Examining the neck
Reviewed by: Badr Eldin Mostafa
Jan/Feb 12 (Vol 20 No 6)
One of the most difficult tasks facing a head and neck surgeon is to evaluate the neck after radiotherapy. CT scans and MRIs are usually difficult to interpret and repeated studies can be quite costly. Serial ultrasonography is more convenient and much cheaper. The authors compared post treatment US results with pretreatment CT in 133 patients. The results of US and US-guided FNAC were compared with findings at neck dissection and disease outcome. The Positive Predictive Value and Negative PV of initial post treatment US were 11% and 97%. Sensitivity and specificity were 92% and 28%. The PPV and NPV of US-guided FNA were 33% and 95%, and the sensitivity and specificity were 75% and 74%. On serial sonographic surveillance, of 33 patients with nonsuspicious findings, only one (3%) had neck recurrence. Of 22 patients with questionable findings on CT and negative findings on US, none had a neck recurrence. Although very attractive, ultrasonography has a major disadvantage: it is highly operator dependent and results cannot be confidently replicated, except after local validation of the techniques and skills of the available staff.
Brain responses to smell
Reviewed by: Edward W Fisher
Jan/Feb 12 (Vol 20 No 6)
The search for objective methods of assessing olfaction continues. This is not the answer but is nonetheless interesting. The technique of near-infrared spectroscopy measures changes in total haemoglobin concentration in parts of the brain after odour stimulation. The relevant part of the brain here was the occipitofrontal cortex (both sides). This was combined with a questionnaire assessment of subjective response (odour identification) and the odours used were standard ones for experimentation (for example phenyl ethyl alcohol). The left side of the OFC produced a response when the odour was detected, but the subjects who identified the odour registered a change on the right side. At present this may help the understanding of the neurophysiology of olfaction, but is a long way from being a clinical tool.
Abnormal nasal anatomy leads to chronic sinusitis?
Reviewed by: Maher El Alami
Jan/Feb 12 (Vol 20 No 6)
The importance of anatomical variations of the septum and middle turbinates has been of interest for some time. This study compares the CT scans of 418 symptomatic adult patients with that of 73 healthy volunteers. Inclusion and exclusion criteria are clearly stated, as are the diagnostic criteria of concha bullosa (50% pneumatisation of vertical height), pneumatised middle turbinate (lateral rather than medial convexity) and septal deviation. A grading system for the severity is also included. The data is clearly tabled, looking at unilateral versus bilateral disease and comparing the findings in both groups. The prevalence of concha bullosa is around 12%, while significant septal deviation is present in 76% using very tight radiological criteria. However this group was then further divided according to the severity of nasal deformity. Of note is the fact that none of these anatomical variations had much significance on the presence or absence of chronic sinusitis (CRS) and that these findings were similar in both groups. This implies there is little role for naso-septal surgery for the surgical treatment of CRS for nasal deformities per se. This is probably in line with our contemporary understanding of the pathogenesis of CRS. The weakness of this study is that it is a retrospective study, without any further explanation of type of clinical symptoms. However, these results may curb the enthusiasm of some for aggressive nasal surgery for CRS.
Predicting outcome in sudden sensorineural hearing loss
Reviewed by: Idiopathic sudden sensorineural hearing loss (ISSNHL) may well be a mix of pathologies, but a reasonably reliable predictor of likely recovery would b
Jan/Feb 12 (Vol 20 No 6)
Idiopathic sudden sensorineural hearing loss (ISSNHL) may well be a mix of pathologies, but a reasonably reliable predictor of likely recovery would be useful, better than slope and depth of pure tone audiogram loss. This study used distortion product oto-acoustic emissions (DPOAEs) at 11 individual points over a wide range of frequencies and compared hearing recovery with DPOAE amplitude. Hearing improvement was graded simply into greater or less than 50%. At two higher DPOAE frequencies (3 and 4.8kHz), DPOAE strength correlated reasonably well with recovery, whether by simple correlation or multiple regression. It was a fair, rather than a very strong correlation, but the study group at 78 is large for this pathology and does suggest that DPOAEs, if more routinely available, could be useful as a prognostic test for the likelihood of recovery from this condition. But do we want to tell patents they are very unlikely to recover, particularly with an only moderately reliable test?!
Hearing loss associated with TMJ disorders
Reviewed by: Gauri Mankekar
Jan/Feb 12 (Vol 20 No 6)
In this study maximum mouth opening of 464 healthy Greek students with a mean age of 19.6 years was measured with vernier calipers and their aural symptoms and audiograms were recorded. The data was analysed using statistical tests. The study showed that women had a higher incidence of, as well as more severe, TMJ disorders as compared to males; the absence or presence of mild TMJ disorders was associated with normal audiogram, while moderate and severe TMJ disorders were related to hearing loss in the median and low tones respectively. The authors also found that bruxism, joint ankylosis, joint pain and ear itching were more common in TMJ disorders than in non-TMJ patients.
Endonasal endoscopic versus microscopic pituitary adenoma surgery – a review
Reviewed by: Gauri Mankekar
Jan/Feb 12 (Vol 20 No 6)
This article reviews the significant advances in the surgical management of pituitary tumours over the last century. The authors performed a retrospective chart and radiographic review of 160 pituitary adenomas, removed between 2006 and 2010. Of these, 126 patients presented with tumours confined to the sella. Thirty-four patients presented with extension of adenoma into the cavernous sinus. All surgeries were performed with a ‘two nostril’ endoscopic endonasal approach, without the addition of the surgical microscope. All patients had at least one year follow-up. One hundred and thirty-four patients (84%) had gross tumour resection. The authors have provided self-explanatory algorithms of sellar exposure over the past century, as well as invasiveness of the exposures. While exposure of the sella has increased over the past century with the use of the endoscope, invasion of the sella has decreased. The authors conclude that endonasal endoscopic resection of pituitary tumours invading the cavernous sinus allows better visualisation compared with the microscopic view, resulting in complete tumour resection in a much higher percentage of cases. They also suggest that cavernous sinus invasion need not be a negative prognosticator, while recommending the surgical excision of pituitary adenomas with extra-sellar extension.
Can implanted children distinguish happy versus sad music?
Reviewed by: Thomas Nikolopoulos
Jan/Feb 12 (Vol 20 No 6)
It is well known that music is a non-verbal auditory stimulus and a powerful tool for transmitting emotion. Identifying emotional cues is an important part of normal social development and communication and thus music may play an important role in establishing these skills during development. To date, it is not known whether children who use cochlear implants to hear can identify the emotional content carried in music. Therefore the objective of the present study, to determine whether children who have been deaf from infancy and are experienced CI users have acquired the ability to identify emotion in musical phrases, seems very interesting. The study included 18 CI users (ages 7-13 years) who received right unilateral CIs (mean age at CI activation of 2.9 years) and 18 age-and gender-matched controls. Participants were asked to judge 32 brief musical excerpts as happy or sad, by pointing to simple graphics of a smiling or frowning face. The results of the present study revealed that children using CIs were able to correctly distinguish happy versus sad music well above chance levels, but performed more poorly on this task than their peers with typical hearing. Age at CI activation and time since CI activation were both uncorrelated with outcome measures. Another useful study in the right direction – to assess music perception and its limitations through implants, in order to improve the devices and their strategies.
How can we assess music perception in implantees? A new test
Reviewed by: Thomas Nikolopoulos
Jan/Feb 12 (Vol 20 No 6)
It is now timely that we focused on music perception and not only speech perception in deaf people following cochlear implantation. This study was undertaken to evaluate the musical sounds in cochlear implants (MuSIC) perception test, created to assess the music-listening abilities of cochlear implant (CI) users. Thirty-one unilateral implant users and a control group of 67 adults with normal hearing (NH) were included in the study. The new test, called MuSIC, comprises six objective and two subjective modules, employing approximately 2,800 musical files recorded from non-synthesized instruments. A subset was used for comparing CI and NH participants' results. CI and NH participants performed significantly differently on: pitch discrimination, melody discrimination, chord discrimination, instrument detection, and instrument identification. No significant difference in performance was seen on the subtests of rhythm discrimination or dissonance rating and emotion rating. The authors claim that MuSIC test was found to be a valuable tool for assessing music perception in CI users and NH participants, whether investigating one aspect of music perception in depth or conducting a broad survey of music perception. However, further and detailed validation of the test is needed.
How does the brain respond to sequential bilateral cochlear implantation?
Reviewed by: Thomas Nikolopoulos
Jan/Feb 12 (Vol 20 No 6)
This is a very interesting study assessing the auditory and visual cortical activations in bilateral cochlear implant recipients using [18F]-FDG positron emission tomography. The authors aimed to compare the activations from use of the first implant alone, the second implant alone, and both implants together. When both implants were activated simultaneously, summation of cortical activity did not occur. The first and second implants demonstrated evidence of developing distinct neural networks. The first implants showed stronger bilateral recruitment of the auditory areas than the second implants. Visual cortical activations occurred in response to stimulation of the second but not the first implants. When both implants were activated together, there were no visual activations suggesting interaction between the first- and second-implant networks. Some of these findings were rather surprising and need further investigation as the small number of patients does not allow safe conclusions. This work should be continued as it may reveal details of hearing physiology and plasticity that have never been investigated before.
Qualitative case studies of five cochlear implant recipients' experience with music
Reviewed by: Thomas Nikolopoulos
Jan/Feb 12 (Vol 20 No 6)
The authors suggest that music appreciation is an extremely complex experience, that is difficult to quantify through a conventional outcome study. Therefore, they attempted to document the experience of five CI patients with regard to music appreciation using qualitative techniques. This information was obtained through a semi-structured interview process. The interviews were then transcribed and analysed using a constant comparative method of qualitative description. The results, together with medical case records, were used to identify emerging themes. The common themes that evolved were: musical background, the experience of receiving the implant, current experience with music, attention, musical prediction ability, internal hearing, hedonic versus critical listening, determination, and timbre perception. The results revealed that the participants’ satisfaction with regard to music appreciation ranged widely. However, all expressed dissatisfaction with the sound quality they experienced when listening to music. Although the sample size was very small, it is obvious that cochlear implant devices and strategies need further improvement in order to achieve an acceptable level in music appreciation.
Virtual endoscopy of the middle ear
Reviewed by: Jahangir Ahmed
Jan/Feb 12 (Vol 20 No 6)
With recent advancements in computer programming, it is now possible to reconstruct three dimensional anatomy from images obtained by conventional two dimensional CT and MRI scans. Indeed, virtual endoscopic examinations of surfaces of organs such as the colon and bronchi have been utilised and demonstrated to be clinically accurate. Virtual endoscopy (VE) of the middle ear cavity has demonstrated excellent anatomic detail of the relevant structures, thus opening up the possibility of using this as an adjunctive tool in the decision making and planning of subsequent surgical manoeuvres and also as a valuable aid to teaching. In an attempt to validate the utility of this imaging modality, the authors aimed to correlate putative diagnoses made with VE in a cohort of 30 patients with conductive hearing loss, with subsequent findings on formal surgical exploration. Thirteen of the 19 patients diagnosed with pathology on VE did indeed have ossicular chain problems. More worryingly, however, of the 11 diagnosed ‘normal’ on VE, eight had otosclerosis and one had malleus fixation. This equates to an overall sensitivity and specificity of 59% and 25% respectively. As with conventional CT, the positive diagnosis of otosclerosis remains problematic. Despite the relatively small numbers in this study, the conclusions, therefore, at best, are that VE does have potential in the perioperative evaluation of the middle ear cavity. However, further clinical validation and cost benefit analysis, coupled with more technological advances are required before VE makes its way into the routine investigative armamentarium of the otologist.
Dizziness post head injury
Reviewed by: Ian Coulter
Jan/Feb 12 (Vol 20 No 6)
Otolith dysfunction may account for nonspecific dizziness following head injury. This prospective clinical study evaluated otolith function in 28 patients referred within three months of head injury using cervical vestibular evoked myogenic potential (cVEMP) and subjective visual vertical (SVV) tests. The investigators defined otolith dysfunction as either an abnormal cVEMP or SVV test. Of the patients investigated, 18 complained of dizziness and 12 reported hearing loss including six patients who complained of both. Seventy-two per cent (13/18) of patients who complained of dizziness were found to have abnormal otolith function. Although only a small number of patients were evaluated, a significant difference in otolith function was observed between the cohorts with and without dizziness. No significant difference in otolith function was identified between the abnormal and normal hearing cohorts. The authors go on to advocate otolith function testing in patients complaining of dizziness post head injury to direct therapy, but they also suggest that more effective rehabilitation programmes are still required for patients with otolith dysfunction.
Frontal sinus balloon sinuplasty
Reviewed by: Ian Coulter
Jan/Feb 12 (Vol 20 No 6)
Balloon sinuplasty in the frontal sinus may at times be very challenging. This multicentre retrospective study analysed the limitations of balloon sinuplasty in frontal sinus surgery. The notes of 64 patients undergoing balloon sinuplasty over a three year period were analysed. Balloon sinuplasty was attempted in 104 frontal sinuses, with a failure of dilatation of 12 (12%) sinuses reported. Of these instances, either anatomical variations in the frontal recess (frontoethmoidal-cell, frontal-bulla-cell or aggernasi-cell) or osteoneogenesis were to blame. The authors recommend a thorough knowledge of classical functional endoscopic sinus surgery of the frontal recess area in the event of a technical failure of the balloon dilatation. The authors also highlight the lack of a histopathologic exam and the subsequent risk of overlooking pathology in balloon only procedures by reporting a case of lymphoma which was missed, delaying a potential diagnosis by six months had functional endoscopic sinus surgery been used initially.
Pollution and the brain
Reviewed by: Badr Eldin Mostafa
Jan/Feb 12 (Vol 20 No 6)
The deleterious effects of pollution on the respiratory and cardiovascular system are familiar to all physicians. In this epidemiological study the authors add another disturbing aspect, a possible association with attention deficit hyperactivity disorder (ADHD). About 1,000 children living in Delhi, India were studied. Half the study population was within 3km of the pollution detection centre and the other half lived close to their schools. They were matched to children living in rural areas. Delhi has 2.7 times the pollution index compared to Indian standards and this is directly related to traffic and exhaust emissions. ADHD was diagnosed according to American criteria in 11% of the study population compared to 2.7% of the controls (p<.001) hence a prevalence 4.1 times more in Delhi than in rural areas. Other risk factors included a low socio-economic level and age 12-14 years. However the most significant was the pollution index (OR2.07, CI at 95%, 1.08-3.99). In patients with behavioural disorders and communication difficulties, it seems worthwhile to ask about environmental pollution. Whether the effects are reversible or minimised by improving environmental conditions awaits further study.
Hyperbaric oxygen: how it works in angiogenesis.
Reviewed by: Iordanis Konstantinidis
Jan/Feb 12 (Vol 20 No 6)
This is a study dealing with the value of hyperbaric oxygen (HBO) in treating sudden hearing loss and tinnitus via angiogenesis, presenting its relation with the vascular endothelial growth factor (VEGF) and the basic fibroblast growth factor (bFGF). Both cytokines are crucial mediators of angiogenesis and their in-vivo function is still not fully understood.
Forty-three patients were enrolled in this study and the above cytokines were measured. Blood samples of 7.5ml of peripheral blood were taken on day 1, 2, 5 and 10 of HBO treatment. Measurements compared with a control group were matched for age and gender. The main result of the study was that a significant effect of HBO on serum concentrations of bFGF and VEGF was not verified. However many studies revealed that intermittent HBO exposure plays a direct role in vascular growth. I would be happy to see a similar study in skull base infections, where osteomyelitis has a good response to HBO therapy.
A simple prognostic marker for head and neck cancer: work in progress
Reviewed by: Elza Tjio
Jan/Feb 12 (Vol 20 No 6)
White blood cell (WBC) count has been shown to be increased and correlating with severity of disease in conditions like coronary heart disease or stroke, but has not been studied in head and neck cancer before. The authors endeavour here to establish a relationship between raised WBC count and prognosis of oral cancer. This retrospective study selected 278 patients with oral cancer and compared the preoperative WBC count with the clinicopathological information (collected before data analysis) such as age, gender, T status, N status, recurrence, metastases, follow-up time, and time till recurrence / metastases. The only significant result (based on the Pearson chi squared test) was an elevated WCC count correlating with the T status, and no observable correlation was found between elevated WCC count and the development of metastases or recurrence of disease. Limitations to this study include a once off WBC count analysis, rather than a repeated analysis throughout the course of follow-up, which may be able to reflect progression better. Also other confounding factors that influence WBC count have not been considered (for example the use of non-steroidals and their resulting anti-inflammatory effect). There are a few merits to this study, including the duration of follow-up with a mean of 35.97 months. It is also suggested that although there may not be a correlation in established disease, it may be of interest in precancerous lesions, especially those associated with inflammation (such as erosive lichen). This will also be an area of interest in HPV associated with oral SCC.
Endoscopic pituitary surgery does not cause sinonasal problems
Reviewed by: Joanne Rimmer
Jan/Feb 12 (Vol 20 No 6)
Minimally invasive pituitary surgery (MIPS) is now routine, commonly employing an endoscopic transsphenoidal approach to the gland. This gives improved operative views, shorter operative times, reduced blood loss and shorter hospital stays. The increased sinonasal dissection required, compared to standard transnasal transsphenoidal approaches using the microscope, has been suggested to cause increased sinonasal morbidity postoperatively, but there is little data to support or refute this. These authors postulated that endoscopic MIPS should cause no long-term sinonasal issues, and undertook a retrospective review of 50 patients who had undergone pituitary surgery by this approach. They were asked to complete the Rhinosinusitis Disability Index (RSDI), a validated quality of life score, both pre- and postoperatively. There was no significant difference between mean preoperative and postoperative scores across all domains. One flaw is that the RSDI has not been validated for use in patients undergoing extended ESS procedures. Given the ever-increasing numbers of these cases, the authors suggest that such quality of life assessments should be validated for use in endoscopic approaches to the anterior skull base and beyond. Despite that, this study does suggest that patients can be reassured preoperatively that endoscopic MIPS should have no detrimental effect on their sinonasal health.
Lumbar drains in endoscopic skull base surgery – to use or not to use?
Reviewed by: Joanne Rimmer
Jan/Feb 12 (Vol 20 No 6)
Lumbar drains (LD) are often used in endoscopic anterior skull base procedures to reduce the risk of postoperative cerebrospinal fluid (CSF) leak by providing an alternative, low-resistance route for CSF flow. However, there are no standardised guidelines, and the use of LD varies between surgeons and institutions. There is no good level one evidence to support the prospective use of LD or to determine which situations are most appropriate for their placement. This retrospective review looked at 65 patients who had LD placed prospectively at the time of surgery. Twenty-seven of these were for encephalocoele and twenty for CSF leak, eight of which were spontaneous. Eleven were transsphenoidal or tumour approaches, and the remainder were for revision sinus surgery or frontal sinus fracture. Four cases (6.2%) developed a postoperative CSF leak requiring further surgery; two of these had signs of hydrocephalus preoperatively and subsequently required ventriculoperitoneal shunt insertion. CSF leak rates were not significantly different for tumour and non-tumour cases, although the likelihood of an LD complication was significantly higher in tumour cases. Body mass index and the duration of LD insertion did not increase the complication rate. Nine LD complications occurred in eight patients (12.3%), although there were no cases of meningitis. Five patients required epidural blood patches for persistent leak and headache. One catheter tip was retained and required exploration and removal. Intrathecal fluoroscein did not cause any adverse reactions, and the authors discuss their use of fluoroscein via a lumbar puncture when it is needed but an LD is not required. The complications of LD placement may be higher than previously thought, with associated increase in morbidity as well as hospital stay and its related costs. Complications are not predictable in most cases, and the authors advise more judicious use of LD in ‘high-risk’ patients only.
Decreased hearing with styrene exposure
Reviewed by: Patricia Gaffney
Jan/Feb 12 (Vol 20 No 6)
Styrene has been shown by other studies to cause ototoxic changes to the cochlea affecting hearing thresholds. Animal models show clear results regarding the lowest concentration of styrene alone, styrene with noise exposure, and styrene with physical activity to cause ototoxic changes; this study focuses on the effects on human participants. A total of 1,404 participants from Sweden, Finland and Poland completed the study. Four groups were established: those who worked with styrene (fibreglass manufacturing sites), those that worked with styrene in noise, those who worked in noise without styrene exposure, and a control group that worked in a different industry. Results found that those exposed to styrene had poorer hearing thresholds across all frequencies compared to the control group and compared to published standards. Also this study revealed a significant effect for styrene and noise exposure on decreased hearing thresholds. At this time dosing parameters could not be established. It is recommended that those working with styrene should be included in industrial hearing screening programmes.
Monitored live voice word recognition testing not clinically faster than recorded stimuli
Reviewed by: Patricia Gaffney
Jan/Feb 12 (Vol 20 No 6)
Monitored live voice (MLV) presentations of word recognition are often preferred by clinicians because it is quicker to administer and patients score higher than when recorded material is used. In this study two groups of listeners (young normal hearing and older hearing impaired participants) performed a counterbalanced word recognition paradigm with MLV performed by audiologists or audiology student, recorded speech with a short inter-stimulus interval (ISI), and with a long ISI. Results showed that using the NU-6 full lists (50 words) MLV was statistically faster than the recorded stimuli for both listener groups. There was, however, a slower response time for the hearing impaired group. For the hearing impaired group the MLV was only one minute faster, which clinically is not significant. The authors note that due to the advantages of recorded stimuli and no clinically significant differences between MLV and recorded word, a recommended protocol is to use recorded word recognition with a short ISI.
Poorer word recognition and conductive hearing loss in older adults
Reviewed by: Patricia Gaffney
Jan/Feb 12 (Vol 20 No 6)
The majority of epidemiologic data of pure tone thresholds in the elderly has been based on air conduction. The researchers were particularly interested in the addition of bone conduction and word recognition to the hearing screenings of older individuals. This study examined the effects of age on hearing loss and word recognition by comparing 474 younger old adults (70 and 75) and 252 older adults (85 year olds). Results showed approximately 6% of younger old and 10% of old adults had a conductive or mixed hearing loss. Ten per cent of the 85 year old participants had poor word recognition, compared to <1% of the younger old adults. The authors propose that the poorer word recognition is a neuropathy present in the older adults. There was no significant difference in the groups with the diagnosis of sensorineural hearing loss. It is recommended that, when screening older adults, particularly those 85 years of age, bone conduction and word recognition be added to the battery, due to the increased prevalence of conductive / mixed hearing loss and poor word recognition of these older adults.
Risk factors in preschool children with language impairment
Reviewed by: Gauri Mankekar
Jan/Feb 12 (Vol 20 No 6)
The authors investigated the relationships between temperament and language development along with child behavioural adjustment and maternal psychosocial factors, in a sample of four year old children with language impairment and compared it with typically developing children from a large community. They found that, though the two groups did not differ significantly on temperamental shyness / sociability, children with language impairment showed more negative dispositions on the persistence/self-regulation factor and on overall temperamental difficultness. These are strong risk factors and lower mother education and literacy contribute towards further disadvantage. The authors suggest that clinicians should be aware of the whole package of risk factors which are common in this population of children.
Mandibular distraction osteogenesis – an alternative to tracheostomy in neonates with micrognathia associated upper airway obstruction
Reviewed by: Mary-Louise Montague
Jan/Feb 12 (Vol 20 No 6)
This review article considers mandibular distraction osteogenesis and its efficacy in neonates with Pierre Robin sequence. It is clear from this review of the current literature that this is indeed the case. It should therefore, conservative measures having failed, be considered as a safe, acceptable alternative to tracheostomy in neonates with micrognathia-associated upper airway obstruction. The detail of the review is such that it goes a long way to increase awareness of the various issues surrounding neonatal distraction procedures, including preoperative work-up, distraction protocols and potential complications. This is all supported by good quality radiographic images, demonstrating the placement of a distraction device bilaterally, a three-dimensional craniofacial CT of a neonate with micrognathia and illustrations depicting the two main types of distraction devices – internal and external. There is also some discussion regarding the cost effectiveness of distraction osteogenesis compared to tracheostomy with particular reference to duration of hospital stay postoperatively, long-term care costs and morbidity and mortality. Although there have been no formal cost-analysis studies published on this subject to date, the author of the review surmises that the former is more cost-effective, taking account of the above mentioned factors. As with all surgical procedures patient selection is critical to a successful outcome and this review also manages to address this important area well.
Hydroxyapatite bone cement in stapedectomy
Reviewed by: Stephen James Broomfield
Jan/Feb 12 (Vol 20 No 6)
In some stapedectomy procedures, crimping onto the long process of incus sufficiently to avoid a loose piston, whilst avoiding potential necrosis due to over-crimping, can prove difficult. In this study, the authors present their experience of using hydroxyapatite bone cement placed onto the dry long process of incus, alongside the prosthesis, in a series of 23 stapedectomies in which the initial crimping was found to be unsatisfactory. The air-bone gap closure to within 10dB was found to be worse in the study group than in a group of 301 historical controls at 12 months, though the authors account for this difference by the inclusion of two outliers in the study group. No late deterioration in hearing or adverse reactions to the bone cement were reported. The authors report one further case, not a part of this study that required revision stapedectomy following trauma. Interestingly, more than three years after primary surgery, the bone cement was found to be vascularised and still firmly attached to the incus
Does otitis media affect the balance between surface area and volume of the mastoid air cell system in adults?
Reviewed by: Madhup K Chaurasia
Jan/Feb 12 (Vol 20 No 6)
It is commonly understood that smaller mastoid air cell volume predisposes the middle ear to certain pathological conditions such as cholesteatoma and otitis media and larger mastoid air cell systems depend less on Eustachian tube opening to equalise pressure with the atmosphere.
In this study, 20 adults with disease-free ears and with or without a history of childhood otitis media underwent estimations of mastoid air cell system volumes and surface area with help of Schuller’s projection X-rays of the mastoids and then CT scans. For varying mastoid volumes, this study found a linear relationship between the right and left mastoid volumes, right and left mastoid surface areas and, on each side, the same linear relationship between mastoid volumes and mastoid air cell system surface area. A couple of outliers were excluded. The study contradicts previous hypotheses. Clinical correlates are not very clear in this study but it appears that larger air cell volumes are not associated with smaller surface area. From the study it appears that if the gas exchange across the air cell mucosa is related to the surface area, then problems in larger mastoids are associated with the efficacy of blood perfusion or other factors – a complex hypothesis, requiring further studies in larger numbers.
Is it necessary to clean sinuses after FESS surgery?
Reviewed by: Madhup K Chaurasia
Jan/Feb 12 (Vol 20 No 6)
There are wide variations in the management of post-FESS patients in terms of office procedures and medicinal treatment. Endoscopic cleaning of the sinuses in the immediate postoperative period is time consuming and costly in terms of resources and often the procedure is poorly tolerated by patients. This study compares the effects of immediate postoperative intervention of cleaning of the sinuses at two, four and six week follow-up appointments against no intervention, until six weeks, when the first follow-up was arranged. The patients chosen underwent bilateral FESS, the disease on both sides being similar according to Lund-MacKay staging system. This was a single blinded study, with patients acting as their own control, because only one sided, randomly selected, were cleaned at two, four and six week intervals. The results were measured in terms of oedema, polypoid changes of the mucosa, granulation tissue, discharge, adhesions and crusting. According to the severity, these were scored from one to three. The results indicated no statistically significant differences between the two groups, except in terms of development of adhesions, the incidence of which was higher in the group left untouched for six weeks. Several studies mentioned from the literature also do no support frequent cleaning immediately after FESS operations. Although this study does convey cost effectiveness by supporting simpler post FESS follow-up protocols, attention to adhesions is desired because, unlike the other problems, these are not amenable to medical treatment.
Benefits derived from a multidisciplinary balance clinic
Reviewed by: Madhup K Chaurasia
Jan/Feb 12 (Vol 20 No 6)
he authors describe a multidisciplinary clinic which modifies the patient pathway for individuals with balance problems. After initial exclusion of patients with suspected sinister pathology, the rest were seen in a balanced assessment clinic run by audiologists and physiotherapists with a special interest in vestibular rehabilitation. The proceedings of these were discussed in a weekly review meeting which also involved an ENT consultant with interest in balance disorders. From hereon the patients were referred for further tests, discharged, sent onwards to a balance specialist clinic or offered vestibular rehabilitation. Some patients were brought back to the weekly review meetings and then placed in one of the usual pathways as described. A diagnostic review suggested a high proportion of patients with unilateral peripheral vestibulopathy and benign paroxysmal positional vertigo. The patient satisfaction survey showed good results for the clinic set-up, assessment outcomes and overall satisfaction but the booking system proved not very satisfactory. The authors contend that this system essentially reduced the vestibular rehabilitation waiting times and increased the efficacy of it. It was also noted that a vast majority of patients require vestibular rehabilitation and if this is given early in the patient pathway it greatly helps towards patient satisfaction. Only 26% of patients required individual consultant assessment. This does seem to be an effective method so long as patients with sinister pathologies are not missed in the screening process which is conducted by less experienced clinicians.
Results of revision stapes surgery for conductive deafness
Reviewed by: Madhup K Chaurasia
Jan/Feb 12 (Vol 20 No 6)
Although stapedectomy / stapedotomy surgery is highly successful, sometimes there is recurrence or persistence of conductive hearing loss. The usual causes are prosthesis failure, adhesions, necrosis of long process of incus and perforations. Revision of stapes surgery is often a challenge and is fraught with complications. In this study, the author has looked into the success rate of revision surgery of his own primary operations and in those where primary surgery was performed elsewhere. The senior author performed 233 stapedectomies, using various techniques, ranging from old fashioned picking on the stapes footplate to stapedotomies with laser and use of vein graft. Results with these 233 primary operations showed an air-bone gap closure within 10dB in 80% of cases. Twenty-five revisions on these primary operations resulted in about 52% success with little variation between revision operations performed within a year or later. In a series of 100 patients where the primary operation was performed elsewhere, the success rate was only 29%. It is therefore contended that the best results are obtained in primary stapes surgery. Results are very much poorer with revisions and if these are required, the alternative of using a hearing aid should be seriously considered.
Recipient vein reconstruction
Reviewed by: Stuart Clark
Jan/Feb 12 (Vol 20 No 6)
This paper, from Taiwan, analyses reconstruction of the lower extremity in 362 free-tissue transfers. The vast majority of flaps were all flaps that a reconstructive head and neck surgeon would be familiar with. They outlined that male patients and composite defects were associated with higher rates of venous insufficiency. There was no significance arising from the age, co-morbidities, aetiology, or location of the defects. The super venous system was associated with a higher rate of venous insufficiency and partial flap loss compared to the deep venous system, and that the deep venous system was more reliable than the superficial system. The use of more than one vein for anastomosis does not correlate with a better flap outcome. Accepting that this relates to a non head and neck site, it is interesting to read the thoughts of our colleagues dealing with different anatomical areas.
Ageing and stabilisation of gaze
Reviewed by: Victor Y Osei-Lah
Jan/Feb 12 (Vol 20 No 6)
The Gaze Stabilisation Test (GST) is a fairly new test of the vestibulo-ocular reflex (VOR) that evaluates an individual’s ability to maintain gaze head perturbations. In this test, a target ‘E’ is presented randomly at a fixed target size to the patient for a brief period during the active head shake movement in the yaw (side-side horizontal) plane to determine the maximum speed that the subject can observe the target in focus. After adhering to strict exclusion criteria, the authors recruited 89 adults (20 years to 79 years) to study the effect of age on GST, which previous studies have not evaluated fully. Two subjects were further excluded due to visual acuity abnormalities. Subjects were divided into six age groups. GST maximum velocity in yaw and velocity asymmetry was determined for all 87 subjects. There was a significant negative correlation of maximum GST velocity with age. Older subjects (over 60 years) showed significantly slower GST maximum velocity than younger subjects (20-39 years). The authors concluded that age must be taken into account in the interpretation of GST results. Further studies are underway in standardising protocols for GST as well as determining age effects of GST in pitch and roll.
Pathophysiology of horizontal canal BPPV – the debate continues
Reviewed by: Victor Y Osei-Lah
Jan/Feb 12 (Vol 20 No 6)
Lateral semicircular canal BPPV (L-BPPV) is rare compared with the posterior canal type. There are two forms: geotropic (that is nystagmus beating to the undermost ear) and apogeotropic (nystagmus beating to the uppermost ear). Spontaneous resolution is common in all types of BPPV but many particle re-positioning manoeuvres have been described for the two forms of L-BPPV. The pathophysiology of these two forms has been debated over the years and the authors attempt to address this issue further. Among their cohort of BPPV patients, they identified 91 patients, who had L-BPPV – 61 geotropic and 30 apogeotropic. Of the former, four resolved spontaneously during diagnostic testing (for example Dix-Hallpike or horizontal head roll). Fifty resolved after forced prolonged positioning (FPP) and three each after barbecue and Gufoni manoeuvres. One patient had Brandt-Daroff’s exercises after a failed FFP. In the apogeotropic group, five transformed to the geotropic type during diagnostic examination. A further five transformed after barbecue manoeuvre and / or FPP. In the rest, (20 patients), apogetropic nystagmus resolved without any transformation to the geotropic type. The authors hypothesised that canalolithiasis is the pathophysiological mechanism for geotropic L-BPPV. For apogetropic L-BPPV, several mechanisms were proposed: in those that can be transformed by diagnostic manoeuvres or FPP to the geotropic type, the mechanism is canalolithiasis; in those that do not transform, two mechanisms are possible a) cupulolithiasis in which the debris could be on either side of the cupula, b) a heavy cupula, which is not amenable to mechanical manouevres but symptoms resolve spontaneously as a result of habituation. The paper adds little to current understanding of the pathophysiology of L-BPPV but it serves as a good revision of this condition.
Parotidectomy or no parotidectomy
Reviewed by: Badr Eldin Mostafa
Jan/Feb 12 (Vol 20 No 6)
For the average surgeon, parotidectomy means a possible facial nerve disaster. The main risk of extracapsular excision of benign parotid tumours is residual tumour and a high recurrence rate. Forty-one patients with pleomorphic adenoma of the parotid gland underwent surgery and were divided into two groups: Extra capsular dissection (ED) 21 patients and Superficial Parotidectomy (SP) 20 patients. All patients were followed up postoperatively and the mean follow-up time was 194 (range 117 to 264) months. No recurrences were recorded in either group. However the SP group had a higher rate of complication: three cases of salivary fistula, one of Frey's syndrome, three cases of temporary facial paresis and 13 of cosmetic deformity. Seemingly a simpler procedure, we should remember that extracapsular dissection is as demanding as a superficial parotidectomy and the surgeon should avoid breaking the capsule or damaging the crossing facial nerve branches to achieve this result.
Treating Ménière’s disease
Reviewed by: Badr Eldin Mostafa
Jan/Feb 12 (Vol 20 No 6)
Diuretics are central in the management of MD in some guidelines. In fact, these are the only recognised therapies in the recommendations of the AAO-HNS. The authors propose an interesting hypothesis: can an abrupt lowering of blood pressure induced by the diuretics lead to an exaggerated vasomotor response inducing local ischemia causing a more or less permanent damage? An abrupt decrease in systemic blood pressure can trigger an adverse sympathetic reaction and transmit misleading information to the cochlear vasopressin receptors causing vasoconstriction which, in such an end-artery system, can be deleterious to function. Maintaining a stable systemic blood pressure may counteract this effect and at the same time benefit from the hypothetical sodium-controlling properties of this drug class.
Comparison of surgical approaches for paediatric craniopharyngiomas
Reviewed by: Gauri Mankekar
Jan/Feb 12 (Vol 20 No 6)
In this review, the authors analysed findings from 61 studies which reported preoperative characteristics and postoperative outcomes after transcranial or transsphenoidal surgery for craniopharyngiomas in children. They found that patients treated with the transcranial approach tended to have more hydrocephalus, larger tumours, and more suprasellar disease compared to those treated with transphenoidal disease. These differences create selection bias, which could explain the improved rates of disease control and lower morbidity of transphenoidal craniopharyngioma surgeries. Therefore the authors conclude that direct comparison of outcomes after transcranial and transsphenoidal surgery may not be valid for paediatric craniopharyngiomas.
Contralateral aneurysm – cause of hemifacial spasm
Reviewed by: Gauri Mankekar
Jan/Feb 12 (Vol 20 No 6)
This case report describes the unusual case of a 55 year old lady with left sided hemifacial spasm which worsened gradually over a period of two years. Cerebral angiography revealed a right vertebral artery fusiform aneurysm near the vertebral artery union that inclined toward the left side. This was considered to be the cause of the left hemifacial spasm due to compression of the left facial nerve by the aneurysm. Endovascular coil embolisation of the right vertebral artery was performed and the hemifacial spasm disappeared within three months
Cochlear implants with positioner as a risk factor for meningitis
Reviewed by: Rebecca Heywood
Jan/Feb 12 (Vol 20 No 6)
Cochlear implantation is associated with an elevated risk of meningitis and in 2002 the Advanced Bionics cochlear implant with a positioner was withdrawn by the manufacturers following identification of the positioner as a particular risk factor. Publications following this confirmed the higher incidence of meningitis in patients with the positioner in situ four to five years after implantation. This paper looks at the data eight years following withdrawal of the device to assess longitudinal risk of meningitis in this group of patients with a view to determining whether there is benefit in removing implants with a positioner. The manufacturer’s database was used to acquire data. Between their introduction in 1999 and withdrawal in 2002, 8,329 devices that may have used a positioner were implanted. The incidence of meningitis in patients with these devices during the three year spans of 1999 to 2001, 2002 to 2004, 2005 to 2007 and 2008 to 2010 was 33, 40, 11 and 2 respectively. Only a single case of meningitis was reported in a patient with a positioner more than 96 months postimplantation. The cumulative risk of meningitis eight to 12 years after implantation with a positioner-containing device was calculated as 114 cases per 100,000 patient-years (120-150 cases per 100,000 patient-years associated with implants without a positioner). The authors therefore conclude that prophylactic removal of the positioner-containing devices is not necessary. Of note, acute otitis media was diagnosed within the week before meningitis in 49% of these patients and more than a third of them had been fully immunised, prompting a look at the efficacy of vaccination in preventing meningitis.
How can we reduce CSF leak post translabyrinthine acoustic neuroma surgery?
Reviewed by: Rebecca Heywood
Jan/Feb 12 (Vol 20 No 6)
Translabyrinthine acoustic neuroma surgery creates a large bony defect and typically does not allow for watertight closure of the dura. Despite numerous modifications in technique for closure of the dura and surgical cavity, CSF leak remains a problem in many institutions and can result in meningitis, prolonged hospital stay and return to theatre. This prospective non-randomised trial compared CSF leak rates in 149 historic control patients closed with abdominal fat grafting and oversewing of the periosteum to 71 patients who had the abdominal fat graft reinforced with a resorbable poly-L/DL lactide fixation plate with the intention of increasing back pressure on the fat graft. There was no significant difference in CSF leak, requirement for lumbar drain, requirement for reoperation or length of hospital stay between the two groups. They compare their results to those of another group who successfully decreased their rate of CSF leak from 10.9 to 3.3% using titanium mesh reinforcement of the fat graft and postulate that the discrepancy may lie in differences in surgical technique rather than repair material used. Indeed following these results they changed their method of Eustachian tube closure rather than switching to titanium mesh. While some institutions advocate using other biosynthetic products for closure, others report very low rates of CSF leak by limiting dissection in the regions of the incus buttress, facial recess and sinus tympani and meticulous closure in layers without biomaterials. This paper is unusual in reporting an intervention that confers no additional benefit over the authors’ standard technique.
The effects of obesity and weight loss on voice
Reviewed by: Laith Tapponi
Jan/Feb 12 (Vol 20 No 6)
The topic of obesity and its impact on health is timely and important. Eight obese and eight non-obese adults participated in this study; obese participants underwent bariatric surgical procedures. It studied cross-sectional analysis for group differences and longitudinal analysis for multidimensional changes in vocal function from four assessments collected over six months. This study resulted in no statistically significant differences for perceived voice quality, acoustic measures, or aeromechanic measures between obese and non-obese participants at the beginning of this study. This was surprising because BMI differed maximally between the groups at this time. Nonetheless, when data were examined longitudinally, a few auditory-perceptual and aeromechanic differences emerged. Due to high individual variability, longitudinal studies are expected to be more informative than cross-sectional designs to evaluate the effects of obesity and weight loss on voice. Additional studies are needed with larger numbers of participants, along with repeated baseline assessments, and perhaps longer follow-up periods.
Voice evaluation and treatment for essential vocal tremor
Reviewed by: Laith Tapponi
Jan/Feb 12 (Vol 20 No 6)
Several publications reported successful use of Botox injections to the laryngeal musculature for individuals with vocal tremor. However, many individuals do not tolerate the potential side-effects of severe breathiness and difficulty swallowing associated with the injections which can last from three to six months depending on the individual. This study offers a rationale and description of the voice evaluation and treatment methods successfully conducted with a client presenting with a mild to moderate vocal tremor. Based on vocal tremor pattern during various speaking tasks, the objectives of treatment were developed to increase the articulation rate, reduce the duration of voicing segments during connected speech, increase the use of a breathier and softer voice quality, and reduce the occurrence of decreased pitch inflections at the end of utterances. Thus, the goal of this treatment was not to eliminate the vocal tremor. Rather, it provided the client with strategies for reducing the perception of vocal tremor while speaking, so that the client could improve the work-related speech activities. Overall, the outcomes of the treatment programme appeared beneficial to the client, who indicated a high level of satisfaction immediately and one year subsequent to completion. Future investigation is needed to determine the extent to which this approach is useful with other clients with consideration given to its severity level as well as its aetiology.
Assessments of predictors for thyroid cancer recurrence
Reviewed by: Marcos A Martinez Del Pero
Jan/Feb 12 (Vol 20 No 6)
This paper is a retrospective case note review of 431 patients, spanning from 1979 to 2007 and it aimed at demonstrating predictive factors for persistence and recurrence of well differentiated carcinomas of the thyroid (that is, papillary, follicular or Hurthle cell carcinomas). The outcome measures were dichotomised into tumour factors (tumour size, histologic type and number of tumour foci) and patient factors (gender, race and age at thyroid surgery) There was not enough clear data to include local or regional invasion. Although the number of patients looks impressive (n=431), the information collected and the outcome measures, by the authors’ own admission, had been analysed before. In addition, the sample 'was not powered for the primary outcome'. The statistical analysis included different permutations of variables and modified the same variable to be entered into the models (for example tumour size divided into two or four groups). The authors found that increasing age was associated with an increased risk of recurrence / persistence of the tumour. Tumour factors did not appear to be predictive. Another salient point is that tumour recurrence can occur up to 23 years post-surgery (mean 6.1 years +/- 5.6 SD). This paper demonstrates the difficulties in deciding which patients need close monitoring and for how long.
Functional impairment from head and neck cancer – can planning make a difference?
Reviewed by: Victoria Possamai
Nov/Dec 2011 (Vol 20 No 5)
It is always tempting to skip over the studies with negative findings, but important to remember there is a lot to learn from them. This Swedish group ran a programme of early preventative rehabilitation for a group of patients with head and neck cancer undergoing external beam radiotherapy. The programme aimed to ameliorate the common consequences of swallowing problems, reduced mouth opening and neck stiffness. The intervention involved patients meeting with and receiving instruction by a speech therapist and physiotherapist with verbal and written information regarding specific exercises tailored to achieve objective end points. The study group was of 190 patients, with 184 controls. The chosen principal measures of effect were weight loss and two-year survival. Neither of these showed any significant difference between groups. There were also no significant differences in patient-reported measures of working ability, swallowing, speech problems, trismus and neck stiffness and anxiety / depression. The authors propose several possible reasons for these findings, including an increased awareness and expectation amongst the study group. The authors concede that the strategy in its present form does not seem to work, however they suggest a need to avoid abandoning the concept of preventative rehabilitation altogether, rather to move forward in identifying new approaches.
Some help for the empty nose patient?
Reviewed by: Edward W Fisher
Nov/Dec 2011 (Vol 20 No 5)
Few conditions induce the heartsink effect in the rhinologist as much as empty nose syndrome (ENS). This small series of three patients included two who were previously addicted to topical decongestants, so the sensory anomalies are likely to be complex and these patients may not represent a cross-section of the range of patients seen in ENT clinics with ENS. Whether a ‘typical’ ENS patient exists is open to question. The treatment consisted of injection of hyaluronidase into the nasal septum and turbinates under local anaesthesia, using a cannula (rather than a needle). The initial responses were favourable, but this is early days. The procedure can be repeated, is relatively non-invasive and so has advantages over some of the more aggressive options for the management of this difficult condition. Further work is likely to need more than one centre, since the condition is comparatively uncommon, so a single unit will have difficulty getting the numbers needed.
Use of antidepressants (sertraline) in improving quality of life in severe tinnitus patients
Reviewed by: Vinaya KC Manchaiah
Nov/Dec 2011 (Vol 20 No 5)
Tinnitus is known to have several consequences including reduced quality of life, sleep disturbance, depression and so on. The severity of tinnitus perception may play an important role on what consequences it may have on an individual. Several different types of treatment options have been used with tinnitus; however, there is no universally agreed treatment method. Refractory tinnitus is a chronic type causing absence from work and/or frequent visits to clinic for up to 18 months from the initial consultation. In this study the influence of antidepressants (that is sertraline) on health-related quality of life (HR-QoL) on patients with severe refractory tinnitus has been studied. Seventy-five consecutive patients with severe refractory tinnitus were randomly assigned to 16 weeks of either placebo or sertraline at fixed dose in a double blind trial. The group who took placebo were offered to continue with sertraline after they completed with placebo and returned for follow-up after 12 weeks. The group who took sertraline alone were studied up to 28 weeks. Psychological General Well-Being (PGWB) which served as an indicator of HR-QoL showed sertraline to be more effective than placebo. In addition, the improvements seen in HR-QoL are also maintained over time. Overall, this study shows sertraline to be an effective treatment option for severe refractory tinnitus.
