perceived vocal effort in this population. Level of Evidence 2b. Laryngoscope, 124:1869–1876, 2014

Vascularized tissue to reduce fistula following salvage total laryngectomy: a systematic review.

Abstract: OBJECTIVES/HYPOTHESIS: Pharyngocutaneous fistulae (PCF) are known to occur in nearly one-third of patients after salvage total laryngectomy (STL). PCF has severe impact on duration of admission and costs and quality of life and can even cause severe complications such as bleeding, infection and death. Many patients need further surgical procedures. The implications for functional outcome and survival are less clear. Several studies have shown that using vascularized tissue from outside the radiation field reduces the risk of PCFs following STL. This review and meta-analysis aims to identify the evidence base to support this hypothesis. DATA SOURCES: English language literature from 2004 to 2013 REVIEW METHODS: We searched the English language literature for articles published on the subject from 2004 to 2013. RESULTS: Adequate data was available to identify pooled incidence rates from seven articles. The pooled relative risk derived from 591 patients was 0.63 (95% CI: 0.47 to 0.85), indicating that patients who have flap reconstruction/reinforcement reduced their risk of PCF by one-third. CONCLUSION: This pooled analysis suggests that there is a clear advantage in using vascularized tissue from outside the radiation field in the laryngectomy defect. While some studies show a clear reduction in PCF rates, others suggest that the fistulae that occur are smaller and rarely need repair.

Comparison between endoscopic and microscopic stapes surgery

Abstract: Objectives/Hypothesis To investigate whether endoscopic stapes surgery is safer and less invasive than conventional stapes surgery using an operating microscope. Study Design Retrospective study. Methods The subjects were 15 patients (15 ears) who underwent endoscopic stapes surgery for otosclerosis or congenital stapedial fixation. Another 35 patients (41 ears) in whom microscopic stapes surgery was performed by the same surgeon were assigned to the control group. The procedures for endoscopic surgery were fundamentally the same as those for microscopic surgery, unless there was no anterior or posterior auricular skin incision. The two surgical techniques were compared with respect to the operating time, postoperative hearing, complications, postoperative pain, and the extent of drilling at the posterosuperior part of the external auditory canal. Results There were no differences of operating time or postoperative hearing between the endoscopic and microscopic groups. There was very little postoperative pain in the endoscopic group. Postoperative dizziness was mild in all patients who received endoscopic surgery. Drilling at the posterosuperior part of the external auditory canal was less extensive in the endoscopic group than in the microscopic group. Conclusion Endoscopic surgery is particularly suitable for stapedial disease. Endoscopic stapes surgery can even be done in patients with a curved and narrow external auditory canal. Endoscopic surgery is also suitable for education: The surgical anatomy can be understood easily and both the surgeon and assistants can observe the procedure on the same monitor. However, it should only be performed by experienced surgeons because one-handed manipulation is required and stereoscopic vision is not available. Level of Evidence 3b. Laryngoscope, 124:266–271, 2014

Effectiveness of subcutaneous immunotherapy for allergic rhinoconjunctivitis and asthma: a systematic review.

Abstract: Objectives/Hypothesis To systematically review the effectiveness and safety of subcutaneous immunotherapy (SCIT) for treatment of allergic rhinoconjunctivitis and asthma, using formulations currently approved in the United States. Study Design We searched the following databases up to May 21, 2012: MEDLINE, Embase, LILACS, and the Cochrane Central Register of Controlled Trials. Methods We included randomized controlled trials published in English comparing SCIT to placebo, pharmacotherapy, or other SCIT regimens that reported clinical outcomes of interest. Studies of adults or mixed age populations were included. Studies were excluded if the diagnosis of allergy and/or asthma was not confirmed with objective testing. Paired reviewers selected articles for inclusion and extracted data. We assessed the risk of bias for each study and graded the strength of evidence for each outcome as high, moderate, or low. Results Sixty-one studies met our inclusion criteria. Majority of the studies (66%) evaluated single-allergen immunotherapy regimens. The literature provides high-grade evidence that SCIT reduces asthma symptoms, asthma medication usage, rhinitis/rhinoconjunctivitis symptoms, conjunctivitis symptoms, and rhinitis/rhinoconjunctivitis disease-specific quality of life in comparison to placebo or usual care. There is moderate evidence that SCIT decreases rhinitis/rhinoconjunctivitis medication usage. Respiratory reactions were the most common systemic reaction. There were few reports of anaphylaxis; no deaths were reported. Conclusions Generally moderate to strong evidence supports the effectiveness of SCIT for treatment of allergic rhinitis and asthma, particularly with single-allergen immunotherapy regimens. Adverse reactions to SCIT are common, but no deaths were reported in the included studies. Level of Evidence 1a. Laryngoscope, 124:616–627, 2014