Anti-reflux treatment for laryngopharyngeal symptoms – it does work apparently!
Reviewed by: Neil C Molony
Nov/Dec 2011 (Vol 20 No 5)
This paper rightly points out that as a specialty we prescribe proton pump inhibitors rather empirically for a variety of symptoms attributed to laryngopharyngeal reflux (LPR), with fairly non-specific findings on examination. However, performing pH monitoring on what would be a huge number of patients would be invasive, and for LPR of limited sensitivity. This study, therefore, started with 127 patients who had oesophagitis proven by biopsy on upper GI / endoscopy, and then assessed them for LPR symptoms with a reflux symptom index (RSI), and reflux finding score (RFS) at videolaryngostroboscopy, after excluding other pathologies such as the effects of smoking or asthma. This found 50 of the gastroenterology patients to have LPR as well, and they formed the study group, who were treated with lansoprazole for three months and then re-evaluated for RSI and RFS. Symptoms, and most of the signs used for RFS, were statistically significantly improved. So it seems our empirical treatment is reasonable, as long as we are reasonably rigorous in diagnostic criteria, given the side-effect profile of these medications. This study has many good features, such as the RSI and RFS assessors being blinded to the other’s scoring; and the statistics are reasonable.
Are otorhinolaryngologists familiar with current trends in allergic rhinitis?
Reviewed by: Evangelia Tsakiropoulou
Nov/Dec 2011 (Vol 20 No 5)
This is an interesting questionnaire survey among British consultants. The investigators aimed to approach the management and treatment trends on allergic rhinitis. Three hundred and nine (response rate 56%) registered consultant members of the British Association of Otorhinolaryngologists – Head and Neck Surgeons (BAO-HN), answered the questionnaire. Strong evidence exists regarding the connection of AR and Asthma within the current literature in epidemiology, pathogenesis and treatment. Interestingly, only 63% of the respondents were familiar with allergic rhinitis and its impact on asthma (ARIA) guidelines. Despite the fact that all consultants were familiar with the united airway theory, only 1% of them refer AR patients to a respiratory physician in case of associated lower respiratory tract pathology. Regarding investigation, skin prick test was the most popular test. On the contrary, only 3% of consultants ordered pulmonary spirometry. The most common reported treatment modality was intra nasal steroids. A significant percentage of the consultants inform and educate their patient on quality of life issues through advice leaflets. The authors suggest that a combined treatment strategy of allergen avoidance, pharmacotherapy, immunotherapy and education could reduce the treatment cost with better and long lasting results.
How to reconstruct a paralysed face
Reviewed by: Jahangir Ahmed
Nov/Dec 2011 (Vol 20 No 5)
Reconstructing a paralysed face is perhaps one of the most complicated tasks faced by an otolaryngologist; with numerous decision making stops likely to be encountered en route to a satisfactory outcome. A delicate balance between the need for function and aesthetics will be required at each step. The authors aim to comprehensively review a difficult area in surgery. Commencing with a discussion of the anatomy of the facial nerve, they discuss the aetiology of facial nerve paralysis, patient evaluation and the multitude of surgical options for dynamic and static reconstruction of the paralysed face. Dynamic reconstructive options may be summarised as procedures encompassing a) nerve repair, b) nerve transposition and c) muscle transfer. Surgical management of the eye is also adequately covered. Their review of the literature is not exhaustive and merely serves to reinforce the appropriate point(s) made; but this does add to readability. Facial nerve re-approximation or interpositional grafting is associated with the best end results and dynamic reconstructive procedures, as expected are better than static ones. Nevertheless, optimal reconstruction will necessarily encompass both types of surgery. Patients must be extensively counselled about expected results before they embark on what is often a lengthy reconstructive process. In general, patients should not expect a House Brackmann score better than three following any reanimation procedure. An easy to follow decision making algorithm is presented. Taken together the authors skilfully summarise a very large topic into a readable succinct article that should be useful revision for examinations on the subject.
Use of pectoralis major myocutaneous flap in reconstructive head and neck surgery: when and how
Reviewed by: Elza Tjio
Nov/Dec 2011 (Vol 20 No 5)
The authors of this article review the indications and reliability of the pectoralis major myocutaneous flap in reconstructive head and neck surgery. Benefits of this flap are perceived to be the simplicity of harvesting, the proximity to the head and its use as an alternative following failure of microsurgical flaps. Disadvantages include reduced neck mobility, and the need to rotate the vascular pedicle 180 degrees when using a skin paddle. The bulkiness of the flap may also represent a disadvantage, but is appropriate when coverage of the carotid artery is required. A total of 20 reconstructions between 1998 and 2009 took place at their unit, with 13 patients of T4 status. In six patients a complication led to further surgery. This is a significant complication rate, and the authors feel that despite an easier technique, the morbidity associated with further procedures as a result of complications cannot be ignored. The authors reviewed current literature and have also made suggestions to reduce these complications, namely using ties instead of cautery to avoid necrosis, tension free closure of donor site (may be achieved with Ventrofil or buttons), reducing supraclavicular bulge by turning it under the clavicle, and using either a inframmary approach, lateral incision or only a muscle flap in female patients to avoid breast distortion. Limitations to this paper include small patient population, single centre study, and also a large proportion of patients with high risk of morbidity (T4 status) pre intervention. However it does reiterate that microvascular free flaps should be preferred in general, which has been the prevailing practice.
Smoking does not affect FESS outcomes
Reviewed by: Joanne Rimmer
Nov/Dec 2011 (Vol 20 No 5)
Smoking is known to affect mucociliary function, but its role in chronic rhinosinusitis (CRS) has not been defined. It is often thought that smokers are likely to do less well after endoscopic sinus surgery (ESS), perhaps due to reduced healing or ongoing problems with ciliary function. This prospective multicentre study refutes that theory. Patients undergoing ESS for CRS were assessed for smoking history, and divided into non-smokers, light smokers (up to 20 cigarettes per day) and heavy smokers (more than 20 cigarettes per day). Quality of life scores and endoscopic appearances were recorded postoperatively for at least six months. All groups reported significantly improved quality of life scores following surgery, with improvement over time; there was no difference between groups. However, smoking did cause worsening of postoperative endoscopy scores, as measured by the Lund-Kennedy score. There were statistically significant differences between non-smokers, light smokers and heavy smokers, with worsening scores related to increased smoking volume. Smokers’ sinus cavities will therefore look worse postoperatively but they will still feel much better.
Long-term paediatric use of non-linear frequency compression amplification
Reviewed by: Patricia Gaffney
Nov/Dec 2011 (Vol 20 No 5)
Frequency lowering hearing instruments have shown benefit for those with high frequency hearing loss, the purpose of this study is to evaluate the long-term effects of this technology in children with moderate hearing losses. Sixteen children (mean age 10.4 years old) were fitted binaurally with non-linear frequency compression (NLFC) devices. In phase one of the study, it was determined that NLFC devices improved speech recognition after six weeks, now in phase two, the results appear to hold true six months post-fitting. Results also showed a significant improvement in nonsense syllable testing from six weeks to six months; other speech testing did not show significant improvement partly due to ceiling effects. Although no difference between NLFC on and off was seen for speech recognition performance in noise at six weeks, there was a significant improvement seen over six months. The NFLC data shows that over six months performance is equal or better than the performance seen six weeks post-fitting and prolonged exposure to this fitting strategy may improve listening in noise.
Tinnitus Retraining Therapy with sound generators and open ear hearing aids
Reviewed by: Patricia Gaffney
Nov/Dec 2011 (Vol 20 No 5)
Tinnitus Retraining Therapy (TRT) success was evaluated using two groups of participants, the first utilised a thin tube behind the ear sound generator (SG) and the other used open ear hearing aids (OE-HA) throughout therapy. Participants had either normal hearing or significant hearing loss with severe tinnitus (Jastreboff tinnitus patient categories 1 and 2); all 91 subjects were randomly assigned either an SG or an OE-HA. Both groups received the same education and counselling. The Tinnitus Handicap Inventory (THI) was used throughout twelve months of treatment. Results show a significant reduction in scores on the THI for both groups. Researchers found no significant differences in results for those with the SG and OE-HA suggesting that both instruments are equally successful with TRT treatment in these types of tinnitus patients.
Negative consequences of stuttering in adults – validation of the UTBAS scale
Reviewed by: Gauri Mankekar
Nov/Dec 2011 (Vol 20 No 5)
Stuttering is often associated with negative consequences and anxiety is a significant concomitant of the disorder. The authors of this study attempted to validate the original UTBAS (Unhelpful thoughts and beliefs about stuttering) scale and to develop two additional scales to assess beliefs and anxiety associated with negative thoughts. The study demonstrated the validity and utility of the UTBAS scales in assessing negative cognitions associated with speech related anxiety among adults who stutter. The results also confirmed previous evidence of a high rate of social phobia among adults who stutter and reveal that the UTBAS discriminates between adults with and without social phobia. The authors suggest that the UTBAS scale could be used to screen for indicators of social phobia among adults who stutter and may prove useful in identifying negative cognitions which have the potential to impact treatment outcomes.
Consult the CONSORT statement
Reviewed by: Mary-Louise Montague
Nov/Dec 2011 (Vol 20 No 5)
The findings of this review of randomised controlled trials on adenotonsillectomy published after 2001 beggars belief. Hopefully all will have heard of the Consolidated Statement for Reporting of Trials (CONSORT) statement, published for the first time in 1996, with revised versions in 2001 and 2010. It does what it says on the tin – offering guidance on reporting of randomised controlled trials (RCTs). The investigators in this review from the Royal Free and St Mary’s Hospitals London identified 25 trials, all but one of which were ‘sold’ as RCTs in either their title or abstract. A number of criteria were assessed against the gold standard CONSORT 2010 statement. No single trial fulfilled all the CONSORT criteria. Of particular interest, a sample size calculation was reported in only one quarter of trials, the method of generating a random allocation sequence and randomisation reported in only one third and a clear flow of trial participants in only one fifth of trials. Not surprisingly the authors conclude that the quality of reporting in this very common paediatric area of practice needs to be improved if erroneous conclusions are to be avoided. This is in effect a retrospective first-cycle audit and unfortunately only one database was searched and the search was limited to English language only. The authors acknowledge this limitation, which may have meant relevant trials were missed. All those about to submit an RCT to a peer reviewed journal should consult the CONSORT statement and make the necessary revisions before hitting the send button, bearing in mind that RCTs guide clinical practice and assist in the establishment of guidelines. Granted, complete compliance with the CONSORT statement will not mean that a trial is of high quality – merely that it has been reported in line with a pre-determined standard.
Does noise exposure add to presbyacusis?
Reviewed by: Madhup K Chaurasia
Nov/Dec 2011 (Vol 20 No 5)
About a fifth of the elderly population has sensorineural hearing loss which may produce isolation, lowered self esteem and cause anxiety. All of these can affect mental health and thus the quality of life. Whether occupational noise induced hearing loss adds to presbyacusis remains a matter of speculation. Depending on exposure levels, one in four workers may develop permanent hearing loss. This study compared 367 patients with a history of presbyacusis alone and 93 who had both presbyacusis and a history of noise exposure. Occupational noise exposure was defined as exposure for three or more years. There was a statistically significant difference between the two groups at 4kHz and, at this frequency, the patients exposed to noise had a higher threshold. However, on performing analysis of variants adjusted for age and gender, it was noted that noise exposure alone did not explain the observed difference. Analysis of variants also showed that, when patients were divided by sex, age was the only factor affecting hearing threshold levels.The authors therefore conclude that the hearing loss which develops in exposure to noise worsens only slightly if the exposure to noise is continued but the progression of hearing loss is mainly related to ageing. Further studies are required to establish this correlation between NIHL and presbyacusis considering that this is a significant issue in industrial claims for noise induced damage to hearing.
Effective sedation for middle ear surgery
Reviewed by: Madhup K Chaurasia
Nov/Dec 2011 (Vol 20 No 5)
Performing middle ear surgery under local anaesthesia has several advantages, such as reduced bleeding, postoperative nausea and vomiting and earlier mobilisation. In this study, the authors assessed the advantages of sedation with midazolam and a combination of midazolam and remifentanyl with no sedation, which formed the control group. The study is based on VAS analogue and results were subjected to statistical analysis. Tympanomastoidectomies and myringoplasties were the operations performed. It was observed that pain on injection of the local anaesthetic was significantly lower in the sedation groups in comparison with the control group, as was the case with most parameters. However, combination of midazolam with remifentanyl provided additional benefits over just midazolam in terms of reduced anxiety, obliteration of memory of surgery and alertness. Patients were more satisfied with combination sedation as compared with midazolam alone. Respiratory and haemodynamic stability was well maintained in both sedation groups. Also there was a much lower incidence of postoperative dizziness. In the present climate, where cost effectiveness cannot be ignored, the article provides useful reading to encourage operations under local anesthesia.
2D modified head impulse test
Reviewed by: Fiona Barker
Nov/Dec 2011 (Vol 20 No 5)
This paper gives a nice explanation of the principles behind head impulse testing in the horizontal and vertical planes. It goes over why testing the vertical canals is more difficult both in terms of performing the test correctly and interpreting the result. The main point of the research was to compare head impulse testing using a traditional and a modified technique. Eye movement was measured with scleral coils. 3D coils capable of measuring horizontal, vertical and torsional eye movements were used with the traditional technique and 2D coils that measure horizontal and vertical movements were used with the modified technique. The number of subjects was small (n=5) but there was a control group (n=4). The authors conclude that the modified test technique is valid and can capture results that are at least equivalent and in some cases better than the traditional technique. This has implications for those of us hoping to use other 2D measurement systems such as VNG to record and analyse head impulses.
Visual analogue scales in BPPV follow up
Reviewed by: Fiona Barker
Nov/Dec 2011 (Vol 20 No 5)
BPPV is a very common cause of dizziness and vertigo. Much of the outcome work on BPPV has focused on the resolution of vertigo and nystagmus. This paper makes some interesting points about follow-up for BPPV patients. The authors asked patients undergoing repositioning manoeuvres for unilateral posterior canal BPPV (n=226) to use visual analogue scales to rate vertigo and dizziness in the five days following their treatment. The results suggest that patients are able to distinguish between vertigo (defined as a sensation of spinning) and dizziness (defined as a sensation of rocking). Both scales showed decreased scores (improved symptoms) over the five day follow-up period but the decrease in the two scales was not correlated indicating that the scales are measuring two different phenomena. Particle repositioning manoeuvres have proven benefits in terms of managing vertigo, but a sensation of vague residual dizziness can persist despite the apparent ‘success’ of treatment. The authors propose that visual analogue scales are an effective, quick, user-friendly way to monitor the rapid, often daily, variation in symptoms seen in BPPV.
Washing up?
Reviewed by: Naishadh Patil
Nov/Dec 2011 (Vol 20 No 5)
There is an ever-increasing focus on the use of nasal douching (hypo/iso/hypertonic saline, baby shampoo) for rhinosinusitis, as well as for postoperative care following endoscopic sinus surgery. In this article the authors conduct a systematic review of the literature on this topic, and find that saline irrigation has a limited (level Ia) effect on adult acute rhinosinusitis. Furthermore, it is effective (level IIb) in the paediatric population in addition to standard medication, and can prevent repeated episodes (level IIb) in this group too. No side-effects of prolonged use were noted. In all, a total of 13 studies were included for consideration.
[Nasal douching in acute rhinosinusitis]
Hildenbrand T, Weber R, Heubach C, Moesges R.
LARYNGO-RHINO-OTOLOGIE
Endoscopic endonasal aneurysm clipping
Reviewed by: Showkat Mirza
Nov/Dec 2011 (Vol 20 No 5)
This controversial paper from the neurosurgical and ENT Departments of Strasbourg, France describes the first case of successful clipping of an unruptured anterior communicating artery (ACoA) aneurysm. To date, only three transnasal clipping of aneurysms have been reported, two of which were endoscopic and one microscopic. The pterional and supraorbital craniotomy are the standard approaches for an ACoA aneurysm but risk injury to the brain. The applications for a transnasal endoscopic approach are increasing with the excellent panoramic view offered but it remains controversial for vascular lesions due to its difficulty in achieving proximal vascular control, as well as the risk of cerebrospinal fluid leak. The case reported is of a 55 year old woman where the aneurysm's small size and broad neck prohibited coiling. The vascular aspects of the lesion led to the decision to undertake a transnasal route after appropriate patient counselling. The procedure is detailed with excellent photographs. A number of comments are included highlighting the controversy but one feels this innovative approach will develop further.
Physician-owned hospitals
Reviewed by: Showkat Mirza
Nov/Dec 2011 (Vol 20 No 5)
This review paper directed at neurosurgeons in America looks at the controversial issue of physician-owned hospitals. Proponents argue that an ownership stake leads to surgeons having control over all facets of the patient experience with the potential for better patient satisfaction and outcomes. On the other hand opponents claim hospital profits may create a conflict of interest for physicians with ownership. In addition physician-owned specialty hospitals focus only on profitable service lines undermining the ability of general acute-care hospitals to cross-subsidise less profitable services. However the competition may prompt efficiencies in the general hospital. Disclosing conflicts of interest are discussed before looking at health reforms and legislation to limit the growth of specialty hospitals. An interesting paper particularly considering the current healthcare reforms in the UK.
Management of otogenic sigmoid sinus thrombosis
Reviewed by: Rebecca Heywood
Nov/Dec 2011 (Vol 20 No 5)
This article looks at a small series of five children with sigmoid sinus thrombosis as a complication of otologic disease. All patients had a history of acute otitis media with symptoms for between five and 28 days prior to diagnosis. All had headache, vomiting and papilloedema. Although all five patients had some abnormality of the tympanic membrane, one patient only had retraction of the posterosuperior quadrant. Three patients had a VI nerve palsy. Sigmoid sinus thrombosis was identified or suspected in four out of five patients on CT with contrast enhancement; in the other patient it was diagnosed on MRI. Thrombosis extended to the proximal IJV in three patients, transverse sinus in three patients, and even sagittal sinus in one patient. Patients were anticoagulated for six months after surgery if the thrombus progressed to the proximal IJV, or transverse sinus (four out of five patients); there were no complications related to this. All patients were treated with broad-spectrum intravenous antibiotics and simple mastoidectomy with ventilation tube insertion. The sigmoid sinus was aspirated with a needle in all cases and in those in whom no blood was aspirated, the sinus was opened and thrombus removed. Partial or complete recanalisation was observed on MRI in all patients over a period of six to 24 months. The authors’ main observations are that the symptoms and signs of sigmoid sinus thrombosis may be masked by the use of antibiotics for acute otitis media and that early surgical and pharmacological treatment confers a better prognosis. A very similar series of patients is presented by another group in the same edition. Though an interesting read, with such small numbers neither are able to provide any further information on controversies such as indications for anticoagulation and extent of surgical intervention.
Manual versus laser stapedotomy depending on colour of footplate
Reviewed by: Rebecca Heywood
Nov/Dec 2011 (Vol 20 No 5)
The senior author of this article has previously stratified the degree of difficulty of stapedotomy surgery and complication rates according to characteristics of the stapes footplate on direct inspection. He classifies otosclerosis as blue (blue footplate before removal of the stapes superstructure), white (white footplate) or obliterative (non-visible footplate due to massive otospongiotic focus covering it). He takes this concept further in this paper and looks at how the incidence of footplate complications in blue and white groups differ with type of footplate perforator used. Stapedotomy was performed in the first 43 patients (group A) using a Fisch manual perforator and in the subsequent 40 patients (group B) using a laser. The procedure was otherwise identical in each case. Both groups had approximately three blue to one white footplate. No complications occurred using either method of perforation in patients with a blue footplate. The blue footplate is composed of healthy and elastic bone and is resistant to trauma. In those with a white footplate however there was a 70% complication rate using the manual perforator (five complete footplate fractures and two disarticulation of the anterior half of the footplate) and a 20% complication rate with the laser (two anterior half disarticulation). Hearing outcomes in manual perforator and laser groups were not significantly different. The authors conclude that in cases of white footplate, the fragility of the bone dictates that the least traumatic method possible, in this case laser, be used for stapedotomy to prevent footplate complications.
SLIT for allergic rhinitis in children
Reviewed by: Evangelia Tsakiropoulou
Nov/Dec 2011 (Vol 20 No 5)
The sublingual immunotherapy (SLIT) route is widely accepted and several related publications exist in literature. However, the efficacy of SLIT in children is still under discussion and no evidence-based guidelines exist.
This is a well designed meta-analysis assessing the methodological quality of systematic reviews on sublingual immunotherapy (SLIT) for allergic rhinitis in children. The primary search from 2000 through 2008 revealed 541 publications. Surprisingly, only ten studies met the inclusion criteria. The measurement tool used was ‘assessment of multiple systematic reviews’ (AMSTAR). According to the authors none of the included reviews presented high methodological quality. An interesting finding was that 40% of the reviews demonstrated low methodological quality. Additionally, the quality of reviews has not improved in recent years. The authors underline the need of well-conducted randomised clinical trials that follow global guidelines once they are the fundamental elements of systematic review or meta-analyses. Due to the lack of methodological quality and homogeneity no safe conclusion can be drawn regarding the efficacy of SLIT in cases of allergic rhinitis in the paediatric population.
Gentamicin and hearing loss
Reviewed by: Badr Eldin Mostafa
Nov/Dec 2011 (Vol 20 No 5)
Gentamicin is used extensively in neonatal intensive care units for gram-negative infections. Although in high-dose, extended-interval dosing protocols aim at minimising side-effects, hearing is still at risk. In this study the authors evaluated the effect of gentamicin on TOAE. It included 528 critically ill neonates stratified according to their body weights into very low birth weights (VLBW) <1500 gm. and non-VLBW. Multivariate analysis of non-VLBW neonates determined that each 1μg/ml increase in gentamicin C(max) was associated with an increased risk of OAE screen failure (odds ratio [OR] 1.4, 95% confidence interval (CI) 1.1-1.7, p=0.003). Further, the non-VLBW neonate subpopulation had an increased rate of OAE screen failure if the gentamicin C(max) exceeded 10μg/ml (OR 2.2, 95% CI 1.1-4.2, p=0.022) compared with neonates whose C(max) was 10μg/ml or lower. No association between serum gentamicin concentration and OAE screen failure could be determined among the VLBW neonates. Monitoring and maintaining gentamicin C(max) at or below 10μg/ml may minimise hearing impairment; however, further studies are necessary. It seems that in spite of current protective attempts aminoglycosides are still risky drugs to use and less toxic alternatives have to be recommended.
Outcomes of induction chemotherapy for stage IV tonsillar cancer
Reviewed by: Marcos A Martinez Del Pero
Nov/Dec 2011 (Vol 20 No 5)
This is a retrospective study of 41 patients treated over a two-year period with induction chemotherapy followed by radiotherapy alone or concomitant chemoradiotherapy. All patients had induction chemotherapy with cisplatin and 5-fluorouracil while waiting for radiotherapy. Docetaxel was not used, as the evidence of its efficacy was not yet available. Radiotherapy varied between accelerated hypofractionated (n=9) and ‘conventional’ radiotherapy (n=32) with or without concomitant chemotherapy (cisplatin on day 1 and on final day of hypofractionated radiotherapy and on days 1, 22 and 43 of ‘conventional’ radiotherapy). The intended regime was to give four cycles, but only two patients received the full course and 23 received two doses. The reason given was the treatment was stopped when radiotherapy became available. No patient managed a full course of concomitant chemotherapy due to low tolerance. The overall three year survival was 66%. The progression free survival for patient who had induction chemotherapy and radiotherapy alone was 82% and for those who had additionally concomitant chemotherapy the progression free survival was 72% (p=0.6). The levels of toxicity appear acceptable, though high, when compared to other cohorts, although it is worth noting the death of a patient who received three cycles of induction chemotherapy followed by concomitant radiotherapy due to carotid blowout secondary to tissue necrosis. Overall the paper is well set out and the demography, treatment regimes and outcomes are clearly described. However, the induction therapy used in this paper has now been replaced by a different regime: cisplatin, 5-fluoruracil and docetaxel (TPF), hypofractionated radiotherapy is not recommended by the royal college of radiologists for these carcinomas any more and, by their own admission, they did not establish the HPV status of the patients. The authors argue that induction therapy is safe and does not compromise radiotherapy and that it is a viable alternative to surgery, although there were no comparisons made in terms of outcome or tolerance with surgical management to back this statement.
Understanding the velo-pharyngeal dysfunction
Reviewed by: Laith Tapponi
Nov/Dec 2011 (Vol 20 No 5)
This article helps to acquaint the reader with what is required for normal velo-pharyngeal function. The velo-pharyngeal valve is important for production of oral speech sounds, singing, whistling, blowing, sucking, kissing, swallowing, gagging and vomiting. This is a comprehensive study in which: 1) the components of normal velo-pharyngeal function are listed, 2) the types of velo-pharyngeal dysfunction are described along with the various causes of each, and 3) the implications of the type of Velo-Pharyngeal dysfunction on treatment and prognosis are discussed. ENT surgeons and speech-language pathologists need to be knowledgeable about the cause of velo-pharyngeal dysfunction, because treatment and prognosis are different for the different types of velo-pharyngeal dysfunction.
Paediatric free flap reconstruction and malignant head and neck tumours
Reviewed by: Andy Hall
Nov/Dec 2011 (Vol 20 No 5)
This retrospective review looked at patients under 18 who underwent free flap reconstruction following resection of malignant head and neck tumours in a tertiary referral centre. The eight tumours resected in this patient population were uniquely malignant sarcomas with all the children having undergone preoperative chemotherapy or chemoradiation. The transferred free flaps were somewhat heterogenous varying from rectus abdominis, gracilis, fibula and anterolateral thigh. The early complication rate was deemed 50%, yet only one patient returned to theatre for revision of a venous anastomosis. The late complications were also recorded in the form of an anterocutaneous fistula and osteoradionecrosis respectively (25%). The authors outline the limitations of their study yet overall the data they have obtained contributes usefully to a sparsely documented topic.
How to improve quality in hearing care?
Reviewed by: Vinaya KC Manchaiah
Nov/Dec 2011 (Vol 20 No 5)
Improving quality of services in hearing healthcare has received considerable attention in recent years. This may be partly due to changes in focus of healthcare management towards patient-centred approaches. The author has made a good attempt to bring some examples from personal experiences (for example airlines and hotel industry) to demonstrate contrast between good and poor quality services. The paper briefly talks about the factors which may determine the patient’s perceived quality of audiology practice, which may depend on the professional care provided and the perceived quality of the hearing device. More importantly, this paper provides list of simple questions one may ask to evaluate the quality of service provided in their practice by considering what added benefit a patient may have. Overall, this short paper makes a simple and useful point “no better marketing technique, than a database full of patients who appreciate all of your effort to help them hear well”.
Tonsils and pain
Reviewed by: Badr Eldin Mostafa
Sep/Oct (Vol 20 No 4)
Many drug combinations are used to alleviate posttonsillectomy pain. However the ideal combination is still elusive. In this article the authors investigated the analgesic effect from combinations of paracetamol, pregabalin and dexamethasone in adults undergoing tonsillectomy. Preoperatively, patients received either paracetamol 1,000mg, pregabalin 300mg, dexamethasone 8mg or placebo according to their allocation. Postoperative pain treatment included paracetamol 1,000mg 4x and ketobemidone 2.5mg p.n. Ketobemidone consumption, pain scores [visual analogue scale (VAS)], nausea, sedation, dizziness, number of vomits and consumption of ondansetron were recorded 2, 4 and 24h after the operation. This seems to be an adequate combination. However its use in children is barely possible and the side-effects of pregabalin may be unacceptable in some patients.
Pregabalin and dexamethasone improves post-operative pain treatment after tonsillectomy.
Mathiesen O, Jørgensen DG, Hilsted KL, Trolle W, Stjernholm P, Christiansen H, Hjortsø NC, Dahl JB.
ACTA ANAESTHESIOLOGICA SCANDINAVICA
2011;55(3):297-305.
Pre-operative tests can predict which nerve is involved in a vestibular schwannoma
Reviewed by: Victoria Possamai
Sep/Oct (Vol 20 No 4)
This German study retrospectively reviewed patient data for preoperative posturography and electronystagmography. Results of these tests were correlated with the nerve of origin of the tumour, that is, inferior (IVN) or superior vestibular nerve (SVN). Pathological findings for both tests were significantly more frequent in subjects with SVN schwannomas. The study also assessed the success of these patients undergoing attempted hearing preservation surgery. As expected from previous studies, hearing loss due to surgery was significantly higher in the IVN group. The clinical relevance? The authors suggest that there are significant numbers of patients who may be border-line for conventional criteria to determine whether hearing preservation surgical approaches are indicated. In such individuals, the additional information gained by these preoperative tests may be of prognostic value in suggesting the nerve of origin of the tumour and, therefore, predicted success of hearing preservation. The starting point of the study was a group of 349 patients, however, when cut to include only those with definite identification of nerve of origin of the tumour, then again to only include those who had undergone attempted hearing preservation surgery, the sample size fell to 47 patients, with only 10 in the SVN group. I am not convinced there is yet the weight of evidence to support these tests being included in the routine work-up of every patient.
Pre-operative prediction of vestibular schwannoma’s nerve of origin with posturography and Electronystagmography.
Borgmann H, Lenarz T, Lenarz M.
ACTA OTOLARYNGOLOGICA
2011;131(5):498-503.
How effective and safe is SLIT?
Reviewed by: Evangelia Tsakiropoulou
Sep/Oct (Vol 20 No 4)
Over the last three decades, much attention has been focused on the sublingual administration of immunotherapy (SLIT) for treatment of allergic rhinitis. This is a Cochrane systematic review and meta-analysis, updated to 2009. The aim was to evaluate the efficacy and safety of SLIT. The authors examined parameters like symptom reduction, alteration of immunological markers in blood and allergen sensitivity in target organs (nose, eye, skin). In total 60 trials, randomised, double-blind, placebo-controlled, of sublingual immunotherapy in adults and children are included. The results demonstrated significant reductions in symptoms and medication requirements compared with placebo. None of the trials reported severe systemic reactions, anaphylaxis or use of adrenaline. Compared to the subcutaneous administration, sublingual immunotherapy appears safer and has a better sideeffect profile. Regarding paediatric population, the data support the use of SLIT in children. Additionally, SLIT appears to be more effective with perennial allergens (predominantly house dust mite) when compared to seasonal allergens. The authors suggest that more studies of perennial rhinitis are needed to confirm or exclude the above finding. In general, the authors suggest that SLIT is an effective and safe alternative of subcutaneous administration. This is a very comprehensive paper that gives a detailed review for sublingual immunotherapy.
Systematic reviews of sublingual immunotherapy (SLIT).
Radulovic S, Wilson D, Calderon M, Durham S.
ALLERGY
2011;66(6):740-52.
Time for a new theory of hearing?
Reviewed by: Vinaya KC Manchaiah
Sep/Oct (Vol 20 No 4)
This is an interesting study which looks at the fundamental aspects of hearing, by assessing the effect of experimental manipulations of the cochlea on the auditory threshold to both air and bone conduction stimulations. Three mechanical manipulations (a hole in the vestibule, immobilisation of the round window, and round window perforation) were introduced in different ears and ABR thresholds were assessed for both air and bone-conducted stimulations, before and after each such manipulation. There was no change in ABR threshold and latency noticed during these manipulations for both air and bone-conduction stimulations. These findings cannot be explained in detail by current theories of sound transmission and the findings may challenge the classical hearing theories, in which both air and bone-conduction auditory stimulations are thought to begin due to sound-induced relative motion between the cochlear shell and the stapes footplate, producing a passive mechanical travelling wave along the basilar membrane. These findings add to the growing body of evidence, showing that the classic concepts of cochlear activation may be inadequate and the authors suggest that it is likely to require an ‘alternative mode of cochlear excitation’. It appears that it’s the right time for researchers to consider a ‘new theory to explain the hearing mechanism’.
‘Yogic’ technique in tinnitus treatment
Reviewed by: Vinaya KC Manchaiah
Sep/Oct (Vol 20 No 4)
Tinnitus is still a relatively poorly understood disorder in terms of its origin and mechanism. To date there is no standard or universally agreed treatment for this condition. Therapeutic techniques, such as relaxation techniques, medication and also sound therapies like TRT and masking, have proved to have some alleviating effect on both the somatic and psychological effects of tinnitus. Moreover, a number of alternative approaches, such as meditation, ginkgo biloba, and homeopathic remedies, have also been tried and the literature shows mixed opinions and results about the efficiency of such treatments. This study looked into the effects of a ‘Yogic’ technique ‘Bhramari Pranayama (BP)’ on both the physical and emotional aspects of tinnitus. This technique involved a combination of a relaxing posture and the process of producing a humming sound during exhalation, along with simultaneous pressing of the closed eyelids. The researchers administered treatment for a hundred adult ears, in four different groups, each receiving either pharmacotherapy, masking therapy, BP or the combination of all. The status of tinnitus was evaluated using a combination of tests to measure tinnitus loudness and also questionnaires to understand tinnitus handicap, anxiety and depression. The results showed that combining all the treatments had the best effects. However, a significant level of relief was also noticed in the patient group who received BP. The authors suggest that this simple technique acts as a sound therapy, in itself. In addition, this technique also had associated advantages, by addressing the emotional aspect of tinnitus, by activating the parasympathetic system, achieved by pressing of the eyeball, and also by providing the relaxation element of the therapy. Even though it is in its early stages, this simple technique has the potential to be added to the list of cost effective tinnitus treatment methods.
Beware whinging about whiplash!
Reviewed by: Neil C Molony
Sep/Oct (Vol 20 No 4)
This is a study asking a valid question and getting a negative result, which is probably a good outcome for the subject matter. The question is whether analysis of eye movements gives any valid findings in patients complaining of whiplash injury. Thirty-three subjects, complaining of imbalance after a whiplash injury, were compared with 23 controls. Assessment was by clinical examination, audiometry and ENG (electronystagmography). Four subjects were excluded for having either demonstrable Benign Paroxysmal Positional Vertigo or posttraumatic deafness. Basically, no difference was then found between controls and subjects, using reasonable analysis. Personally, I would have been interested to see how the subjects handled posturography, but the study used basically finds no use for ENG in this situation, which, on the one hand, prevents a flood of work, but admittedly leaves the ‘expert witness’ still with a very subjective judgement to make in these cases!
Hearing changes after sac surgery
Reviewed by: Neil C Molony
Sep/Oct (Vol 20 No 4)
This study describes low-tone air bone gaps (LTABGs) being found audiometrically after endolymphatic sac surgery, and attempts to describe why this should occur. Of 50 patients assessed following sac surgery, half were found to have this on postoperative audiograms at three months, with normal tympanometry and stapedial reflexes, and good speech discrimination scores; a conundrum suggesting a sensorineural mechanism despite the ABG. In their conclusions, the authors point out that, paradoxically, this may be associated with better subjective auditory function. The paper then seeks to explain this phenomenon. Inclusion criteria for surgery, and statistical analysis are fair, but the surgery used was not a simple decompression or shunt, but rather inserting sponges soaked in dexamethasone, after making a serious and sometimes successful attempt to find the operculum. Postoperative CT scans were used to look for exposure of posterior fossa dura around the vestibular aqueduct. Finding or exposing the operculum at surgery was significantly associated with having a postop LTABG, as were air conduction hearing gain and improved speech discrimination, while CT evidence of a wellexposed postop vestibular aqueduct had no association. The mechanism of this is discussed in terms of third window theories, similar to those proposed for similar LTABGs in patients with superior canal dehiscence, whereby the flow transmission in the inner ear is reduced by the decompressed inner ear structure, a theory which seems plausible. What is the clinical relevance? It is good to read a fairly large series, though personally I have not met this LTABG phenomenon in my admittedly smaller series, and wonder if it could also relate to technical surgical factors? In any case the subjective improvement in audition in many of these patients is reassuring that no overall harm to function appears to be being caused!
Early blindness does not affect olfactory function
Reviewed by: Iordanis Konstantinidis
Sep/Oct (Vol 20 No 4)
In this well conducted study the authors explore the effects of early visual deprivation on olfactory function. The idea is based on previous studies on auditory and tactile functions and anecdotal reports of outstanding olfactory abilities of individuals with visual impairments in everyday life contexts. Event-related potentials (ERPs) were recorded in eight early blind humans and eight sighted controls during olfactory stimulation with 2 phenyl ethyl alcohol and trigeminal stimulation with CO2. Olfactory stimuli generated responses of smaller amplitude than those observed in response to trigeminal stimulation. In addition, ERP analyses did not reveal any major difference in electrocortical responses in occipital areas in early blind and sighted subjects. These results suggest that passive olfactory and trigeminal stimulation elicit the same electrophysiological responses in both groups. However the small number of subjects and the passive form of stimuli may leave an open window for further research.
Synchronous cancers – an exceptional case
Reviewed by: Gauri Mankekar
Sep/Oct (Vol 20 No 4)
These authors present a rare case of synchronous cancers in a 47 year old Moroccan woman. The cancers were in the nasopharynx and in the breast. The woman was treated successfully with chemotherapy, radiation therapy and surgery and she remains disease free after 27 months of follow-up.
Why revision FESS?
Reviewed by: Gauri Mankekar
Sep/Oct (Vol 20 No 4)
This is a retrospective review of axial and coronal CT scans of 63 patients who underwent revision FESS. The authors attempted to identify anatomic factors that may predispose to persistent or recurrent disease in these patients. The study revealed that in 15.9% there was significant nasal septal deviation, 11.1% had lateralised middle turbinate, 57.1% had residual uncinate process, residual cells in the frontal recess 96%, in the anterior ethmoids in 92.1% and in the posterior ethmoids in 96% cases. The authors conclude that persistence or recurrent disease in revision FESS cases may be due to the persistent anatomic structures and non-dissected residual cells. They recommend a trial to compare outcomes of conservative FESS versus radical sinus dissection surgeries.
Can we ‘smell’ cancer?
Reviewed by: Badr Eldin Mostafa
Sep/Oct (Vol 20 No 4)
Using nanoparticle technology in an artificial nose, the authors tried to determine whether a simple breath test can differentiate between normal controls, patients with head and neck cancer and patients with lung cancer. The NA-NOSE (nanoscale artificial nose) signals were analysed to detect statistically significant differences between the sub-populations using (i) principal component analysis with ANOVA and Student's t-test and (ii) support vector machines and cross-validation. The identification of NA-NOSE patterns was supported by comparative analysis of the chemical composition of the breath through gas chromatography in conjunction with mass spectrometry (GC–MS), using 40 breath samples. Statistically significant differences were found between all three subpopulations. Validation of this technique may be useful in screening of high risk populations and especially for detection of recurrences, second primaries and possibly for treatment failures.
Cochlear implant electrode insertion. Is deeper always better?
Reviewed by: Thomas Nikolopoulos
Sep/Oct (Vol 20 No 4)
Although it is in general believed that there is a positive association of sufficiently deep insertion and speech perception, the literature is very limited on the possible detrimental effects on speech recognition when deep insertion corrupts optimal use of the cochlear implant. This is a very interesting case that describes, in detail, the evaluation, explantation, and subsequent re-implantation of a cochlear implant recipient with an unusually deep electrode array insertion. According to the authors, this unique case report challenges the assumption that deeper insertion will result in improved speech understanding and demonstrates the importance of fully evaluating recipients' complaints and recognising the impact of frequency-to-place mismatch. However, it seems that the problem in this case was not the deep insertion but the fact that there were no electrodes in the first part of the basilar turn. Deep electrode array insertion is desirable as long as there are electrodes in the first part of the basilar membrane of the cochlea.
Transcanal cochleostomy in cochlear implantation: alternative to classical cochlear implant surgery?
Reviewed by: Thomas Nikolopoulos
Sep/Oct (Vol 20 No 4)
Several alternatives to the classical mastoidectomy / posterior tympanotomy approach have been proposed in the literature. The authors propose the combined approach technique (CAT), a variation of the traditional method, that uses a transcanal approach to the cochleostomy combined with a small mastoidectomy and an equally small posterior tympanotomy for the insertion of electrodes. The study presents a detailed description of this alternative procedure, reporting the authors’ experience in 50 cases. According to the authors, all cases were successfully implanted using CAT and no major complications, such as facial paralysis or paresis, meningitis, cholesteatoma, or cerebrospinal fluid leaks, were observed. The authors concluded that CAT is a safe and efficient variation of cochlear implantation surgery, especially appropriate if cochlear calcification or malformations are present, or whenever cochleostomy has to be performed anteriorly, and when the position of the facial nerve prevents an adequate posterior tympanotomy. However, the median follow-up of 29 months (range: 3 to 56 months) is not long enough for definite conclusions as many complications occur many years following implantation.
Is the sinus mucosa of patients who have failed FESS fundamentally different from those in whom FESS works?
Reviewed by: Jahangir Ahmed
Sep/Oct (Vol 20 No 4)
Whilst the Caldwell Luc procedure was performed routinely even as recently as the early 1980s, the current gold standard surgical treatment for chronic rhinosinusitis (CRS) is a well performed functional endoscopic sinus surgery (FESS) procedure. Nevertheless, there is a significant minority of patients who remain symptomatic despite multiple FESS operations and may benefit from more invasive manoeuvres such as the Caldwell Luc, particularly if their recalcitrant disease is within the maxillary sinuses. The fundamental question the authors of this study aim to answer is: does the mucosa of this latter cohort of patients differ from those who benefit from FESS? They compared 80 patients who underwent a CL procedure with 40 patients who were treated with FESS only. The pertinent findings included a significantly reduced eosinophil count (5.68 versus 28.33 per high power field) in the CL group and the presence of necrotic bone or debris in four of the CL specimens compared to none in the FESS-only group. The authors conclude from this that there does appear to be a fundamental difference in the mucosa of CL patients. It appears to be ‘burnt out’ in terms of inflammation (the eosinophil count being a marker of chronic inflammation) and the observation of necrotic material further supports the hypothesis that the sinus mucosa in these patients is so dysfunctional and diseased that nearly all mucociliary function is gone; that in these cases FESS does not work because there is no capacity for mucosal recovery, whereas a CL procedure removes these pathological linings. There are clearly methodological flaws in this study; not least in it being retrospective and that there is no attempt to match the groups (indeed there are significant differences in patient number, age, sex and co-morbidities including smoking status). Thus clearly and as acknowledged by the authors, further matched, controlled studies will be required to further clarify these findings and indeed characterise other differences in the mucosa of patients who differ in their response to FESS.
Subjective and objective measures of nasal patency after septoplasty
Reviewed by: Ian Coulter
Sep/Oct (Vol 20 No 4)
It remains a widely held belief amongst clinicians that the relationship between a patient’s sensation of nasal obstruction and the actual severity of nasal obstruction, as demonstrated by objective measures such as rhinomanometry, is poor. Previous studies have suggested that the sensation of nasal obstruction is multifactorial. This study has investigated the relationship between the subjective sensation of nasal airflow resistance, rhinoscopic findings and the objective measures of nasal obstruction in patients followed up after septoplasty. Eighty-six patients, who had previously undergone septoplastic surgery, were analysed. Data concerning the objective and subjective measures of nasal obstruction were collated from anterior rhinomanometry, rhinoscopy and a visual analogue scale (VAS) respectively. The authors found significant correlations between the VAS score and both the rhinoscopic and rhinomanometric findings. They go on to conclude that rhinoscopy and rhinomanometry yield data which correlate significantly to the subjective sensation of nasal patency and can be utilised effectively as diagnostic tools to objectify the symptom of nasal obstruction. They advocate that the decision to operate should be based on rhinoscopic or nasal endoscopic examination findings which can be supported by a pathologically elevated airflow resistance of the more obstructed nasal cavity as demonstrated by rhinomanometry – which is the most sensitive parameter.
Supracricoid laryngectomy as a treatment for locally advanced endolaryngeal cancers
Reviewed by: Ian Coulter
Sep/Oct (Vol 20 No 4)
This study investigated the oncologic validity of supracricoid laryngectomy (SCL) as a treatment for locally advanced endolaryngeal cancers and as a salvage procedure after initial treatment failure. The authors also examined functional outcomes including complications after SCL to assess its safety in maintaining laryngeal physiology. One hundred and fourteen cases that underwent SCL were retrospectively examined via case note analysis. The authors examined whether extended procedures, salvage procedures, adjuvant treatment, and type of reconstruction had any association with patient survival, the average timings of decannulation and nasogastric tube removal. No significant difference was observed in survival according to the extent of the resection of the primary tumour and whether or not the patient had received previous treatments. As perhaps expected, patients undergoing cricohyoidopexy and salvage surgery required longer periods of time before resuming oral feeding when compared to other patients within the cohort. The commonest complication observed was aspiration pneumonia. The authors conclude that when utilising SCL to treat locally advanced laryngeal cancers and as a salvage procedure, it is possible to conserve laryngeal function without jeopardising patient survival. They go on to advocate postoperative swallowing rehabilitation to prevent aspiration pneumonia, particularly in cases undergoing extended and salvage procedures.
Nasal valve surgery
Reviewed by: Showkat Mirza
Sep/Oct (Vol 20 No 4)
This excellent article looks at the anatomy, examination and investigation of nasal obstruction due to nasal valve problems before detailing the various surgical techniques to address internal and external valve abnormalities. Of the internal valve techniques described they include spreader grafts, the butterfly graft and flaring sutures as well as suspension sutures but the relatively simple lateral crural J flap is not included. In the management of external valve problems lateral crural strut grafts, alar battens and turn in flaps are described. A useful paper looking at a difficult area of facial plastic surgery. Excellent diagrams and photographs are included.
Nasal reconstruction
Reviewed by: Stuart Clark
Sep/Oct (Vol 20 No 4)
Many of us have ‘cookbooks’ with the flaps and preferred methods of reconstruction. This edition of Facial Plastic Clinics adds considerably to this with many good illustrations and photographs. There are enough pointers within it to make it a useful edition for a reference when looking for a slightly different view in individual cases. If you don’t have a cookbook then this would be a worthwhile acquisition. Conspicuous by its absence are prosthetic appliances (implant retained) and a chapter on this would have made this all the more comprehensive.
Practice management in facial plastic surgery
Reviewed by: Stuart Clark
Sep/Oct (Vol 20 No 4)
This edition of Facial Plastic Clinics concentrates on practice management. Obviously it is very much for the American reader and that style detracts a little from what would be relevant to practitioners in the UK. Nonetheless there are a number of points throughout all of the chapters which would be useful to many surgeons with their own business. It only needs two or three of these pointers that could add to the overall success of a practice and on that basis it is a worthwhile read, once.
IMRT in the management of locally advanced oropharyngeal SCC
Reviewed by: Marcos Martinez Del Pero
Sep/Oct (Vol 20 No 4)
There is no dispute that there is epidemiological evidence of an overlap between migraine and vertigo. However debate is ongoing in terms of exactly how much of a diagnostic interrelationship exists, both in general terms and for individual patients. These two papers provide an illustration of the different views that clinicians can take on this subject. The authors of the original paper argue that many patients are being diagnosed with migraine-associated vertigo in the absence of a better explanation for their recurrent dizziness. They discuss the difficulty of identifying the disease process underlying ‘recurrent vestibulopathy’ but caution against the temptation to use migraine-associated vertigo as a sort of catch all diagnosis for these patients without some understanding of the pathology involved. The response is written by a veritable ‘who’s who’ of vestibular migraine. It argues that, although the pathophysiology of vestibular symptoms in migraine is not well understood, vestibular migraine should be considered as a valid diagnosis and call for it to be included, at least as an appendix, in the International Classification of Headache Disorders (ICHD). They discuss the epidemiological evidence of a link between migraine and dizziness. Where the two papers agree is in their support for the need for further, welldesigned co-ordinated research in this difficult area to investigate the underlying pathophysiology of both migraine and vertigo. Thought-provoking reading for anyone seeing dizzy patients.
Patient reported outcomes in head and neck cancer
Reviewed by: Marcos Martinez Del Pero
Sep/Oct (Vol 20 No 4)
This is a prospective single-centre series studying the outcome of intensity modulated radiotherapy (IMRT) in patients with stage III/IV disease. All patients were included, regardless of whether they had primary or postoperative parotid-sparing IMRT. The outcome measures were acute toxicity (mucositis, tolerance to treatment admission & weight loss), late toxicity (swallowing measured using disability domain of Therapy Outcome Measure, the presence of trismus, strictures or osteoradionecrosis) and survival. Twenty-four patients were identified over nearly five years. Approximately 60% of patients were T1/2 N2 and 10 patients had primary RT. All patients treated with primary RT and 64% of patients treated postoperatively received a dose of 65Gy in 30 sessions. Half of the patients received concomitant chemotherapy and 42% of these patients did not complete the six planned cycles. Half of the patients developed grade 3 mucositis and a quarter required admissions to hospital during the treatment. Patents lost an average of 13% of their body weight during treatment. Although the authors state weight was recorded, there is no mention of whether this was re gained during the follow-up period. Fifteen patients recovered baseline swallowing at an average of 37 months, while four patients still required non-oral nutritional support. Five of nine patients who did not recover swallowing completely, received postoperative radiotherapy. Three patients had postradiotherapy trismus; one developed a pharyngeal stricture and one symptomatic osteoradionecrosis. Two-year survival was 92% and 83.5% at 32 months. In conclusion, there was good local control and three quarters of patients have normal or near normal diets, as judged by the scoring system (scored by clinicians). Overall, the paper is well designed and clearly explained, although the sample is small and heterogeneous. It might have been useful to include what sort of surgery patients had and whether speech was affected.
Post-treatment surveillance in head and neck cancer
Reviewed by: Rebecca Heywood
Sep/Oct (Vol 20 No 4)
This article compares two health related quality of life questionnaires in 102 patients with head and neck cancer before treatment in the Oncology Institute of Porto. The two scoring systems are the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ) and the Functional Assessment of Cancer Therapy Scales (FACT). Both scoring systems have a general and a specific head and neck cancer domain. The EORTC general and head and neck component consists of 65 questions while FACT consists of 39 questions. EORTC is more symptom-based while FACT ‘explores the existential problems and personal satisfaction’. Outcome measures included sensitivity to tumour location, tumour size and patients presenting with symptoms related to their tumour (the specific symptoms were not specified); autonomy of completion, reliability and construct validity. The latter measure was explained conceptually, but the authors did not determine which were the convergent and discriminant tests. Despite the methods section having an explanation on different statistical tests used, I found it difficult to understand the results section. A more ‘digested’ version of the results would have made it more readable. In essence, both scoring systems were reliable, except when measuring emotional outcomes, were sensitive to whether the patient was symptomatic and had a lower quality of life in patients with T3 and T4 tumours. In terms of construct validity, the scoring systems showed good correlation when measuring physical and functional symptoms, but not when measuring social and emotional outcomes. There are correlations between different domains of the same questionnaire and between questionnaires, which would go against discriminant validity. Thus, the conclusion of the paper rightly points that the questionnaires measure different outcomes, EORTC is more specific and symptom related while FACT is more conceptual.
Migraine and vertigo debate
Reviewed by: Fiona Barker
Sep/Oct (Vol 20 No 4)
In the early stages of the Audiology BSc programme, it falls to me to break it to students that the hearing aids they have so diligently learned to program and adjust will not necessarily be accepted with delight, or even worn at all. To help me with this task I draw heavily on the series of Marke Trak surveys conducted by Sergei Kochkin, which ask large numbers of Americans very sensible questions about what they think of their hearing aids and why they choose to use or abandon them. The most recent survey (we are now up to number 8) was carried out in 2009, and this is the latest of several reports to come out of it. Kochkin manages to get response rates most of us can only dream about; in this case, 84% of 3,789 hearing aid users returned lengthy surveys asking questions about hearing aid benefit and quality of life. How he manages to stir so many people into action would be another paper worth reading. Some of the findings are unsurprising; people find their hearing aids most helpful one-to-one and less helpful (although, for the majority, still of some help) in background noise. What makes this survey interesting is that several questions were asked about the perceived effect of hearing aids on less ‘obvious’ areas of life such as sense of humour, mental and emotional health, cognitive skills and even romance. Although the majority of respondents rated these dimensions as ‘the same’ since hearing aid fitting, around 20-30% reported an improvement in at least one of these areas. The results need to be treated with some caution – if a person gets a hearing aid and then meets a new romantic partner, is that down to the hearing aid or just good fortune? But there is at least a suggestion here that the ‘connectedness’ better hearing brings can have farreaching effects. Another interesting feature of this survey is that practices employed by the clinic fitting the hearing aids are taken into account. There is a separate report elsewhere that looks at this aspect in more detail, but it was music to this hearing therapist’s ears to learn that the majority of patients who received the ‘most comprehensive protocol’ experienced significant reductions in handicap and improved quality of life, while only 15% of those receiving a ‘minimal protocol’ felt their quality of life had improved. Factors that could contribute to a comprehensive protocol included things like longer appointment time, participation in aural rehab group, use of auditory training programme and provision of a self-help book. Which of these factors made the most difference isn’t detailed here but the message seems to be clear; the ‘production line’ approach to hearing aid fitting is denying people some of the real benefits they might obtain with a bit more care and consideration.
Atopy increases treatment failure rates in sinusitis with polyps
Reviewed by: Joanne Rimmer
Sep/Oct (Vol 20 No 4)
The role of atopy in chronic rhinosinusitis (CRS) remains unclear. This study aimed to compare allergen sensitivity in patients failing medical therapy for CRS (with and without nasal polyps) with both rhinitis patients and the general population. A retrospective review of 334 consecutive patients undergoing surgery for CRS after failing maximal medical treatment was undertaken. This group was compared with 50 rhinitis patients without CRS, and results were also compared with a large North American population-based survey (NHANES III) as a control group. Positive skin prick tests were observed in 82.4% of CRS patients who underwent surgery, significantly higher than the control group but not the rhinitis group. There was no difference between groups for specific antigens, but patients with nasal polyps had higher median numbers of positive skin test results compared to non-polyp patients and rhinitics. The authors postulate that this may be due to a dysfunctional epithelial barrier allowing sensitisation to multiple environmental allergens. However, further work is still needed to investigate whether there is a true causal relationship between CRS and atopy.
Lack of evidence for oral steroids in CRS without polyps
Reviewed by: Joanne Rimmer
Sep/Oct (Vol 20 No 4)
Corticosteroid therapy remains the mainstay of medical treatment for chronic rhinosinusitis (CRS), both with and without polyps. Although there is evidence supporting the use of oral steroids in CRS with polyps, these authors felt that such evidence was lacking in patients without polyps and undertook a systematic review to investigate. Of 126 relevant abstracts on systemic steroid use in CRS, 33 studies involving CRS without polyps were identified; three of these were for allergic fungal sinusitis and were excluded. Of the 30 studies reviewed, 20 were level five evidence (reviews / expert opinion), with differing recommendations. Three of the studies, including one level three study, used oral steroids in combination with antibiotics and nasal steroids and found that this multidrug regimen led to symptomatic benefit and radiological improvement. Although there is scientific rationale for the use of oral steroids in CRS without polyps, given their anti-inflammatory action, as well as supporting expert opinion, there were no randomised controlled trials found to support their use. No clinical study using single modality oral steroid treatment was found. The authors conclude that high quality studies are required to support the widespread practice of oral steroid use in CRS without polyps.
Binaural listening benefit in bilateral cochlear implant users
Reviewed by: Patricia Gaffney
Sep/Oct (Vol 20 No 4)
Yoon, et al. examined the performance of bilateral cochlear implant (CI) users in monaural and binaural listening conditions to determine binaural benefit. The nine adult participants, all implanted sequentially, performed speech recognition testing to consonants, vowels and sentences in +5 to +10dB signal to noise ratios (SNR). Testing was performed using right implant, left implant and bilaterally. The results showed an overall trend that binaural performance was better when unilateral testing was more symmetrical, those that showed asymmetries in unilateral performance showed small binaural benefit or no binaural benefit. Sentence material showed more of a binaural benefit than consonants or vowels alone. The results also showed a binaural benefit in noise more so than in quiet. The researchers hypothesise that binaural listening advantage may be due more to the symmetry of performance and the listening environment than the speech material itself.
No changes in hearing with epidural anesthesia
Reviewed by: Patricia Gaffney
Sep/Oct (Vol 20 No 4)
The purpose of this article was to examine the effect of epidural anaesthesia on the auditory system using distortion product otoacoustic emissions (DPOAEs) and auditory brainstem response (ABR). The authors used a group of women who were giving birth with epidural anaesthesia and a group without an epidural. Researchers measured DPOAEs and ABR three times each at admission to the hospital, fifteen minutes after administration of the epidural, one hour after the epidural and three hours after removal of the epidural catheter. The control group had the same testing at admissions and during labour pains, during labour and three hours after labour. The results showed no significant changes between the control and study groups for ABR. During labour there were no significant differences between the DPOAEs of the two groups. After labour, researchers found an enhancement of higher frequency DPOAEs for both groups and a decrease in DPOAEs in the study group for 500, 750, 1,000, and 3,000Hz. Overall the research presented does not show a significant change in ABR or DPOAE results during labour with and without epidural.
Efficacy of speech telerehabilitation in people with Parkinson’s disease
Reviewed by: Gauri Mankekar
Sep/Oct (Vol 20 No 4)
Parkinson’s disease is associated with hypokinetic dysarthria which includes reduced loudness and stress, monotony of speech and loudness, imprecise articulation, variable rate and short rushes of speech, inappropriate silences and a harsh and breathy voice. This study evaluated thirty four participants with Parkinson’s disease and mild to moderate hypokinetic dysarthria who received the Lee Silverman Voice Treatment (LSVT) in either the online or the face to face environment in a randomised controlled non-inferiority trial. The study found that it was possible to deliver LSVT online although some networking difficulties were encountered on a few occasions. The authors conclude that telerehabilitation may be a feasible solution to the current problems faced by people with Parkinson’s disease in accessing speech pathology services.
Treatment of stuttering with visual signals
Reviewed by: Gauri Mankekar
Sep/Oct (Vol 20 No 4)
It has been known that overt stuttering behaviour can be reduced with presentation of auditory and visual second signals. This was attributed formerly to a decreased speech rate effect. However recent research has shown similar stuttering frequencies at normal and fast speech rates while speaking under altered auditory feedback. This paper prospectively studied ten stuttering adults who recited memorised tokens of eight to 13 syllables, under five visual speech feedback conditions, at both normal and fast speech rates. The authors found that the capabilities of visual speech feedback signals to reduce stuttering frequency was independent of the speaker’s rate of speech. The authors conclude that although the visual system appears to be a relatively less effective medium for transmission of speech gestures compared to the auditory system, further investigation into the nature and extent of reduction of stuttering across signals presented in the visual mode is required.
Interpret results of ABR under general anaesthesia with caution
Reviewed by: Mary-Louise Montague
Sep/Oct (Vol 20 No 4)
Those that work closely with the paediatric audiology team will be all too aware of the difficulties in assessing hearing by behavioural tests in children with complex medical conditions or when the child is unable to cooperate sufficiently. In these cases, auditory brainstem response (ABR) testing is performed to estimate the hearing thresholds. This may require a general anaesthetic and may be combined with other surgical procedures under general anaesthesia. ABR testing is known to be reliable, accurate and objective but the results obtained under general anaesthesia have been questioned in some clinical studies. The authors of this paper from Children’s Hospital Boston and Harvard Medical School undertook a retrospective review of 116 children. The aim was to investigate the factors which contribute to the discrepancies seen between ABR thresholds obtained under general anaesthesia in the operating theatre and hearing outcomes obtained at follow-up. They found that in children with glue ear who underwent ventilation tube insertion immediately prior to ABR, the average threshold difference between ABR under general anaesthesia and follow-up audiological assessment was approximately 10dB. In children with dry ears or in whom there was no requirement for ventilation tube insertion, the average threshold difference was only 3.8dB. The discrepancy was seen to be greater in children with mucoid effusions than those with serous effusions and was greatest at low frequency (1,000Hz). Their findings also suggest that the elevated ABR threshold seen under general anaesthesia in the operating theatre may be temporary and usually resolves after a few weeks. The authors postulate that this temporary threshold shift is multifactorial in aetiology incriminating residual middle ear fluid, high intensity noise created by suction and swelling and inflammation of the middle ear mucosa. They also list nonsurgical factors as potential contributors, namely the high background noise level in the operating theatre and electromagnetc interference from medical equipment and some patient devices (for example pacemaker, vagal nerve stimulator). Accepting the limitations of a retrospective study, this does support the findings of other studies and underlines the need for clinicians to be cautious in their interpretation of ABR results obtained under general anaesthesia. It also emphasises the need for follow-up audiological assessment, rather than relying solely on the ABR results.
Universal neonatal screening in Tuscany – how they do it
Reviewed by: Codruta Neumann
Sep/Oct 2011 (Vol 20 No 4)
The paper presents the results of the universal neonatal audiological screening programme, introduced in a tertiary neonatal referral centre between April 2005 and November 2009. All newborns underwent hearing screening, but formal protocols were not introduced until 2008. Prior to the introduction of universal screening, only neonates at risk would have their hearing tested, while babies deemed not at risk would have their hearing tested at eight months only, by Boel test, a behavioural test that is difficult to perform and interpret. Transient evoked otoacoustic emission (TEOAE) test was used for all newborns, while auditory brainstem response (ABR) was added in babies with a risk of auditory neuropathy. If a baby failed the first TEOAE, the test was repeated within 30 days from birth. If they failed the second TEOAE, then an automated auditory brainstem response (AABR) was performed. A failure prompted onward referral for further investigations within the first 90 days of life. In babies with audiological risk factors both TEOAE and AABR were performed after 35 weeks gestational age. An initial failure was followed by a repeat TEOAE and AABR before discharge from hospital. If the second test was failed as well, the baby would be referred for further investigations. For both groups this included audiological tests (clinical ABR, clinical TEOAE, and so on), clinical examination and blood tests, including cytomegalovirus DNA testing in a urine sample collected at birth, and genetic analysis. A cohort of 7,621 neonates without risk and 492 deemed at risk were tested. In this cohort, 34 neonates (0.42%) had a final diagnosis of hearing impairment, with 26 neonates (0.32%) having bilateral hearing loss and 44 neonates (0.54%) had false positive results. A slightly larger proportion of newborns with hearing impairment than in other screening programmes is explained by a larger number of babies in the cohort having spent time in intensive care, as the hospital is a tertiary referral neonatal unit. The authors present the identified causes for hearing loss, and offer guidance for monitoring of the auditory function in children at risk in order to detect late-onset hearing impairment. The paper is written partly as guidelines for running a newborn audiological screening programme, partly as an epidemiological study, and one cannot help but feel that separating the two would have been more useful for the reader.
Are cellular phones harmful to the cochlea?
Reviewed by: Madhup K Chaurasia
Sep/Oct 2011 (Vol 20 No 4)
Use of cellular phones has become extremely common and there is an increasing concern that the non-ionising electromagnetic waves they emanate may, amongst other things, cause cochlear damage. The significance of this is enhanced with development of fourth generation mobile phones and the continuous proximity of this source of electromagnetic waves to the ear and the head. In this study, the authors used adult and newborn rats, who were exposed to the electromagnetic energy from a mobile phone for six hours a day for thirty days and assessment was done by measuring distortion product OAEs, before and after this period, under general anaesthesia. The ratio between stimulus intensities was kept at 1.22 at intensities of 65 and 55dB SPL. Each of the newborn and adult exposed group was compared with adult and newborn controls, not exposed to the electromagnetic waves. Mean distortion product OAE values were compared before and after the test period of 30 days. The values of the distortion product OAEs decreased in both the adult controlled and exposed groups. It increased in both the newborn exposed and control groups, presumably due to further development of hearing in the 30 days of the test. None of these differences were statistically significant. This study claims more substantial exposure to electromagnetic waves. It compares in a similar way with a fair number of other publications mentioned, in that none have documented hearing loss in particular. However, some studies have noted other changes, namely neurological and musculoskeletal. This study, though inconclusive, evokes useful thoughts in relation to the ever modulating cellular phone technology.
Bacterial link between adenoiditis and sinusitis in children
Reviewed by: Madhup K Chaurasia
Sep/Oct 2011 (Vol 20 No 4)
A child’s nose that is blocked and snuffly may not be only due to an adenoidal hypertrophy or just adenoiditis, but in such cases both adenoids and sinuses may be infected. In this study, the authors have sought a bacterial correlation between adenoiditis and concurrent sinus infection. Swabs were taken from the middle meatus at the time of performing endoscopic adenoidectomy. The adenoids were divided and core tissue taken for culture. Organisms that featured were coagulase negative Staphylococci, Staphylococcus aureus, Streptococcus pneumonia, Haemophilus influenzae and group A Streptococci, both from the adenoids and the middle meatus. The adenoid core culture had a positive predictive value of 91.5 in forecasting the middle meatal culture result and a negative predictive value of 84.3, demonstrating a significant positive correlation between quantitative bacteriology results for adenoids and the paranasal sinuses. Use of adenoid core culture rather than surface swabs and a quantitative estimate (more than 105 colony forming units per gram of adenoid tissue) enhances this study and helps to establish that adenoids may form a reservoir for pathogenic bacteria which can involve paranasal sinuses. Adenoidectomy should therefore help restrict sinus infections. This study could be applied to all children undergoing adenoidectomy to assess the simultaneous involvement of the sinuses, the disease of which may not always manifest clinically.
Does adenotonsillectomy cure sleep apnoea?
Reviewed by: Madhup K Chaurasia
Sep/Oct 2011 (Vol 20 No 4)
A number of children present with sleep disordered breathing, resulting in a number of day time problems as well. Often these are children with large tonsils and adenoids and the question of adenotonsillectomy is often pivoted on the problem of obstructive sleep apnoea syndrome. In this study of 26 children, the subjects were assessed for obstructive sleep apnoea on clinical grounds and also by polysomnography. They then underwent adenotonsillectomy and the changes were assessed with the help of the Obstructive Sleep Apnoea 18 quality of life questionnaire which assesses improvement in five domains namely sleep disturbance, physical suffering, emotional distress, day time problems and caregiver concerns. The authors noted a marked improvement in sleep domain scores and caregiver concern domain. Less obvious changes were noted in daytime problems and emotional distress. A meta-analysis of other studies has been used for comparison. These studies also used OSA-18 and the results were generally similar although the improvements were much greater in this particular study. This is creditable considering other studies were performed in tertiary centres where children with more severe OSA presented. There are several limitations in this study, of which the authors are well aware. Firstly, there is no control group and the procedure of adenotonsillectomy can result in biased reporting. This problem, however, is insurmountable because the parents cannot be blinded to surgery! It would have been interesting to compare results between children in whom the diagnosis of OSA was made clinically with those in whom polysomnography was used. This study is useful reading because expensive investigations and surgical intervention are involved in the management of OSA.
Factors governing success rate of myringoplasties in the long term
Reviewed by: Madhup K Chaurasia
Sep/Oct 2011 (Vol 20 No 4)
It is generally believed that the success of myringoplasty depends on a number of factors such as the cause of perforation, the site and size of it, the surgeon’s experience and the surgical method used. In this retrospective study of 243 consecutive myringoplasties, the authors evaluated each of these factors to see how they affected the success rate. All these patients had good Eustachian tube function and surgery was performed in a dry ear. The pure tone average for 500-4kHz at audiometry was used for pre- and postoperative assessment. All patients received prophylactic antibiotics. Surgery was mainly by a retro auricular approach. The technique is well described. Logistic regression analysis was used to assess the relationship between tympanic membrane healing and cause of perforation, size and site, surgical method and the surgeon’s experience. The most common cause for perforation was iatrogenic and due to insertion of ventilation tubes. The incidence of re-perforation in cases undergoing T tube insertion was no higher than failed myringoplasty in other cases. It is interesting that the surgeon’s experience did not really count and although junior surgeons and trainees took longer, the results were similar. This is attributed to standardised methods. There was no correlation between the healing rates and the primary cause for perforation. The size of the perforation also did not matter. The results of mini myringoplasty were much poorer. This ten year series with an ample number of cases does answer many questions in this every day operation of myringoplasty which is performed by surgeons of various grades.
Intratympanic Gentamicin: an effective treatment for Ménière’s disease
Reviewed by: Madhup K Chaurasia
Sep/Oct 2011 (Vol 20 No 4)
Many publications have emerged in recent years on intratympanic Gentamicin therapy for the treatment of Ménière’s disease. This is one such study which uses a simple method of delivery of Gentamicin into the middle ear under local anesthesia, as an office procedure. The drug was used in a relatively higher concentration of 26.7mg/ml. Three to four Gentamicin doses, repeated after 7-30 days with an average of 3.3 doses per patient were administered. Control of the vertigo was estimated with the application of AAO-HNS control classification. The authors also used the AAO-HNS 1995 functional vertigo scale for assessing quality of life after intratympanic Gentamicin therapy. The results were subject to statistical analysis. The authors found that there was a substantial vertigo control in 84% of patients, and 18.3% patients suffered a significant hearing loss which falls within the range reported in other studies. The incidence of hypoacusia and intense vertigo crisis is relatively low in this study. The authors report a recurrence rate of 46.5% but also state that this was controlled by a single subsequent injection of Gentamicin. The highlights of this study are that a very simple method has been used and spacing between injections has shown a highly competitive result and a rather low incidence of complications.
Intratympanic steroid treatment for sudden hearing loss
Reviewed by: Madhup K Chaurasia
Sep/Oct 2011 (Vol 20 No 4)
Sudden hearing loss, without any obvious cause, is defined as elevation of threshold by 30 decibels at three contiguous frequencies. Intratympanic and systemic steroids have been used for quite some time now for the treatment of sudden SNHL. In this study the authors have evaluated the effect of this treatment in terms of dosage, the timing of the treatment and the hearing improvement in different frequencies. One hundred and twenty-eight patients were enrolled in the study and each of them received 0.5ml of Dexamethasone (5mg / ml) intratympanically twice a week for two weeks. Thus, four doses were given. Improvement of hearing was assessed after every dose in this group. It was noted that after a single dose the improvement was only 30% and this rose to 68.75% after the fourth injection. Hearing at lower frequencies improved more than at higher frequencies after this therapy, although theoretically higher frequencies should have improved more, because the intratympanic steroid should affect the basal turn of the cochlea more than the apical turn. It was also noted that there was more improvement in patients who received the treatment within seven days of the onset of deafness. Patients with vertigo responded less, but age did not seem to be an important factor. Some of these results were statistically significant. This is a neat study and provides useful reading in the management of this rare but alarming condition.
Is conventional curettage adenoidectomy effective?
Reviewed by: Madhup K Chaurasia
Sep/Oct 2011 (Vol 20 No 4)
The conventional treatment for removing adenoids is to take a curette and scrape the tissue behind the nose. The procedure is often combined with tonsillectomy or insertion of grommets or both. Two important questions remain. Firstly is enough adenoid tissue removed? Secondly, is the remaining adenoid tissue clinically significant? The first question is undoubtedly answered in this study. The authors removed adenoid tissue with the conventional curettage method. They then had a look with a nasopharyngoscope and assessed the sites where adenoid tissue remained after the conventional procedure. This was followed by removal of adenoid tissue under direct vision, through an endoscope, and volumes of adenoid tissue removed with conventional method and further tissue removed with endoscopy were measured. This study suggests that conventional curettage adenoidectomy resulted in retention of 34.3% of the total preoperative adenoid tissue volume. It is therefore suggested that following curettage adenoidectomy, residual tissue should be removed under direct vision through an endoscope to complete the procedure. Coming to the second question, it remains to be answered whether the residual adenoid tissue is of significance. The nasal passage would be clear, even with partial removal of adenoid tissue. As for the adenoid tissue in the region of Eustachian tube openings, it remains to be seen whether complete clearance of adenoid tissue would outweigh the risk of damage to Eustachian tube openings by instrumentation in that region. Further studies are therefore required to prove these points.
Is preservation of ossicular chain in cholesteatoma surgery associated with better hearing outcomes?
Reviewed by: Madhup K Chaurasia
Sep/Oct 2011 (Vol 20 No 4)
Whether to preserve or not to preserve the ossicular chain is a decision that is difficult to make in surgery for cholesteatoma. Dicta such as ‘if it is on the ossicles it is in the ossicles’ further confound the issue especially because eradication of cholesteatoma is the primary issue. In this retrospective study, a comparison was made between hearing outcomes with and without preservation of the ossicular chain in patients undergoing surgery for cholesteatoma. The series comprised 33 cases of cholesteatoma. In 17 of these patients the ossicular chain was preserved and in 15 it was sacrificed. At the outset the postoperative hearing thresholds appeared better in patients with a preserved ossicular chain. However when the authors applied multivariable logistic regression analysis, excluding other factors, there was no significant difference in the hearing outcome between cases of ossicular chain preservation and disruption. Patients with good preoperative hearing thresholds had better hearing outcomes after surgery. To eradicate cholesteatoma completely it may be necessary to sacrifice the ossicular chain. This study therefore provides useful information to help the surgeon to achieve that goal.
Modernising otolaryngology teaching
Reviewed by: Madhup K Chaurasia
Sep/Oct 2011 (Vol 20 No 4)
The conventional form of teaching is based largely on fact memorisation rather than discovery of facts and thereby it differs from the modern concept of teaching based on problem solving, self directed learning and independent study. The latter involves clarification, definition and analysis of the problem, sifting and sorting information, identifying learning objectives for self directed learning and finally reconvening as a group for further discussion. Students were offered sessions in important otolaryngology topics, after which they did research in the library and on the Internet. This was followed by group discussions carried out with help of a facilitator. After the initial fact finding, students took a history from inpatients in the hospital and there were further discussions on the diagnosis, again in a group scenario. The use of a simulation laboratory was incorporated to facilitate anatomic learning, clinical examination skills and to familiarise with common otolaryngological procedures. The authors contend that the application of problem based learning to teaching in otolaryngology has increased the knowledge of students and they seem to accept it more happily than conventional teaching methods. The study however has not gauged this in more convincing terms and some sort of comparison between problem based teaching and a conventional one would be interesting.
Problematic mastoid cavities
Reviewed by: Madhup K Chaurasi
Sep/Oct 2011 (Vol 20 No 4)
Persistent otorrhoea is often a problem with mastoid cavities. This is a series of 140 revision mastoidectomies in 131 patients with a midterm follow-up. The common reasons for continuing discharge as observed by the authors were large cavity size, bony overhang, residual infected mastoid cells possibly harbouring cholesteatoma and open middle ear segment. Some of these cases had inadequate meatoplasty. The procedures in revision mastoidectomy comprised reconstruction of attic wall, removal of mastoid tip, smoothening of the mastoid cavity, obliteration with soft tissue flaps or hydroxyapatite granules and in two cases a subtotal petrosectomy, plus obliteration using fat and blind pit closure. Middle ear reconstruction to improve hearing was carried out in a third of the cases. Some of these unsatisfactory mastoid cavities showed damage to structures such as exposure of the dura, sigmoid sinus or the facial nerve. Labyrinthine fistulae and dead ear were other findings. After three years 95% of the ears had become completely ‘dry’ and ingress of water did not remain a problem. In half the number of cases the hearing improved to an air bone gap of 20 decibel or less. The role of revision mastoidectomy and associated procedures is encouraged. This publication and the procedures described are particularly useful to improve general outcomes in chronic ear disease surgery and reduce the follow-up rates.
Significance of ECG in deaf children
Reviewed by: Madhup K Chaurasia
Sep/Oct 2011 (Vol 20 No 4)
Jervell-Lange-Nielsen syndrome occurs only in 1.66 per million births. Deafness is a significant feature of this syndrome. This study aims to emphasise the need for timely electrocardiogram and its accurate interpretation by experienced clinicians before something serious happens to these deaf children. A questionnaire was sent to all UK cochlear implant centres and it was noted that only 42% of the 19 cochlear implant centres surveyed did a routine electrocardiographic screening. As many as 13 cases of long QT syndrome were reported from seven cochlear implant centres. Two of these children died possibly due to related cardiac problems. Genetic mutation which leads to Jervell-Lange-Nielsen syndrome is described and the pathophysiology is explained. Specific genetic studies are complex and expensive but a simple electrocardiogram showing prolonged QT interval is useful for screening deaf children and should be carried out on a routine basis for each and every deaf child. This is a useful publication to encourage an essential practice which surprisingly is not carried out routinely.
The role of vestibular assessment in predicting recovery from idiopathic sudden hearing loss
Reviewed by: Madhup K Chaurasia
Sep/Oct 2011 (Vol 20 No 4)
Sudden hearing loss can occur due to the involvement of the cochlea, otolith organ, semicircular canals and the auditory tracts in the brain stem. In this study of 104 patients who developed sudden idiopathic hearing loss, the role of vestibular tests namely the calorics and vestibular evoked myogenic potentials (VEMP) is assessed. Performing these tests on every patient along with MRI and pure tone audiogram, the authors have deduced the possibilities of topographical diagnosis and prediction of recovery from the sudden hearing loss. It was observed that in patients with normal VEMP and normal caloric test the lesion was confined only to the cochlea. In patients who had abnormalities in both caloric and VEMP tests the lesion involved the cochlea, semicircular canals and the otolith. Abnormal VEMP tests with normal calorics pointed towards involvement of the cochlea and otolith, whereas normal VEMP and abnormal caloric tests indicated that the lesion might be in the cochlea and the semicircular canals. The pattern of the audiogram was not helpful in localising the site of lesion. However greater high tone loss was associated with more extensive damage to the cochlear and otolith and recovery in these cases was less likely. Contrary to earlier studies, the presence of vertigo, spinning or non-spinning, had no value in predicting hearing recovery. The treatment regimen of these patients was based on intravenous steroids for nine days followed by oral therapy for another nine days in tapering doses. The study offers a detailed discussion highlighting the role of VEMP and caloric tests in predicting the site of lesion and recovery but there is not much mention of how results were related to the treatment plans which would have highlighted the validity of these complex investigations.
Otosclerosis and superior canal dehiscence
Reviewed by: Fiona Barker
Sep/Oct 2011 (Vol 20 No 4)
This report sits somewhere between a full case history and a brief overview of superior canal dehiscence. A short case history is presented of a lady who appears to have had a previously undiagnosed, asymptomatic superior canal dehiscence ‘revealed’ following stapes surgery. It is a very brief overview sadly without the benefit of audiometric and other results showing the time course of the hearing loss and other symptoms. In this example the patient presented at the authors’ clinic after three stapedectomy operations elsewhere. Perhaps this is the reason that full audiometric results were not included. It would have been nice to see the effect on her results of the presumed ‘unmasking’ of the dehiscence following the stapes surgery. The outcome of the ultimate diagnosis of SCD in this case was also not presented although management options are discussed in general. This is not the only case report in the literature highlighting the overlap in case presentation between otosclerosis and superior canal dehiscence. This is a case not of incorrect diagnosis but incomplete diagnosis. Hence it highlights the need for further investigation if things do not turn out as planned and emphasises the importance of carrying out additional assessment such as acoustic reflexes to investigate hearing loss.
Retropharyngeal abscess in a 16 month old baby
Reviewed by: Gauri Mankekar
Sep/Oct 2011 (Vol 20 No 4)
The authors report on the management of a retropharyngeal abscess caused by a fish bone foreign body in a 16 month old baby at a resource-challenged centre. The baby was initially treated for pneumonia at another centre and was referred to the authors’ centre with fever, difficulty in swallowing and neck swelling. Lateral soft tissue X-ray neck revealed widening of the prevertebral space with mixed opacity and lucency extending from the skull base to the seventh cervical vertebra, anterior displacement of the airway and loss of cervical lordosis. In the absence of a flexible laryngoscope and advanced anesthesia medications like propofol, halothane anaesthesia was used and the child was intubated with a 2.5 endotracheal tube to drain the abscess and remove the fish bone. The pus culture revealed growth of mixed organisms: Klebsiella pneumonia, Staph aureus and anerobic Streptococci. Following a course of antibiotics and analgesics the child was sent home after five days. The report highlights the problems faced by surgeons and anaesthetists in resource challenged centres.
Tinnitus and genes
Reviewed by: Badr Eldin Mostafa
Sep/Oct 2011 (Vol 20 No 4)
In this experimental study, tinnitus was induced by intraperitoneal instillation of salicylates in mice. Tinnitus is suggested to be the auditory equivalent of phantom pain. In this respect TNF-a, IL-1b and IL-6 and central N-methyl d-asparate are assumed to play a role at both central and peripheral levels. This study demonstrated that salicylate-induced tinnitus correlates with increased gene expression of TNF-a and IL-1b. The tinnitus scores of salicylate-treated mice showed significant positive associations with the expression levels of the TNF-a and IL-1b, and N-methyl d-asparate genes. The authors suggest that these proinflammatory cytokines might lead to tinnitus directly or via modulation of NR2B gene expression in salicylate-induced tinnitus. The induction of pro-inflammatpry cytokines by viruses, bacterial infection and drugs may be the central pathway of hearing loss and tinnitus. Measures to block these genes or activators may help prevent hearing loss and/or tinnitus or at least decrease the intensity of tinnitus.
Another recipe for the cookbook
Reviewed by: Stuart Clark
Sep/Oct 2011 (Vol 20 No 4)
This is a paper from Portugal advocating a horizontal V-Y myotarsocutaneous advancement flap to reconstruct the upper eyelid. They report their experience of 16 cases in the treatment of predominantly basal cell carcinomas. They found the flap to be a simple, reliable, expeditious option, for full thickness eyelid defects of up to 60% of the eyelid width and completed in a single procedure. It adds to the armoury of our own respective cookbooks of facial skin flap repairs.
Botox for masseteric hypertrophy
Reviewed by: Stuart Clark
Sep/Oct 2011 (Vol 20 No 4)
This paper from China involved 30-50 units of Botox Type A to both masseters. The change in facial appearance and satisfaction with facial morphology was improved at 2-4 weeks postinjection, with a maximum reduction at 2-3 months. Whilst this may not be a surprise to anybody, the authors do recognise they have as yet failed to resolve the interval time between injections and most effective dose. Furthermore, they do not comment about the longevity of their results, which is often one of the first questions the patients will ask
Correcting prominent nasolabial folds
Reviewed by: Mr Stuart Clark
Sep/Oct 2011 (Vol 20 No 4)
Prominent nasolabial folds are a major aesthetic concern for Asian women. This paper from Taiwan reviewed 209 patients where a dermo-fascial detachment was used to dissect attachments, with the space being filled with fat grafts. This is a relatively simple technique as described with minimal morbidity. They claim long lasting results.
Dividing the pectoralis major pedicle
Reviewed by: Stuart Clark
Sep/Oct 2011 (Vol 20 No 4)
This paper from the Netherlands describes 12 myectomies completed on 10 patients, ranging from five months to seven years following their pectoralis major flap reconstruction. Indications for myectomy were pain and functional restriction due to neck flexion contracture, caused by muscle based contraction, with or without radiodermatofibrosis. They claim success and symptomatic relief and the paper obviously questions the accepted theory that muscle flaps remain dependent upon the dominant pedicle.
Don’t forget propranolol
Reviewed by: Mr Stuart Clark
Sep/Oct 2011 (Vol 20 No 4)
Propranolol is becoming increasingly the method of choice for treatment of haemangiomas, based on Propranolol 1.5 to 2mg per kg per day in divided doses, until the lesion is completely involuted or the child is 12 months old.
Don’t forget trapezius
Reviewed by: Stuart Clark
Sep/Oct 2011 (Vol 20 No 4)
This paper from China describes the extended vertical lower trapezius island myocutaneous flap versus salvage surgery for neck recurrence from oral skin cell carcinoma. They describe it for 11 patients and advocate use in preference to a pectoralis major believing the latter to be too bulky and not suitable for reconstructing neck defects. It may obviously be a preference for some women.
Hiding your face
Reviewed by: Stuart Clark
Sep/Oct 2011 (Vol 20 No 4)
This paper from Korea looks at 50 patients who had congenital facial anomalies, 22 of whom concealed them, 28 did not, and 15 controls. These patients were due to have facial surgery. Following a quality of life assessment they confirmed that those who concealed their anomalies exhibited a significantly higher level of depression, anxiety, dissatisfaction, antisocial personality traits, self accusation, hypochondria, weight loss, and lower quality of life, than those that did not conceal their anomalies. In addition, the concealment was a significant predictor for lifetime depressive disorder. This paper acknowledges the small sample size, the variety of patients within the group, concealment to be intentional, and the age discrepancy between the groups. Nonetheless it does suggest that attitudes relating to facial anomalies have an effect both on depression and quality of life.
Lip cancer in Portugal
Reviewed by: Stuart Clark
Sep/Oct 2011 (Vol 20 No 4)
This assessed 225 lip cancers of which 193 were TI or T2 squamous cell carcinomas. Their review confirms that ablative surgery with appropriate margins irrespective of type of reconstruction is of the most significance, implying that good margins would not comprise the reconstruction.
Merkel cell carcinoma
Reviewed by: Stuart Clark
Sep/Oct 2011 (Vol 20 No 4)
This a review of seven patients treated in Korea between 2000 and 2008. They are from varying sites, although four are from the head and neck. They conclude it to be an aggressive skin cancer where node involvement is important. Wide excision is the primary modality of treatment, without elective nodal dissection. Adjuvant radiotherapy could be considered if the tumour is found to be large and not confined to the dermis.
Simplifying malar osteotomies
Reviewed by: Stuart Clark
Sep/Oct 2011 (Vol 20 No 4)
This paper from Korea describes 20 patients who underwent revision malar osteotomies via coronal approach after an initially unfavourable primary reduction malarplasty. They outline the coronal approach to the anterior zygomatic arch / malar prominence and repositioning this superomedially. For the Asian face it is one of the most popular aesthetic surgical procedures since Asian people tend to have prominent malar complexes. The aim of this procedure is to reduce the prominence. They describe the procedure with a mid face facelift, advocating both procedures particularly in more elderly patients. However, complications of facial nerve weakness, asymmetry, and cicatrical alopecia, still occur, and it remains an operation that can have complications that are sometimes unacceptable. The role for this in the UK is more likely to be for malar asymmetry secondary to trauma and to that end its simplicity has its attractions.
Surgical management of AV malformations
Reviewed by: Mr Stuart Clark
Sep/Oct 2011 (Vol 20 No 4)
This is a review from New Zealand discussing their experiences of 53 patients with arteriovenous malformations. They discuss their results and give a brief outline of a number of cases. Therein lies the problem as it can present as a wide spectrum of lesions, of which this article only really skims the surface.
Bedside tracheostomies: are they safe?
Reviewed by: Badr Eldin Mostafa
Sep/Oct 2011 (Vol 20 No 4)
Based on an experience of 100 patients spanning 20 years, the authors emphasise that this technique should be considered as the gold standard for patients requiring tracheostomy for mechanical ventilation. They report an outstanding complication rate of 1.4% which is much lower than any other series or technique. Although this seems attractive, it reflects their wide experience and this should not be extrapolated to other facilities with less experience and less workload. Percutaneous tracheostomy is a technique which must be learned and practised with a long learning curve. It should be popularized in ICU but its performance should be relegated to personnel with surgical training or at least a surgical back-up team should be at hand to prevent emergency airway problems and to deal with possible complications.
Posturography: are current methods sufficient or are there ways postural testing can be improved?
Reviewed by: Patricia Gaffney
Sep/Oct 2011 (Vol 20 No 4)
Static posturography and computerised dynamic posturography (CDP) are used clinically throughout the world with mixed messages in the literature as to their value. The researchers held a meeting where sixty clinical balance specialists from differing in clinical fields met to discuss posturography and ways to improve upon it. Both static posturography and CDP were deemed, by the panel, to have significant flaws. Static posturography yields poor sensitivity and specificity and CDP is not sensitive enough to localise the source of impairment. The group created a list of what aims posturography should fulfill including identification of the disorder, localisation of the impairment, and quantification of the deficits in rehabilitation. The group put forth recommendations regarding how posturography could be improved. They first recommended that using force plates in combination with several 3D or 2D accelerometer-gyroscopes would yield more accurate recordings. The group could not come to a consensus on perturbations and analysis techniques, except to say that perturbations are necessary in the evaluation of the postural system and should mimic everyday movements and analysis techniques would depend on what perturbations are employed in the system. Overall, there are flaws in our current methods of evaluating postural control and this study recommends changes to re-focus testing to meet proposed aims of testing and improve test sensitivity and specificity
Validity of the Visual Vertigo Analogue Scale (VVAS)
Reviewed by: Patricia Gaffney
Sep/Oct 2011 (Vol 20 No 4)
The aim of this study was to evaluate the validity of the Visual Vertigo Analogue Scale (VVAS). This assessment scale is used for patients who experience dizziness in visually complex and dynamic environments such as a supermarket. The researchers gave this survey to 102 participants in the vestibular disorders group and 101 participants in a control group comprised of orthopaedic patients. The questionnaire contains nine visual analogue scales pertaining to specific visually provoking situations. Results showed that the vestibular group showed significantly worse scores than the orthopaedic group suggesting good internal validity of the questionnaire. There was also a significant correlation between the VVAS and the Dizziness Handicap Inventory (DHI). The authors note that this questionnaire is easy to administer. Given the findings presented in the article, the VVAS may be a clinically useful tool to evaluate the impact of visual stimuli on patients.