Subglottic stenosis: A ten‐year review of treatment outcomes

Abstract: Objectives/Hypothesis To evaluate the endoscopic surgical management of adult subglottic stenosis and describe treatment outcomes. Study Design Retrospective review. Methods Ten-year review of adult patients with subglottic stenosis. Results Ninety-two adults (23 male, 69 female) with subglottic stenosis underwent 247 endoscopic dilations between 2001 and 2010. The mean age was 48 years at time of first surgery. Etiology was GPA (granulomatosis with polyangiitis, formerly Wegener's granulomatosis) (45%), intubation (25%), or idiopathic (33%). Forty-one patients (45%) underwent a single procedure; 51 patients (55%) required multiple surgeries. The average interval for patients requiring a subsequent procedure was 13.7 months. Variations in surgical technique did not show differences in time to next procedure, and the use of mitomycin-C did not result in longer intervals between procedures. No significant complications were encountered after dilation. Conclusions Subglottic stenosis remains a treatment challenge. Although patients are often symptomatically improved after endoscopic dilation, recurrence rates remain high. Level of Evidence 4. Laryngoscope, 124:736–741, 2014

Idiopathic subglottic stenosis: an evolving therapeutic algorithm

Abstract: Objectives/Hypothesis Idiopathic subglottic stenosis (ISS) is a rare type of airway stenosis of unclear etiology. Open resection, while effective, remains a complex surgery and requires a hospital stay. Endoscopic management is often preferred but has historically been associated with a high recurrence rate. We aimed to analyze our experience, consisting of a standardized endoscopic approach combined with an empiric medical treatment. Study Design Retrospective cohort study. Methods All patients with ISS managed with standardized endoscopic treatment at our institution between 1987 and 2012 were identified, and their electronic medical records were reviewed. The treatment consisted of CO2 laser resection without dilatation and local infiltration with steroids and application of mitomycin C. Patients were also treated with antireflux medications, inhaled corticosteroids, and occasionally trimethoprim-sulfamethoxazole. The influence of medical management on annual recurrence rate was analyzed using negative binomial logistic regression. Results A total of 110 patients treated with standardized endoscopic management were included in our analysis. The procedure was well tolerated by all patients without complications. Recurrences were observed in approximately 60% of patients at 5 years. There was a trend suggesting an association between aggressive medical treatment and a reduction in the rate of recurrence/person/year (relative risk = 0.52, P = 0.051). Conclusion A standardized endoscopic management of ISS consisting of CO2 laser vaporization of the fibrotic scar appears effective in symptom control, with 40% of patients not requiring retreatment in the follow-up period, and with recurrence noted in a majority of patients. Aggressive medical treatment may have a role, but further prospective studies are required to confirm these findings. Level of Evidence 4. Laryngoscope, 124:498–503, 2014

Is type 2 diabetes mellitus associated with alterations in hearing? A systematic review and meta-analysis.

Abstract: Objectives/hypothesis: The aim of this study was to systematically and quantitatively review the available evidence on the effects of type 2 diabetes mellitus on hearing function. Data sources and review methods: Eligible studies were identified through searches of eight different electronic databases and manual searching of references. Articles obtained were independently reviewed by two authors using predefined inclusion criteria to identify eligible studies. Meta-analysis was performed on pooled data using Cochrane's Review Manager. Results: Eighteen articles fulfilled the inclusion criteria. Hearing loss (HL) was defined by all studies as pure tone average greater than 25 dB in the worse ear. The incidence of HL ranged between 44% and 69.7% for type 2 diabetics, significantly higher than in controls (OR 1.91; 95% confidence interval 1.47-2.49). The mean PTA (pure tone audiometry) thresholds were greater in diabetics than in controls for all frequencies [test or overall effect Z = 3.68, P = 0.0002]. Auditory brainstem response (ABR) wave V latencies were also statistically significantly longer in diabetics when compared to control groups [OR 3.09, 95% CI 1.82- 4.37, P < 0.00001]. Conclusions: Type 2 diabetic patients had significantly higher incidence for at least the mild degree of HL when compared with controls. Mean PTA thresholds were greater in diabetics for all frequencies but were more clinically relevant at 6000 and 8000 Hz. Prolonged ABR wave V latencies in the diabetic group suggest retro-cochlear involvement. Age and duration of DM play important roles in the occurrence of DM-related HL.

Indication criteria and outcomes with the Bonebridge transcutaneous bone‐conduction implant

Abstract: Objectives/Hypothesis The aim of this study was to evaluate functional hearing gain, speech understanding, and preoperative bone-conduction thresholds with the bone-conduction implant Bonebridge. Study Design Retrospective study at a tertiary referral center. Methods Twenty-four consecutive Bonebridge patients were identified. Nine patients suffered from combined hearing loss (HL), 12 from atresia of the external auditory canal and three from single-sided deafness. One patient was lost to follow-up. Twenty-three patients were therefore analyzed. Results The overall average functional hearing gain of all patients (n = 23) was 28.8 dB (±16.1 standard deviation [SD]). Monosyllabic word scores at 65 dB sound pressure level in quiet increased statistically significantly from 4.6 (±7.4 SD) percentage points to 53.7 (±23.0 SD) percentage points. Evaluation of preoperative bone-conduction thresholds revealed three patients with thresholds higher than 45 dB HL in the high frequencies starting at 2 kHz. These three patients had a very limited benefit of their bone-conduction implants. Conclusions The Bonebridge bone-conduction implant provides satisfactory results concerning functional gain and speech perception if preoperative bone conduction lies within 45 dB HL. Level of Evidence 4. Laryngoscope, 124:2802–2806, 2014