Walking a straight line with a vestibular disorder
Reviewed by: Patricia Gaffney
Sep/Oct 2011 (Vol 20 No 4)
Research completed prior to this study from the same researchers demonstrated that patients with impaired vestibular systems veer from a linear path sooner and further off the course than normal participants. The aim of this study was to evaluate those with vestibular disorders and how well they stay on a linear trajectory while walking and doing a secondary task. Forty-five participants made up three groups: normal subjects, those with benign paroxysmal positional vertigo, and those with various vestibular disorders (VVD). The participants had four tests: 1) walk a straight line, 2) walk in a straight line while performing a cognitive task, 3) walk in a straight line while performing a motor task (nodding head up/down), and 4) walk in a straight line while performing a cognitive and motor task; each of these conditions were completed with eyes open and closed. The researchers then measured the time of the veer onset, the velocity of movement, and the angle off the straight line. Not surprisingly, the elimination of visual cues had an impact on all three groups and all conditions. The cognitive tasks also had a greater influence on performance than the motor tasks. The normal control participants showed a later veer onset than the impaired group with eyes closed, no significant difference with eyes open. The velocity of movement was also slower with the impaired groups and became worse with the addition of the cognitive tasks. The VVD group showed the largest angle of deviation particularly with the conditions involving the cognitive tasks. This study suggests that even the addition of a mental task to walking can have an effect on a vestibular patient’s ability to walk in a straight line
Roll model
Reviewed by: Naishadh Patil
Sep/Oct 2011 (Vol 20 No 4)
It remains every otologist’s dream to be able to create a true-to-life model of the middle ear, reflecting as accurately as possible its delicate and often complex responses not just to sound but also to pressure. Some of these experiments are conduction in a virtual environment, via elegant software and computer programming. This paper from the Universities of Hamburg, Rostock and Lubeck describes an elegant apparatus using a 2ml syringe fixed with latex foil at one end to mimic a tympanic membrane. This foil can be perforated or strengthened to reflect pathological states. A green semi-conductor laser (1mW output) is employed to track minute movements of the foil using optic triangulation. This experiment serves to track pressure changes in the model, the ultimate aim being to develop a screening tool for assessment of Eustachian tube function in the clinical setting.
Strutting your stuff
Reviewed by: Naishadh Patil
Sep/Oct 2011 (Vol 20 No 4)
This is a well written, fairly lengthy review article on the use of spreader grafts in septorhinoplasty. The authors, based at the University of Tuebingen, focus on 100 consecutive procedures undertaken at their Institution in 2009. Of these, 70 required grafts, the majority of which (47) were derived from septal cartilage. Indications included nasal humps, overprojection, deviations, saddle noses, dorsal irregularities, and as part of an extracorporeal septoplasty. Cartilage from conchae was used in 17 patients, with the remaining using ribs. Spreader grafts were placed for a multitude of reasons, including prevention of internal valve stenosis and / or collapse of the mid-dorsum. The article includes a number of line drawings. Good quality photographs outlining the various stages in the procedure are also shown, rather than just the pre- and postoperative pictures one often sees in rhinoplasty reviews.
Acoustic tumours are usually subarachnoid tumours!
Reviewed by: Gauri Mankekar
Sep/Oct 2011 (Vol 20 No 4)
Over the years there has been extensive dispute whether acoustic tumours are subarachnoid tumours or epiarachnoid. The authors retrospectively examined consecutively operated 118 patients with acoustic neuromas. They used intraoperative views and light and electron microscopy to confirm the existence of an arachnoid membrane after the arachnoid fold had been removed. Eighty-six of 118 patients were judged to have subarachnoid tumours, two with epiarachnoid and in 30 patients it was difficult to make a clear judgement. The authors conclude that the majority of tumours are subarachnoid and grow subarachnoidally. Therefore although surgical techniques need not be modified, it is important to move the arachnoid fold toward the brainstem to avoid injury to nerve and vessels.
Complication of BAHA surgery
Reviewed by: Gauri Mankekar
Sep/Oct 2011 (Vol 20 No 4)
The authors report the case of a fifteen year old girl who had conductive hearing loss following tympanomastoidectomy and underwent BAHA surgery for the same. Postoperatively she was noticed to be lethargic with dilated, non-reactive pupils and extensor posturing. Her CT scan showed a right temporal epidural hematoma with midline shift. She was taken to the operating room for an emergency craniotomy and evacuation of the extradural hematoma. Subsequently, she slowly emerged from coma, rehabilitated and made a good recovery. This report emphasises the need for a high index of suspicion for this rare, but life threatening, complication of BAHA surgery.
Epidural hematoma after tympanomastoidectomy and bone –anchored hearing aid (BAHA) placement: case report.
Mesfin FB, Perkins NW, Brook C, Foyt D, German JW.
NEUROSURGERY
2010:67:1451.
Incidence of vestibular schwannomas
Reviewed by: Gauri Mankekar
Sep/Oct 2011 (Vol 20 No 4)
In this study, the authors present updated epidemiological data on the incidence of vestibular schwannoma. They studied cases of vestibular schwannoma, which were diagnosed and registered from 1976 to 2008 in a national database covering 5.0- 5.8 million inhabitants. They also retrieved data of patient age, sex, hearing and tumour size at diagnosis from the data base. They found that after a steady increase over the past four decades, the incidence of vestibular schwannomas appeared to peak and decrease in recent years stabilising at about 19 tumours per million per year. While the sex ratio and age at diagnosis remained grossly unchanged over the years, hearing improved and tumour size considerably decreased. They suggest that the incidence of sporadic unilateral vestibular schwannomas has increased due primarily to more widespread access to magnetic resonance imaging.
Less favourable outcomes with cystic vestibular schwannomas?
Reviewed by: Gauri Mankekar
Sep/Oct 2011 (Vol 20 No 4)
Cystic vestibular schwannomas (VS) are suggested to be more aggressive than solid tumours. The authors of this article selected 468 vestibular schwannoma patients from a prospectively collected database of patients who underwent microsurgical resection of vestibular schwannoma. They also analysed the hearing data and facial nerve dysfunction. Fifty-eight patients with cystic changes and 410 patients with solid vestibular schwannomas were identified. The study found that cystic VS patients tended to have larger tumours compared with the solid VS group. This affected outcomes by reducing the rate at which hearing preservation is attempted and by worsening hearing outcome in medium-sized tumours. They also found that peripheral cysts caused lower rates of hearing preservation compared with centrally located cysts. However the authors conclude that reasonably similar outcomes can be achieved in cystic tumours using a judicious surgical management approach.
Closure of dural defects
Reviewed by: Gauri Mankekar
Sep/Oct 2011 (Vol 20 No 4)
Increasingly, cranial base lesions are being removed via the minimally invasive endonasal approach. Accessing, as well as removing, the lesion leaves a large dural defect which is difficult to close in a watertight manner through the limited nasal space and, therefore, there is a postoperative risk of cerebrospinal fluid leaks. In this review the authors discuss the basic principles of dural defect repairs, materials used for the repair and the region-specific closure issues. According to the authors, the sole factor in favour of successful repair is the well vascularised and highly proliferative nasal mucosa surrounding the defect. They emphasise the need to preserve this mucosa during exposure of the skull base lesions, to ensure successful dural defect closure. Secondly, successful repair depends upon layered closure of the defect. Finally, the authors suggest that the layered closure should be able to resist reasonable stresses and this can be ensured by temporary implantation and inflation of the Foley catheter balloon or securing thicker portions of the repair to surrounding tissue with a U-clip. Supporting the layered closure provides a head start for healing as it prevents extrusion of the repair construct.
Reconstruction of dural defects of the endonasal skull base.
Sughrue ME, Aghi MK.
NEUROSURGERY CLINICS OF NORTH AMERICA
2010;21(4):637-41.
Endonasal endoscopic approach for anterior skull base lesions
Reviewed by: Gauri Mankekar
Sep/Oct 2011 (Vol 20 No 4)
This article discusses the current state of minimally invasive endonasal techniques, starting with the early work of Harvey Cushing, demonstrating the feasibility of transsphenoidal techniques for sellar tumour resection. With technological advancements in endoscope technology as well as neuronavigation systems, neurosurgeons have realised the potential of the extended endonasal endoscopic approach for anterior skull base lesions. Endonasal endoscopic technology provides improved visualisation, less brain retraction and the promise of less morbidity than traditional open approaches. The authors are optimistic that the indications for this approach will continue to increase as surgeons gain experience and comfort with the technology.
Ensuring smooth flow of CSF – endonasally!
Reviewed by: Gauri Mankekar
Sep/Oct 2011 (Vol 20 No 4)
This review article discusses the role of endoscope in removing obstructions to CSF flow and / or diverting the flow with little disruption of normal brain tissue via the minimally invasive endonasal approach. According to the authors this technique is superior to shunting in appropriately selected patients. They suggest further investigations to provide a more thorough understanding about patient selection and factors that predict treatment failure as well as a prospective evaluation of the comparative efficacy of endoscopic procedures compared with traditional shunting and open craniotomy operations.
Orlistat and changes in body weight in subjects with sleep related breathing disorders
Reviewed by: Angela Griggs
Sep/Oct 2011 (Vol 20 No 4)
Sleep related breathing disorders (SRBD) are known to worsen as body mass index (BMI) increases and, as this paper states, the recommendation for these patients is to lose weight. However, maintaining weight loss is often difficult for these patients and strategies for weight loss maintenance are required. This study looks at one strategy, that of using orlistat, a drug that reduces the intestinal absorption of fat. This study looked at changes in body weight and dietary intake during a one year treatment with orlistat, after an initial weight loss in obese subjects with SRBD. The study had 63 participants, who initially had dietary intervention of increasing intake of vegetables and fruit to achieve an initial weight loss; they were then treated with orlistat for a year and had dietary and behavioural interventions to attain weight loss, through a course of 14 group sessions. Participants were assessed for dietary intake, energy density and food choices and a food frequency questionnaire was used before and after orlistat treatment. The study found that body weight did decrease by a mean of 3.5kgs, but the intake of energy dense foods increased while the intake of oils, fish and vegetables decreased. They concluded that orlistat did induce weight loss, but dietary compliance decreased overtime. They did find that those participants who had a high attendance rate at the sessions had better dietary maintenance than lose who had low attendance.
Psychological issues for the oral maxillofacial surgeon
Reviewed by: Stuart Clark
Sep/Oct 2011 (Vol 20 No 4)
This edition of the North American Clinic Series concentrates on psychological issues. It covers 12 areas ranging from psychological assessment, through body dysmorphic disorder, occupational stress, and managing patients with chronic pain. It covers sleep apnoea, but two areas that I feel are noticeable by their absence are snoring and patients with gender issues. Coverage of these areas would have been well served as they are either common or present with specific problems to the surgeon. All the chapters are a little ‘dry’, as chapters are theoretical with no practical or clinical advice or suggestions. As a result the potential for the chapters is not fully realised.
Re-operative oral and maxillofacial surgery
Reviewed by: Stuart Clark
Sep/Oct 2011 (Vol 20 No 4)
This issue attempts to tackle a vast subject ranging from reconstruction, post-traumatic enopthalmos, and hard and soft tissue trauma, rhinoplasty, facelifts, orthognathic and TM Joint surgery. This list is not exhaustive! There are many interesting chapters and as a brief overview it is very good. In some chapters it may say nothing new or unexpected and acts as a reminder more than anything, whilst other chapters may be of more value to the reader in areas which they may be less familiar with. It is certainly a useful adjunct and may give that little nugget of information to help significantly in one’s practice.
Models for best practice: nurse practitioner facilitated percutaneous tracheostomy service
Reviewed by: Angela Griggs
Sep/Oct 2011 (Vol 20 No 4)
With the advent of early tracheostomy insertion in intensive care units for patients requiring prolonged mechanical ventilation has come the issue of identification of appropriate patients for early tracheostomy as well as issues of scheduling and staffing. This study investigates the effect of introducing a tracheostomy nurse practitioner as part of a percutaneous tracheostomy service and whether this role improved standards of care, efficiency of care and patient outcomes. The study used a retrospective design looking at electronic patient records and chart reviews comparing data from before and after the role of tracheostomy nurse practitioner was introduced. The study looked at 110 patients who had undergone a percutaneous tracheostomy in 2006 and 2008, 55 prior to the role commencement and 55 after. Seven outcomes measures were used that covered documentation outcomes (4) such as screen tool, consent, postoperative orders and procedure recording, timeliness of the service and patient outcomes (3), such as length of stay and complication rates. The study found that there was significant improvement in the documentation outcomes and timeliness of the service, but that there were no significant differences in the three patient outcome measures. This study shows the effect of having a tracheostomy nurse practitioner who is screening and co-ordinating the management of these patients and facilitated the improvements in standards of care, documentation and efficiency as they were able to introduce care bundles and standardise care delivered.
Evidence-based protocol for the classification and treatment of allergic rhinitis in children
Reviewed by: Evangelia Tsakiropoulou
Sep/Oct 2011 (Vol 20 No 4)
This is a cross-sectional, multicentre study aiming to validate Allergic Rhinitis and its Impact on Asthma (ARIA) classification in children. Data from one thousand two hundred and seventy-five children, aged between six and 12 years, from 271 centres were collected. Allergic rhinitis (AR) classification was based on symptom duration (intermittent versus persistent) and severity (mild versus moderate / severe) according to ARIA guidelines. Additionally, AR symptoms were assessed using the Total Four Symptoms Score (nasal obstruction, rhinorrhoea, nasal itching, and sneezing – T4SS). Severity was also evaluated by the patient using a visual analogue scale (VAS). Main finding of the study was that symptoms assessed using T4SS were significantly different among the diverse ARIA categories. On the contrary, allergen-based classification for AR, VAS and T4SS showed no significant differences between seasonal and perennial AR. These results provide evidence that this classification is not able to categorise properly children suffering from AR. However, ARIA classification by itself was able to discriminate severity grades in children. Therefore, ARIA classification is a valid tool that can be considered as a reference point for physicians who treat children with AR. The authors support that an accurate classification of AR is particularly important in order to maximise therapy’s efficacy and to minimise its adverse effects in paediatric population.
Trend of Recurrence pattern of HNSCC after 3D conformal (chemo)-radiotherapy
Reviewed by: Sachin Patil
Sep/Oct 2011 (Vol 20 No 4)
This is a very well presented paper in which the authors have tried to establish recurrence patterns among locally advanced head and neck non-nasopharyngeal HNSCC patients treated with radical chemo-radiotherapy. This study was performed at a tertiary cancer centre. This had local ethical approval by the institutional review board and had good inclusion and exclusion criteria. For planning treatment, they have used two different methods to create the planning treatment volume(PTV). Different radical radiotherapy was in standard use, of which commonly used was conventional fractionated dose of 60-70Gy in 33-35 fractions and an accelerated fractionated schedule of 55Gy in 20 fractions. The choice depended on the clinician preference. The use of chemotherapy was, as well, based on clinician assessment of multiple factors. Analysis of response to treatment was noted by regular post treatment follow-up. Appropriate statistical tests were used to analyse the data. Figure 1 shows a good example of reconstruction of the site of recurrence on the pretreatment planning CT and dove volume histogram analysis to determine the site of recurrence in relation to the treatment volume. This paper highlighted the importance of understanding the patterns of treatment failure. This will guide future attempts to optimise radiotherapy planning and improve the therapeutic ratio. In this series the success rate was 82.8 %. This was after four months post treatment, to allow adequate time for response to radiotherapy. This series has shown that conformal radiotherapy offers high rates of local regional control and overall cure.
The management of tracheal stenosis
Reviewed by: Badr Eldin Mostafa
Sep/Oct 2011 (Vol 20 No 4)
In this retrospective study the authors analysed their 10 years’ experience in 33 consecutive tracheal stenosis patients. Well defined criteria were set for the selection of patients to endoscopic versus surgical management. Using these criteria, at the end of the intervention, 50% of the patients were decannulated in the surgically treated group versus 84.2% in the endoscopically treated group. However, the decannulation rates at six months and the symptomatology at rest and on exertion on the last follow-up visit were comparable in the two groups. This is a very interesting article as it addresses the controversy of which is the best way to manage post-intubation tracheal stenosis. The best answer is that all techniques work if patients are properly selected and the appropriate technique is applied and not a rigid protocol, made to fit all.
Weight and metabolic effects of CPAP
Reviewed by: Angela Griggs
Sep/Oct 2011 (Vol 20 No 4)
Obstructive sleep apnoea is associated with obesity, insulin resistance and diabetes. This paper looks at whether continuous positive airway pressure (CPAP) has an effect on these metabolic associations. They used a pre- and post-treatment design with 20 obese obstructive sleep apnoeic participants. They recorded insulin and appetite regulating hormones, as well as body weight prior to and six month after commencement of CPAP use. The results showed that CPAP effectively reversed hypoxia in all subjects, but there was a total weight gain by the group compared to the original baseline and 40% of participants gained a significant amount of weight. Cardiovascular observations of blood pressure and heart rate showed no change during the six months. When looking at the insulin and appetite regulating hormones they found that fasting glucose levels were unchanged, but fasting insulin levels increased significantly and CPAP treatment did not improve insulin resistance in obese participants and they found that in those participants who gained weight during the study their insulin resistance increased. Therefore weight gain had more of an effect on insulin resistance than CPAP. They did find that CPAP treatment decreased fasting ghrelin levels; despite weight gain in most participants and that adipokines levels remained unchanged after six months of CPAP treatment. They concluded that weight change had a greater effect on insulin and appetite regulating hormones than the elimination of hypoxia by CPAP and that other measures targeting obesity should be used when CPAP is commenced. This study shows that eliminating hypoxia with CPAP does not change weight and metabolic effects of obesity, and so measures to tackle these effects, rather than those targeting obesity, should be used.
Weight and metabolic Effects of CPAP in Obstructive Sleep Apnea patients with obesity.
Garcia J, Sharafkhaneh H, Hirshkowitz M, Elkhatib R, Sharafkhaneh A.
RESPIRATORY RESEARCH
2011;12:80.
Management of Single-Sided Deafness
Reviewed by: Vinaya KC Manchaiah
Sep/Oct 2011 (Vol 20 No 4)
Management of Single-Sided Deafness (SSD) is often challenging. Patients with SSD typically report difficulties recognising speech when the signal is on the side of the poor ear and also difficulties understanding speech in noisy situations. There have been a lot of recent developments related to management of Single-Sided Deafness (SSD). However, one of the management options which could potentially have greater benefit, due to advancements in feedback management, noise reduction algorithms and microphone technology, is the transcranial contralateral routing of the signal (TCROS). This paper provides a very good overview of TCROS and how the advances in technology have made TCROS one of the preferred options for management of SSD. This paper also provides detailed information on factors which need consideration while choosing this method which may include: medical clearance, localisation, hearing aid style, earmould, comfort, motivation and so on. In addition, clinical issues including performance verification measures using real-ear-aided response (REAR) and real-ear measures (REM) have been discussed.
A robotic surgical approach to skull base reconstruction
Reviewed by: Andy Hall
Sep/Oct 2011 (Vol 20 No 4)
The role of robotic surgery within the skull base remains very much an area of ongoing experimentation rather than established fact. This preliminary technical note applies the principles of robotic surgery to repair dural defects in a preclinical cadaveric model. A variety of suture materials and techniques were utilised with varying degrees of success, in particular difficulties with monofilament, self-tightening sutures and U-Clips were experienced. The authors speculate the benefit of the DaVinci robot without providing any empirical data at this stage. Instead the ‘technical feasibility’ is focused on with the added acknowledgement that any use of DaVinci in the skull base remains ‘off label’ and awaiting FDA approval.
Intraoperative frontal sinus illlumination
Reviewed by: Andy Hall
Sep/Oct 2011 (Vol 20 No 4)
This is an interesting introduction to a method of delineating the extent of the frontal sinus. The intuitive technique utilises intraoperative fibre-optic transillumination through the superomedial orbital wall in a subcranial approach to the anterior skull base. By subsequently marking the boundary with a marker pen, a frontal sinus anterior wall osteotomy was performed with a sagittal saw (5mm within the transillumination marking). Out of the 13 patients the technique was used for in this case series, there was no inadvertent dural injury. This technique appears to represent a useful alternative to the creation of a CT-generated frontal sinus template, that the authors suggest in their experience often limits the size of the bone flap and subsequent skull base exposure.
Morphometric measurements of the anterior skull base
Reviewed by: Andy Hall
Sep/Oct 2011 (Vol 20 No 4)
This study gives us the cold hard facts of the bony limits of the transnasal and transoral approaches to the anterior skull base. Consequently, the article aims to provide a tool to aid surgeons in preoperative planning. Forty-one high resolution Computed Tomographic scans were used to take a complicated set direct measurements and calculated angles to assess the dimensions of the skull base. Interestingly, the exclusion criteria included those with a history of any sinus or skull base pathology (surely the very dataset you would be most likely to use the technique on!). Nonetheless we are left with the theoretical maximum reach of transoral and transnasal surgical approaches to the anterior skull base using straight endoscopes (38mm along the clivus and 22mm below the plane of the hard palate respectively). This leaves us with a worthy paper tempered by the fact that for any patient naturally their own CT scan will provide you with the most precise information relevant for any upcoming surgery.
Nasoseptal flap closure of CSF leaks
Reviewed by: Andy Hall
Sep/Oct 2011 (Vol 20 No 4)
This is a retrospective case series review of 14 patients who underwent nasoseptal flap closure in a tertiary academic hospital following traumatic CSF leaks. This vascular flap utilises the nasoseptal artery and is composed of the mucoperichondrium and mucoperiostieum of the nasal septum. The clear technical description, advantages and potential limitations are clearly outlined within the article. The reliability of this local reconstructive technique in recreating the barrier between the arachnoid space and sinonasal tract is worthy of attention. The authors publicise an impressive 100% outcomes in both repair rate and defect coverage at 10 months. This is particularly notable as four patients had failed previous avascular grafts or craniotomies for repair.
Vestibular schwannoma incidence in SSHL
Reviewed by: Andy Hall
Sep/Oct 2011 (Vol 20 No 4)
This study aimed to establish the incidence of vestibular schwannoma with sudden sensorineural hearing loss. This retrospective review from 2002-2008 evaluated the MRI results of 295 patients; vestibular schwannoma was found in 12 cases. All patients had intrameatal or small to medium-sized tumours. Unusually there were three cases of sudden sensorineural hearing loss in one ear and an incidental finding of vestibular schwannoma in the contralateral ear. This occurrence presents a troubling problem for the otologist.
Kochkin provides a strong argument against the “get ‘em in, get ‘em out” approach to hearing aid fitting
Reviewed by: Lucy Handscomb
Sep/Oct 2011 (Vol 20 No 4)
This is a very good case report. Diabetic ketoacidosis has contributed to additional morbidity in a poorly managed patient with Grave’s disease. This, though being a level IV evidence, does add to the educational value of the case report. A good primary care of this patient would have prevented this complication. Table 1 describes good diagnostic criteria for thyroid storm from the Japan Thyroid Association and Japan Endocrine Society. The discussion has been well written with good review of literature.
Thyroid storm associated with Graves' disease covered by diabetic ketoacidosis: a case report.
Osada E, Hiroi N, Sue M, Masai N, Iga R, Shigemitsu R, Oka R, Miyagi M, Iso K, Kuboki K, Yoshino G.
THYROID RESEARCH
2011;4:8.
A rare case of thyroid storm with diabetic ketoacidosis
Reviewed by: Sachin Patil
Sep/Oct 2011 (Vol 20 No 4)
This is a very good case report. Diabetic ketoacidosis has contributed to additional morbidity in a poorly managed patient with Grave’s disease. This, though being a level IV evidence, does add to the educational value of the case report. A good primary care of this patient would have prevented this complication. Table 1 describes good diagnostic criteria for thyroid storm from the Japan Thyroid Association and Japan Endocrine Society. The discussion has been well written with good review of literature.
Thyroid storm associated with Graves' disease covered by diabetic ketoacidosis: a case report.
Osada E, Hiroi N, Sue M, Masai N, Iga R, Shigemitsu R, Oka R, Miyagi M, Iso K, Kuboki K, Yoshino G.
THYROID RESEARCH
2011;4:8.
Pricking Bell’s palsy
Reviewed by: Badr Eldin Mostafa
Sep/Oct 2011 (Vol 20 No 4)
This a protocol review on the use of acupuncture in the management of the sequelae of Bell’s palsy. It is a randomised, assessor-blinded, wait-list controlled trial. The study includes a screening period before randomisation and a treatment period of eight weeks (three sessions per week). Subjects will be randomised to either the acupuncture group or the wait-list group. The endpoints will be facial disability scores (social and physical) House-Brackmann scores, lip mobility and stiffness index. Patients will be assessed at enrollment, five and eight weeks later. Acupuncture is a tested therapy for many ailments in the Far East and has been historically used for a variety of problems. However standardisation and proper evaluation of its efficacy are lacking in many fields. This study aims at determining acupuncture’s efficacy on the sequelae of Bell’s palsy. However, the authors did not specify which sequelae they are addressing (paresis, spasm, contractures …) so we must wait for their results to determine the true value of acupuncture in this group of patients.
Balloon tracheoplasty in children after LTR
Reviewed by: Maher El Alami
Jul/Aug 2011 (Vol 20 No 3)
There is now a range of options when dealing with tracheal or subglottic stenosis in children. Following tracheoplasty / reconstruction a residual stenosis may still persist, making a tracheostomy necessary. The authors describe their results in children with this problem and repeated dilatation using an angioplasty balloon. A widening of the lumen was accomplished by a factor of 1.9 on average. Steroids were injected before treatment and a laser was used pre-dilatation. Following treatment seven children did not require tracheostomy anymore, while the remaining three still found an improvement and widening of the tracheal lumen. The authors emphasise the simplicity of this technique, the advantage over rigid dilatation and also argue that this is possible even with an intact cricoid. This series seems to be an honest detailed account of the difficulties when dealing with this problem. Laryngotracheoplasty in infants, even though rare, continues to generate a lot interest.
Not seeing the forest for the trees
Reviewed by: Maher El Alami
Jul/Aug 2011 (Vol 20 No 3)
Forestier’s disease is a rare condition associated with hypercalcification anterior to the cervical spine. Patients may present with dysphagia, dysphonia and tenderness in the neck. X-rays show the typical appearance of often extensive calcifications along the longitudinal ligament of the cervical spine. The authors present their case series, perioperative results and follow-up experience over 24 months. Surgery was performed via a transcervical anterolateral approach. One patient required a temporary tracheostomy and all patients accessible for follow-up (11/12) found an improvement of their symptoms (one of their patients also had a laryngectomy for cancer, not sure they graded his symptoms). As expected, this surgery can be performed, but this series fails to convince that this treatment is ideal to treat this chronic condition. The authors allude to the risk of recurrence in their discussion, but claim their technique makes this unlikely. Let’s wait on long-term results before sharing the authors’ enthusiasm for this op.
Classification of communication disorders
Reviewed by: Diego Zanetti
Jul/Aug 2011 (Vol 20 No 3)
Communication is a complex behaviour, combining physical and mental events, with the aim of exchanging messages between two or more individuals. It plays a significant role in the lives of both animals and men, but only humans can also take advantage of the use of a coded spoken language. Communication modalities may be divided into two broad categories – verbal, which is communication, based on a language system (oral, signed, oral-derived, as in Morse code), and non-verbal. It is an activity of daily living, driven by the cognitive functions that are aimed at transferring the thoughts to an external receiver. In this article, the authors adopt the terms and definitions reported by the International Classification of Functioning, Disability and Health (ICF) for approaching the complex aspects of communication disorders from a phoniatric viewpoint. In its taxonomy, aetiology does not play a role; on the contrary, the system is based on the functional systems that contribute to communication. Among the many medical and non-medical professions involved with people with impaired communication (otolaryngologists, audiologists, occupational therapists, psychologists, psychomotor specialists, teachers for the deaf, pedagogists, bioengineers), the speech and language pathologist is the only professional entirely devoted to the assessment and management of communication disorders. This article is a valid support to the assessment and management of patients with communication disorders and provides a framework for clinical research in the different disciplines involved.
Communication disorders in aged people
Reviewed by: Diego Zanetti
Jul/Aug 2011 (Vol 20 No 3)
Increased ageing of the general population is raising the need for better therapeutic approaches to physiological and pathological age-related changes such as dysphonia, dysarthria, aphasia / dysphasia and dysphagia.
Elderly people, with high standards of healthcare and longer life expectancy, today enjoy much more active and socially interactive lives than previous generations. However, communication difficulties, due to diseases affecting phonation, articulation, respiration, speech and deglutition, can cause social isolation, anxiety and depression, with a negative impact on quality of life. Up to one half of elderly people suffer voice problems; three quarters have speech and / or language problems, and up to 40% have dysphagia. Many older individuals are often unaware of treatment options, since dysphonia and dysphagia in this population group are often viewed as a normal part of ageing. In this paper, the rehabilitative options are presented from a phoniatric point of view. For dysphonia, good vocal hygiene (avoidance of vocal strain), adequate rest and hydration, physical fitness, prevention of gastroesophageal reflux, low fat and low sugar diets, elimination of tobacco smoke, and drug treatment of inflammations of the upper airways do parallel the voice rehabilitation sessions with speech therapists. The latter are aimed at reducing maladaptive compensatory behaviours and at improving consistency in voice quality and breath support. Therapeutic approaches for aphasia are based on preserving residual communication skills and utilising compensatory strategies. In dysarthria, speech training and non-speech oral motor exercises, prosthetic devices (for example palatal lift to compensate for hypernasality in speech) and pharmacological treatment may be used. Compensatory approaches for dysphagia are based on modifications of the bolus flow by postural adjustments, by modifications of the preparation of food according to the capabilities of the individual, and by assisted eating. Active exercises are also recommended, with the purpose of achieving safe oral ingestion and prevention of aspiration.
Intratympanic dexamethasone for sudden deafness: is it any use?
Reviewed by: Neil C Molony
Jul/Aug 2011 (Vol 20 No 3)
I am probably far from the only clinician to have mixed feelings about this subject, arising from mixed results! I, therefore, found this study interesting, though remain confused. It is two studies, one clinical, one animal. For the clinical study, 66 patients with idiopathic sudden sensorineural hearing loss, of under two weeks duration at start of treatment, were offered intratympanic dexamethasone, but this in addition to a ‘standard treatment’ of hyperbaric oxygen, intravenous prostaglandin and intravenous steroids. Twenty-two of the 66 accepted the additional intratympanic steroid, and were compared with the remaining 44; no statistically significant difference in recovery was found. The problems? Not clear which tests were used, the text merely refers to the programme stata 8.0. Not randomised, but there is a control group. This study can state that additional intratympanic dexamethasone does not confer benefit above IV, but there is no no-treatment group. What about intratympanic alone? The animal study was closer to answering this question. Increasing concentrations of dexamethasone were injected into the middle ears of rats, then inner ear concentrations were assessed by immunohistochemistry after ‘sacrificing’ them at various times after injection. Dexamethasone levels peaked 30 minutes after injection and cleared fully by 24 hours. Increasing doses gave higher peaks of longer duration. I would have liked a study giving intratympanic alone, at differing concentrations, to look at clinical effect, but perhaps that will come in the future.
Intratympanic dexamethasone, quality of life and Ménière's
Reviewed by: Neil C Molony
Jul/Aug 2011 (Vol 20 No 3)
This study compared the much-loved Glasgow Benefit Inventory (GBI) with serial audiometric tests, following intratympanic dexamethasone treatment for Ménière’s disease. Inclusion criteria for having been given the treatment were fair and based on failure of previous therapies; its weakness was in being a retrospective postal survey with a 60% response rate to 30 GBI questionnaires! The audiometric data, being from clinic attendances, gives data on all 30, with a minority having improved audiograms and / or speech discrimination, but this is not easily correlated to the questionnaires, where nine patients (of 16) report benefit and three feel worse. The authors’ conclusion, that the mean GBI scores indicate improved quality of life, is true for their data, but I would have liked better correlation to the audiometric data, to patients reported in the notes as having better vertigo control, and in particular to those having further treatments including surgery! Sadly, as with many treatments for this condition, some patients (three questionnaires) end up feeling worse off whatever their treatment.
Adenotonsillectomy reduces antibiotic use and doctor visits
Reviewed by: Iordanis Konstantinidis
Jul/Aug 2011 (Vol 20 No 3)
Although the rate of adenotonsillectomy has significantly reduced within the last decades, it still accounts for approximately 20% of ENT procedures. An open discussion exists in many countries regarding the cost for the health system of such interventions. This study is timely to respond to managers who believe that adenotonsillectomy is a weight on the budget of healthcare systems. Specifically, the authors provide a large database, with 11,000 children coming from the biggest health insurance company of Belgium. The main comparison was the use of antibiotics one year prior and one year post-adenotonsillectomy. The second comparison was of the number of doctor visits pre- and postsurgery for the same period of time. All ages showed a significant reduction in antibiotic use and doctor visits. Patient age was a significant factor, as antibiotic use was higher for children 8-12 years old, postoperatively. In total, children experienced post-adenotonsillectomy an average of three fewer episodes needing antibiotics and three fewer doctor visits. The study has some bias (we have to consider the placebo effect postop). However it presents a measurable effect of adenotonsillectomy in a large group of children.
Tetracaine solution for inferior turbinate diathermy
Reviewed by: Iordanis Konstantinidis
Jul/Aug 2011 (Vol 20 No 3)
This is a nice prospective study conducted from the team of Crete University comparing lignocaine and tetracaine solution as local anesthetics for submucosal diathermy of inferior turbinates. I was pleased with their results, as the authors confirmed something anecdotally known by otolaryngologists regarding the efficacy of tetracaine in such interventions. Their results were based on subjective ratings of patients. Specifically patients rated the degree of pain using a 10 point scale (0-10) with tetracaine mean score being 2.29 and lignocaine mean 3.04. The discussion, regarding the safety of tetracaine, still exists, however although systemic effects have been reported after application of tetracaine in the pharynx or trachea, nasal mucosa seems to be a safe region if the dose does not exceed 1mg / kg. I would be happier if the authors could use both anesthetic agents in the same patient (one nasal cavity with lignocaine, tetracaine in the other) because, this way, subjective pain is better evaluated, as every patient is reference for him / herself.
Basic research in phonology and audiology - significance for children with cochlear implants
Reviewed by: Thomas Nikolopoulos
Jul/Aug 2011 (Vol 20 No 3)
Cochlear implantation has contributed to significant speech development in profoundly deaf children. However, there are considerable gaps in our knowledge on the basic elements of phonology and audiology in normal and deaf children, especially in Eastern languages, such as Chinese. Mandarin Chinese is a tone language in which pitch variations are used to change the meanings of words. The present study focused on the production of the four tones of Mandarin, by adults and eight year old children with normal hearing, who spoke Mandarin as their first language. All speakers were recorded producing the tones in the syllable [ma]. Analysis of the speakers' productions of the four tones showed that all children were able to produce the appropriate tonal contrasts. Although the methodology had several weaknesses, for example very noisy environment in a percentage of the cases studied, some interesting differences between the children and adult speakers were found in the duration of the tones. In addition, the variation was sometimes considerable. The authors claim that the results of this study would contribute in further analysis of the speech of implanted Chinese children. This is true, as basic research in phonology of all languages will help in assessing the differences or possible weaknesses of implanted children.
EST: a new environmental sound perception test for implantees
Reviewed by: Thomas Nikolopoulos
Jul/Aug 2011 (Vol 20 No 3)
There are several environmental sound perception tests that have been used in assessing profoundly deaf children before and following cochlear implantation. However, many of these tests suffer from internal weaknesses (floor and ceiling effect, reliability, validity). The purposes of this study were to develop a new test of environmental sound perception, the Environmental Sounds Perception Test (EST), to compare the performance of experienced cochlear implant (CI) recipients with that of age-equivalent normally hearing (NH) listeners using this new test, and finally to pilot test its clinical use as a pre-to-post assessment tool. The closed-set EST consisted of 45 different sounds classified into nine categories, with each sound being represented by two different tokens. The authors found that the NH participants scored significantly higher than the experienced CI users (p<0.001). For the pre- to post-CI group, higher scores were obtained postsurgery with the CI; however this difference did not reach significance. The authors concluded that CI recipients perform poorer than NH participants on the EST but better than hearing-aid users with a similar level of hearing loss. Although, some of these conclusions are weakened by the small numbers, the new test seems very promising in assessing the environmental sound perception in cochlear implant users.
A comparison of the frequency of nasal septal deviation between different age groups
Reviewed by: Jahangir Ahmed
Jul/Aug 2011 (Vol 20 No 3)
The nasal septum has caused much debate in ENT, much of it focussing on its significance in contributing to nasal obstruction, with the subsequent need for surgical intervention. Demographic studies of septal deviation are important, given septal surgery forms a large proportion of adult ENT operations. This study aimed to compare deviations in the septum between different age groups, using radiological measurements. CT and MRI of head and neck structures (performed for other aetiologies) of 81 patients in different age groups were analysed with regards to the septum. A novel measurement, which the authors refer to as ‘tortuosity’ of the septum (defined as the ratio of the ‘actual’ vertical length of the septum to the length of a straight line drawn from the superior to the inferior aspect of the septum), was measured at four points along the horizontal septum. Children aged less than five years of age demonstrated significantly less tortuosity than older children or adults. The authors thus conclude that such a finding argues against a congenital aetiology of septal deviations. However, this study has a number of flaws, which the authors acknowledge. The number of subjects is relatively small, the group will obviously be biased towards a cohort suffering with a head and neck ailment and, most importantly, it is retrospective. It thus does not preclude a predisposition for a deflected septum that may manifest at a later date, through a genetically determined facial skeletal growth pattern. Nevertheless, a valiant attempt at comparing septal deviations between different age groups with an objective measurement tool.
Otorrhoea resistant to ofloxacin? Think MRSA
Reviewed by: Jahangir Ahmed
Jul/Aug 2011 (Vol 20 No 3)
MRSA (Methicillin resistant Staphylococcus aureus) infections of the head and neck have been steadily increasing throughout the last decade. The majority of these appear to occur in otologic infections, usually manifest as otorrhoea. This small case series of patients with MRSA positive otorrhoea highlights the difficulties in detection and treatment and outlines general principles in management. The cases included are representative of typical scenarios: a patient with a tympanostomy tube in situ, otorrhoea following a tympanomastoidectomy operation and one case following acute mastoiditis. The authors based their treatment on culture-determined drug sensitivities in conjunction with an algorithm endorsed by the American Academy of Pediatrics. Specifically, combinations of oral trimethoprim / sulfamethoxazole with gentamicin ear drops for three to four weeks or for the more severe case, linezolid with gentamicin ear drops for six weeks were curative. Vancomycin should be reserved for failures with the above treatment, although Vancomycin resistance is not uncommon. In this series, organisms were resistant to fluoroquinolones, which are currently many otolaryngologists’ first choice of empirical treatment in this setting. With the ever increasing prevalence and consequences of MRSA both in the hospital and in the community, it is important to be vigilant for this condition and to treat it aggressively. All ENT surgeons should be up to date with local infection control policies, as the head and neck is an important site for MRSA infection and colonisation
An analysis of a tasty new test
Reviewed by: Ian Coulter
Jul/Aug 2011 (Vol 20 No 3)
This paper reports the analysis of a simple taste test, based on liquid tastants. The authors tested the taste of 944 healthy subjects by applying a drop (approximately 20µl) of varying concentrations of tastant solution on both sides of the anterior / posterior third of the extended tongue. The solutions had four different concentrations of sweet (sucrose solution), sour (citric acid), salty (sodium chloride) and bitter (quinine hydrochloride) tastants. The authors found that gustatory sensitivity decreased with age and women were more sensitive to gustatory stimuli than men. Interestingly, in contrast to most other studies with normal subjects and taste function, significant side differences were found, particularly in elderly subjects but not in subjects under the age of 35. The analysis found the taste test to have a good test-retest reliability with a correlation coefficient of 0.78. The taste solution spreading over the tongue, immediately after the application of the drop, remains a disadvantage to this liquid solution test. Nevertheless, the authors conclude that the test can easily be self-made, is inexpensive and demonstrates a good test-retest reliability. They go on to suggest that this psychophysical taste test is advantageous when compared with electrogustometry and the test is also recommended as a reliable alternative to ‘taste strips’ for the assessment of gustatory sensitivity in the clinical environment.
Family history - a risk factor for idiopathic sudden sensorineural hearing loss
Reviewed by: Ian Coulter
Jul/Aug 2011 (Vol 20 No 3)
Multiple factors are implicated in the aetiopathogenesis of idiopathic sudden sensorineural hearing loss (ISSNHL). In this study the authors have performed a retrospective clinical characterisation and analysis of family history of patients with ISSNHL to investigate influences on the disease. They investigated 186 patients diagnosed with ISSNHL by an examination of case notes and standardised questionnaire. Seventy-five individuals that had never experienced an event of ISSNHL were included in the analysis as controls. The questionnaire revealed that 21.4% of patients with ISSNHL reported a positive family history. Of the study group, 10 families were identified with at least two family members as having ISSNHL. Interestingly, the authors also observed that when compared to controls, ISSNHL patients tended to be younger, experienced more episodes of ISSNHL, and showed less of a response to therapeutic treatments, although none of these observations were statistically significant. Stronger differences were observed between smokers, with a positive family history and non-smokers with a negative family history. According to the authors, the relevance of a positive family history of ISSNHL has, until now, not been reported. Although this study lacks a corresponding genetic analysis, the authors’ conclusions, that ISSNHL patients with a positive family history may represent a clinical subgroup within the disease, goes some way to implicating a genetic basis to the condition.
Otologics® semi-implantable middle ear transducer ossicular stimulator - not very promising
Reviewed by: Codruta Neumann
Jul/Aug 2011 (Vol 20 No 3)
The authors analyse, retrospectively, a series of 19 preoperative temporal bone CT scans in patients ‘successfully’ implanted with a semi-implantable middle ear ossicular stimulator from Otologics®. The CT scans were analysed and measurements in ‘easy’ versus ‘difficult’ ears were compared in order to inform future surgical decisions. The distance between the incus and cortical measured on a line following the long axis of body of incus, was 33.1±2.6mm. On a perpendicular line to this, the distance measured between the most lateral point of the sigmoid sinus and the cortical was 13.8±2.3mm. These two measurements were found to be considerably smaller (more than 2 standard deviations) in one case with an anteriorly placed sinus and sclerotic mastoid. Drilling to gain access to the antrum and attic can be technically challenging due the dimensions of the implant (23.5-28.5mm in length, 7.8mm in height and 4.8mm in width). In three of the cases the authors encountered difficulties during surgery: one case with sclerotic mastoid required the sigmoid sinus to be skeletonised and displaced with the dura into the posterior fossa, the ear canal to be thinned out excessively, while the implant was sub-optimally placed at a 45° angle to the axis of incus; in the two other cases the low dura had to be exposed and skeletonised, one of them resulting in a CSF leak (repaired on the table). Two of the cases required revision: one for implant extrusion in a patient on steroids, the other one for technical failure of the implant. One patient is not using the implant, but refused explantation. Although the reported average gain on PTA was 46±9dB in the severe sensorineural hearing loss group and 25±18dB in the moderate sensorineural hearing loss group, with 20db gain of intelligibility for 14/15 patients, one wonders whether these results justify the considerable risks involved with surgery. The decision to offer this implant to patients with moderate hearing loss and unfavourable mastoid anatomy is to be questioned.
Beware of the tonsillar remnant
Reviewed by: James Kennedy
Jul/Aug 2011 (Vol 20 No 3)
Squamous cell carcinoma (SCC) of the tonsil is the most common malignant tumour of the oropharynx. However, squamous cell carcinoma of the tonsillar remnant (SCCTR) in a previously tonsillectomised patient is rare, with only one previously documented case report in the literature. This well presented study is a retrospective review of patients presenting with SCCTR at the head and neck unit at Guy’s, Kings and St Thomas’ NHS Trusts from 2000 to 2007. In the seven-year period, 251 patients presented with SCC, and ten (4%) had a tonsillectomy performed in childhood. In this study, five patients (50%) had no obvious site of primary tumour when initially seen in clinic. In patients with no primary indentified the authors stress the importance of a systematic approach and advocate following the BAO-HNS guidelines for the management of head and neck cancer. The therapeutic strategy for SCCTR will depend on the stage of the disease at diagnosis. In this series all patients deemed curable were given combined treatment with surgery and radiotherapy. The two year disease free survival was found to be 89% and for five year 83%. The study highlights the importance of a high index of suspicion in patients who have previously undergone tonsillectomies and who present with, potentially, occult primary SCC in the head and neck region. A tonsil biopsy should be performed when investigating an unknown primary, despite childhood tonsillectomy and a normal appearance of the tonsillar remnant. The series concludes by suggesting that SCCTR can be considered as a clinical sub-group within SCC of the tonsil. The management strategy of these patients however should be the same as for patients with primary SCC and they appear to have similar oncologic outcomes.
Prevalance of HPV in tonsillar cancers
Reviewed by: Sachin Patil
Jul/Aug 2011 (Vol 20 No 3)
This article represents the increasing prevalence of head and neck squamous cell carcinoma (HNSCC) associated with human papillomavirus (HPV). The incidence of tonsillar cancer due HPV has almost tripled over the last few years. Inclusion and exclusion criteria were presented but there seems to be a lot of selection bias in this study. The HPV genotyping was performed centrally using the INNO-LiPA HPV test, which allowed detection of 28 HPV types, 15 high-risk (HR) and 13 low-risk (LR). This study shows a high prevalence of HPV in tonsillar SCC but this very small sample size may not apply to a the general population. This is highlighted in the limitations of the study. This, being a retrospective study, has lots of limitations to apply to clinical practice. The discussion includes a good review of the literature. This study clearly points out the importance of prevalence of HPV, in young women who have been vaccinated against HPV, to clarify the possible association between tonsillar cancer and HPV.
Getting the douche into the sinus
Reviewed by: Joanne Rimmer
Jul/Aug 2011 (Vol 20 No 3)
Whilst most of us advocate the use of nasal douches to patients with chronic rhinosinusitis (CRS), both before and after surgery, there are numerous different commercial and homemade means of doing so. This study aimed to compare seven commercially available devices to assess how well the irrigation is actually delivered to the sinuses. Seven cadaveric heads underwent maximal endoscopic sinus dissection, and trephination was then performed to allow direct visualisation of the frontal, sphenoid and maxillary sinuses during irrigation. Devices were either ‘heavy irrigators’ or ‘atomisers’. The amount of douche delivered into each sinus was recorded. All atomised particle delivery systems achieved mist penetration of all sinuses with four attempts (squeeze / pump devices) or 30 seconds (mechanised unit). There were significant differences between the heavy delivery systems; NeilMed Sinus Rinse achieved significantly higher levels of irrigations than the other three types tested. The authors discuss the differences between devices, some of which are better for certain sinuses than others. They conclude that the delivery system should be tailored according to the desired effect, be that consistent delivery of medication to certain sinuses or larger volume irrigation for debridement purposes. However, as clinicians, we must also consider the patient and their preferences.
Balloon sinoplasty: a supplement to FESS surgery
Reviewed by: Madhup K Chaurasia
Jul/Aug 2011 (Vol 20 No 3)
Balloon sinoplasty is a new development in FESS surgery and proponents of it feel it is a useful supplement to the established treatment of chronic rhinosinusitis. In this report, 27 cases in which balloon sinoplasty was performed are reported. It was possible for the authors to dilate the sinuses in 98%, but subjective symptomatic improvement was observed in only 62% of these patients. The authors state that the main role of this procedure is in patients with frontal sinus disease, particularly when CT scans fail to demonstrate significant mucosal thickening or there is pain associated with only minimal CT evidence of sinus involvement. The procedure is not applicable in cases of nasal polyps. After some practice, cannulation can be done without CT guidance and hence radiation both to patient and the surgeon is minimised. The success rate is lower than that expected with conventional FESS and this is related to poor selection of cases. Undoubtedly, this is a useful adjunct to surgical treatment of chronic rhinosinusitis, but needs to be further developed and its best applications established with more usage and research.
Better imaging for cholesteatoma
Reviewed by: Madhup K Chaurasia
Jul/Aug 2011 (Vol 20 No 3)
CT imaging for cholesteatoma has gross limitations because it cannot differentiate between soft tissue and cholesteatoma. Echo planar diffusion weighted MRI imaging can also have some limitations. This is because when bone and air occur next to each other, a higher intensity MRI signal results. This is known as a susceptibility artefact. It can also occur when the temporal lobe lies next to the temporal bone. In this article the authors have emphasised the usefulness of non echo planer diffusion weighted MRI, which uses a single shot turbo spin echo diffusion weighted imaging. The procedure takes only 35 seconds, as opposed to gadolinium enhancement which can take 45 minutes, and it is specific in picking up cholesteatomas as small as 2mm. This will often eliminate the need for a ‘second look’ operation. The authors claim they were able to exclude cholesteatoma by this method in a couple of cases in which the CT scan raised a high suspicion of it. The equipment is expensive but if the centre has facility for echo planar diffusion weighted MRI then a simple modification is all that is required to do this imaging. The cases are few and a larger correlation between clinical findings, CT scan findings and non echo planar diffusion weighted MRI scan for cholesteatoma would be a very useful study for the future.
Cholesteatoma in an unusual place
Reviewed by: B Viswanatha
Jul/Aug 2011 (Vol 20 No 3)
Cholesteatoma is a relatively common disease within the middle ear cavity and temporal bone, whereas cholesteatoma of the nasal and paranasal region is an exceptionally rare entity. However, a case of cholesteatoma inside the concha bullosa is not published in the English language literature. Concha bullosa is the pneumatisation of the middle turbinate and is one of the most common variations of the sinonasal anatomy. Here, the authors have described a case of cholesteatoma inside the concha bullosa in an 81-year-old Caucasian woman. The presenting complaints were nasal obstruction, headache and diplopia. She had experienced nasal obstruction for over ten years and her headache had worsened for three months. An endoscopic examination revealed a massively large middle turbinate on the left side. The mucosa was normal and no infection signs were detected in the nasal passage. Computed tomography scans showed a homogenous fluid or soft tissue density lesion surrounded by a bony shell in the left nasal cavity. The mass was removed through a transnasal endoscopic approach. The diagnosis of cholesteatoma was established by histopathological evaluation of the mass inside the concha bullosa. The authors are of the opinion that cholesteatoma should be considered in the differential diagnosis of slow-growing and destructive paranasal masses. Total excision is the treatment of choice for paranasal cholesteatoma.
Analysis of the caloric response is not for the naive
Reviewed by: Victor Y Osei-Lah
Jul/Aug 2011 (Vol 20 No 3)
The caloric test has stood the test of time in the identification and quantification of peripheral vestibular asymmetry. It is also a useful guide when monitoring intratympanic gentamicin therapy. The authors compared four methods of analysing the caloric response, derived from both electronystagmography (ENG) and videonystagmography (VNG). The aims were to identify any differences between ENG and VNG and to compare interpretation of results between experienced and inexperienced assessors. Method A analysed the ‘three beats in 10 seconds’ slow phase velocity using the VNG. Method B used the ENG for a similar analysis to method A. In method C, the analysis was carried out, a naïve assessor with limited training in vestibular diagnostics, while in method D, the analysis was derived from the VNG computer software algorithm. There were no differences between the ENG and VNG, as assessed by the senior experienced assessor. Both were found to be equally sensitive in detecting pathology. When responses were atypical, the naïve assessor and the computer algorithms recorded a significant proportion of results as being normal although in these instances, the computer was more accurate than the naïve assessor.
Reliability of vibration-induced nystagmus
Reviewed by: Victor Y Osei-Lah
Jul/Aug 2011 (Vol 20 No 3)
A relatively new clinical test for detecting peripheral asymmetry is the application of a hand-held vibrator on the mastoid process and sternocleidomastoid muscle (SCM) to elicit nystagmus – vibration-induced nystagmus (VIN). This study was designed to assess the test-retest reliability of VIN at four different stimulation sites (right and left mastoid processes and right and left SCMs). Fifty-two consecutive adult patients with various vestibular disorders were recruited for the study. The vibrator with a fixed frequency of 100Hz was applied to the four stimulation sites in each subject for 10 seconds each time at two separate sessions, 30 minutes apart. The maximum slow phase velocity (SPV) of the VIN was recorded after each stimulation. The SPV was considered abnormal if it was >2 degrees/s at all stimulation sites or if the average of maximum SPV from either the mastoid processes or the SCMs was >5 degrees/s. In both criteria, the nystagmus should beat to the same side, the side of the lesion. In the first and second sessions respectively, 98% and 73% of the subjects had abnormal results. Although in 10% of subjects, the VIN changed direction, this occurred at only one stimulation site with three other sites remaining unchanged. Statistical analysis (Pearson’s coefficient) showed high intra-class and inter-session reliability. The authors conclude that VIN is a reliable test to detect peripheral vestibular dysfunction in the clinical setting. VIN is a useful addition to other non-invasive techniques such as the head-impulse test and head-shaking tests in the identification of peripheral vestibular asymmetry.
Learning curve for endoscopic endonasal pituitary surgery
Reviewed by: Gauri Mankekar
Jul/Aug 2011 (Vol 20 No 3)
This is a retrospective study of 125 patients who underwent endoscopic transnasal transsphenoidal surgery for pituitary fossa lesions between 2005 and 2007 by one surgeon. The authors studied changes in a number of parameters between two equal time periods: period 1 (53 patients) and period 2 (72 patients). They found that there was a decrease in the mean duration of surgery for nonfunctioning adenomas, although surgery for functioning adenomas took longer to perform. The proportion of patients with an improvement in their visual field deficits increased over the study period. Overall length of hospital stay decreased between the time periods 1 and 2 from 7 to 4 days. The authors conclude that the presence of an operative learning curve is confirmed for endoscopic pituitary surgery especially with respect to the duration of surgery and visual outcome after approximately 50 operative cases. In view of this they highlight the benefits of subspecialisation in pituitary surgery and the need for an adequate training program.
Endscopic versus microscopic sella surgery
Reviewed by: Gauri Manekar
Jul/Aug 2011 (Vol 20 No 3)
Traditionally, neurosurgeons were trained to use the microscope for pituitary surgery. In the past decade however, endoscopic technology has revolutionised surgical approaches to the paranasal sinuses and skull base. This article reviews the published experience of other neurosurgeons, as well as introducing the authors’ own insight into the development of an endoscopic pituitary program. According to some neurosurgeons, one of the disadvantages of endoscopic approach to the sella is a monocular view. This is mitigated with improving endoscope technologies, larger high definition visualisation video screens and the increasing training with endoscopes in neurosurgical residencies. According to the authors, endoscopic approach provides superior visualisation and potentially more complete tumour resections and further studies will reveal whether this translates into better patient outcomes with reduced clinical complications.
Ozone and bone
Reviewed by: Badr Eldin Mostafa
Jul/Aug 2011 (Vol 20 No 3)
This is a trial of ozone in an oil suspension, by local application, in the management of manidibular osteonecrosis. The authors applied O3 in an oil suspension for 10 minutes to the exposed bone lesions 3-10 times after antibiotic pretreatment. In all 10 patients, mucosal lesions resolved with complete reconstitution of oral and jaw tissue. In two cases the sequestred bone was spontaneously extruded. There were no side-effects reported. The authors concluded that this treatment is effective in lesions <2.5cms with excellent tolerability. Previous reports on the use of hyperbaric oxygen showed some positive effect on the healing of osteonecrosis. However, if the present results could be duplicated and proven in a larger number of patients this would be a much simpler (and apparently more effective) addition to the management of these difficult cases.
Should initial surveillance of vestibular schwannoma be abandoned?
Reviewed by: Andy Hall
Jul/Aug 2011 (Vol 20 No 3)
Conservative radiological surveillance of vestibular schwannomas (VS) to establish whether they are growing before intervening has been recommended by some recent data. This study analyses the results of 54 consecutive patients who underwent yearly MRI scanning. Using volumetric analysis, 29.72% grew by at least 2mm a year and 70.82% did not grow in five years. Age, symptoms, gender and side were found not to be predictive but growth in the first year of surveillance and initial volume were both statistically significant predictors of future growth. These results lead the authors to conclude that intervention should be considered if the initial VS volume is >1.2cm3, while initial radiological surveillance is justified in patients with small vestibular schwannomas (<1.2cm3) and non-serviceable hearing loss.
How cost influences individual decisions about hearing aids
Reviewed by: Lucy Handscomb
Jul/Aug 2011 (Vol 20 No 3)
There have been many studies which seek to understand why the majority of people who could benefit from hearing aids do not obtain them. In countries where hearing aids are not provided by the state, cost is often listed as a factor. However not much is known about how cost influences hearing aid acquisition. This study sets out to investigate this question. The authors retrospectively examined data from a random selection of 1,200 clients with mild to moderate hearing loss who had obtained hearing aids from a large private health centre in Pittsburgh, USA. All subjects were over 50 years of age. Subjects were divided into three groups; a 'fully covered' group, whose health insurance covered the cost of hearing aids and the audiology consultations associated with them, a 'partially covered' group, whose health insurance provided a fixed amount towards the cost of hearing aid services, and a 'private pay' group who met all of the costs themselves. The three groups were compared with regard to age of hearing aid acquisition and severity of hearing loss, determined by pure tone average. Perhaps not surprisingly, clients without full coverage tended to put off getting hearing aids for longer. The average age of acquisition was 70 years for the fully covered group and 78 and 79 years for the private pay and partially covered groups respectively. The fully covered group also had significantly less severe hearing loss at time of hearing aid fitting than the others, although the authors do not seem to account for the fact that their younger age may be the reason for this. As one might expect, patients whose insurance covered two hearing aids were very likely to get two, but more intriguingly, far fewer patients (65%) in the partially covered group obtained bilateral aids than in the private pay group (83%). Similarly, those who met the full cost themselves were most likely to obtain the most expensive hearing aids. Those whose insurance covered the full cost of 'basic level' hearing aids were unlikely to pay a supplement for more expensive technology. Personal income is not controlled for in this study and this could clearly be a factor. However, the authors suggest that a sense of entitlement may play a role in people's decision making. Put simply, people who are paying out of their own pocket will buy the best they can afford, while people who are not will get the maximum they are entitled to but be reluctant to supplement this from their own funds, even though they would end up paying substantially less than the private payers. Although the system for obtaining hearing aids in the UK is quite different, with the current 're-structuring' of the NHS, the increasing involvement of the private sector in NHS hearing aid provision and the government's promise to 'increase patient choice' (which I suspect may include choosing to buy extras) the findings of this study should be of interest to us all.
Is paracetamol that safe?
Reviewed by: Badr Eldin Mostafa
May/Jun 2011 (Vol 20 No 2)
Paracetamol is used extensively during pregnancy and early childhood due to its safety profile. The authors investigated whether paracetamol exposure in pregnancy and until six months of age was associated with allergic disease in school children. They found that maternal paracetamol use in the first trimester increased the risk for allergic rhinitis at 10 years in boys and girls. Paracetamol use until six months in girls increased the risk for allergic sensitisation and a history of asthma, even considering concomitant airway infections. This raises serious questions on the use of this drug during pregnancy and in children with allergic airway diseases (NSAIDS are contraindicated and the only option as a pain killer / antipyretic is paracetamol). More studies must be conducted to confirm these findings as this will leave us bare handed in the face of fever and pain in these kids.
A painless technique for closing defects after drain removal
Reviewed by: Furrat Amen
May/Jun 2011 (Vol 20 No 2)
Placing a drain can leave an unsightly scar on areas which are cosmetically sensitive. The author describes a technique in which the drain is placed in the centre of the wound. Stitches are placed and secured with steristrips either side of the corrugated drain. When the drain is removed, the steristrips are removed and the stitches are tied. This technique may be used with either interrupted or subcuticular sutures. Perhaps what is more elegant, is an article in the next edition of the journal which uses a similar technique, but the drain is placed at the end of the wound, between stitches, closed with a subcuticular suture. The end of the suture is secured to the skin with a steristrip. When the drain is removed, the steristrip is removed, the suture is pulled tight and a steristrip is used to secure it to the skin again leaving a perfect closure.
Spreader flap modification with asymmetric mattress suture
Reviewed by: Furrat Amen
May/Jun 2011 (Vol 20 No 2)
There is a trend to make rhinoplasty surgery more conservative and reversible. In this vein, the spreader flap was described which allowed for the medial edges of the upper lateral cartilages to be folded downwards and sutured to the septum rather than placing spreader grafts. This paper describes a variation on the theme by using an asymmetrical mattress suture to secure the upper lateral to the septum. Apparently, this allows the width of the dorsum to be controlled and increased according to the placement of the sutures. It is almost impossible to describe the technique so I was thankful for the inclusion of some diagrams. However, judging by the patient photos, it is difficult to see if this technique is superior to spreader grafts or indeed spreader flaps.
Is a symptom-based definition of CRS reliable?
Reviewed by: Evangelia Tsakiropoulou
May/Jun 2011 (Vol 20 No 2)
According to the European Position Paper on Rhinosinusitis and Nasal Polyps (EP3OS), the clinical diagnosis of chronic rhinosinusitis is based on symptoms, endoscopic and radiologic findings. However, more epidemiological studies use a symptom-based definition. Analysing data from 1,700 subjects and 11 centres, the Global Allergy and Asthma European Network of Excellence (GA2LEN) tested the reliability and validity of a symptom-based definition of CRS. Symptom criteria were compared to endoscopy and to self-reported doctor-diagnosed CRS. Study results demonstrated significant association of symptoms with positive endoscopy in nonallergic subjects, and with self-reported doctor-diagnosed CRS in all subjects, irrespective of the presence of allergic rhinitis. Additionally, reliability of a symptom-based definition of CRS is affected by time but not by the presence of allergic rhinitis. Also, the prevalence of CR and its geographic variation can be assessed by a symptom-based definition of CRS. The study underlines the need for further research regarding the specificity of symptom criteria and endoscopy in relation to radiologic changes.
Using steroid infused foam for refractory polyposis
Reviewed by: Edward W Fisher
May/Jun 2011 (Vol 20 No 2)
Giving systemic steroids in patients with nasal polyposis is effective, but it would be attractive if local administration could give good results, to prevent the concerns over systemic adverse effects. This study of polyp patients, who had undergone ethmoid surgery as well as simple polypectomy, placed foam in the ethmoid cavities, which was infused with steroids. This seemed to have a good effect for many weeks, although just how long was not clear. The main piece of missing information in this study is how much systemic absorption is happening in these patients – perhaps the effect is mainly systemic and not topical (a doubt expressed by the authors)? This needs to be pursued further, since topical delivery of effective medication in the intermediate term might help in the more difficult subgroup of polyp patients.
CT and minimal lesions
Reviewed by: Badr Eldin Mostafa
May/Jun 2011 (Vol 20 No 2)
Mucosal lesions of the upper airway have always been difficult to depict on CT. In this article the authors describe a new 'mucosal window' to evaluate the CT densities of small head and neck mucosal cancers. They derived a guideline mucosal window settings – a window width of 120HU and a window level of 60HU. Using these settings they found that early T-stage tumours have higher CT density than normal mucosa. Their conspicuity can be amplified using display windows with narrower window width and higher window level. The potential clinical applications are for the improved detection of unknown primary tumours and delineation of a known mucosal tumour. This pilot study has to be further refined in a larger number of patients. If reproducible it can provide a further step in the early detection of subtle mucosal lesions.
Adenotonsillectomy for OSA in children
Reviewed by: Maher El Alami
May/Jun 2011 (Vol 20 No 2)
This prospective study looked at 84 children with OSA and the changes in sleep studies following their surgery. Children with severe health problems, craniofacial or syndromal abnormalities had been excluded. The authors looked at the severity of the OSA, age, weight and postsurgical sleep studies. As one would expect, sleep studies improved in 86.9% based on a definition of an AHI<5. However, when examining some of the subgroups, obese children, only 50% had resolution of their sleep apnoea. Interestingly, age did not seem to influence outcome of treatment and the QOL OSA-18 outcome tool did not correlate with the sleep study findings. This study seemed to be well-designed and highlights again the discussion of the parameters for sleep studies in children. In addition to AT hypertrophy it emphasises the need to look for other factors and, in particular, obesity as a risk for persistent sleep apnoea. In children with obesity or other associated features surgery adenotonsillectomy may not solve all their problems.
Implanting stem cells into the olfactory epithelium: can we transplant smell?
Reviewed by: Maher El Alami
May/Jun 2011 (Vol 20 No 2)
Olfactory neurons have the unique ability to regenerate to a certain degree. Using this concept, labelled stem cells were implanted into the nasal cavity of mice, while controls had cells reviews implanted into the tail. The cells had been labelled and were analysed regarding their differentiation and maturation using immune-histochemical techniques. Interestingly, in contrast to the control samples, these stem cells matured into olfactory neurons when implanted into the olfactory cleft. However, these new ORNs were still immature. This is an interesting article showing how basic science research in this field has advanced.
It's not acid, it's pepsin
Reviewed by: Maher El Alami
May/Jun 2011 (Vol 20 No 2)
Is persistent reflux disease LPR / GORD a cause of persistent acid damage, or do these changes at a cellular level relate to the presence and activity of pepsin? Comparing postcicoid biopsies of cases with and without known reflux confirmed the presence of intracellular pepsin in the patients with LPR. Furthermore, the authors were able show on-going mitochondrial damage in the cells of patients affected by the disease. These findings suggest active uptake, in vitro, of pepsin by hypopharyngeal cells via receptor mediated uptake. This mechanism could be inhibited and activated in vitro showing the intracellular damage. The authors hypothesise that activated genes may be stimulated for this receptor mediated uptake. The rationale of this study sounds attractive and may explain the findings of non-acidic reflux disease and limitations of acid suppression. Controlling this mechanism of pepsin metabolism may hold the key to effective reflux control. This study may fascinate believers in reflux disease, while there is still a need to convince the sceptics of the results of prolonged treatment.
Petrous bone cholesteatoma classification and approach
Reviewed by: Maher El Alami
May/Jun 2011 (Vol 20 No 2)
Petrous bone cholesteatomas are often difficult to diagnose and often present at an advanced stage. The authors present their results over a 30 year period. Out of a total of 4,500 cholesteatoma cases, 130 were found to have petrous bone cholesteatoma. Of these 13 were found to be complex, involving major vascular or other extratemporal structures. Sanna et al. present their classification and their recommendations on treatment. The majority of 'complex' cases (11/13) presented with a facial nerve paresis and 7/13 had a profound hearing loss on presentation. Interesting cases are documented with otoscopic and clinical findings, as well as MRI scans. There are some very good diagrams to illustrate the technique and the disease extent. Certainly an interesting case series, from a well-established institution, this may serve as reference for the management of these rare cases. For the majority of practising ENT surgeons it may help to establish the diagnosis before referring these cases for complex surgery.
Atypical cytologic results – lobectomy or total thyroidectomy?
Reviewed by: Shabbir Akhtar
May/Jun 2011 (Vol 20 No 2)
Fine needle aspiration biopsy results are usually classified as benign, indeterminate (atypical), suspicious for malignancy, or malignant. Cytologists give a report of indeterminate or atypical when 2 to 3 but not all the characteristics for papillary carcinoma are present. This creates a management dilemma when deciding on the extent of thyroidectomy to be offered to patients, because nearly half will have nonmalignant disease. Total thyroidectomy, in the setting of benign disease, exposes patients to unnecessary intervention and potential morbidity, such as recurrent laryngeal nerve injury and hypoparathyroidism. Conversely, performing a hemithyroidectomy for malignant disease, in most instances, creates the undesirable requirement for a second operation to remove the residual thyroid lobe. This study aimed to identify factors that could assist surgeons and patients in their decisionmaking processes by identifying those patients who were at highest risk of harbouring a malignant nodule. Two hundred consecutively treated patients, who underwent thyroid surgery after having a fine-needle aspiration biopsy procedure yielding a specimen that met the criteria for atypical cytologic features, were studied. Different factors including age, sex, family history of thyroid malignant disease, exposure to head and neck irradiation, nodule size, rim enhancement on ultrasonography, intranodular vascularity, microcalcifications within the nodule on ultrasonography and nodule size were included. Multivariate stepwise logistic regression modelling was used to identify a model that could reliably predict a higher probability of malignant disease. Only two factors, microcalcifications and nodule size 2cm or larger came out significant for prediction of malignancy. This study changed the authors' practice and now patients with nodules larger than 2.0cm and ultrasonographic evidence of microcalcifications are typically recommended to undergo a total thyroidectomy, while a recommendation of hemithyroidectomy is given to patients without these factors.
Papillary thyroid microcarcinoma! How to go about it
Reviewed by: Shabbir Akhtar
May/Jun 2011 (Vol 20 No 2)
Papillary thyroid microcarcinoma (PTMC) is defined as carcinoma measuring less than 1cm. There has been a debate regarding total thyroidectomy versus hemithyroidectomy for papillary thyroid microcarcinoma. This study explores clinical decision-making by a group of United States surgeons in the treatment of PTMC. A 10- question survey was designed to evaluate surgeons' choices in the treatment of patients with PTMC. A total of 438 responders completed the survey. Given a single subcentimeter PTMC, 70% of surgeons recommended no further surgery after a hemithyroidectomy, yet 30% believed that completion thyroidectomy was necessary. Given PTMC with lymphatic invasion, 89% responders recommended completion thyroidectomy. Given multifocal PTMC, 85% chose completion thyroidectomy. The authors have done an excellent review of the literature but unfortunately this weak study design, based just on a survey of opinion, still leaves us with uncertainty.
Augmenting communication in alternative ways
Reviewed by: Diego Zanetti
May/Jun 2011 (Vol 20 No 2)
The main form of communication among human beings is speech. It depends on vocal production and auditory comprehension of a set of symbols controlled by grammatical, semantic and syntactic rules, which are grouped in a language. Speech relies on effective use of voice emission at the laryngeal level, articulation, resonance, breathing co-ordination and prosody. All persons communicate in some way; however, the effectiveness and efficiency of this communication vary according to individual and environmental factors. Individuals with severe disabilities develop unconventional means to communicate, that can be facilitated by the use of technological devices or by means of environmental interventions. Augmentative and alternative communication (AAC) refers to any communication method used to increase natural communication or to replace it if entirely absent. The representation systems or symbols used in AAC include gestures, hand signals, pictures, line drawings, words and letters. Symbols can be strictly visual when located on boards or screen displays or they can be tactile such as with the Picture Exchange Communication System (PECS). AAC is generally slower than spoken language and requires training by the subject and by the listener (or 'receiver'). Thus, in an AAC system, all symbols are categorised and organised to facilitate an easy and effective communication mode. In this interesting review, the authors describe the general principles of AAC and discuss its applications with the available devices.
Growing with language disorders
Reviewed by: Diego Zanetti
May/Jun 2011 (Vol 20 No 2)
Developmental language disorders (DLD) or specific language impairment (SLI), is a common childhood disorder with a prevalence of around 7%, accounting for one of the largest disability groups in preschool children. The International Classification of Disease (ICD-10) defines it as “Disorders in which normal patterns of language acquisition are disturbed from the early stages of development”. The conditions are not directly attributable to neurological or speech mechanism abnormalities, sensory impairments, mental retardation, or environmental factors. SLI is divided into receptive language disorder in which the child’s understanding of language is below the age level and speech is less affected, and expressive language disorder in which the child’s speech is below the appropriate level for his / her age. The basis of the diagnosis of SLI is a discrepancy between verbal and nonverbal performance, confirmed with behavioural tests, troubles in the use of language in a natural context, and exclusion of other known causes of developmental disorders. This article gives an overview on quality of life aspects in subjects with developmental language disorders. In summary, the subjective QoL did not differ between children with SLI and normal children, when the tests were repeated at an adult age, even though the SLI group showed poorer outcomes in communication, cognitive / academic performance, educational attainment, and occupational status. It seems that despite ongoing problems, subjects with SLI perceive their QoL as satisfactory, at least in the early phases of adulthood. As the author states, “It is likely that they are yet not aware of the opportunities denied them.”
A treatment for tinnitus?
Reviewed by: Badr Eldin Mostafa
May/Jun 2011 (Vol 20 No 2)
The assumption that dysregulation of cochlear N-methyl-Daspartate (NMDA) receptors may underlie aberrant excitation of the auditory nerve, which in turn is perceived as tinnitus, led the authors to attempt blocking these receptors by AM-101 (an NMDA receptro blocker). In a phase I/II clinical trial, the safety and local tolerance of intratympanic injections of the NMDA receptor antagonist AM-101 was evaluated for the first time in humans. The results from the double-blind, randomised, placebocontrolled study show that intratympanically injected AM-101 was well tolerated by study participants, and provided the first indications of therapeutic efficacy. This compound was first experimented with in acute tinnitus and showed some efficacy. However its effect on acute tinnitus, following acute acoustic trauma and sudden deafness, is still being evaluated in an onoing clinical trial. It will be a real breakthrough if it proves to be effective in some other forms of tinnitus (that can be readily categorised).
Effect of myringoplasty on inner ear function
Reviewed by: Ahmed A Saada
May/Jun 2011 (Vol 20 No 2)
This is an interesting prospective study that describes bone threshold changes after myringoplasty, thus reflecting the effect of such a procedure on inner ear function. Eligible subjects included 134 patients who underwent primary underlay type I tympanoplasty (myringoplasty). Bone conduction thresholds were determined before surgery and 6-12 months postoperatively. Details of the surgical procedure and audiological testing are described; and several variables were considered such as possible ossicular chain trauma, cochlear dysfunction, perforation size, presence of tympanic granulation tissue, myringosclerosis or tympanosclerosis, ossicular chain fixation and external canal drilling. A transcanal approach was used in 59% of cases, whereas a postauricular approach was used in the remaining 41%. There were no significant differences in preoperative threshold by all variables except ossicular chain fixation, granulation tissue and tympanosclerosis. Postoperatively, the only significant differences were noted by perforation size, ossicular chain fixation, surgical approach and external canal drilling. Details of such differences in bone conduction threshold for each frequency tested are displayed in tables. Mechanisms of cochlear damage in cases of otitis media are discussed, including the role of endogenous and exogenous substances. However, other factors that may play a role in bone conduction hearing impairment are thoroughly analysed. In conclusion, the authors observed statistically significant evidence that mechanical factors are associated with poorer bone conduction thresholds. Moreover, they stated that anatomically successful myringoplasty can slightly improve bone conduction with minimal risk of impairment.
Endoscopic removal: a gold standard in the management of foreign bodies of the aerodigestive tract
Reviewed by: Evangelia Tsakiropoulou
May/Jun 2011 (Vol 20 No 2)
This is a well conducted study from the Bugando Medical Centre, reporting 98 cases of aerodigestive tract foreign bodies. Rigid endoscopy, with endoscopic forceps removal under general anesthesia, was performed in all cases. Groundnuts and coins were the commonest type of foreign bodies and the trachea and cricopharyngeal sphincter were the commonest sites in the airway and oesophagus respectively. The main findings demonstrate predominance of males and children younger than two years old. In accordance with previous published studies, chest / neck plain radiography detected foreign bodies in almost half of the cases. Interestingly, the complication and mortality rates in this study were higher than in other studies. The authors attribute this firstly to the lack of experience in doctors who were the first on call and secondly to admissions of patients after the failed first attempt in district hospitals. The authors underline the need for adequate training of young doctors. Additionally, parental education is necessary in order to prevent this potentially fatal condition. A point to remember: the most effective treatment of foreign body accidents is their prevention.
Impact of dental appearance on patients
Reviewed by: Sachin Patil
May/Jun 2011 (Vol 20 No 2)
This is a very good article on cosmetic dentistry. Females outscore in the expectation of looking perfect compared to males. The significant factors affecting overall dental appearance are tooth colour, shape, and position; quality of restoration; and the general arrangement of the dentition, especially of the anterior teeth. This is a cross sectional study applied to a group of cohort patients attending a dental clinic. Though the study was randomised it has a selection bias. This study had an approval by Research and Ethics Committee (Human), Universiti Sains, Malaysia. The model of this study was assessed for its validity using the Hosmer-Lemeshow goodness-of-fit test. The results were very well presented in tables. The sensitivity and specificity of this model was just above 60%. This paper provides useful indications of the potential demands for dental treatment, particularly aesthetic treatment. This also highlights the importance of understanding the patient's perceptions of their dental appearance, which may assist dentists in planning treatments that are acceptable to the patients, leading to higher levels of patient satisfaction.
Adult cochlear implant candidates: their views
Reviewed by: Thomas Nikolopoulos
May/Jun 2011 (Vol 20 No 2)
The majority of national health systems are now patient centred and maximise their efforts in order to provide services of better quality. Since the end of December 2008, the minimum expectation of consultant-led elective services in the UK is that no one should wait more that 18 weeks from the time they are referred to the start of their hospital treatment, unless it is clinically appropriate to do so, or they choose to wait longer. The 18 week pathway was implemented at the authors' centre from the end of November 2007. This paper reviews the impact of the 18 week pathway on patients' perceptions of quality of service and the decision process. Questionnaires were sent to those patients whose assessment had been completed within the 18 weeks. Of the 43 patients sent a questionnaire, 21 were offered an implant and 22 were not, 24 were female and 19 male. Although most of the candidates answered that the information they had was adequate and that they understood the whole procedure, 12 out of 16 were surprised by the final decision. This highlights that improvements in the quality of the service offered to patients as perceived by the system or even by what the patients report themselves, may differ substantially from what actually patients feel or experience.
Are ESRT measurements reliable in generating speech processor programmes in children?
Reviewed by: Thomas Nikolopoulos
May/Jun 2011 (Vol 20 No 2)
Electrically elicited stapedius reflex thresholds (ESRT) have been used in several cochlear implant centres in order to set maximum comfort levels. The present study aimed to outline the procedure for generating programmes from ESRT measures and demonstrate the feasibility of this fitting method through outlining a number of studies evaluating incidence and stability of ESRT's and children's acceptance of, and performance with ESRT generated programmes. The authors studied 22 children and the percentage of children fitted with an implant using ESRT method increased from 68% at first fit to 82% at fourth fit. ESRT were elicited during natural sleep or when children were passively entertained. The authors claim that the straightforwardness of this procedure, high incidence and stability of ESRTs, ready acceptance of and satisfactory performance with ESRT generated speech processor programmes indicate this fitting technique can be used extensively with children. Although, it seems a very promising method, it should be further standardised and validated using other fitting methods.
Cochlear implantation in children with CHARGE syndrome
Reviewed by: Thomas Nikolopoulos
May/Jun 2011 (Vol 20 No 2)
CHARGE syndrome is a rare congenital condition that manifests with anomalies of coloboma, heart defects, choanal atresia, mental retardation, genitourinary and ear anomalies that can affect almost any part of the auditory pathway. In those patients with a significant sensorineural hearing loss, cochlear implantation has become a potential therapeutic option. The authors reported three patients who had met the clinical diagnostic criteria of CHARGE syndrome and had abnormal inner ear anatomy with profound sensorineural hearing loss. One child had previously undergone cochlear implantation, which was unsuccessful due to increasing non-auditory stimulation. All patients had successful cochlear implantation with full insertion of the cochlear implant device. All patients showed improvement in their audiological function; one child has high functioning verbal communication, one child uses both sign and verbal communication with improved speech quality and ability to lip-reading, and one child responds reliably to sound, understands short phrases and attempts to vocalise, but this is limited by a tracheostomy. The authors concluded that cochlear implantation faces numerous challenges in children with CHARGE syndrome, but, with appropriate patient selection, it can result in successful outcomes and improvement in quality of life. In addition, surgeons should be very cautious during the assessment and the actual operation as middle and inner ear abnormalities, including altered route of the facial nerve, may significantly increase complication rates.
Cochlear implantation surgery: step by step
Reviewed by: Thomas Nikolopoulos
May/Jun 2011 (Vol 20 No 2)
In this article the author reviews the developments that have occurred in the past twenty-five years in the field of cochlear implantation. During this time numerous challenges have come to light. This short review details some of the author's personal experience and his recommendations on several topics. For example, the author takes into account that 10% of implantees have meningitis as cause of deafness and about a third of these have ossification visible on computer tomography or magnetic resonance imaging. He describes the related difficulties in cochlear implant surgery and describes the available options, including scala vestibule insertion, double array electrodes, and so on. Another challenging condition is chronic otitis media and the author suggests blind sac closure of the ear canal as a reliable method of management, although some revisions in the 19 cases he described were needed. A short but concise review.
Cochlear implantation: what about tinnitus?
Reviewed by: Thomas Nikolopoulos
May/Jun 2011 (Vol 20 No 2)
It is well known that tinnitus may very well affect patients' quality of life. In profound deafness, however, the major aim of cochlear implantation is the restoration of hearing and oral communication. Recently, there is a debate whether cochlear implantation should be performed in cases with single sided deafness and severe tinnitus, in order to improve or alleviate the latter. It is widely accepted, not always based on strict evidence, that many people who undergo cochlear implantation experience an improvement in tinnitus. However, for some this is not the case. The present paper reviewed the related literature and concluded that about 25% of adult cochlear implant patients continue to experience troublesome tinnitus. Some emergent evidence indicates that for children with cochlear implants the burden may not be as high, but the related literature is rather poor. The latter seems to be true in the case of single sided deafness and very severe tinnitus where the few related studies are rather encouraging. I would agree with the author of the article that much work remains to be done in this issue as many factors may affect the outcomes of related studies.
Is testing for dead regions (TEN test) useful in assessing cochlear implants candidates?
Reviewed by: Thomas Nikolopoulos
May/Jun 2011 (Vol 20 No 2)
The author of this paper suggests that there is underreferral of adult patients within the UK for assessment for suitability for cochlear implantation and proposes a new model for the optimisation of services for patients in this clinical population, such that patients have access to high quality audiological care and onward referral where appropriate. The author claims that the audiological assessment should include testing for dead regions, using the threshold in equalising noise (TEN) test where possible. Therefore the author used TEN test in 157 adult patients with hearing loss and meaningful results were obtained in one quarter of subjects. In 16% of the subjects dead regions were measured and hearing aid performance was adjusted accordingly. Some of these patients were successfully implanted. Although many details of the patients studied were not given in this paper, it seems that assessing the dead regions may be needed in some cases and audiologists should have the related test in mind.
Vestibular implant: is it a reality?
Reviewed by: Thomas Nikolopoulos
May/Jun 2011 (Vol 20 No 2)
It is well known that some patients with bilateral loss of vestibular sensation, due to irreversible injury of vestibular hair cells suffer from blurred vision during head movement, postural instability, and chronic disequilibrium. If compensation does not occur, there is a significant effect on patients' quality of life. Similar to a cochlear implant in concept and size, the Johns Hopkins Multichannel Vestibular Prosthesis (MVP) includes miniature gyroscopes to sense head rotation, a microcontroller to process inputs and control stimulus timing, and current sources switched between pairs of electrodes implanted within the vestibular labyrinth. In rodents and rhesus monkeys, rendered bilaterally vestibular deficient via treatment with gentamicin and / or plugging of semicircular canals, the MVP partially restores the vestibulo-ocular reflex for head rotations about any axis of rotation in three-dimensional space. The efforts now focus on addressing issues prerequisite to human implantation, including refinement of electrode designs and surgical technique to enhance stimulus selectivity and preserve cochlear function, optimisation of stimulus protocols, and reduction of device size and power consumption. The concept of the vestibular implant seems a very promising method of management. However, it remains to be seen if the actual outcomes will reward all these efforts.
Management of laryngomalacia
Reviewed by: Susan A Douglas
May/Jun 2011 (Vol 20 No 2)
This is a well-written paper on the management of laryngomalacia. Examination with flexible fiberoptic laryngoscopy is 88% reliable, regardless of the experience of the examining physician. The most common finding is that of short aryepiglottic folds. The evaluation and treatment of associated comorbidities is presented. Gastroesophageal and laryngopharyngeal reflux are the most commonly associated conditions. Patients with laryngomalacia may also have secondary or synchronous airway lesions and these are more easily diagnosed via rigid endoscopy. The association with congenital anomalies, such as congenital heart disease and genetic disorders such as Down syndrome, is also described, as these patients may have more severe disease. An evaluation and treatment algorithm is presented, where the management varies according to the severity of the disease. The author states that factors associated with disease progression in patients with mild to moderate disease are persistent symptoms despite acid suppression therapy, lower APGAR scores, lower baseline resting oxygen saturation, hypoxia and secondary airway lesions. The treatment of any associated reflux is important in managing patients with laryngomalacia. Revision supraglottoplasty may be required in those with acid reflux and comorbidities.
Endoscopic sinus surgery reduces antibiotic usage in sinusitis
Reviewed by: Joanne Rimmer
May/Jun 2011 (Vol 20 No 2)
Chronic rhinosinusitis (CRS) and its acute exacerbations are often treated with antibiotics, for varying periods of time. Given the potential side-effects of antibiotics and their effect on bacterial resistance, the authors rightly point out the multiple benefits of reducing antibiotic utilisation where possible. Their aim was to evaluate the specific effect of endoscopic sinus surgery (ESS) on antibiotic use in CRS patients. Of 718 patients who failed medical therapy and went on to undergo ESS, 503 completed both pre and postoperative symptoms scores (Chronic Sinusitis Survey). Following surgery, there was an overall significant improvement in symptoms and medication use over time. Preoperatively, 79.5% of patients had reported at least two weeks of antibiotic use in the eight weeks prior to surgery. Following surgery, that figure fell to 40%, which was significant. Subgroup analyses showed that patients with CRS and nasal polyposis also showed a significant reduction in antibiotic usage postoperatively, as did those who underwent surgery for recurrent episodes of acute rhinosinusitis. Mean follow-up for all patients was 17.3 months. The authors discuss how their series compares favourably with smaller reports in the literature, and comment on how the results are important from both economic and public health perspectives. It is certainly relevant in today's financial climate, where healthcare budgets are falling, and this evidence could perhaps be used to justify the need for ESS when such justification is required.
Histological inflammation does not predict symptoms severity
Reviewed by: Joanne Rimmer
May/Jun 2011 (Vol 20 No 2)
People have long sought to grade the severity of chronic rhinosinusitis (CRS) to aid in treatment planning and inform prognosis. Radiological staging can be helpful in determining whether surgery is indicated, but has not shown any correlation to symptom severity scores. This study aimed to correlate the degree of mucosal inflammation in CRS at the time of surgery with postoperative symptom severity scores. One hundred and twelve consecutive patients undergoing endoscopic sinus surgery (ESS) for CRS were included. All completed a preoperative Rhinosinusitis Symptom Inventory (RSI), and repeated it at least 12 months after surgery. Ethmoid mucosa was graded with a five-point Likert severity scale. Whilst preoperative RSI scores predicted postoperative RSI scores, the pathological severity score showed no significant statistical correlation. The author concludes that increasing pathological severity at the time of ESS does not predict worse symptom control postoperatively.
Steroid-eluting ethmoid stents for sinusitis
Reviewed by: Joanne Rimmer
May/Jun 2011 (Vol 20 No 2)
Topical nasal steroids are prescribed after surgery for chronic rhinosinusitis (CRS), in the hope of controlling mucosal inflammation and preventing recurrent disease and symptoms. As the underlying cause of the inflammation remains unclear, long-term treatment is usually needed. The authors suggest that a steroid-eluting stent placed into the ethmoid sinus cavity at the time of endoscopic sinus surgery (ESS) could improve surgical outcomes by preventing postoperative adhesions and middle turbinate medialisation, as well as deliver high concentrations of steroid to the local tissues. The stent used has previously been tested in rabbits only and is not yet licensed for use in humans. It is made of pollactide-co-glycolide and elutes mometasone furoate. This was a prospective multicentre randomised double-blind trial of 43 patients. One group of 38 patients had a control (non-eluting) stent placed in the contralateral ethmoid cavity to determine efficacy, and a second group (five patients) received bilateral drug-eluting stents to assess the safety profile. All patients underwent 'standard' ESS after failing medical treatment of CRS. At the end of the procedure their sinus cavities were randomised to receive the drug-eluting stent or control stent. At follow-up assessments (until 60 days), the cavities were examined endoscopically and findings recorded. All 86 stents were successfully deployed, and the drug-eluting stent led to a statistically significant reduction in inflammation when compared to the control stent. Polyp recurrence and adhesion formation was also significantly reduced. There were no adverse events and no evidence of systemic absorption of the steroid. The authors conclude that this bioabsorbable steroid-eluting stent is safe and effective in reducing inflammation in CRS, but how long the effects last has not been quantified. As less than 10% of the stent remains by 30 days, presumably the need for topical steroid treatment returns soon after that point?
Technology and margins
Reviewed by: Badr Eldin Mostafa
May/Jun 2011 (Vol 20 No 2)
Local recurrence of disease, in advanced carcinomas of the head and neck, is strongly correlated with the presence of positive or close resection margins after operative treatment. In this study the authors assessed resection margins intraoperatively using image-guided surgery based on positron emission tomography / computed tomography (PET / CT) image fusion. A PET / CT image fusion was done on the workstation of a 3D-navigation system. Intraoperative image guided navigation of the defect following surgical ablation of the tumour was performed in every patient. Suspected positive margins on PET / CT were pathologically confirmed. This can be a useful tool to assess and improve local control in advanced cancer of the head and neck, a sort of sci-fi Mohs' surgery in a way. We can imagine a further addition: coupling this system to a surgical robot similar to the TORS system and the surgeon would just be having a coffee and playing at the console with much better patient outcomes!
Is bare below the elbow clothing really acceptable to patients?
Reviewed by: Madhup K Chaurasia
May/Jun 2011 (Vol 20 No 2)
With recent awareness of Methicillin Resistant Staphylococcus Aureus and Clostridium difficile infections, trusts have enforced policies on doctors' attire and it is believed that 'bare below the elbow' policy helps patients' confidence, considering that one of the main concerns most patients have is the possibility of acquiring hospital based infections. In this study both inpatients and outpatients, in four 20 year age groups starting from 0 to over 61 years, where asked about their preferences on seeing doctors either in theatre attire, the traditional formal attire or bare below the elbow. Photographs of each of these were presented to patients and they were asked which of these three would be most appropriate from the point of view of professionalism, hygiene, easy identification and overall preference. There was no difference of opinion between the age groups. The formal outfit was considered to be most professional. Inpatients preferred the theatre scrub outfit as best from the point of view of hygiene and from the identification point of view the formal outfit was again considered most appropriate. Overall preference was given to the formal outfit. There is, however, no clear evidence linking health care workers' attire to the transmission of hospital acquired infections. Therefore if the 'bare below the elbow' is neither based on any clear medical evidence, nor does it inspire confidence in patients where exactly are we heading by enforcing this regimentation and ignoring common sense?
MRI evaluation of airway improvement after bipolar radiofrequency volumetric tissue reduction
Reviewed by: Madhup K Chaurasia
May/Jun 2011 (Vol 20 No 2)
In this study the authors have evaluated the changes that occur in the airway after application of bipolar volumetric reduction to the palate and the base of the tongue. In a small series of five cases, patients underwent different procedures, ranging from palatal and base of tongue volumetric reduction to tonsillectomy and palatoplasty. Magnetic resonance imaging was performed preoperatively and repeated a week and six weeks after the surgery. In the T1 weighted images, hyper-intensity was observed in 'lesions' in the palate and base of tongue following surgery. The hyper intensity was due to coagulation and haemorrhage, whereas hypo-intensity was due to oedema. The authors also used short Tau inversion recovery (STIR) sequences. In these images there were central hypo-intensities with surrounding high intensity signal. It was noted that these lesions expanded in the first three to four days and then subsided, but also persevered for six weeks in a couple of patients. The initial expansion of lesion explains worsening of snoring and occurrence of globus sensation in the first few postoperative days. The study also involved measurement of the airway pre- and postoperatively by cephalometric measurements and sagitttal STIR sequence magnetic resonance imaging films. There was a distinct improvement in the airway after the surgery. The authors contend that bipolar treatment requires less energy and avoids secondary thermal damage to the surrounding tissues and neurovascular structures. It is also claimed that this study explains the pathophysiology and postoperative symptoms, but without indicating the site for precise application of the bipolar technique. The authors accept that the numbers are too small and a larger study with statistical analysis is required. Interestingly, the outcome regarding snoring is not mentioned nor related to the images, but presumably these patients recovered from the symptom!
Sub-annular ventilation for persistence of middle ear effusion
Reviewed by: Madhup K Chaurasia
May/Jun 2011 (Vol 20 No 2)
Persistent middle ear effusion is often a problem and the short life of grommets does not help the situation. Insertion of transtympanic 'long-term' tubes causes infection, persistent perforation and cholesteatoma. These tubes have double the rate of complications compared with grommets. In this publication the authors have assessed the usefulness of long-term ventilation tubes, placed through the bony annulus, in terms of reducing complications and at the same time, providing long-term ventilation. A total of 57 tubes was placed in 45 patients, of ages ranging from nine to 64 with a mean of 23 years. Thirty-one patients also had other procedures, ranging from canalplasty, cortical mastoidectomy or ossiculoplasty and even atticotomy. A groove was drilled in the inferior part of the external auditory canal, after elevating a tympanomeatal flap. A long-term tube was placed therein and fashioned to come out to the external auditory canal. Complications still did occur in 33% of these patients. These were blockage (9), perforation (5), granulation (3) and infection (2). However, the complication rate is certainly lower than transtympanic ventilation tubes, but more than those associated with grommets. The study does not indicate the association of nasal problems in these patients, but in patients where middle ear effusion occurs due to problems in the ear itself, this may be a useful alternative.
Endoscopically assisted full face lift
Reviewed by: Stuart Clark
May/Jun 2011 (Vol 20 No 2)
This paper from Brazil promotes endoscopically assisted limited incision full face lift. This procedure involves up to 11 small incisions approximately 1.5cm in length to allow the appropriate undermining for a face lift. It was completed on 35 female patients, with the advantages of shorter recovery time, with diminished risks and cost. They claim it has a low complication rate, with high satisfaction, although they recognise its limitations in this patient group and the learning curve involved. This technique seems most appropriate in smokers and bald male patients and I note that the mean age of treatment is 38. Therefore, whilst it may have some attractive features, they only undertook the procedure in 54 patients (13% of total patients undergoing face lift) over a 10 year period.
Laissez-faire for the lower eyelid
Reviewed by: Stuart Clark
May/Jun 2011 (Vol 20 No 2)
This paper from Liverpool reminds readers of the role of healing by secondary intention as a means of lower lid repair. Each of the four patients apparently had circumstances precluding them from involved methods of reconstruction. The author acknowledges the limitations and exclusion criteria for the technique are yet to be determined despite the fact that the results were 'surprisingly good'.
Scalp replantation
Reviewed by: Stuart Clark
May/Jun 2011 (Vol 20 No 2)
This case report from South Korea outlines what can sometimes be achieved even when prognosis is poor. This patient suffered the traumatic avulsion of the whole scalp including eyebrows, right ear, and approximately 1/3rd of the right cheek. There was an ischaemic time of 15 hours (the normal maximum quoted is 5-6 hours), heavy contamination, poor condition of the amputee and large surplus area involved. Some skin loss of the cheek and auricle occurred whilst the remainder of the scalp remained viable. The authors advocate that the sub dermal plexus rich areas despite being perforator-poor are worth considering to reconstruct acutely.
Endoscopic approach to the jugular foramen
Reviewed by: Gauri Mankekar
May/Jun 2011 (Vol 20 No 2)
This is an excellent anatomical paper, with beautiful pictures, showing how the limits of 'micro-invasive' endoscopic approaches can be expanded to approach hidden areas like the jugular foramen. The authors performed endoscopic transnasal dissection of the infratemporal fossa in three fresh heads. Two other double injected specimens were dissected externally to compare the different views and better understand the three dimensional relationships. They found that a septal and posterior maxillary window allows surgeons to gain access to the jugular foramen. During the procedure managing the vessels, especially the veins, and identification of the muscles is mandatory. They confirmed the fundamental role of the vidian canal in targeting the anterior genu of the internal carotid artery as well as the crucial role of the maxillary and mandibular branches of the trigeminal nerve and the Eustachian tube in this approach.
Facial reanimation with masseteric innervation
Reviewed by: Gauri Mankekar
May/Jun 2011 (Vol 20 No 2)
Loss of facial nerve function, especially both facial nerves, can influence the patient's quality of life. In this study the authors retrospectively analysed the functional outcomes of microneurovascular facial reanimation using masseteric innervation. Seventeen patients with irreparable facial paralysis following benign lesions of the facial nuclei (14 patients), and Mobius syndrome (three patients) were treated with free muscle flaps for oral commissural reanimation, using ipsilateral masseteric innervation and using temporalis muscle transfer for eyelid reanimation. In conjunction with electrical stimulation and retraining of the facial muscles, a natural smiling response was observed in 10 of 17 patients (59%) but synkinesis persisted for long periods after surgery. The authors conclude that masseteric innervation may play a future role not only in Mobius and Mobius-like patients but also in long-standing unilateral facial nerve paralysis due to other causes.
Trans-sphenoidal pituitary surgery
Reviewed by: Showkat Mirza
May/Jun 2011 (Vol 20 No 2)
This paper investigated the evidence of an operating learning curve after the introduction of endoscopic transsphenoidal surgery in a neurosurgical unit. The first 53 cases were compared with the next 72. They found a decrease in the mean duration of surgery for non-functioning adenomas from 120 to 91 minutes and the proportion of patients with an improvement in their preoperative visual field deficits increased from 80% to 93%. Endocrine remission rates for patients with Cushing's disease (50% to 83%) and acromegaly (80% to 86%) improved, but not to statistical significance. Nine cases had early re-exploration for residual disease. The mean hospital stay decreased from seven to four days. The authors made a note that there was no input from ear, nose and throat surgeons, but it is interesting to consider, that with collaboration, the results may have been even better, with a decreased need to re explore cases and no need for lumbar drainage or subsequent repair procedures for CSF leaks.
Transorbital approach to the anterior skull base
Reviewed by: Gauri Mankekar
May/Jun 2011 (Vol 20 No 2)
In this article, the authors describe their initial experience in 16 patients who underwent 20 transorbital neuroendoscopic surgeries (TONES) for anterior skull base lesions like repair of CSF leaks, optic nerve decompression, repair of cranial base fractures and removal of three skull base tumours. TONES describes a group of endoscopic surgical pathways that use a system of orbitotomies without removal of the orbital rim or frontal bone. To minimise orbital complications, the authors used corneal protectors with reduction of intra-orbital pressure at regular intervals. Only one of their patients had mild enophthalmos, without functional significance. The advantage of the procedure is that there are no visible scars, the craniotomy is minimal in size, only slight retraction is required for coplanar path-to-target dissection and even brain retraction is limited to that required for end target manipulation. Based on the anatomic studies and their own experience, the authors recommend precaruncular (PC) approach for access to the medial orbital apex, optic nerve and interorbital anterior cranial fossa; the preseptal lower eyelid approach (PS) for access to the floor of the orbital apex and the infraorbital nerve as it enters foramen rotundum; the lateral retrocanthal (LRC) approach access to the lateral orbital apex, infratemporal fosa and middle cranial fossa and the superior eyelid crease approach (SLC) for pathology of the supraorbital anterior cranial fossa.
Early intratympanic steroid for sudden sensorineural hearing loss
Reviewed by: Joanne Rimmer
May/Jun 2011 (Vol 20 No 2)
The diagnostic criteria and possible aetiologies of idiopathic sudden sensorineural hearing loss (ISSNHL) are reported, and features thought to relate to a worse prognosis are discussed. The mechanisms of action of steroids are explained, with the rationale for using intratympanic steroids. This study is a randomised controlled trial of 76 patients with 'poor prognosis' ISSNHL over two years. Thirty-nine 'control' patients were treated with 'conventional' systemic steroids, while 37 were given additional transtympanic injections of methylprednisolone after seven days of conventional treatment. Audiological assessment (with pure tone audiogram (PTA), speech discrimination score (SDS) and tympanometry) was performed every other day for the first week, then once or twice weekly. Patients who received additional transtympanic steroids had a significant improvement in PTA compared to the control group; 45.9% had at least a 15dB improvement at eight weeks compared with only 20.5% of controls. There were no long-term complications. SDS improvement was also significantly better in the transtympanic group. The reasons for a possible advantage of intratympanic steroid treatment are discussed, and the authors advocate larger controlled studies to evaluate this further.
Function after laser cordectomy
Reviewed by: Joanne Rimmer
May/Jun 2011 (Vol 20 No 2)
The debate over treatment of early glottic carcinoma continues to rage on, with little or no differences reported by many authors for local control, survival and function. This prospective study assesses functional outcome after unilateral laser cordectomy over 12 months. Sixteen patients were included, all of whom had been treated for T1 or T2 vocal cord tumours, with various types of laser cordectomy. Postoperative voice therapy began after four weeks, and both subjective and objective voice measurements were made at specific intervals over 12 months. Following limited surgery (type I or III cordectomy), there was a tendency toward gradual subjective voice improvement over the year. After more extensive surgery there was no clear trend found. More objective parameters, including videolaryngostroboscopy and acoustic analysis, showed broad variability but with a slight tendency to improve over time. The authors discuss variability as perhaps relating to the individual healing process, as well as the extent of surgery. Interestingly, there was a subjective deterioration for most patients at three to six months, despite corresponding improvements in objective parameters. The authors advocate voice therapy to commence as early as possible after surgery to minimise scarring and prevent unhelpful compensatory mechanisms of phonation.
The role of evolution on otitis media: bipedalism and the big brain and facial flattening?
Reviewed by: Annabelle CK Leong
May/Jun 2011 (Vol 20 No 2)
This is an extremely interesting invited article by Bluestone, postulating the role of evolution on the development of Otitis Media (OM). The high prevalence of middle ear disease is thought to be restricted to humans, in contrast to other species, as the associated hearing loss would render the predator or prey at a significant survival disadvantage in the wild. The advent of bipedalism in humans has resulted in constriction of the female pelvic outlet, due to the need for osseous support of abdominal contents and changes to increase biomechanical efficiency for locomotion. The resultant constraints on the rapidly enlarging human brain, on passing through the relatively small pelvic outlet, means that the human newborn is born 12 months too early, apparently a welldocumented anthropological fact. One consequence of being ‘born too soon’ is the structural and functional immaturity of the Eustachian tube, set against the context of an immature immune system, perhaps explaining the high incidence of acute OM in the first year of life. The added loss of facial prognathism, so-called facial flattening, due to adaptations for speech and cooking of our food, with subsequent changes in morphology of teeth, maxilla and mandible, has led to concomitant effects on Eustachian tube function. The Cavalier King Charles spaniel is used as a canine model of OM, as there is 40% prevalence of OM, requiring tympanostomy tube insertion. The breed has been artificially-selected to be brachycephalic (reduced front-to-back diameter of skull) with a short snout and hence has a constricted pharynx, with abnormal palatal anatomy. Analogously, it might be speculated that with the loss of their prognathic face, humans became susceptible to OM, an unintended result of natural selection. However, the racial variations in OM (the Chinese have a very low incidence of middle ear disease) certainly cannot be explained by these evolutionary theories!
Native language preference evident in infants following early cochlear implantation
Reviewed by: Rebecca Heywood
May/Jun 2011 (Vol 20 No 2)
Normally hearing infants demonstrate a preference for speech over other sounds, facilitating language development, and, even as newborns, seem to show a predilection for their native language over other non-native languages. Severe to-profound hearing impaired infants with cochlear implants also show a preference for speech, implying that suitably complex cues are provided by the CI and that sufficient auditory plasticity exists to develop this preference in response to a distorted speech signal. This study compared the perceptual bias for language of normal hearing infants (mean age 8 months) with that of infants with profound congenital hearing loss (mean age 18 months) who had undergone cochlear implantation 1-2 months earlier, by assessing the duration of gaze towards a screen, while the native or a non-native language was randomly emitted. The sample size was small – 28 infants in total. They found that the mean listening time was longer in response to both native and non-native languages in the normal hearing than the CI group. This can be explained by shorter exposure to any auditory stimulus (1-2months only) of the CI infants, but could also imply a degree of attention deficit arising as a result of their period of absent auditory input – which may affect later acquisition of cognitive skills. In both groups, mean listening time was significantly longer in response to the native language, indicating that perceptual bias for the native language is maintained despite a period of auditory deprivation. Future work will hopefully further assess language acquisition and attention to auditory input in CI children over longer periods post-implantation.
Robotic assessment of force profiles during cochlear implant electrode insertion
Reviewed by: Rebecca Heywood
May/Jun 2011 (Vol 20 No 2)
Robotic surgery is fairly new on the scene in ENT, but has potential advantages in surgery such as cochlear implantation, where minimisation of insertion force may reduce surgical trauma to residual hair cells. Robotic electrode insertion is also repeatable and can reduce intra- and intersurgeon variability in force of insertion. Here the authors used a robotic insertion device to compare the force profiles of two methods of insertion of stylet containing electrode arrays; first, using the traditional technique whereby the stylet is removed after full insertion of the electrode, and, secondly, using the Advance Off Stylet (AOS) technique, where the electrode is inserted a designated distance and then advanced, while the stylet is held steady relative to the cochlea. The automated device consisted of an insertion tool coupled to a force-sensing carriage. Four successful insertions into a 3D model of the scala tympani were performed for each technique. The average forces recorded during insertion were very similar for the first 7mm of insertion but, thereafter, the force applied during traditional straight insertion increased rapidly, with a statistically significant difference in force between the two techniques at 9.74mm. The average force recorded during AOS insertion was less than that required to rupture the basilar membrane in a human cadaver, while during straight insertion the average force exceeded it. They conclude therefore that the electrode is more likely to remain in the scala tympani using AOS insertion with better hearing outcomes. It will be interesting to watch the progress of robotic techniques in cochlear implantation and their applications in vivo.
Can air pollutants have an effect on foetal immune development?
Reviewed by: Evangelia Tsakiropoulou
May/Jun 2011 (Vol 20 No 2)
The impact of air pollution exposure on foetal immune development is examined in this interesting Czech study. Total cord serum IgE and mothers’ total IgE levels from 459 births were correlated with concentrations of polycyclic aromatic hydrocarbons measured in ambient air. The study results revealed a lower prevalence of elevated cord IgE, when high pollutant exposure occurred during the first trimester. In contrary, increased exposures in mid-pregnancy were associated with a higher prevalence of elevated cord IgE. Regarding gestational months four to seven, polycyclic aromatic hydrocarbon exposure was associated with elevated cord IgE concentrations. However, no significant association of cord IgE with exposures was observed in the eighth and ninth months. The above findings suggested that exposure in the critical period of foetal organogenesis may have a longer term impact on immunologic maturation through stimulation of B-cell and increased production of circulating IgE. Another interesting point was that infants whose mothers were non-atopic were more sensitive.
Bimodal hearing or bilateral cochlear implants?
Reviewed by: Vinaya KC Manchaiah
May/Jun 2011 (Vol 20 No 2)
The evidence from psychoacoustics and hearing aid literature has demonstrated a number of advantages from binaural stimulation. For this reason, there has been an increase in clinical use of bimodal hearing (a unilateral cochlear implant and a hearing aid on the other ear) and bilateral cochlear implants (CI). There has also been an increase in interest in research evaluating the clinical efficiency and the cost effectiveness of these treatment options. This review evaluates the recent clinical research in terms of speech recognition in quiet and noise, localisation ability, and perceived benefit. It is recognised that both bimodal hearing and bilateral CIs are advantageous in providing stimulation of both ears, and both the treatment approaches have significant advantages for the patient, compared with unilateral listening. The bilateral CI showed benefits in one or more areas, such as speech recognition in quiet and in background noise across several listening configurations, in lateralisation and localisation abilities, and in perceived benefit and satisfaction compared to unilateral CI. However, bimodal hearing appears to provide a good nonsurgical alternative to bilateral CIs for patients who have sufficient residual low-frequency hearing sensitivity. In addition, the authors also provide some recommendations on candidacy for bimodal hearing and binaural CIs.
Endoscopic transcranial and intracranial resection: perioperative management protocol
Reviewed by: Andy Hall
May/Jun 2011 (Vol 20 No 2)
This case note review of patients treated for anterior skull base neoplasms from September 2005 to April 2009 at the University of Pennsylvania Otolaryngology department aims to evaluate perioperative management in this subgroup of patients. Through evaluation of their data, lumbar drain placement is now only performed for patients undergoing a transplanum-transtuberculum approach due to the relatively low risk of postoperative CSF leak in transcribriform / transclival cases. The authors acknowledge that due to inability to derive a randomised controlled trial for this patient group due to epidemiological and ethical reasons, it is instead only through prospective analysis of treatment paradigms and outcomes that patient management can be optimised. I share the authors' belief that is only through multi-institutional collaboration across disciplines that the most pertinent questions may be answered, but the article represents a useful 'stop-gap' in outlining the experience of one centre in purely endoscopic anterior skull base ontological surgery.
Outcomes of direct facial to hypoglossal neurorrhaphy with parotid release
Reviewed by: Andy Hall
May/Jun 2011 (Vol 20 No 2)
This retrospective case series aims to evaluate the outcomes of a single American centre following facial-hypoglossal neurorrhaphy with parotid release. The technique necessitates sacrifice of the nerve to stapedius and the chorda tympani during the transposition but the parotid release manoeuvre facilitates a single tensionless anastamosis to the hypoglossal nerve distal to the ansa hypoglossi. Twenty-one patients between 1999-2008 were included and objective measurements of subsequent facial nerve function utilised the Repaired Facial Nerve Recovery Scale (RFNRS), along with subjective patient satisfaction questionnaires. Postoperative improvement from absent function to independent movement of eyelids and mouth, slight mass motion and slight forehead movement was found in two thirds of cases with no complications of hemi-lingual atrophy or loss of tongue function. Eye-dryness was, however, identified in 50% of cases. Interestingly the effect of prior paralysis duration on outcome is unclear from this case-series. Assessing this technique in a prospective manner with blinded facial assessment would be a means of further improving the evaluation of this technique.
The stomach and the ear!
Reviewed by: Badr Eldin Mostafa
May/Jun 2011 (Vol 20 No 2)
We are all familiar with the nauseous sensation resulting from inner ear stimulation and in this article the effect of proton pump inhibitors on the ear was studied. The authors observed that patients with Ménière’s disease, taking PPI for other indications, suffered fewer attacks than those who did not. The authors admit the shortcomings of the study, which was retrospective without stratification of the patients or any sort of objective evaluation. However, the subjective improvement in the symptoms during the intake of the PPI for other reasons rules out the placebo effect and is more than coincidental. A more prospective and well designed study deserves to be conducted to confirm or refute this interesting hypothesis.
GORD and surgery
Reviewed by: Badr Eldin Mostafa
May/Jun 2011 (Vol 20 No 2)
Laryngopharyngeal symptoms such as cough and sore throat are common manifestations of gastroesophageal reflux. A number of patients do not have heartburn or lower oesophageal manifestations. Treatment is usually medical but, when it fails, surgery may be needed. The authors compare the results of fundoplication on the satisfaction score of patients with GORD-related laryngopharyngeal symptoms. Scores were higher in patients who had heartburn as well compared to those without. They conclude that these patients may not be the ideal candidates for surgery and they should be advised on the limited benefit expected. It seems that fundoplication should be revised as a concept as its longterm efficacy versus side-effects is not very impressive in most cases of GORD.
Unilateral sudden sensorineural hearing loss – a new intratympanic steroid protocol
Reviewed by: Victoria Possamai
Mar/Apr 2011(Vol 20 No 1)
This study was carried out at the University of Rome. The investigators aimed to assess the success of using intratympanic steroids alone, early in the course of sudden sensorineural hearing loss. Thirty-four patients were recruited in a nine month period in 2009. All had administration of steroid therapy within 15 days of onset of symptoms. The regimen used was 0.4mls of 62.5mg/ml prednisolone in saline. This was injected across the tympanic membrane after local anaesthetic administration, on three consecutive days. Outcome criteria used were based on those used in a previous study by Furuhashi, and described as being the most stringent of those in the literature on this topic. Complete recovery = PTA average 30dB, partial improvement = improvement of PTA average of 10-30dB, non-recovery = improvement in PTA average
Does smoking increase the risk of recurrence of sinonasal inverted papilloma?
Reviewed by: Edward W Fisher
Mar/Apr 2011(Vol 20 No 1)
This paper evaluated 132 patients with inverted papilloma over a 22 year period in a large unit in Seoul. Recurrence rates were looked at in relation to a wide variety of variables (such as stage / site, surgical methods, diabetes, smoking behaviour and hypertension). The recurrence rate was higher in smokers (28%) compared to non-smokers (10%). The extent of extranasal / extrasinus extension was also a bad prognostic factor. I am a little sceptical about the validity clinically of the smoking finding, since the numbers are comparatively small for such an important finding to be regarded as proven, but the behaviour of other tumours in relation to smoking habit would suggest that on balance of probabilities it would be wise to advise our patients to stop smoking. As good doctors, though, we should have already advised them to stop smoking for a host of other medical reasons.
Keep on checking the immunoglobulins in rhinosinusitis patients
Reviewed by: Edward W Fisher
Mar/Apr 2011(Vol 20 No 1)
ENT surgeons are encouraged by immunologists to check routinely the serum immunoglobulin levels in sinusitis patients and to check the functional antibodies in patients with normal immunoglobulin levels. At times this can seem a lot of effort for little return, but this study encourages us to continue with such a policy. The patients were all surgical patients who had undergone endoscopic surgery for sinusitis which had failed trials of adequate medical therapy. Although the study was retrospective, the authors excluded known causes of secondary immunodeficiency in their analysis. Out of 67 patients, 9% had a low IgG, 12% a low IgM and 3% a low IgA. Moreover, out of 51 patients who underwent detailed functional antibody tests before and after vaccination to pneumococcal polysaccharide, 67% failed to produce a good response. We are encouraged to continue to look for humoral immodeficiency in our patients.
Technology helping the surgeon around the frontal recess
Reviewed by: Edward W Fisher
Mar/Apr 2011(Vol 20 No 1)
This beautifully illustrated article uses three dimensional CT reconstructions to allow mapping and analysis of the ostial orientation in the frontal recess. This is a field in which there is potential for patients' problems to be compounded by iatrogenic complications and while it can be helpful to use navigation systems to assist, this is not the whole answer. 3D reconstructions allow a much more intuitive analysis of the anatomy and if this can be achieved practically and at reasonable cost, it is hard to see a frontal sinus surgeon refusing such an ancillary technique for improving anatomical analysis.
An imaging trip on the road to hearing
Reviewed by: Diego Zanetti
Mar/Apr 2011(Vol 20 No 1)
Nowadays, computed tomography (CT) and magnetic resonance (MR) can satisfactorily define the anatomical structures along the auditory pathways, from the external ear canal to the auditory cortex. Multi-slice helical CT allows one to scan large volumes in shorter times; post-procressing provides 3D image reconstruction, such as in virtual endoscopy, except in atresia cases. Multiple intensity projection (MIP), surface rendering (SR) and volume rendering (VR) can, at present, be complementary to the axial 2D images (without replacing them); their value in helping the differential diagnosis (for example perilymphatic fistula) or in the postoperative evaluation (for example assessment of the position of an ossicular prosthesis) must be weighed against the cost and time consumed by their use. Their reliability, which is still biased by the operator's interpretation, is expected to be further enhanced by new CT technologies such as 'flat panel volume CT', which uses different x-ray detectors, achieving higher spatial resolution. Similarly, spatial resolution of MR can be increased by higher-field machines; nevertheless, as the author – an experienced oto-neuroradiologist – points out, current algorithms available on 1.5 Tesla devices, when correctly employed and combined, are sufficiently sensitive to detect soft tissue abnormalities within the inner ear fluids, IAC and central auditory pathways. For example diffusion tensor imaging (DTI) or MR tractography permits 'in vivo' depiction of white matter bundles in the brain and spinal cord, utilising the anisotropic diffusion of water along the axonal fibres. Through MR it is possible to analyse not only morphological but also functional aspects of the auditory brain, such as the patterns of cortical activation during listening tasks. Functional analysis of the hearing processes at the cortical level exploits the so-called blood oxygenation level dependent (BOLD) effect used in functional MRI (fMRI). Through fMRI, tonotopy of the auditory cortex may be displayed in real time, although cardiac and pulmonary cycle effects, venous drainage and patient's head misalignment are still potential sources of artefacts to be overcome. Undoubtedly, any advanced or new imaging techniques should be employed with caution, and always interpreted in association with audiological and neurological examination. The plentiful gallery of images included in the article is certainly an amazing tour inside the current imaging capabilities of our sense of hearing.
Images of the listening brain
Reviewed by: Diego Zanetti
Mar/Apr 2011(Vol 20 No 1)
Until very recently, the study of the auditory system, by means of electrophysiological or behavioural methods, had proceeded at a considerably slower pace than of other sensory systems. Substantial advances in the comprehension of the functional organisation of the cortical auditory system have followed the introduction of functional magnetic resonance imaging (fMRI). It does not depict the neural activity directly, but through the local haemodynamic perturbations induced by an acoustic stimulus, via the blood oxygenation level dependent (BOLD) effect. Compared with PET and SPECT, its spatial (fractions of millimetres) and temporal (100msec) resolution is much higher. In order to visualise the processing of auditory stimuli, a number of technical problems had to be solved, including the complex neurovascular anatomy and some peculiar interactions between audition mechanisms and fMRI techniques. One big issue is the loud noise the magnetic field apparatus produces during echo-planar and other images acquisition, interfering with the experimental sound stimuli. To overcome these problems, different approaches have recently been proposed, which generally require a careful tailoring of the experimental designs of fMRI methodology, and of the strategies of data processing, such as silent MRI sequences, passive or active noise reduction devices and de-synchronisation of the stimulus from the processing of the BOLD response. This article reviews the present state of fMRI research on audition, examining the solutions already existing and those under development in relation to the specific problems of auditory fMRI. The increasing knowledge about the functioning of the auditory brain provided by fMRI research has already opened new avenues in the understanding of higher level neural processes in audition.
Pictures of an adapting brain
Reviewed by: Diego Zanetti
Mar/Apr 2011(Vol 20 No 1)
As a consequence of cochlear function damage, the adult auditory brain undergoes a series of degenerative processes. Ultrastructural studies have shown that the degeneration in the ventral cochlear nucleus (VCN) is completed within nine days of cochlear nerve deafferentation. In an adult brain, neuroplasticity, that is the ability to repair, adapt and regenerate, is considered to be almost absent. Over recent years the authors obtained evidence that, following cochlear ablation, degeneration is accompanied by some degree of regeneration, actually from the emergence of the growth and plasticity-associated protein GAP-43. If regenerative processes do indeed occur, it would be important to know which mode they follow: they could reactivate signalling networks that were active during earlier stages of CNS development, or they might summon new molecules and cells that are unique for recovery. In a series of animal experiments, the scientists at Freiburg University either removed the cochlea, or stimulated it electrically via a cochlear implant. Slices of the rats’ brains and brainstems were then examined at different time points, after staining with antibodies against a set of signalling molecules that are thought to boost after loss, or substitution of, cochlear activity in the cochlear nuclei: neuronal markers such as GAP-43; the cAMP binding protein CREB; the microtubule-associated protein, MAP1B; the neuronal adhesion molecule, PSA-NCAM; glial markers such as GFAP, ezrin and OX-42; and the matrix metalloproteinases MMP2 and MMP9. What they were able to demonstrate is that, despite the complete silencing of spiking activity, only a limited loss of synapses (<40%) and no loss of neurons in the cochlear nucleus (and beyond) was triggered by the cochleotomy. Remarkably, a series of molecular rearrangements was promoted by sustained electrical stimulation. The evidence came from the overexpression of GAP-43 and MMP, which might help neurons grow new axons and form new synapses, guided by the artificially stimulated neuronal activity. This kind of knowledge can be essential to open new options for therapeutic interventions.
Impact of diabetes and cardiovascular problems on sensorineural hearing loss
Reviewed by: Ahmed A Saada
Mar/Apr 2011(Vol 20 No 1)
Impact of diabetes and cardiovascular problems on sensorineural hearing loss This manuscript answers some questions about the notion of the role of diabetes and cardiovascular risk factors in the pathogenesis of idiopathic sudden sensorineural hearing loss. This type of hearing disorder presents in an acute form with an incidence of 5-20/100,000 individuals per year; and the site of insult is believed to be localised in the cochlea. The study population included two groups of case and control subjects who were matched for age and gender. Risk factors that were measured included smoking history, total serum cholesterol and triglycerides, history of hypertension and diabetes mellitus. Apart from history taking, otorhinolaryngological examination and lab studies, all subjects underwent complete audiological evaluation. Results showed that cases with idiopathic sudden sensorineural hearing loss had a greater prevalence of diabetes and hypercholesterolemia. However, no statistical differences were noted in the incidence of hypertension, smoking and serum levels of triglycerides. The authors discussed the different theories of pathophysiological mechanisms proposed in the literature, including autoimmune and metabolic disorders, inner ear viral infection as well as vascular causes with a thorough analysis of each. It was concluded that diabetes, hypercholesterolemia and high burden of cardiovascular risk factors are associated with the risk of idiopathic sudden sensorineural hearing loss. Such hazard tended to step up as the number of risk factors increased. It was recommended that patients with idiopathic sudden sensorineural hearing loss should be screened for diabetes and for previously mentioned cardiovascular risk factors. It was further suggested to include the use of glycated hemoglobin test.
Can n-CPAP to inflate the sinuses?
Reviewed by: Iordanis Konstantinidis
Mar/Apr 2011(Vol 20 No 1)
Nasal continuous positive airway pressure therapy provides positive pressure air into the nasal cavity. Similarly to nose blowing, positive pressures are generating in the nasal cavities. Due to the duration of nCPAP therapy its use raises the question as to whether the positive pressure causes bone deformation. The authors evaluated nine OSAS patients with pressure measurements, during nose blowing (Politzer nasal olive connected to a pressure transducer) and CT scans of the sinuses. Evaluation was made initially and after a six month treatment with nCPAP. The authors did not demonstrate any alterations in sinus dimension, suggesting that the paranasal sinus structures are not affected by long-duration therapy. However, the nose blowing pressure decreased. This can be attributed to the reduction of oedema and inflammation of the nasal cavity after long-term therapy, in contrast to the beginning of the treatment. Complications such as pneumosinus or orbital emphysema can occur during nose blowing; however this is a result of an acute and high increase of pressure. CPAP therapy usually produces lower pressure for some hours, a different pattern of pressure application within the nasal cavity. In any case, the idea is interesting. However the sample size is low and the follow-up very limited to report structural changes. It would be interesting to see a comparison between a normal population and long-term users of nCPAP (more than 4-5 years).
The effect of Neramexane on Tinnitus – a Phase II trial
Reviewed by: Victor Y Osei-Lah
Mar/Apr 2011(Vol 20 No 1)
The search for a cure for tinnitus goes on and this Phase II randomised, placebo-controlled, double-blind study is a useful contribution. It is well known that the development and perception of tinnitus is influenced by nicotinic acetylcholine (n-Ach) and N-methyl-D-aspartate (NMDA) receptors. In particular, the a9a10 n-Ach receptors are inhibitory to the efferent auditory pathway. Neramexane mesylate has a dual role of antagonising both a9a10 n-Ach and NMDA receptors and hence was used in this study. After screening, 429 adult subjects (18-65 years) with persistent moderate to severe tinnitus were randomised into the four arms of the study: a placebo arm and three treatment groups receiving 25mg/day, 50mg/day and 75mg/day of neramexane mesylate respectively, over a 16-week period. Three hundred and twenty subjects completed the study. Tinnitus severity was assessed with the German version of the short Tinnitus Handicap Inventory (THI-12) and the Clinical Global Impression of Tinnitus severity (CGI-S). Co-morbid anxiety / depression were assessed with the Hospital Anxiety and Depression Score (HADS). Subjects with pulsatile / intermittent tinnitus, conductive hearing loss, a range of neurological disorders and those on other treatments for tinnitus were excluded. At week 16 the largest statistically significant improvement in THI-12 scores was in the 50mg/d group followed by the 75/d group but there were more side-effects in the latter. Improvement in all treatment groups was better than controls. After discontinuation of treatment, it was interesting that improvement in tinnitus was reported four weeks later in the 50mg/d group (half life of neramexane is 30-45 hours). Another finding was HADS score did not change in all four arms. Overall, the study was well constructed and administered. The results are promising and the outcome of the ongoing international Phase III clinical trial is eagerly awaited.
Cochlear implantation as a medical tourism operation
Reviewed by: Thomas Nikolopoulos
Mar/Apr 2011(Vol 20 No 1)
With the increasing cost of surgical operations in the developed countries, some such procedures are now combined with tourism in the developing countries as most cost-effective. The authors compared the costs of medical tourism in cochlear implant surgery performed in India as compared to the United States. In addition, the cost savings of obtaining cochlear implant surgery in India were compared to those of other surgical interventions obtained as a medical tourist. The results revealed that the range of cost depended on length of stay as well as the device chosen. Generally the cost, inclusive of travel, surgery and device, was in the range of $21,000-30,000, as compared to a cost range of $40,000-$60,000 in the US. The authors concluded that, while cardiovascular and orthopaedic surgery performed outside the United States, in India at centres that cater to medical tourists, is often performed at one-quarter to one-third of the cost that would have been paid in the United States, the cost differential for cochlear implants is not nearly as favourable. Moreover, the quality of the service should be taken into account before any serious considerations of the issue.
Complications of paediatric cochlear implantation in a centre in Canada and comparison with the respective rates in the literature
Reviewed by: Thomas Nikolopoulos
Mar/Apr 2011(Vol 20 No 1)
The authors' aim was to estimate the rates of complications associated with paediatric cochlear implantation in one Canadian cochlear implant centre and compare them with the respective ones in the published literature. This study was retrospective and reviewed the files in the Canadian cochlear implant, so as to assess complication rates. The study included 224 children who had undergone surgery from 1994 to June 2007. The authors, based on the results of the study, suggested that the rates of complications at the local Canadian paediatric CI centre were not significantly different from the literature rates for all examined complication types. However, such conclusions and any comparisons are rather weak, when we take into account the various classification systems used in the literature and the sometimes subjective estimation of how serious a complication is. In addition, the retrospective nature of the study does not contribute to robust conclusions. For example, the fact that mastoiditis had occurred in eight cases would suggest further investigation regarding the true mastoiditis rate and how this complication was defined.
Lean thinking techniques (less waste – more effective) in cochlear implantation
Reviewed by: Thomas Nikolopoulos
Mar/Apr 2011(Vol 20 No 1)
Lean thinking techniques (less waste – more effective) in cochlear implantation Lean thinking has been applied in industry in order to reduce all waste and make companies more effective. The authors attempted to apply similar techniques in the cochlear implant procedure in their department. Analysis of the patient's pathway, from referral to implantation surgery, highlighted areas of 'waste' that were causing delays in the downstream processes. Through a number of streamlining measures, a large waiting list of long-waiting patients (n = 141) has been cleared. Of those patients not receiving a preliminary hearing aid trial, 89% were implanted within 18 weeks (31/35 patients). Of those receiving the hearing aid trial, 100% were assessed and commenced on the trial within 18 weeks, and 47% received implantation within the allotted time frame (7/15 patients). The unit, according to the authors, is continuing to monitor these processes to ensure these changes are continuing to maintain shorter waiting times. However, as the authors admit in their conclusion, irrespective of the waiting times, all patients should feel that they have received optimal care and sufficient information throughout the entire patient pathway. In other words, shorter waiting times and cost-effectiveness should not be based on lower quality.
Complications of adenotonsillectomy
Reviewed by: Susan A Douglas
Mar/Apr 2011(Vol 20 No 1)
This paper is primarily based on working patterns in the USA. It examines the complications of adenotonsillectomy, compared to the surgical techniques used. The authors also examine certain at risk patient groups, such as children with coagulopathy and obesity. The complications of surgical techniques such as microdebrider, coblation or monopolar electrocautery are discussed. The thermal complications of electrocautery are discussed and the potential for soft tissue injury. The authors also give a review of the potential complications of antiemetic drugs and analgesia such as ketoralac and codeine. The potential presence of a genetic abnormality, leading to increased metabolic conversion of codeine to morphine, is described. This abnormality has been implicated in the death of a two year old child, after adenotonsillectomy for obstructive sleep apnoea. The management of post-tonsillectomy haemorrhage is discussed and the less common complication of atlantoaxial subluxation. The authors also discuss surgery in obese children. Obese children have an increased risk of intraoperative desaturations as well as higher rates of overall complications. This paper is well written and gives a comprehensive review of the complications of adenotonsillectomy.
Periocular rejuvenation
Reviewed by: Stuart Clark
Mar/Apr 2011(Vol 20 No 1)
The volume for August 2010, deals with periocular rejuvenation including upper and lower lid, brow, forehead, fats and fillers, including complications. Each chapter is well illustrated both with diagrams and photographs and the layout makes it generally easy reading. At times the detail is a little superficial and therefore throughout each chapter it feels as though it may be a brief overview and lacking some real substance.
Choice of facial nerve reconstruction in a nerve palsy
Reviewed by: Sachin Patil
Mar/Apr 2011(Vol 20 No 1)
Facial nerve reconstruction is the least common procedure performed by head and neck surgeons. This article gives an experience on strategies to ensure optimal functional results for the patients based on a small case series with a large variety of surgical techniques. It also highlights the need for a standardised approach for diagnosis and treatment of patients asking for facial rehabilitation. The term facial palsy summarises incomplete loss (paresis) as well as complete loss (paralysis) of facial nerve function. The distinction is very important as the indication for surgical reconstruction in patients with incomplete facial palsy has to be proven much more critically. On the other hand, reconstruction in case of a complete functional deficit is more complex. Permanent facial palsy and non-transient functional deficits are the main indication for surgical reconstruction of facial nerve function. An exact classification of the individual facial palsy is mandatory prior to surgical decision making. Table 1 gives a good summary of classification of facial palsy causes and guidelines for surgical reanimation. Importance of preoperative evaluation with EMG and MRI scan is very well demonstrated. The basis for the selection of the rehabilitation technique choice depends on the lesion site and the duration of palsy. These two parameters help in categorising all surgical rehabilitation techniques in three categories a) early extratemporal reconstruction, b) early reconstruction in case of proximal lesion or impossibility of direct extratemporal reconstruction, and c) delayed or late reconstruction or congenital facial palsy. The flow chart gives a good summary of choice of procedure depending on category of facial palsy. This to me is overall a good comprehensive review article for facial nerve reconstruction. A bigger case series with some statistical input would have made this review much better.
The clinicopathologic characteristics of oral squamous cell carcinoma in non-smoking and non-drinking patients
Reviewed by: Laith Tapponi
Mar/Apr 2011(Vol 20 No 1)
The authors' aim was to evaluate risk factors in non-smoking and non-drinking patients, in particular gender, site, TN status, and rates of metastases or recurrence. This is a review of files of 278 patients with oral squamous cell carcinoma (SCC) over 12 months. Out of 278 patients, only 67 were non-smoking and non-drinking. The majority of these patients were over 70 years old, and the most common tumour sites were the mandibular alveolar ridge and the oral maxilla, these facts supported other studies which reported a higher average age of non-smokers in comparison to smokers. The tongue and floor of the mouth SCC were the most common tumour site in smokers. This study however differs from previously recorded data showing higher rates of oral cancer for women, whether exposed to tobacco or alcohol or not. In relation to the TN status, recurrence and metastases rates seem to be no different between patients with or without smoking or alcohol consumption. The limitations of a non-randomised retrospective study warrant multi-institutional prospective based studies for the future.
Pneumatisation of the suprabullar recess and the vertical distance of the anterior ethmoidal artery from the skull base: Radiological correlation
Reviewed by: B Viswanatha
Mar/Apr 2011(Vol 20 No 1)
The anterior ethmoidal artery [AEA] is an important landmark in functional endoscopic sinus surgery. Its identification in preoperative CT scans is very essential to prevent any damage to AEA. According to the authors, there are few studies which correlate the presence of a supraorbital ethmoidal cell with the location of AEA. This retrospective study of CT scans was done to determine the reliability of identification of the artery on the coronal CT scans and to determine whether a correlation exists between the pneumatisation of the suprabullar recess and the vertical distance of the AEA from the skull base. This article presents data from randomly selected 50 preoperative CT scans. The AEA was identified on coronal CT scans on each side and its distance from the base of the skull was measured individually. The bony canal of the AEA was identified, running across the ethmoidal cavity. CT scans were divided into two groups, based on the presence or absence of supraorbital ethmoidal cell. Each group was further subdivided into three subgroups, based on the distance of the AEA from the base of the skull (Group I 5mm). The AEA was reliably identified in 97 sides and it could not be identified in three sides on the CT scans. Only 20% of the AEA were seen in the base of the skull and 80% of the AEA were seen lying at a level lower than the base of the skull. This study has shown a strong correlation between the vertical distance of the AEA from the base of the skull and the presence of supraorbital ethmoidal cell. In the presence of a supraorbital ethmoidal cell, the AEA crosses the ethmoid cavity at much lower level, as compared to when supraorbital ethmoidal cell is absent. The authors are of the opinion that AEA is more susceptible to injury in cases where the supraorbital ethmoidal cell is present.
Importance of history taking
Reviewed by: Rhodri C Costello
Mar/Apr 2011(Vol 20 No 1)
The authors describe a rare complication following maxillary tooth extraction, and oroantral fistula formation. Following maxillary tooth extraction, fistula formation occurs in 1-55% patients, depending upon the location of the tooth extracted. Maxillary sinusitis can develop within hours if an oroantral fistula is left open, hence prompt closure is required. The buccal mucoperiosteal flap (Published by Rehrmann, 1936) is the commonest technique, amongst many, for closure of these fistula. A 51 year old female presented to the authors, with symptoms of serous nasal discharge upon eating, six months after extraction of 1st and 2nd upper premolars, with subsequent closure of an oroantral fistula with a Rehrmann flap. On examination, the papilla of the Parotid duct could not be demonstrated, and saliva could not be expressed on the affected side. CT examination was performed and demonstrated a fluid level in the right maxillary sinus. Suspecting iatrogenic transfer of the Parotid duct into the right maxillary sinus, methylene blue was injected into the Parotid gland intraoperatively, the duct was identified, and repositioned into the buccal mucosa. Post-op the patient has remained asymptomatic. Clearly the link between food intake and symptoms, absence of saliva secretion into the oral cavity on the affected side, and the serous secretion from the nose leads the clinician towards the diagnosis of this rare complication, of iatrogenic transposition of the Parotid duct into the maxillary sinus. This case demonstrated how a clear thought process, along with thorough history taking and clinical examination, can lead the clinician to the diagnosis, even when the diagnosis is a very rare complication.
Cartilage island graft tympanoplasty
Reviewed by: Susan A Douglas
Mar/Apr 2011(Vol 20 No 1)
This article gives a retrospective review of the use of island cartilage grafts in tympanoplasty. The procedures were performed for chronic otitis media with cholesteatoma, polyps or adhesive otitis / retraction pocket with or without cholesteatoma. The author gives a description of the surgical technique used to harvest and insert the graft. The graft success rate for the 36 cases was 88.9%. The mean follow-up was 24.8 months. The results indicate that the island cartilage graft is reliable for use in middle ear surgery. An evaluation of the audiology results is also given. The article gives a clear description of the surgical technique. The numbers of patients are however small and the follow-up relatively short. Larger studies with longer follow-up are needed to confirm these results.
Noise damage can cause asymmetrical hearing loss
Reviewed by: Madhup K Chaurasia
Mar/Apr 2011(Vol 20 No 1)
An individual's claim for noise induced hearing loss is often impeded if the hearing loss is asymmetrical. In this study the authors found the prevalence of asymmetric hearing loss as high as 22.6% in 208 consecutive clients, referred following assessment of hearing loss for compensation purposes. Several studies from the literature report asymmetric hearing loss, presumably due to noise exposure, ranging from 4.7 to 35%. Various causes for asymmetry are discussed. Apart from the source of noise, which may be primarily on one side, such as in those using rifles or unilateral headphones, the susceptibility of the ears and individual considerations also matter. Tolerance to sound may vary between individuals and recovery from noise of one ear may not be the same as the other. This article provides interesting reading on the methodology to infer noise induced hearing loss in the legal setting and methods relying on probabilities are discussed. In this context, the authors feel that, on the balance of probabilities, it should be possible for an ENT expert to relate hearing loss to noise even if it is asymmetric, without the support of an MRI to exclude retrocochlear causes. Reference is made to the current Australian Society of Otolaryngology / Head and Neck Surgery guidelines for evaluation of occupational noise induced hearing loss, which seem to unjustly favour the employer at the cost of the employee in cases of asymmetrical hearing loss. This article is particularly helpful to expert witnesses involved in assessing noise induced hearing loss, specially where compensation may be tedious and difficult if the hearing loss is unilateral.
Patient related outcomes of FESS surgery
Reviewed by: Madhup K Chaurasia
Mar/Apr 2011(Vol 20 No 1)
Functional endoscopic sinus surgery is now an established treatment for chronic sinusitis, in patients who have failed medical treatment. In this study the outcome of surgery is assessed from two view points, namely improvement in symptoms and improvement in the quality of life. The former was assessed by the disease specific quality of life outcomes. These were evaluated with the help of a chronic sinusitis survey, which is a six item duration- based questionnaire focusing on nasal and sinus symptoms. There was a statistically significant improvement in 72% patients, 12% became worse and 15% were the same after surgery. Their quality of life was assessed using a short form 12 questionnaire. This had physical and mental components in the evaluation. However, there was no statistically significant improvement reported by this method of assessment. The message here is that FESS improves the quality of life, in terms of abatement of symptoms, but there is no significant effect on general health. It must however be understood that the results are largely subjective and overlay of factors other than symptoms of chronic sinusitis needs to be assessed more thoroughly.
Canthal reconstruction
Reviewed by: Stuart Clark
Mar/Apr 2011(Vol 20 No 1)
This review from Rotterdam primarily consists of a long list and overview of the literature. There are brief suggestions for a variety of defects and these on occasions relate to the list of references. The list of references is a useful 'cookbook' in itself and this is the greatest value of this article.
Check of electrode fitting in CI patients with normal contralateral hearing
Reviewed by: Iordanis Konstantinidis
Mar/Apr 2011(Vol 20 No 1)
This is an interesting study concerning the relationship between the neural excitation produced by stimulating a cochlear implant electrode and that produced by a given acoustic stimulus in the normal contralateral ear. Four patients were enrolled in this study with a rare condition of having normal hearing in the non-implanted ear. All patients received a cochlear implant for alleviating tinnitus. The authors investigated the locus of excitation along the auditory nerve produced by electric and acoustic stimulation. The techniques used were pitch adjustment, constant stimuli, and interleaved adaptive procedures. The main finding of the research was that all three techniques are subject to non-sensory biases arising from the range of acoustic stimuli presented. Similar biases occur even for normal hearing listeners and for other widely used procedures. However, it is nevertheless possible to obtain reliable electric acoustic matches that are relatively free from range biases, for a subset of cochlear implanted subjects and conditions. The results of the study may give useful information regarding the fitting of cochlear implants in cases with residual hearing in one ear. However the number of patients is relatively low for clear conclusions.
Concurrent abnormalities of the vocal fold associated with polyps
Reviewed by: B Viswanatha
Mar/Apr 2011(Vol 20 No 1)
This retrospective review was done at tertiary teaching institute. The objective of the study was to report the finding of unsuspected underlying concurrent abnormalities of the vocal fold [VF] associated with polyps. This article presents data from operative and clinical notes of 81 adults submitted to suspension laryngoscopy for vocal fold polyp [VFP] excision from 1998 to 2007, which had no previous report of associated structural abnormalities. A total of 81 patients met the inclusion criteria. The variables studied were: patient’s age, duration of complaints, type of polyp, side of polyp, presence of associated (previously unsuspected) lesions on the VFs, side of associated lesion(s). The diagnosis of VFP was both clinical and histological with hematoxylin-eosin staining of excised material. Most of the polyps were described as myxoid (56/81; 63.5%), 15 were haemorrhagic (18.5%) and 10 were fibroid (8%). Associated lesions were present in 54 patients (67%) (35 contralateral, 16 ipsilateral, and three bilateral): 18 reactive nodules, 21 sulcus vocalis, five cysts, two microwebs, and eight capillary ectasias. Statistical analysis was carried out using Student’s t test for comparison of averages, the Chi-square test for values expressed in frequencies, and Pearson’s correlation for numerical data. A positive correlation was found between the presence of polyps and structural abnormalities (r=0.0035; p<0.005). This study has shown a high incidence of concurrent previously unsuspected VF lesions in patients with VFPs. The authors suggest that either these minor underlying anatomical deviations render the VF more vulnerable to vocal abuse, or that phonotrauma may cause a number of VF lesions that can lead to dysphonia.
Of hormones and ears
Reviewed by: Badr Eldin Mostafa
Mar/Apr 2011(Vol 20 No 1)
In this prospective study on postmenopausal women, the authors found an improvement of low frequency thresholds after six months of hormone replacement therapy. The other odd finding was that this was more marked on the right side compared to the left. This might be explained by differences in distribution of estrogen receptors (ER) in the ear, in another words lateralisation of ER concentration. ER-a and -b might be more dense in the right ear. Another reason might be difference in bone mineral density of each sides of the body, ie lower on the right side. Similarly, lower bone mineral density in right ear bone would imply better response to estrogen therapy and greater improvement in audiometry results on that side. Although speculative, this finding may direct us in the interpretation of audiometric findings in post menopasual women, especially in asymmetric losses and assessment after hormone replacement therapy.
Middle fossa versus Retrosigmoid approaches for vestibular schwannomas
Reviewed by: Gauri Mankekar
Mar/Apr 2011(Vol 20 No 1)
The authors performed a retrospective critical analysis of the outcome in 125 patients with small vestibular schwannomas operated on via the middle fossa (MFA) or the retrosigmoid (RSA) approach. They compared the surgical results between the two approaches based on cochlear and facial nerve outcome, operative time, blood loss and symptoms related to cerebellar and temporal lobe retraction. They conclude that RSA is associated with shorter operating time, blood loss and a better early facial function, although there is no difference in hearing function and late facial results. However, in this series, patients who underwent tumour removal with RSA did not show any complications related to cerebellar retraction, compared to temporal lobe retraction with MFA but there was a higher rate of residual tumour in the fundus of the internal auditory canal with the RSA.
Quality of life after CP angle tumor surgery
Reviewed by: Gauri Mankekar
Mar/Apr 2011(Vol 20 No 1)
Complete tumour removal, hearing preservation and preservation of facial nerve are not the only criteria for a successful outcome after CPA tumour surgery. The authors performed a retrospective analysis of a small sample size of forty eight patients operated on for either a vestibular schwannoma or a meningioma in the Cerebello-pontine angle region. Using a visual analog scale the authors assessed the patient's subjective impairment of quality of life by tinnitus, vertigo, hearing loss, and facial nerve palsy. They also determined objective facial nerve and hearing function using House- Brackmann and Gardner-Robertson classification systems. Although their sample size was small and about one-third of the patients dropped out, their data suggested that tinnitus and vertigo may be as important or may even play a greater role in the well-being of patients after surgical removal of CP angle tumours.
Occupation and acoustic neuromas
Reviewed by: Badr Eldin Mostafa
Mar/Apr 2011(Vol 20 No 1)
In this article, the authors observed an increased risk of acoustic neuroma associated with occupational exposure to mercury, benzene and textile dust. Men working as truck and conveyor operators <10 years before the reference year had the highest increased risk of acoustic neuroma, but it is unclear what in those occupations might contribute to disease development. These two articles show a clear association between certain occupations and the incidence of acoustic neuromas. The occupations seem totally unrelated and a missing link should be sought. Other studies associated noise with an increased incidence of AN, and this might be a factor. Would acoustic neuromas be listed as an occupational hazard?
Medical treatment for sudden low-frequency hearing loss
Reviewed by: Joanne Rimmer
Mar/Apr 2011(Vol 20 No 1)
The authors discuss the condition of acute low-tone sensorineural hearing loss (ALHL), which is well documented in Japan but not in Europe or North America. It is thought to have a similar cause to sudden sensorineural hearing loss (SSNHL) or endolymphatic hydrops, and hearing often recovers after a short period with or without treatment. A retrospective review of 156 patients with this diagnosis over nine years was undertaken. As there are no defined diagnostic criteria, the authors used patients who attended within seven days of symptom onset, with purely sensorineural hearing loss and a normal examination, and in whom the sum of hearing loss at three low frequencies (125, 250 and 500Hz) was 70dB or more, and the sum of hearing loss at three high-tone frequencies (2, 4 and 8kHz) was 60dB or less. Patients were treated with steroids (49 patients), diuretics (40 patients), both (46 patients) or neither (21 patients). They were followed up for eight weeks or until hearing improvement was documented. The rate of recovery (complete and partial) was 66.7% in the control group, 75.5% in the steroid group, 75% in the diuretic group, and 91.3% in the combination group. The authors conclude that the reason the steroid-diuretic combination therapy was more effective is related to the potential aetiologies of the condition, that is, immunological or endolymphatic hydrops. As with SSNHL, the dose and route of steroid treatment has not yet been defined; patients in this series received varying doses of different steroids. Perhaps a randomised control trial would be the next step, as is awaited in SSNHL, although the small numbers make this a difficult task.
Robots for parapharyngeal space tumours
Reviewed by: Joanne Rimmer
Mar/Apr 2011(Vol 20 No 1)
Transoral robotic surgery (TORS) brings cutting edge robotic technology to the world of ENT. This group have tested various uses for the technique in treating tumours of the oral cavity, oropharynx, hypopharynx and larynx. Advantages are listed as a minimally invasive approach, excellent 3-dimensional visualisation and the ability to perform two- to four-handed surgery. Here the authors describe the use of TORS in treating tumours of the parapharyngeal space as they seek to advance its uses. Ten patients with benign lesions of the parapharyngeal space have been treated with a TORS resection, with a mean follow-up of 29.9 months (12-40 months). One patient was converted to an open approach on the table but the technique, described carefully in the article, was successful in nine of the 10 cases. Complications were only minor, with no cranial nerve injuries or trismus, and so far there have been no recurrences. The authors conclude that TORS is a promising surgical approach to the parapharyngeal space – although presumably only in the hands of surgeons who are familiar with the use of a robot.
Publication misrepresentation among ENT residency applicants
Reviewed by: Annabelle CK Leong
Mar/Apr 2011(Vol 20 No 1)
This study looked at the extent of research publications misrepresented by ENT residency applicants in the United States, for the year 2010 and found that over 5% were either unverifiable or erroneously reported. Errors included inappropriately stating an article as 'provisionally accepted', when it was actually submitted or rejected, incorrectly listing oneself as first author and improperly stating that the article appeared in a peer-reviewed journal. Provisional acceptance means that the journal in question has shown commitment to publish the article, but this is distinct from having 'submitted' it or when it is 'under review'. Whether these were honest mistakes or intentional errors was not clarified, but the competition for these coveted training positions cannot be more obvious. It would be interesting to conduct a similar study in the UK and even more worrying should there be similar results among those applying for ENT specialist registrar training numbers in this country!
Early cochlear implantation recommended in patients with AIED
Reviewed by: Rebecca Heywood
Mar/Apr 2011(Vol 20 No 1)
Patients with autoimmune inner ear disease (AIED) who fail to respond to medical treatment or are unable to tolerate side-effects of long-term treatment with steroids or immunosuppressants are often left with unserviceable hearing requiring rehabilitation. Inflammation within the cochlea may result in fibrosis, calcification and loss of spiral ganglia cells similar to meningitis-related hearing loss which could lead to poor cochlear implantation outcomes in such patients. The authors compare audiological outcomes in implanted AIED patients with those post-lingually deafened through other causes and implanted in the same period. Audiological data were recorded in 12 AIED ears (10 patients) and 12 control ears pre-operatively, up to 12 months (short-term) and more than 12 months (long-term) post-operatively. No significant difference was found in pre- and postoperative speech reception thresholds, short and long-term word scores or short and long-term sentence scores between the two groups. However the text states that pre- and postoperative pure tone averages were recorded, though only the pre-operative values are recorded in the results. Two patients in the AIED group required drill out for osteoneogenesis; three more (four ears) were found to have fibrosis, scarring or osteoneogenesis that was not severe enough to require drill out. Interestingly, only two of these six ears had evidence of cochlear pathology on MRI, while three ears with abnormal cochlear imaging had normal intraoperative findings. Although full electrode insertion was possible in all AIED cases, the authors suggest that early implantation may be indicated in AIED patients in view of these findings. The study only looks at a small sample of patients but nevertheless supports cochlear implantation as a feasible and effective option for hearing rehabilitation in patients with AIED.
Predictive factors for success of the Hybrid cochlear implant
Reviewed by: Rebecca Heywood
Mar/Apr 2011(Vol 20 No 1)
The Hybrid short-electrode cochlear implant was designed with a view to rehabilitating patients with severe to profound high frequency sensorineural hearing loss, but only mild low frequency impairment. Long electrode cochlear implant insertion destroys residual hair cells and hence eliminates any potential improvement in frequency resolution achieved through amplification of residual low frequency hearing. The Hybrid CI preserves the low frequency hearing in the apical end of the cochlea and has a short electrode which electrically stimulates the basal end. This paper looks at whether or not preservation of acoustic hearing enables better understanding of speech in a background of other talkers. Twenty-five Hybrid patients were compared with 31 long electrode CI patients with matching speech recognition scores in quiet. Speech recognition in background noise was then assessed for both groups. The Hybrid group performed better on average by more than 5dB, implying a small additional benefit from preservation and amplification of residual hearing. Patient factors which are predictive of success with Hybrid CI use were also assessed. The only factors with significant predictive value were found to be duration of hearing loss and age at implantation. As with conventional CI, it is thought that a long period of deafness prior to implantation results in either degeneration of auditory nerve fibres or failure of central auditory pathways, following a long period without stimulation. Elderly patients were found to gain less benefit from Hybrid devices, attributed to loss of plasticity and the consequent inability to adapt to the mismatch between low frequency acoustic and high frequency electric signals. As current technology stands, Hybrid implants are useful in carefully selected patients.
Anatomical variation in Michel aplasia
Reviewed by: Andy Hall
Mar/Apr 2011(Vol 20 No 1)
Anatomical variation in Michel aplasia Michel aplasia is characterised by bilateral absence of differentiated inner ear structures but there is a degree of variation in associated other skull base anomalies. The course of the facial nerve passing through the temporal bone in these patients was studied in an attempt to prevent potential complications in surgery on these patients. Data from six Michel aplastic ears were evaluated for a facial nerve course from CT and MRI scans. The facial nerve anatomy obtained was widely variant between these individuals however the authors allude to the fact within this small study that, when normal middle ear structures are present, seemingly the facial nerve follows a normal course with distinct tympanic and mastoid portions.
Endoscopic skull base reconstructive options
Reviewed by: Andy Hall
Mar/Apr 2011(Vol 20 No 1)
This complex review explores the various options for endoscopic skull base reconstruction through utilising either avascular or vascular grafts. The article also introduces a newly published prospective case series of one hundred and sixty-six skull base intradural deficits reviewing the outcome of nasoseptal flap reconstructions. Cumulatively this provides the largest report evaluating a CSF leak rate of 6.2% for reconstruction after an endoscopic endonasal approach with vascularised tissue. What should be noted however is the technical learning curve in reconstruction, with analysis of the first twenty-five patients who underwent nasoseptal flap reconstruction showing a 24% CSF leak rate. The authors sought to create a reconstructive algorithm based on defect location as well as the type and nature of intraoperative CSF leak in an attempt to formalise the management of these patients. The increased use of vascularised reconstructions for larger and higher complexity skull base deficits is felt by the authors to be indicated according to their experience.
Unacceptable results with polyacrylamide hydrogel
Reviewed by: Furrat Amen
Jan/Feb 2011 (Vol 19 No 6)
A group of Iranian plastic surgeons report an experience of complications in 98 patients that had received soft tissue augmentation with the permanent synthetic filler polyacrylamide hydrogel (otherwise known as Aquamid, Interfall, Outline, Formacryl, Bioformacryl, Bio-alcamid, Amazing Gel, and Argiform). A number of photographs of terrible complications are presented: infections and abscess formation, granulomatous and anaphylactoid reactions, inflammation, scarring and puckering of the skin, and gel migration. The surgeons often had to make an incision to try to extract the substance to avoid continuing discomfort and inflammatory reactions. These complications may have arisen from injections of large quantities or inadequate injection technique. As always, try to use autologous material for augmentation or failing that a temporary filler.
Oral steroids in rhinosinusitis: be careful with the bones
Reviewed by: Edward W Fisher
Jan/Feb 2011 (Vol 19 No 6)
Oral steroids in rhinosinusitis: be careful with the bones The increasing use of oral steroids in patients with chronic rhinosinusitis (CRS) has transformed the efficacy of medical management in many sufferers. This is particularly true in polyp cases. The duration of treatment has needed to be tempered by the known adverse effects of oral steroids, with ‘rules of thumb’ being applied to limit such effects. The evidence backing up such empirical rules is often unclear. This study looks at a large group (197) of CRS patients, the majority (around 90%) of whom suffered from polyp-associated CRS and who were taking oral steroids. Eighty-two percent of the group had concomitant asthma. Bone density measurements allowed the authors to evaluate the patients for metabolic bone disease, and they found a high prevalence of this disorder (osteoporosis or low bone density) – over 62% in those over 50 years of age (4-14% in the younger group). This is not altogether surprising when the steroid dosage is considered: only those with over three months usage of oral prednisolone at an equivalent dose of at least 5mg per day, which is a different mode of usage than would be usual in the UK for polyp patients (who tend to be given short, sharp courses). Nonetheless, the article is timely in reminding us of the need to advise patients to consider calcium and vitamin D supplementation, exercise and avoidance of excessive alcohol consumption if they are needing to use steroid courses regularly.
A touch of glass
Reviewed by: Maher El Alami
Jan/Feb 2011 (Vol 19 No 6)
Finding an ideal allograft to obliterate mastoid cavities remains a challenge in treating in particular canal-down cavities. The authors describe their experience using 'Bio-Glass' granules (BAG S53P4 Vivoxid Ltd, Finland). The advantages of using this compound are its relative bactericidal properties, its good biocompatibility and its relatively simple use. Using a relatively small group of seven patients the authors illustrate their results with a mean follow-up of 57 months. No early extrusion or compound related complications were reported with good surgical results in terms of a dry cavity and good function. Despite stating no risk of infection in the introduction of the paper, one patient developed a fistula which resolved spontaneously. The authors claim a lack of any displacement or resorption of the allograft throughout the length of the follow-up. Keeping in mind the difficulties of the stabilities of mastoid cavity obliteration, this compound may be an alternative. This study is however very small and the cases are heterogenous. There is no standardised volumetric assessment of the cavities and little standardised assessment to confirm osseointegration. Of note was also that the manufacturers of this compound were using this article to advertise the product in the same journal citing this article. A conflict of interest?
Ball games: fungal or bacterial?
Reviewed by: Maher El Alami
Jan/Feb 2011 (Vol 19 No 6)
Ball games: fungal or bacterial? Fungal balls in the paranasal sinuses are notoriously difficult to treat and to eradicate. The authors of this study describe the microbiological findings of surgical specimens taken from 229 patients undergoing surgery for fungal sinusitis. In addition to their fungal infection, bacterial infection was found in 73.4%: gram positive cocci (44.8%), gram negative rods (41%) and anaerobes (10.4%) were confirmed. These patients had more pronounced symptoms of foul taste, purulent discharge, and cough compared to the culture-negative patients who complained of more headaches. Most common bacteria were coagulase negative staphylococci resistant to Ciprofloxacin in 21.4%, to Clindamycin (26.3%) and to erythromycin in 44%. MRSA was shown in 19.4%. Enterobacter isolated was resistant to Ampicillin in 93.3% and to ampicillin-sulbactam in 37.5%. Pseudomonas was resistant to antibiotics in 10%. This study highlights the need to consider more than one causative organism in the aetiology of complex infected rhinosinusitis. This study focused on cases selected for surgery and may contain selection bias in particular as previous treatment of these patients was not indicated. This study did not mention the treatment response for these patients. Until we have fully understood the role of biofilms, fungal infections or immune mediated causes of severe rhinosinusitis treatment may include concurrent antifungal and antibiotic treatment.
Dysphagia after HN cancer treatment: who swallows better?
Reviewed by: Maher El Alami
Jan/Feb 2011 (Vol 19 No 6)
Good data collection may help to quantify the extent of long-term sequelae of cancer treatment. Using the Surveillance Epidemiology and End Results (SEER) Medicare Database the authors were able to access some of the clinical data of 8,002 cancer patients diagnosed and treated between 1992-1999. Their records were available in view of their primary tumour, modality of treatment and comorbidity index based on previous insurance claims. This database only included patients over 65 with otherwise the expected distribution of cancers of the general population. The majority of tumours were laryngeal (40%) and oral cavity (31%). The most common treatment was surgery and radiation (33%) followed by primary radiotherapy (RT) or combined chemoradiotherapy (CRT). Of all patients 39.8% reported dysphagia, 7.1% stricture and 10.4% pneumonia within three years of treatment. The highest rate of these complications was reported for hypopharyngeal tumours. Strictures were more common in laryngeal tumours rather than oral cavity or oropharyngeal cancers. Oropharyngeal tumour patients had a relatively higher rate of pneumonia. In terms of modality of treatment in the CRT group dysphagia was highest (64%) with strictures in (20%) and lowest in the surgery group (25%). Also of note was the increase of these complications in this treatment group during the observation period as the use of CRT increased. Using insurance claims as a source for morbidity data showed a higher than previously reported rate of strictures and interestingly a lower than previously reported incidence of pneumonia. This study is a different approach to ascertain data regarding long-term complications of cancer treatment. It has the drawbacks of most longitudinal retrospective study in an older patient cohort and there was no data on the staging of these tumours. Nevertheless post-treatment data is usually not well recorded and looking at the actual provision of healthcare for patients treated may provide more accurate data about complication rate of cancer survivors. One would hope that with the increased use of these databases and their expanding versatility we should be able to produce a more realistic and accurate outcome for our treatment regimes.
Post-tonsillectomy pain
Reviewed by: Badr Eldin Mostafa
Jan/Feb 2011 (Vol 19 No 6)
Tonsillectomy is a painful procedure. Postoperative analgesia is difficult. Opioids are associated with respiratory depression and nausea whereas non-steroidal anti-inflammatory can be associated with an increased risk of bleeding. In this study, two doses of intraoperative dexmedetomidin were compared to standard morphine doses. This drug is an alpha 2 agonist, it has mild analgesic properties, and it causes sedation without respiratory depression and does not affect the coagulation profile. The effects of 1ug/kg dexmedetomidin and 100ug/kg morphia were comparable as regards the total postoperative rescue opioid requirements and time for first analgesic requirement. Although dexmedetomidine has been shown to decrease postoperative analgesic or opioid consumption in adults, this study did not show any advantage over morphine in the paediatric population undergoing tonsillectomy.
History of cochlear imaging
Reviewed by: Diego Zanetti
Jan/Feb 2011 (Vol 19 No 6)
In the audiological and otological world, the author is an admired and respected scientist who devoted his life to the microscopic and histologic study of the cochlea at the INSERM in Montpellier (France). To the internet fans of the ear, his 'Promenade 'round the cochlea' is a fascinating 'must have' tour inside our hearing organ. In this editorial, he revives the progress in cochlear micro-imaging that he has witnessed during his professional lifetime. Up to the 1960s, the only visualisation technique for the cochlea was light microscopy, using paraffin sections. Results were not remarkably different from the 18th Century handmade drawings of Retzius or the lucida pictures by Ramon y Cajal in the beginning of the 20th Century. The introduction of transmission electron microscopy (TEM) around 1970, new fixation techniques and improvements in optics and cameras, constituted the elements of a giant forward leap in cochlear ultrastructure imaging. They allowed more precise morpho-functional correlation and, thus, boosted physiological studies. A decade later, scanning electron microscopy (SEM) added a further step forward, allowing surface analysis (for example tracking the development of stereocilia). Combined with immunostaining techniques, it permitted the identification and localisation of most cochlear neurotransmitters. Confocal microscopy, developed in the early 1990, is defined by the author as 'THE' current cochlear imaging modality, since it accomplishes 3D localisation and dynamic histology of the living cells by multiple intravital staining. What's next? Combinations of TEM and confocal fluorescence microscopy, and, maybe, atomic force microscopy. A suggestion? Take a look at the amazing pictures in this paper.
Signals from the cochlea
Reviewed by: Diego Zanetti
Jan/Feb 2011 (Vol 19 No 6)
The supporting cells in the organ of Corti are linked by a network of tight junctions. Their roofs are a mosaic of opposing phalangeal processes which forms the reticular lamina, a stiff plate which seals the endolymphatic poles of the hair cells. Intercellular gap junction (GJ) channels mediate the transfer of ions, metabolites and second messengers between cells. In the so-called potassium recycle hypothesis, the GJ network is presumed to intervene in the cycling of K+ following the mechano-electric transduction activated by a sound stimulus. Almost all intercellular GJ channels are composed of two types of transmembrane proteins subunits, Cx26 and Cx30, which share 77% amino acid identity. The genes encoding Cx26 (GJB2) and Cx30 (GJB6) are found within 50kb of each other in the DFNB1 deafness locus. Their mutations, which are almost as frequent as those causing cystic fibrosis, account for around 50% of genetic cases of severe to profound non-syndromic hearing losses. The development of the cochlear GJ system, which precedes the functional maturation of the inner ear, is crucial for the maturation of a functioning hearing organ. Cx26 and Cx30 are widely expressed in the inner ear and form hemichannels (connexons) that release ATP from the endolymphatic surface of supporting and epithelial cells, determining the intercellular diffusion of Ca2+, thus mobilising second messengers. The authors review in detail all the available evidence on the functional role of the Cx and the GJ system, and present their own experimental data about the mechanism of release of Ca2+ from intracellular stores, ensuing in the regenerative propagation of intercellular Ca2+ mediated signals across the coupled supporting and hearing cells. In the authors' opinion, Ca2+ level oscillations are of great interest in relation to the responses evoked by damaging stimuli delivered to hair cells, and may play an essential role in the development of the whole organ of Corti and of hearing itself. An in-depth review of the physiology of our sensory organ at a molecular level.
Staining alive! The cochlea in live humans
Reviewed by: Diego Zanetti
Jan/Feb 2011 (Vol 19 No 6)
The outer hair cells (OHC) have a peculiar contractile activity that is voltage-dependant, hence called electro-motility, which is mediated by the protein Prestin. Through this mechanism the OHC act as the cochlear amplifier, boosting the incoming acoustic stimulus and also sharpening the frequency selectivity of the organ of Corti. So far, most knowledge of the functional role of prestin derives from translational works on rodents. This paper is highly valuable because it confirms for the first time the findings obtained from laboratory animals also in human cochleas harvested at surgery during skull base approaches for removal of meningiomas. The authors applied immuno-staining with a combination of multiple antibodies (anti-parvalbumin, prestin, peripherin, neurofilaments, Tuj1), associated with fluorescent confocal microscopy and high-resolution scanning electron microscopy (SEM), The details of all the applied methods are thoroughly described. Unlike other proteins within the inner ear, prestin is expressed solely in the baso-lateral cell membrane of the OHC throughout the whole length of the organ of Corti, but not in IHC. Hence, prestin’s gene mutations could play a pivotal role in selective recessive hearing losses or fine tuning disturbances. Genetic analyses are undergoing in patient populations. Don’t miss the magnificent glimpse of the interior of our cochlea through the awesome coloured pictures published in this article.
Vestibular schwannoma and pilots
Reviewed by: Badr Eldin Mostafa
Jan/Feb 2011 (Vol 19 No 6)
The odds of associating acoustic neuromas with pilots seemed quite low. However in this article, out of 40,000 pilots reviewed, 10 had acoustic neuromas. Decisions on fitness to fly were based on several factors: minimally disturbed audition, that is, less than a 35dB hearing loss with a good speech discrimination score; good balance, that is, no reported difficulties; no spontaneous nystagmus recorded on videonystagmography(VNG); no postural deviation; and a normal head-shaking test. Of the 10 reviewed pilots, only two were declared unfit, although four had total deafness in the affected ear and nine had vertigo. This is rather disturbing in two ways; the prevalence here seems to be very high compared to the accepted rates (1:4,000 compared to 1:80,000) and further studies in this respect are warranted. Flying with a vertiginous pilot or one with unilateral total deafness does not seem very appealing. Similarly, as the authors point out, the therapeutic decisions in this particular population should aim at minimising any possible morbidities.
Agenesis of sphenoid sinus, is it rare?
Reviewed by: Iordanis Konstantinidis
Jan/Feb 2011 (Vol 19 No 6)
This nice study from Ankara examines the prevalence of sphenoid sinus agenesis within the general population, excluding craniofacial anomalies and syndromes. It is a retrospective study with a large enough sample size. The authors evaluated CT scans of 1,193 subjects. They demonstrated a low incidence (0,67%) of sphenoid sinus agenesis, however the percentage is not minimal. Specifically, eight patients were found with three of them having bilateral agenesis. Sphenoid hypoplasia is commonly seen in patients with cystic fibrosis, although agenesis is very rare in this group. The existence of cases with sphenoid sinus agenesis, although rare, allows the addition of a fourth type in the classification of sphenoid sinus pneumatisation. Therefore the sinus types are rudimentary, hypoplastic, postsphenoid type and sinus agenesis. The pneumatisation status of the sphenoid sinus is of great value in endoscopic sinus surgery in order to avoid complications. The authors underline the need for evaluation of the sphenoid pneumatisation and awareness regarding agenesis, especially in transphenoidal approaches for hypophysectomy.
MRI and the incidentaloma
Reviewed by: Peter Radford
Jan/Feb 2011 (Vol 19 No 6)
MRI scanning of patients with unilateral sensorineural hearing has become an increasingly common, cost-effective and accurate method for detecting cerebellopontine angle (CPA) tumours. Quoted studies show that only a small percentage of these scans reveal a causative pathology for the patients’ symptoms but a surprisingly high percentage reveal incidental findings, some of them rather serious. This interesting paper looks at 200 consecutive MRI scans, requested for patients with audiovestibular symptoms (asymmetrical hearing loss, unilateral tinnitus, sudden sensorineural hearing loss and atypical vertigo) and characterises the findings. Both T1, T2 imaging was used, as was gadolinium enhancement. Fifty-two percent of the scans were reported as completely normal and one patient (0.5%) had a vestibular schwannoma on the ipsilateral side to his symptoms. This left some 47.5% of patients with other incidental findings. Twenty-seven percent of patients had White Matter Lesions (WML) consistent with an ageing brain, but in 7% this was seen in combination with other pathology. Three per cent of patients had inflammation in the middle ear or mastoid and 5.5% had signs suggesting of pathology in the para-nasal sinuses. The most significant discovery of the study was that five (2.5%) patients had serious incidental findings, these included two patients (1%) with gliomas, one patient (0.5%) with a lipoma of the quadrigeminal plate cistern and two patients (1%) with extensive WML requiring referral to neurology to exclude an active demyelinating condition. This paper helps to show that, by requesting an MRI scan on patients with audiovestibular symptoms, we may inadvertently uncover serious incidental findings. The onus is on the referring clinician to interpret these findings, inform the patient and make appropriate referrals for further management.
Can we assess auditory maturation in children with cochlear implants?
Reviewed by: Thomas Nikolopoulos
Jan/Feb 2011 (Vol 19 No 6)
The assessment of auditory maturation is very important in deaf children following implantation regarding basic knowledge and research, as well as in audiology. However the related methods of assessment are rather limited. The long latency auditory evoked potential (LLAEP) has been used for tracking changes in latency and morphology of the P1 peak in order to evaluate the maturation of the auditory system in children with cochlear implants (CIs). Cochlear implants can induce an artefact in the recordings when sounds are presented, which makes the analysis of LLAEPs much harder. Independent component analysis (ICA) has been used to remove this artefact. In this paper the authors applied a procedure based on ICA to reduce the CI artefact, to detect the LLAEPs and to use the changes in the spatial projections of their independent components (ICs) for a robust evaluation of the maturation of the auditory system in children with CIs. The results are very encouraging and may improve our understanding in this difficult area.
Comparison of unilateral to bilateral (simultaneous) cochlear implantation in adults
Reviewed by: Thomas Nikolopoulos
Jan/Feb 2011 (Vol 19 No 6)
It is well known from audiological research in normally hearing people and the experience accumulated from hearing-aid users, that there are significant benefits from having two 'ears', particularly for determining where sounds come from and for understanding speech in noisy environments. Users of two cochlear implants may have the opportunity to experience some of these bilateral advantages. The aim of this study was to compare bilateral with unilateral listening benefit in 15 postlinguistically deafened adults implanted simultaneously. Speech perception (in quiet and in noise) and localisation accuracy were assessed for each ear alone and both ears together. Subjects showed improved sound localisation, although it did not reach the levels of normal listeners, and better speech perception in quiet and in noise when using two implants compared with using one implant alone. However, the variation was wide and there were cases with better outcomes from the better ear in comparison with bilateral stimulation.
Device failures in cochlear implantation. A protocol of good practice
Reviewed by: Thomas Nikolopoulos
Jan/Feb 2011 (Vol 19 No 6)
It is well known that device failures in cochlear implantation are causing tremendous problems in patients and their environment. Assessment, diagnosis, and management are very difficult in certain cases. However, even in the most straightforward cases, the stress to the recipients and the family is still a very significant issue. Clinicians should ensure that the process of confirming the failure, re-implantation and subsequent rehabilitation is as smooth as possible. In order to benefit from each others’ experience, a working party of cochlear implant centre co-ordinators and representatives from the Ear Foundation met on a number of occasions to draw up a protocol which could be used widely throughout the British Cochlear Implant Group. The protocol indicates quality standards of clinical care to be used in the event of device failure. It includes all the necessary steps from diagnosis to re-implantation taking into account every implantee’s particular needs, especially reducing the time gaps and periods of uncertainty. An article that should be read by clinicians who sometimes forget how patients with device failure feel.
Do clinicians and parents agree with regard to implanted children's progress?
Reviewed by: Thomas Nikolopoulos
Jan/Feb 2011 (Vol 19 No 6)
All cochlear implant centres use specific tests to assess progress in implanted children. However, most of these tests suffer from certain weaknesses such as variable or unknown validity and reliability, and no applicability in different ages. The authors of this study have assessed 168 implanted children with regard to auditory capacity, level of speech and language and communicative skills. The assessments were made by speech and language pathologists and parents. The children were assessed with the Tait Video Analysis, the receptive part of the Reynell Test, a phonological test and a vocabulary test. The four objective tests were analysed for potential associations between results. In addition, potential associations between the results of the four tests and parental assessment of their child's auditory capacity (CAP) and speech intelligibility (SIR) were investigated. The results of all the four auditory and structural speech and language tests were positively associated with each other, which, according to the authors, strengthens the validity of the individual tests and substantiates the observed results. Parental assessments were positively associated with the results of the four objective tests, which may suggest that parents are valid reporters of the level of their child's auditory, as well as speech and language development. Although these results were rather encouraging regarding the validity of the assessments, most of the tests used are able to detect only 'large' differences among children and the statistics just show a general agreement.
How important is the duration of auditory deprivation in the voice quality of implanted post-meningitic deaf children?
Reviewed by: Thomas Nikolopoulos
Jan/Feb 2011 (Vol 19 No 6)
The authors aimed to assess the critical time period between the onset of sensorineural hearing loss and cochlear implantation with respect to normal voice production in children with post-meningitic hearing loss. Acoustic measures of voice production were obtained from 10 paediatric cochlear implant recipients with post-meningitic hearing loss. Acoustic measures were obtained utilising the Multi-Dimensional Voice Program and Computerised Speech Laboratory. Measures were based on sustained phonation of the vowel /a/. Acoustic parameters included fundamental frequency, short- and long-term frequency perturbation, and short- and long-term amplitude perturbation. Measures of fundamental frequency and short-term frequency and amplitude perturbation were comparable to values of children with normal hearing. Long-term control of frequency was within normal limits for subjects with a period of auditory deprivation of less than four months. Measures of long-term amplitude perturbation were normal for all patients except those with cochlear ossification. The authors concluded that early restoration of auditory feedback with cochlear implantation, the absence of cochlear ossification, residual aided hearing following meningitis, and auditory-verbal therapy are contributing factors in preserving the long-term control of frequency and amplitude in the setting of post-meningitic hearing loss. However, the lack of statistical comparisons, the small number of children studied, and the rather limited range of auditory deprivation weaken these conclusions.
Is minocycline able to improve residual hearing preservation in cochlear implantation?
Reviewed by: Thomas Nikolopoulos
Jan/Feb 2011 (Vol 19 No 6)
The authors’ aim was to assess if perioperative minocycline improves preservation of residual hearing in adult patients undergoing cochlear implantation. Minocycline was chosen as it is supposed to block inflammatory mediators in cell signalling pathways. Nine patients undergoing cochlear implantation who received minocycline peri-operatively and a historical control group of nine matched patients who did not receive minocycline were compared in terms of pure tone audiogram before and after implantation. Minocycline was given 200mg orally preoperatively and 100mg daily postoperatively for 10 days. The main outcome measure was the change in residual hearing thresholds at 250Hz and 500Hz. The average loss of residual hearing at 250Hz post-cochlear implant for those who had not received minocycline was 18.9dB (SD 12.2) compared to 16.7dB (SD 15.0) for those who had received perioperative minocycline and this was not statistically significant. The average loss of residual hearing at 500Hz post-cochlear implant for those who had not received minocycline was 24.4dB (SD 15.9) compared to 19.4dB (SD 14.3) for those who had received minocycline and the difference again was not statistically significant. Two patients who did not receive minocycline lost all residual hearing at both 250Hz and 500Hz post-implantation and only one patient who had received minocycline lost all residual hearing at 500Hz. The authors concluded that the neuroprotective effect of minocycline may help to preserve residual hearing post-cochlear implant. However, the lack of power analysis and of any statistically significant differences, as well as the small numbers, weaken this conclusion. I fully agree with the authors’ last conclusion that further studies are needed.
Multiple sclerosis and cochlear implantation
Reviewed by: Thomas Nikolopoulos
Jan/Feb 2011 (Vol 19 No 6)
It is known that outcomes of cochlear implantation in individuals with known central nervous system conditions vary widely although there are few related studies. In addition, longstanding deafness is supposed to be a negative predictor postlinguistically deaf adult implant users. The authors presented a case study of cochlear implantation in a postlingual adult having bilateral profound hearing loss for over 30 years in addition to multiple sclerosis unrelated to his deafness. Following implantation and after an initial disappointment, the patient improved considerably in word recognition scores, telephone use, and quality of life. The authors concluded that long-term auditory deprivation and co-incidental multiple sclerosis are not a contraindication for cochlear implantation. However, based on one study we should add that thorough counselling and careful evaluation are needed in these patients, as well as conservative expectations as the results may vary widely.
Macrolides and neurological manifestations
Reviewed by: Badr Eldin Mostafa
Jan/Feb 2011 (Vol 19 No 6)
Macrolides have an acceptable safety profile, with relatively few side-effects. This article reports serious neuropsychiatric manifestations after azithromycin intake. These included visual and auditory hallucinations, multiple partial complex seizures, severe headaches, and recurrent cortical blindness. Symptoms started within 24 hours and slowly recovered within two to four weeks. Although this is a case report, caution may be warranted in treating patients with or susceptible to neurological disorders. The risk of newer long acting formulations should also be taken into consideration.
A serial study of malignant otitis externa
Reviewed by: Madhup K Chaurasia
Jan/Feb 2011 (Vol 19 No 6)
Malignant otitis externa is a potentially fatal condition and over several decades the disease pattern can undergo a change. In this extensive series of 37 patients the authors have studied various factors of the disease and compared it with other studies. The main symptom was otalgia and otorrhoea. Hearing loss was present in only 54.1% of these patients. Most of these subjects had granulation tissue in the external auditory canal on radiological finding. The incidence of cranial nerve palsies was rather high as compared with previous studies but all cases improved and this factor did not make the prognosis any worse. Multiple nerve palsies were found in 24% of these cases in contrast to previous studies where it is considered to be less common. Pseudomonas aeruginosa was the commonest organism involved. Patients were treated with Ciprofloxacin but dual and multiple regimes were also used and antifungals added if fungal infection was suspected. Interestingly enough drug resistance to Ciprofloxacin was not noted in any of these patients. The co-existence of diabetes in these patients was rather low (51%) as compared with previous studies where 65-100% involvement has been noted. The most helpful radiological investigation was CT scanning. None of these patients required magnetic resonance imaging nor nuclear medicine imaging such as gallium or technetium scanning presumably because none of the cases progressed to skull based osteomyelitis where these investigations would have been useful. This is a fairly large series and the interesting fact here is that none of the cases progressed to skull based osteomyelitis.
Is computer assisted FESS safer and more effective?
Reviewed by: Madhup K Chaurasia
Jan/Feb 2011 (Vol 19 No 6)
Computer guidance is finding increasing application in functional endoscopic sinus surgery. Whether this technological support reduces the rate of complications and renders the surgery more effective, thereby reducing the need for revision surgery still remains a matter of speculation. In this study the authors compared the rate of complications and the need for revision surgery. In a retrospective study of 276 patients, 108 of whom had computer assisted FESS surgery and the remaining 168 received non computer assisted FESS. Interestingly, the only selection criteria applied was whether or not the surgeon was appropriately trained in the computer assisted surgery technique. Patients were assessed by Lund-McKay score on CT findings. In the computer assisted group the average score was 14 compared with 10 in the non computer assisted group. The mean follow-up time was 18.4 months. There was no significant difference in the rate of both major and minor complications. However it appears that in the computer assisted group major bleeding occurred in two whereas orbital damage occurred in the non-computer assisted group. There was no statistically significant difference in the need for revision surgery between the two groups. The selection of cases for computer assisted surgery in this study could have been better based on the severity of the disease. However, the authors have rightly pointed out that computer assisted surgery should be reserved for difficult cases and not taken up as a routine. Perhaps a comparison of the two groups involving only cases with very high Lund-McKay scores and cases with grossly distorted anatomy would provide the right answer to the question.
Is the patient outcome in epistaxis related to the site of bleeding?
Reviewed by: Madhup K Chaurasia
Jan/Feb 2011 (Vol 19 No 6)
In this article the authors claim that the identification of the site of bleeding is the key to effective management of the condition. The definition of anterior or posterior is generally unclear in relation to the site but the study has clearly defined these as anterior or posterior, upper or lower both on the septum and the lateral wall of the nose. In this prospective study 100 patients were included and in each the bleeding site was identified. The treatment modalities offered were cauterisation, Merocel packing and in more severe cases posterior nasal balloon and BIPP were used. One patient required ligation of the sphenopalatine artery. There was no relationship between agent site or primary epistaxis but the association with medical co-morbidity was common. Almost all cases of anterior epistaxis could be treated with silver nitrate cautery whereas the posterior bleeding required anterior packing sometimes also with a posterior pack in the form of balloon. None of the patients bled from the classic Woodruff's area. Hospital admission was required more often for patients with posterior epistaxis and they stayed in longer as well. There was no correlation between the site of bleeding and age or gender. The study emphasises the need for better protocols, also incorporating the site of bleeding. Interestingly, protocols for epistaxis management exist in no more than twenty percent of ENT services.
Laryngeal problems after ITU treatment
Reviewed by: Madhup K Chaurasia
Jan/Feb 2011 (Vol 19 No 6)
There is an increasing interest in follow-up clinics for patients receiving treatment in the intensive care unit. Most of these clinics are nurse-led, support a multidisciplinary approach and a fast track referral system for these patients. The authors have applied an otolaryngologic viewpoint into this follow-up as it appears that at least a third of these patients have vocal function problems following their stay in the intensive care unit where intubation or trachestomy may have been incorporated into the management. This is a questionnaire based study involving 273 consecutive admissions over a seven month period. The questionnaires were sent through General Practitioners to avoid them reaching bereaved families. The response rate however was very low and this was because some patients of course had deceased and nearly half of those alive did not respond. Of those who responded some declined to be involved and finally only 81 patients could be subjected to this study. Of these 53% underwent tracheal intubation and the mean length of intubation was 49.7 hours. The vocal outcomes were assessed by a voice symptom scale score. Thirty-three per cent had a voice symptom scale score of over 20 while 16% scored over 40. Fifty-one patients had a voice symptom score of 10 or more and were invited to the clinic but only 16 attended. The patients had laryngopharyngeal reflux, vocal cord cancer and functional dysphonia and only six of these 16 patients did not require any further treatment. The incidence of vocal morbidity is rather high and affects quality of life. The concern here is an extremely low response rate. The study points out the requirement for a routine follow-up of patients treated in the intensive care unit particularly those requiring intubation and the appointment should be made at the time of their discharge from the ITU.
Repair of nasal septal perforation
Reviewed by: Madhup K Chaurasia
Jan/Feb 2011 (Vol 19 No 6)
Perforation of the nasal septum often presents a challenge to the otolaryngologist in terms of achieving a long-term success rate and remission of symptoms which usually are epistaxis, crusting, nasal obstruction and whistling. In this article the authors present 28 cases which underwent repair of the nasal septum. The same surgeon performed the operation. Patients were assessed in terms of severity of their symptoms using a visual analogue scale. Every attempt was made to identify the cause of nasal septal perforation and patients underwent cANCA, tpha and ACE tests. If all these were negative a biopsy was taken. The method used was open rhinoplasty and advancement of superior and inferior flaps with placement of a collagen sheet between the flaps. A vertical mattress suture was used to approximate the margins. The authors report a 96% success in closure of the perforation and 100% success in improvement of symptoms. A review of medical literature is presented in which most studies seem to use mucosal advancement flaps with use of temporalis fascia, conchal cartilage and even mastoid cortical bone. The general aim is to provide a three layered septum as it naturally exists. A point of merit of this study is that it also provides assessment of pre- and postoperative symptom score in addition to closure of perforation. The article provides useful reading and highlights the usefulness of open approach and interposing material.
Surgical treatment for granular myringitis
Reviewed by: Madhup K Chaurasia
Jan/Feb 2011 (Vol 19 No 6)
Granular myringitis is a rather uncommon condition and may prove refractory to medication such as steroid antibiotic drops or chemical cautery. The disease really penetrates all layers of the tympanic membrane and the middle ear is almost never involved. Conductive hearing loss is not a feature of this condition. In this article the authors have illustrated a method to deal with advanced granular myringitis that is one with granulation tissue involving the tympanic membrane and extending into the external auditory canal, conforming to grades 3 and 4 according Wolfe's classification. In this operation exposure is made through a post auricular incision. The pinna and the meatal flap are retracted anteriorly starting at the cutaneous margin of the lesion whether on the external auditory canal or on the tympanic membrane. The epithelial layer is peeled off. Haemostasis is carefully achieved and a temporalis fascia larger than the tympanic membrane is placed over the exposed fibrous middle layer of the tympanic membrane. This is covered with a silastic sheet which is retained with antibiotic / steroid soaked gel foam. The series comprises 21 patients all of which were cured after just one operation. The authors emphasise the grading of this condition and the need for meticulous surgery sparing deeper layers of the tympanic membrane. The illustrations are good and the article is worth reading.
The effect of MMC on surgical consent practices
Reviewed by: Madhup K Chaurasia
Jan/Feb 2011 (Vol 19 No 6)
The advent of MMC, in the UK, has seen relatively junior doctors rotating through the department of otolaryngology for a much lesser duration than the 'SHO's' of previous years. In departments where consent is being taken by the junior trainees it is a matter of interest how this change has affected the quality of surgical consent practice. In this study the authors compared results with similar surveys in 2002 and 2005. This was a telephonic survey involving junior doctors in 40 otolaryngology units across the country. In the 40 randomly selected UK ENT departments one junior trainee was surveyed. Of these, 15 were Foundation Year doctors and 22 specialty trainee and one on a fixed term specialty trainee. Two-thirds of the respondents had less than six months ENT experience. There was a slight decrease in the number of departments employing junior trainees for surgical consent. There was an increase in the use of patient information sheets and it was encouraging that the potential reduction in the consent quality was not obvious from this study despite shorter training duration in the specialty. It was interesting to note that some of the complications were informed to the patients more often than in the previous years, namely failure of improvement after FESS and the possibility of a tracheostomy and thyroxine replacement being required after thyroidectomy. The shorter training time has indeed posed challenges but the authors reveal this can be overcome by careful induction in this specialty and more departments having protocols for taking consent and a regular teaching programme. Ways of memorising complications have also been mentioned. It is interesting that the time of the consent is not mentioned as it would be ideal to do this when the patient goes on the waiting list in the clinic.
Timely diagnosis and treatment of cervical necrotising fasciitis
Reviewed by: Madhup K Chaurasia
Jan/Feb 2011 (Vol 19 No 6)
Cervical necrotising fasciitis, characterised by rapidly progressive destruction of fascia and subcutaneous tissue often has an unsuspecting presentation and it is paramount that an early diagnosis and management is accomplished for this condition which has a mortality rate ranging from 20-73%. Serial reports of this condition are rare in literature. This useful presentation includes seven patients, three of whom also had diabetes mellitus and one had human immunodeficiency virus infection. Most of these patients presented with mild symptoms such as sore throat, fever and pain in the neck, with no respiratory distress, dysphagia or antecedent dental infection. In fact, the infections were quite localised. Only three had findings on CT scans which prompted an unequitable diagnosis of necrotising cervical fasciitis. One patient needed an anterior cut down procedure to help make a diagnosis. The bacteriology was mainly beta haemolytic group F streptococcus and streptococcus viridens. Six patients underwent immediate surgical procedure and five of these required additional serial debridement and washout of the neck and the mediastinum. There were two deaths. The authors emphasise the apparent innocuous nature of this condition, a condition not always suggested by radiologic findings. A useful protocol has been worked out and the general emphasis is on early diagnosis and prompt treatment for this highly fatal condition.
ALT flap for the hypopharynx
Reviewed by: Stuart Clark
Jan/Feb 2011 (Vol 19 No 6)
This paper from Nijmegen is a retrospective report of morbidity and mortality following hypopharyngeal resection and reconstruction over a 7½ year period for 20 patients. They had a five year survival of 20%, with a 100% success with the microsurgical reconstruction. Fistulas occurred in 25%, strictures in 30% and wound dehiscence in 10%. There were no significant donor site complications. They advocate the use of this flap accepting that their study is small and without a control. When cure was not achieved it was thought that good palliation was attained.
Bilateral microtia reconstruction
Reviewed by: Stuart Clark
Jan/Feb 2011 (Vol 19 No 6)
This paper from Peking reviewed 21 cases of congenital bilateral microtia repaired with a post-auricular skin flap, autogenous rib cartilage post-auricular flap lifting and split-thickness free skin graft. Nineteen of these cases showed good symmetry in size, shape and location. Two cases showed different levels of absorption and cartilage deformation. They advocate that bilateral treatment of the ears can be treated simultaneously, the first stage of skin expansion, the second stage of rib cartilage and framework sculpture, the third stage six months after the first stage of removal of mcrotic cartilage and residual excess soft tissue.
Nasal tip haemangiomas
Reviewed by: Stuart Clark
Jan/Feb 2011 (Vol 19 No 6)
This paper from France advocates the best treatment for nasal tip haemangiomas is early surgery. Thirty-nine children were treated with a mean age at the first operation of 35 months. Multiple surgical procedures were performed in 14 patients. The average follow-up was 48 months. These groups were defined according to their cutaneous involvement, the less severe, the better the results. They regarded it as optimal to complete surgical treatment before school age although they also suggested many surgical steps and a conservative attitude would be preferred to immediate resection.
The desire for the ovoid face
Reviewed by: Stuart Clark
Jan/Feb 2011 (Vol 19 No 6)
In Asian countries prominent mandibular angles are thought to be an unaesthetic feature and the correction of these features to achieve an ovoid appearance is appealing to some patients. The reduction of the angles of the mandible (a mandibuloplasty!) is usually done through an intraoral approach and they describe a corticectomy of the mandibular angle in 519 patients with successful improvement in 84% of females and 60% of males. There was a 4% minor complication rate with no facial nerve injury. They advocate their method using an endoscope to perform the ostectomy of the buccal plate from the ramus to the mandible and en bloc full thickness ostectomy of the angle itself. They do not comment about symmetry.
The free flap in difficulty
Reviewed by: Stuart Clark
Jan/Feb 2011 (Vol 19 No 6)
This paper from Leeds covers free flaps that were used throughout the whole body. Over a 23 year period they identified 327 flaps out of a total of 2,569 which were re-explored (13%). Eighty-three per cent of the flaps had a successful outcome and these re-explorations took place at a mean period of 19 hours postop. Unsuccessful re-explorations had a mean of 56 hours postop. The clinical diagnosis prior to re-exploration was confirmed at surgery in 91% of cases. This leads to one of their conclusions that human judgement is the core to monitoring. They found age a preoperative predictor for re-exploration with children having a significantly lower re-exploration rate. They ascribed this to the healthy vessels of children. There was no intraoperative predictor of re-exploration. They suggest that if a flap is in doubt urgent, assertive surgical intervention should be undertaken. This is a fact that was shown to have the biggest impact upon outcome.
An unusual cause of laryngeal granuloma
Reviewed by: B Viswanatha
Jan/Feb 2011 (Vol 19 No 6)
An unusual cause of laryngeal granuloma This retrospective review was done to present a case series of patients with isolated superior laryngeal nerve (SLN) paresis who developed contralateral vocal process granuloma. According to the authors, an association between SLN paresis and laryngeal granuloma formation has not described earlier. In this study there were three patients with SLN paresis and contralateral vocal process granuloma. Videostroboscopy examination for each of these patients demonstrated signs of SLN paresis, including the appearance of a foreshortened right vocal cord and asymmetric arytenoids contact on phonation. These patients had a granuloma where it appeared to contact the contralateral arytenoids on phonation. First patient showed improvement after one month of antireflux therapy and speech therapy. Follow-up videostroboscopy examination after two months showed symmetric vocal folds movement and complete resolution of vocal fold granuloma. Second patient underwent direct laryngoscopy with CO2 laser removal of granuloma, bilateral injection laryngoplasty with collagen and EMG-guided injection of botulinum toxin in to the left cricothyroid muscle. Though there was no improvement in voice, there was no recurrence of granuloma. Third patient underwent microlaryngoscopy with CO2 laser removal of granuloma and EMG-guided injection of botulinum toxin into the left cricothyroid muscle. Patient had recurrence of granuloma at ninth month of follow-up. Contact granulomas are prone to recurrences because of repeated injury from contact of opposite arytenoids during phonation or coughing. This article describes the presentation, treatment and outcomes for a series of patients with unilateral SLN paresis and associated contralateral vocal process granuloma. The authors are of the opinion that, as most granulomas are multifactorial in nature, a full range of etiologies and treatment options should be considered in these patients.
Abducens nerve - an endoscopic anatomic study
Reviewed by: Gauri Mankekar
Jan/Feb 2011 (Vol 19 No 6)
This is an excellent anatomic study of the most medially located parasellar cranial nerve, the abducens nerve. The authors dissected ten anatomic specimens using endoscopes attached to a high definition camera. They explain all important anatomic details in the course of the abducens nerve encountered during (para) sellar and clival transphenoidal surgery. In addition they have exemplified their study with a few very illustrative cases and have recommended choice of approach based on their anatomic study. This article is a must-read for all those performing extended transsphenoidal surgery.
Anterior cervical spine surgery and recurrent laryngeal nerve palsy
Reviewed by: Gauri Mankekar
Jan/Feb 2011 (Vol 19 No 6)
As otorhinolaryngologists we are called in to review patients who have undergone anterior cervical spine surgery and have developed hoarseness. These patients usually have unilateral recurrent laryngeal nerve palsy but, occasionally have even bilateral palsy. In 2005 the authors demonstrated the high incidence of asymptomatic recurrent nerve palsy (RLNP) in a right-sided approach. This follow-up prospective study of 242 patients was designed to test two options to reduce the incidence of palsies: reduced endotracheal cuff pressure and sinistral approach. All patients underwent a left sided approach but 149 patients in group 1 were operated with an additional reduction of endotracheal cuff pressure while the remaining 93 served as control group. They found a 1.3% rate of persisting symptomatic and asymptomatic RLNP in Group 1 (reduced pressure group) with a 6.5% incidence of RLNP in group 2 (normal pressure group). The authors conclude that a left sided approach combined with reduced cuff pressure below 20mmHg could reduce the incidence of RLNP in patients undergoing anterior cervical spine surgery.
Is ECoG useful in the diagnosis of Ménière’s?
Reviewed by: Joanne Rimmer
Jan/Feb 2011 (Vol 19 No 6)
The diagnosis of Ménière’s disease is usually a clinical one, based on the classical symptoms of recurrent vertigo, fluctuating hearing loss, tinnitus and aural fullness. Some centres use electrocochleography (ECoG) as an adjunct for ‘confirmation’, in which an increased summation potential (SP):action potential (AP) ratio is thought to indicate endolymphatic hydrops. This retrospective review compared the extratympanic ECoG result with the diagnosis in 632 patients over a ten year period. The SP:AP ration was enhanced in 56.3% of patients with a diagnosis of Ménière’s disease, 40% of those with cochlear Ménière’s disease, 46.2% of patients with delayed endolymphatic hydrops. It was also increased in 37.5% of cases of sudden deafness and cerebellopontine angle tumours. The authors admit that the correlation of increased SP:AP ratio in Ménière’s disease was low compared to other studies, but they report that the incidence was significantly higher if the disease had been present for two years or longer, and / or the frequency of attacks was more than once a year. Interestingly, hearing improvement induced by the glycerol tests was not associated with a reduction in the SP:AP ratio; the authors hypothesise that this indicates that the enhanced SP in Ménière’s disease may be due to hair cell dysfunction rather than displacement of the basilar membrane.
Outcomes in phantosmia
Reviewed by: Joanne Rimmer
Jan/Feb 2011 (Vol 19 No 6)
Phantosmia, also known as olfactory hallucination, is a perceived odour without any trigger. It is a qualitative disorder with no available psychophysical or electrophysiological tests, unlike anosmia or hyposmia. It is usually idiopathic, compared to parosmia (a distorted olfactory perception) which often follows infection or trauma. However, there have been reports that phantosmia can herald the development of tumours, rhinosinusitis, intracranial bleeds, epilepsy, psychiatric problems or Parkinson's disease. The authors performed a retrospective review of 58 patients diagnosed with 'idiopathic phantosmia', and contacted them all by telephone to reassess their condition. Mean duration of phantosmia was just over six years. None of them had developed severe health problems, Parkinson's disease or extrapyramidal symptoms. The phantosmia had disappeared in 31.8%, improved in 25%, was unchanged in 38/7% and got worse in only 4.5% of patients. Gender, age or measurable olfactory function at presentation did not affect outcome. The authors hope that these results will be useful in counselling patients who are diagnosed with this problem, as over 50% will resolve or improve over five years. They can also be reassured that it does not seem to predict future intracranial pathology or disease such as Parkinson's.
A summary of systemic therapies for sinonasal inflammation
Reviewed by: James Barraclough
Jan/Feb 2011 (Vol 19 No 6)
Allergy and inflammation not only exacerbate chronic rhinosinusitis (CRS) but also have a role in its development. There has been a shift of focus in the design of therapies more towards factors relating to the pathogenesis of this heterogeneous disorder. This article examines the current studies that provide evidence for a number of developing therapy modalities for CRS. Patients with allergic rhinitis and asthma have sinusitis due to the leukotrienes that are responsible for the chronic inflammation in these patients. There is a lack of good quality controlled trials but some are beginning to develop as follow-up for current trials increases. Despite the widespread use of systemic corticosteroids, there are few randomised trials that demonstrate an improvement in CRS symptoms with nasal polyps and even less for CRS without nasal polyps. Subcutaneous and sublingual immunotherapy are now widely available but surprisingly not so in the United States. So far in Europe and Asia there have been no reported deaths from anaphylaxis regarding sublingual immunotherapy and, as this article points out, as the number of successfully treated patients increase, it will probably be only a matter of time until this underused targeted therapy becomes more widespread. Immunomodulators were developed initially to target the relationship between interleukins and eosinophils particularly in asthma patients. A number of monoclonal antibodies exist and small trials have investigated their use in CRS patients. Modest improvements in symptom scores have been seen but the cost of these treatments outweigh the benefits at the current time. The small subset of patients with Samter triad may benefit from aspirin desensitisation. This article gives details of a proposed dosing regimen which could be of use to these patients. It should also be noted that patients would need to continue on aspirin at a maintenance dose which may have side-effect implications that this article does not discuss. The use of statins and macrolides have also been shown to modulate symptoms in CRS patients but the mechanisms with these are poorly understood. Overall this is a good overview of the current state of play.
Some good tips for all trainees
Reviewed by: James Barraclough
Jan/Feb 2011 (Vol 19 No 6)
This entire edition of OCNA is devoted to the complications of endoscopic sinus surgery (ESS), including their prevention and management. It was therefore pleasing to see this article included which has some excellent points to make for the avoidance of some of the most common and most serious complications. It begins with a good system for reviewing sinus CT scans so that important features are not missed. Some excellent tips for optimising the surgical field follow this, including factors within and outside of the nose. Technical points are made regarding how to remove the correct portion of the uncinate process safely, how to do this if it is atelectatic and also if there is distorted anatomy. A neat system of identifying landmarks when there seem to be none is then explained and following this, further technical tips regarding removal of bony septations and safe surgery along the skull base. Advice for proper haemostasis ties up this helpful article.
The current situation with biofilms in the nose
Reviewed by: James Barraclough
Jan/Feb 2011 (Vol 19 No 6)
There is a growing body of evidence that biofilms contribute to the persistent nature of chronic rhinosinusitis, resisting maximal medical therapy. There is a good overview of the current understanding of the contents and structure of biofilms here with particular insight into how they are known to protect bacteria from antibodies, immune-system phagocytosis, antibiotic penetration and complement binding. Mucosal biofilms have a unique cascade of gene expression to help to avoid the normal mucociliary clearance within the nose. Mechanisms of bacterial and fungal biofilm antibiotic resistance are currently under investigation and a number of the theories are outlined in this article. This includes an observation that bacteria at the basal layer may lay dormant until stimulated by small or inadequate doses of antibiotics which lead to their up-regulation. Electron microscopy follow-up studies, with small numbers of patients, have shown that patients with biofilms display a number of unfavourable outcomes compared to those without. Treatments proposed include those that interfere with the biofilm life cycle and those that target bacterial attachment. Surgery has also been shown to increase oxygen tension against biofilm formation and leads to mechanical disruption of their structure; there may still be a role for the sinus surgeon yet! A number of topical agents are under scrutiny including honey which has shown to eradicate 91% of pseudomonas biofilms in vitro. A number of surfactant-based therapies are also being investigated including baby shampoo. Results seem promising for the in vitro studies quoted here but there is no mention of results in patients and it appears that we may be some time off this important step.
The evolving world of endoscopic sinus surgery
Reviewed by: James Barraclough
Jan/Feb 2011 (Vol 19 No 6)
This article takes a look at the developing technologies related to endoscopic sinus surgery (ESS) for haemostasis, surgical instruments and surgical management. Topical adrenaline (epinephrine) is discussed. Most of the studies quoted use concentrations lower than that of experience here in the UK (such as 1:50,000) and it was interesting to note that the authors use concentrations of 1:1,000 despite the studies that they refer to. Other topical haemostatic agents are addressed including Merogel, Sepragel, FloSeal and Surgiflo which all seem to improve haemostasis with minimal production of synaeciae. The use of topical antifibrinolytics and other agents is also discussed. The development of smaller and more versatile surgical implements has had a great impact on the surgical management of sinus disease. Radiofrequency coblation technology has shown clinical effectiveness in removing sinonasal soft tissue and may reduce blood loss in comparison with the microdebrider. The authors state that they find this particularly helpful for the removal of sinonasal tumours. The limiting factor is the size of the wand which will probably improve in time as technology advances. The hydrodebrider is emerging as a technology that removes biofilms within the sinonasal mucosa and some results are quoted here with their use in combination with various surfactants. The unltrasonic aspirator is used in neurosurgery for removal of some tumours and its use in ESS is under investigation. The management of CSF leaks is discussed including the use of laser tissue welding with a biologic solder. The advantages appear to be the superior stability of the materials once in situ. Image guidance systems also provide the endoscopic sinus surgeon with greater information as to where instruments are positioned relative to the areas of interest within a patient and may be of particular use in cases with distorted anatomy. Robotic surgery is also beginning to develop in this field. Overall, there are some interesting developments quoted here; it will be interesting to see which of them find their way into UK practice.
Sinus surgery helps you smell… or does it?
Reviewed by: Carl Philpott
Jan/Feb 2011 (Vol 19 No 6)
It is good to see that there are an increasing number of papers considering the effects of sinus surgery on olfactory performance. This particular study has considered 160 patients comparing threshold scores derived using the Connecticut Chemosensory Clinical Research Centre Test (CCCRCT) pre- and postoperatively. It has also scored patients for a subjective sense of smell and for any interference with daily activities (for example taste). They have however defined a heterogeneous surgical group with respect to the extent of surgery, but most disappointingly is the fact that they only tested patients at two weeks postoperatively. Given that it can take four to eight weeks for patients' sinus cavities to fully settle following sinus surgery, it seems a shame that they didn't choose a latter time frame for follow-up testing and also look at the longer-term effects to see if their findings are perpetuated. They have also claimed to be one of only two studies considering olfactory thresholds after sinus surgery and have overlooked one or two other studies. Whilst they have certainly shown evidence that patients at two weeks after sinus surgery feel better about their sense of smell, the conclusions that can be drawn from this study are somewhat limited.
Endoscopic transnasal access to the craniocervical junction
Reviewed by: Andy Hall
Jan/Feb 2011 (Vol 19 No 6)
The myriad of potential complications related to the traditional transoral approach to the craniocervical junction including use of tracheostomy, wound dehiscence, necessary feeding tube insertion and velopharangeal incompetence are well known. In view of this the authors describe their involvement in a case series (N=4) involving an alternative endoscopic approach that has previously only been discussed in individual reports and in terms of anatomical feasibility. They explain the difficulties of obtaining instruments of adequate length for odontoid access and concisely give a summary of their experience. Overall, the concerns of the new approach are clarified explicitly by the authors; recognising the potential risk to the eustachian tube and carotid artery, nasal crusting and learning curve. Complications actually sustained include a CSF leak (repaired intra-operatively) and a one litre venous bleed directly from a vascular tumour. The authors sensibly temper their conclusions with mention of 'potential' but with a need for studies to greater define future utility.
Management of intracranial splinter
Reviewed by: Andy Hall
Jan/Feb 2011 (Vol 19 No 6)
This bizarre case report outlines a fifty-eight year old male who presented to hospital with fevers and a change in mental status indicative of bacterial meningitis. CT images demonstrated defects of the ethmoid roof and a likely encephalocele. He had sustained a penetrating injury to the left maxilla with a stick thirteen years previously. Endoscopic endonasal removal of a sliver of wood was successfully performed with a septal cartilage underlay and free mucosal overlay graft.
Management of petrous bone cholesteatoma
Reviewed by: Andy Hall
Jan/Feb 2011 (Vol 19 No 6)
This takes the form of a retrospective analysis on the management of 28 patients with petrous bone cholesteotoma between 1991-2008 in Paris. A mixture of congenital, acquired, primary and revision surgeries were included and hence the surgical approaches varied greatly. Twenty of the patients experienced no long-term reoccurrence. The authors provide a good synopsis of the classical lateral transtemporal and middle fossa approaches but additionally have cause to promote the first documented endoscopic transphenoidal approach accessing petrous apex cholesteatoma in two cases. This article offers a neat showcase of their experience in what is widely recognised as particularly challenging surgery.
Outcome in skull base malignancies – parotid and temporal bone resection
Reviewed by: Andy Hall
Jan/Feb 2011 (Vol 19 No 6)
This took place as a retrospective single-institution case series in an academic tertiary care hospital in Miami between 1999-2008. This attempted to determine prognostic factors and review outcome of 79 patients with lateral skull base resection (combined temporal bone resection and parotidectomy) for advanced lateral skull base malignancy. Disease free survival was shown as 36.2 months for skin tumours, 42.7 months for salivary gland tumours and 8.5 months for mesenchymal tumours. Log-rank tests for prognostic indicators predictably showed that histology and temporal bone erosion on CT scan were the statistically significant predictors of poor outcome. Somewhat counter-intuitively the use of radiotherapy as a prognostic factor did not appear to be a significant predictor of outcome but the authors recognise their limitations in being restricted to tumours of advanced local extent by virtue of the combined surgical approach taken. Overall, the authors have generated a review of surgical outcomes when this combined approach is taken and have identified prognostic factors that hold a statistically significant effect on patient outcome.
The acousticofacial-glossopharangeal triangle
Reviewed by: Andy Hall
Jan/Feb 2011 (Vol 19 No 6)
This paper reports the relationship between the glossopharyngeal nerve (CN IX) and the acoustofacial complex (AFC) through anatomical dissection. Ten cadaveric specimens were subjected to retrosigmoid suboccipital dissections to expose the spatial anatomical relationship at the cerebellopontine angle. Following an extensive and complex series of measurements, a triangular relationship was observed between the acoustofacial complex, glossopharyngeal nerve and skull base. Data analysis revealed an inverse correlation between the cisternal length of CN IX and the distance between CN IX and the AFC at the skull base. Put more simply, as the cisternal length of CN IX decreases, the distance between CN IX and AFC at the skull base increases. Using this information, the authors were able to mathematically predict reference distances at certain points along CN IX. These predicted differences were found not to be statistically different when compared to cadaveric measurements. The authors hope that recognition of the acousticofacial-glossopharangeal triangle could lead to its use as an anatomical landmark in surgical approaches to the cerebellopontine angle and assessment of the displacement of cochlear and facial nerve fibres in pathology. Mathematical complexities aside, it makes for an interesting read.
Apparent branchial cleft cyst? - remember it could be malignant
Reviewed by: Victoria Possamai
Nov/Dec 2010 (Vol 19 No 5)
This Finnish study reminds us to exercise caution in diagnosing branchial cleft cysts. A retrospective review of cases of provisionally diagnosed branchial cysts was carried out. One hundred and ninety-six patients were included from a seven year period. Postsurgical histological diagnoses were reviewed. A diagnosis of branchial cyst was confirmed in 82%, with 15% showing other benign cystic lesions or non-specific findings. Metastatic squamous cell carcinoma was found in six cases (3%) and papillary thyroid cancer metastasis in one case. On reviewing preoperative tests ultrasound was done in six cases, CT in one, and all had FNAC. None of these investigations had reported suspicion of malignancy. The average age of patients with malignancy was higher (53 for metastatic SCC, 60 for papillary tumour) than for all patients (average age 40). The authors referred to the work of a fellow Scandanavian group who have recently advocated the use of flow cytometry DNA analysis of FNAC samples. This can aid differentiation of benign versus malignant cells in cystic lesions. In my experience FNAC reports in these cases are usually inconclusive… “metastatic squamous cell carcinoma cannot be excluded”. I wonder what the cost implications would be in utilising this test in all cases of probable branchial cleft cyst?
Prevention of acute haematoma after facelifts
Reviewed by: Furrat Amen
Nov/Dec 2010 (Vol 19 No 5)
An acute haematoma is a troublesome complication after facelift and also parotid surgery conducted via a facelift incision. The authors employed their regular practice: avoiding aspirin and nonsteroidal anti-inflammatory drugs for seven days preoperatively, using low molecular weight heparin, a drain, and a head bandage for 24 hours. They split their patients into two groups. Group 1 (n=308) had access to analgesia, blood pressure medication, and antiemetics on patient request. It is not clear how the patients would know how to request blood pressure medication at an appropriate time. Group 2 (n=68) had these medications administered prophylactically. There was a statistical difference in occurrence of haematomas: group 1 had 7%, and group 2 had 0% (p=0.029). This is an interesting take on how to prevent an important complication but it would probably be of more interest if the numbers in each group were more equal.
Changing trends of peritonsillar abscess
Reviewed by: Anurag Jain
Nov/Dec 2010 (Vol 19 No 5)
This is a well conducted and well presented retrospective observational study, in which the authors have analysed 427 patients who were admitted over a 10 year period with a diagnosis of peritonsillar abscess (PTA) by retrospective case note review. They looked at the patient characteristics, such as age, sex, duration of symptoms, previous antibiotic therapy, hospital stay, culture results, comorbidities, smoking habits, complications and the trends. The authors concluded that the incidence of peritonsillar abscess in this study was 0.9/10,000/year with no sex, seasonal or side predominance. Twenty-one per cent of the patients with PTA did not have preceding pharyngotonsillitis suggesting an alternative aetiology in these cases. PTA was found to affect a greater rate of older patients who had a longer and more complicated course of disease with different culture results (a higher incidence of gram positive cocci and gram negative rods) as compared to younger patients. Hence the authors recommend that older patients with PTA should be considered as a high risk group with different antibiotic strategy. Smoking may be a predisposing factor for PTA evolution and a higher complication rate.
Biofilms may predict more stubborn sinusitis
Reviewed by: Edward W Fisher
Nov/Dec 2010 (Vol 19 No 5)
Biofilms are suspected to be important in the pathophysiology of chronic mucosal inflammatory conditions in ENT (such as chronic sinusitis and perhaps otitis media). The link between the presence (or absence) of biofilms and clinical progress of patients needs to be established. This study of rhinosinusitis severity (symptom scales, SNOT for example), endoscopic / imaging staging, biofilm presence in specimens (confocal LASER microscopy) and postoperative clinical course (need for visits, medication and length of follow up) goes a long way towards beginning the accrual of evidence for the importance of biofilms. Biofilms were present in 71% of 51 patients. Those patients with biofilms did significantly poorer in their postoperative course and tended to have more severe pre-operative disease. The study was blinded, so this is a good start.
Carotid body tumours - no need to embolise
Reviewed by: Joanne Rimmer
Nov/Dec 2010 (Vol 19 No 5)
Carotid body tumours are renowned for being highly vascular, and there is much debate about the benefits of preoperative super selective embolisation. Any improvement in visualisation or reduced bleeding must be weighed against the risk of stroke from angiography. This paper is a retrospective review of 25 consecutive cases that underwent resection of a carotid body tumour. Ten of these patients had preoperative embolisation; there was no significant difference in patient age or tumour size between this group and the non-embolised patients. The presumed reduction in intraoperative blood loss was not found when the two groups were compared, although how precisely it was recorded may vary. Based on this study, patients with carotid body tumours should be spared the risks of angiography - although preoperative imaging such as MRI / MRA is essential in planning surgery.
DIY nerve monitoring
Reviewed by: Joanne Rimmer
Nov/Dec 2010 (Vol 19 No 5)
The use of nerve monitoring techniques during thyroid surgery is becoming more common. Most, if not all, departments have access to a nerve monitor that can be used for intraoperative facial nerve or recurrent laryngeal nerve (RLN) monitoring. It is not yet standard practice in all thyroid surgery but, with increasing litigation, it may become so. The commonly used technique involves commercially available endotracheal tubes (ETTs) with integrated electrodes designed to sit at the level of the vocal cords. These authors describe their innovative 'do-it-yourself' technique, which accomplishes the same thing but is much cheaper - they estimate they have saved $15,120 since they began using it in August 2006. The article describes their technique, which uses two disposable intralaryngeal surface electrode pads stuck onto a standard ETT. They have used it successfully in 126 patients with no incidents of electrode migration or failure. As well as the cost benefit, they feel that having two electrodes is better than the solitary one found in most commercial integrated ETTs. They suggest that this technique makes it easier for anaesthetists to ensure correct positioning of the tube and electrode placement, and they can also obtain side-specific readings. It is certainly an interesting idea in the current cost-cutting climate...
Extracorporeal septoplasty
Reviewed by: Joanne Rimmer
Nov/Dec 2010 (Vol 19 No 5)
Extracorporeal septoplasty (ECS) is a technique used to correct a severely deviated septum, whereby the whole quadrilateral cartilage is removed, reshaped and then reinserted and secured. Various different techniques have been reported, particularly focusing on maintaining stability of the refashioned cartilage, and how to secure it within the nose. This article describes the authors' technique, which requires an open rhinoplasty approach. They advocate leaving a small dorsal strip of cartilage at the keystone area. They then create a 'new' septum in the form of an L-strut, which is then fashioned into a Y-shape by suturing a further strip of cartilage to the L-strut. The preserved cartilage at the keystone area is then secured between the two arms of the Y-shaped cartilage and sutured. The upper lateral cartilages are then reattached as well. The authors report good cosmetic and functional results in their series of 27 patients with no postoperative complications. This is a small series with a short follow-up, but perhaps adds another technique to the extracorporeal armamentarium.
Inhaled steroids for vocal process granulomas
Reviewed by: Joanne Rimmer
Nov/Dec 2010 (Vol 19 No 5)
Vocal process granulomas are relatively uncommon lesions, usually secondary to intubation / trauma, vocal abuse and laryngopharyngeal reflux disease. They can be notoriously difficult to treat, and various strategies have been tried. These include voice therapy, anti-reflux medication, surgical excision and injection with steroids. This study is a retrospective review of 67 granulomas, 62 of which were treated with inhaled triamcinolone (300 micrograms tds) and a proton pump inhibitor once or twice daily. After six to eight weeks, 69% had completely resolved, 22% partially responded and nine per cent showed no effect. This treatment could prove a real breakthrough for patients with this difficult problem, and it would certainly seem reasonable to try this medical management before considering anything surgical (unless there is concern over the diagnosis and histopathology is required). The authors advise voice therapy during the six to eight weeks for additional symptomatic relief, and to prevent recurrence in those cases secondary to vocal abuse.
Surgical repair of type I laryngeal clefts - when, why and how
Reviewed by: Joanne Rimmer
Nov/Dec 2010 (Vol 19 No 5)
This paper gives a nice overview of the symptoms, diagnosis, classification (Benjamin & Inglis) and management of laryngeal clefts. It then focuses on the apparent rising incidence of type I clefts (probably a higher index of suspicion rather than a true rise - look and ye shall find), and the different presentations of this congenital laryngeal anomaly. Aspiration remains the most common presenting symptoms, but coughing, choking and reflux were also found commonly in the type I clefts. Management is discussed - obviously most type I clefts are managed conservatively, but 25% of their series required surgical repair for persistent symptoms (all relating to aspiration). Their endoscopic approach using a laser and sutures is described. Success, defined as improvement in aspiration, was reported in 73% of cases. The authors advise consideration of surgical repair in patients with severe symptoms or persistent aspiration above two years of age.
Controversial therapy of tinnitus
Reviewed by: Diego Zanetti
Nov/Dec 2010 (Vol 19 No 5)
Pharmacological treatment of tinnitus has been a subject of long-standing debate. Although in the majority of cases a lesion at the cochlear level is responsible for the symptom, a widely accepted therapeutic protocol is lacking. Paradoxically, some of the drugs that are used to treat common inner ear disorders such as sudden deafness or Ménière’s disease are possible tinnitus inducers. An example: a study found that diuretics sometimes used for Ménière’s disease were correlated with new onset tinnitus, caused by sudden hypotension and sharp vasomotor reaction in the cochlear terminal microcirculation. In this editorial the authors review the likelihood of inducing tinnitus not only by the known ototoxic drugs such as loop diuretics, aminoglycosides, salycilates, anti-malarics and chemotherapeutic agents, but also by anti-hypertensives, other antibiotics, antihistamines, NSAID, anaesthetics, and antidepressants. They also report the existing studies on the efficacy of a drug management of tinnitus, and they conclude supporting the disappointing experience of any otolaryngologist / audiologist facing tinnitus patients in his / her daily clinical practice that “...to date no pharmacological tool can guarantee that the patient’s tinnitus will disappear...”
Sleep endoscopy for better preoperative evaluation of sleep apnoea patients
Reviewed by: Iordanis Konstantinidis
Nov/Dec 2010 (Vol 19 No 5)
This is a study from the Antwerp team evaluating sleep endoscopy in patients with obstructive sleep apnoea (OSA), regarding feasibility and outcome. The patients underwent this examination after intravenous administration of midazolam and propofol. No side-effects were reported. Looking at the results it is noticeable that one in three patients had multilevel obstruction. In addition monolevel obstruction was found in 32% of patients at the palatal level and in 28% at base of tongue / hypopharyngeal level. There is no question that this evaluation gives additional information preoperatively for patients in whom surgery is considered. However it is a drug-induced sleep and not normal sleep. There are authors who perform sleep endoscopy during normal sleep, however this is a topic of controversy. In general, it is a method which needs standardisation in order to avoid inter-observer and inter-anesthesiologist variability. It would be interesting to see in this paper in what percentage the authors changed their initial plan of treatment due to sleep endoscopy findings.
Having no sense of smell doesn't prevent satiety being reached
Reviewed by: Carl Philpott
Nov/Dec 2010 (Vol 19 No 5)
This Dutch study made use of the Dutch Anosmia Association to recruit patients for a study where both anosmics and controls were asked to consume the same measured portions of four different food items consisting of two spreads and two cookies of either cheese or sweet cinnamon. They were asked to rate the hedonics of the food items (pleasantness) on visual analogue scales in terms of flavour and texture. Following this they were randomly assigned one of the four items to consume repeatedly over five minutes in a pattern of 'look, sniff, chew, swallow' and then asked for ratings again. Although the flavour of the test food decreased with repeated consumption, there was no significant difference between the controls and the patients with olfactory disorders. Moreover there was evidence of flavour specific satiety but not texture-specific satiety. The paper does not appear to mention the causes of the patients' olfactory loss and hence this could be a heterogenous group with a potential for a mixture of conductive and sensorineural losses; nonetheless one might expect to see a role in satiety that is not evident here. They propose that the key difference between anosmics and normal subjects comes from the loss of cue-elicited food craving which requires further investigation.
Antibiotics and ASOM again and again
Reviewed by: Badr Eldin Mostafa
Nov/Dec 2010 (Vol 19 No 5)
Parental and corporate pressures lead to an ever increasing use of antibiotics in the management of ASOM and hence an increase in organism resistance. The trend to limit the use of antibiotics is gaining popularity. However the risk of recurrences, complications or additional morbidity should be considered. In this retrospective analysis, the authors assessed AOM treatment failure (AOMTF), recurrent AOM (RAOM), and antibiotic prescription rates for groups of AOM episodes managed with either immediate antibiotics (ABX), tympanocentesis + observation (Tap + OBS), or tympanocentesis + immediate antibiotics (Tap + ABX). No significant differences in rates of AOMTF or RAOM were observed between any of the treatment groups. The 30-day rate of antibiotic prescriptions written for AOM was significantly lower in the TAP + OBS than in the immediate antibiotic therapy groups. Neither the presence of a particular otopathogen, nor the choice of any particular AOM antibiotic therapy correlated with increased risk of either AOMTF or RAOM. Previous studies compared the immediate use of antibiotics versus a wait and see policy and did not find a significant difference in outcome in patients starting to improve after 24-48 hours. What is left to compare is the value of tympanocentesis (an invasive procedure with its own morbidity) versus the observation only policy. If groups can be defined for wait and observe and tympanocentesis only with an acceptable surgical and anaesthetic risk and no increase in antibiotic resistance then this would be (again?) the accepted policy for acute otitis media rather than antibiotic therapy.
How important are inner ear malformations in cochlear implantation?
Reviewed by: Thomas Nikolopoulos
Nov/Dec 2010 (Vol 19 No 5)
It is well known that inner ear malformations may be encountered in up to 20% of children with congenital sensorineural hearing loss. In this review article an updated classification of cochlear malformations is provided. Incomplete partition and cochlear hypoplasia cases are each divided further into three groups. The author also describes the two main difficulties in the cochlear implant surgery in inner ear malformations; gusher and facial nerve various routes. Radiology is very important, especially when we take into account the modern techniques. However, it may mislead surgeons in particularly difficult cases. Moreover, two different types of cerebrospinal fluid leakage are described by the author and the necessary measures to prevent leakage or manage it effectively. Standard posterior tympanotomy may be feasible in many cases with inner ear malformations. However, alternative approaches and surgical methods may be needed to overcome the related difficulties and achieve a full or partial electrode array insertion. Finally, meningitis which may occur with and without cochlear implantation in this special group of patients is emphasised in this review article. This is common in incomplete partition type I patients and is usually due to a fistula in one of the windows, (more often in the oval window) which occurs as a result of cerebrospinal fluid pressure. This may be considered as a medical emergency leading to potential meningitis and all related preventive measures should be taken. A nice review describing inner ear malformations and how they affect cochlear implantation.
Gender and quality of life
Reviewed by: Angela Griggs
Nov/Dec 2010 (Vol 19 No 5)
Quality of life is of increasing importance, as it is a key indicator for patient outcomes. This paper looks at quality of life of patients having surgical treatment for oral cancer and considers gender, age, nicotine consumption and tumour staging factors. This German team evaluated 54 patients one month after surgery, using a recognised quality of life (QOL) tools, the EORTC H&N-35 and EOERC QLQ-C-30 questionnaires. They found that female patients had a more negative assessment of emotional function and male patients had a more negative evaluation of social function. When comparing the genders in relation to tumour specific symptoms they found that female patients showed more severe symptoms in swallowing, salivation, coughing and weight loss. When comparing nicotine consumption they found that smokers scored worse than non-smokers in emotional, social, cognitive and role function and more sleep dysfunction. They also found that smokers lost more weight and their tumour specific symptoms of speech, swallowing, social contact and dental health were worse than non-smokers. Greater tumour size had a significant effect on body function, emotional functions and associated with a higher degree of weight loss, while smaller tumours were significantly associated with sleep disorders. It would have been interesting if they had continued the gender analysis across to their other categories of nicotine consumption and tumour staging.
The hospital burden of head and neck cancers in France
Reviewed by: Angela Griggs
Nov/Dec 2010 (Vol 19 No 5)
This paper looks at the hospital burden of head and neck cancer in France and highlights the high cost of these patients with a mean annual cost per patient ranging from € 2,764 to € 7,673 leading to a total hospital cost of € 323 millions in 2007. This result was obtained through a retrospective analysis of the French national hospital database (PMSI) in which admissions to public and private hospitals are recorded. Finding out the annual number of patients admitted for head and neck cancer and associated hospital costs using the ICD-10 codes and French official tariffs. They found that in 2007 36,268 patients were admitted for head and neck cancer of which 81% were men, which equated to 60,200 hospital stays and 287,846 chemo or radiotherapy sessions. Oropharynx cancer was the most frequent (28%) followed by oral cavity cancer (25%). The peak age range was 55-59 years. They also looked at HPV infection related head and neck cancers finding that 9,430 patients were admitted due to HPV-related cancers, costing € 138 million in 2007. It would be interesting to compare these results with other cancer groups as it would highlight the hospital cost of head and neck cancers.
The drum and the brain
Reviewed by: Badr Eldin Mostafa
Nov/Dec 2010 (Vol 19 No 5)
The somatosensory representation of the middle ear in 15 normal hearing subjects was studied by applying small air pressure variations to the tympanic membrane while performing a 3T-fMRI study. Unilateral stimulations of the right ear triggered bilateral activations in the caudal part of the postcentral gyrus in Brodmann area 43 (BA 43) and in the auditory associative areas 42 (BA 42) and 22. BA 43 stimulation has been found to be involved in activities accompanying oral intake and could be more largely involved in pressure activities in the oropharynx area and activity of the tensor tympani muscle. Activation of BA 42 and BA 22 could reflect activations associated with the bilateral acoustic reflex triggered prior to self-vocalisation to adjust air pressure in the middle ear during speech. The authors did not find representation of tympanic membrane movements due to pressure in the somatosensory cortex, but its representation in the postcentral gyrus in BA 43 seems to suggest that at least part of this area conveys pure somatosensory information. They thus propose that BA 43, 42, and 22 are the cortical areas associated with middle ear function.
Are we adequately managing peri-orbital cellulitis?
Reviewed by: Madhup K Chaurasia
Nov/Dec 2010 (Vol 19 No 5)
Orbital cellulitis is a potentially dangerous condition which threatens permanent loss of vision. Guidelines to ensure adequate management and prevention of complications were issued in 2004. The authors have presented an audit based comparison on management of this condition between a tertiary and a district general hospital. The seven 'standards' outlined in the guidelines have been used for comparison. In tertiary centres, more patients but not all of them were seen by senior ENT surgeons and both specialties, namely otolaryngology and ophthalmology. CT scans, when indicated, were done in all but one patient in each centre. A 100% compliance for monitoring of the vision was not followed in either centre and the same was the case with the use of intravenous antibiotics and the use of blood culture. Although the management appears to be slightly better in tertiary centres, the compliance is still not as desired. It was only fortunate that none of the patients developed permanent loss of vision. The authors emphasise the need for drafting a proforma so that the guidelines are strictly followed. This is only reasonable in view of the extremely serious complications of this condition.
Initial speech discrimination and audiometric tests as predictors of hearing preservation in the wait and scan management of acoustic neuroma
Reviewed by: Madhup K Chaurasia
Nov/Dec 2010 (Vol 19 No 5)
It is generally accepted that large acoustic neuromas should be removed. However smaller tumours do require a careful management plan as the hearing may deteriorate during the wait and scan period, if that line is adopted.In this study of 1,144 patients the authors have tried to correlate the pure tone audiometric and speech audiometry findings at the time of diagnosis with the progress of hearing loss during the wait and scan period which averaged 4.7 years. It was noted that patients with good hearing for higher frequencies and good speech discrimination at the time of diagnosis tended to maintain their hearing more than those who presented with greater high tone hearing loss and poor speech discrimination. These parameters can therefore be used as reasonable predictors. The prediction is more precise with initial hearing levels for higher rather than lower frequencies. However the reliability of this method would be restricted because more patients present with a high tone hearing loss greater than 0-10 decibels. This could therefore be only one of the many other considerations to decide upon the line of management.
Investigations in tinnitus patients with normal hearing
Reviewed by: Madhup K Chaurasia
Nov/Dec 2010 (Vol 19 No 5)
Fewer than ten percent of patients with tinnitus have normal hearing. In this study the authors have compared the incidence of abnormal neuro-otological findings in patients with normal hearing, and tinnitus as the only symptom, with controls without tinnitus. None of these patients had vestibular symptoms. Fifteen out of 17 of these patients had unilateral canal paresis and in 13 of these, it was ipsilateral to the tinnitus. Barany's past pointing test was positive in five patients and lateralised to the side of the tinnitus in four. The laterality of canal paresis and sensitised Romberg's test also agreed with the side of unilateral tinnitus in a majority of these cases. The numbers are small and there is no statistical analysis. However, this study may help to settle the question whether or not patients with unilateral tinnitus need to be screened with an MRI, the opinion on which is divided. It therefore remains to be wished that these patients with unilateral tinnitus and congruently lateralised neuro otological findings also had MRI.
Ultrasound treatment for chronic rhinosinusitis
Reviewed by: Madhup K Chaurasia
Nov/Dec 2010 (Vol 19 No 5)
Bacterial biofilms have been implicated in perpetuating chronic rhinosinusitis and in making it refractory to medical treatment. It is considered that ultrasound therapy tends to cause vibrations and has a mechanical effect in loosening secretions. This increases the effectiveness of antibiotics by allowing greater access through increased permeability of the cell membrane and affecting the metabolic activity and growth rate of the bacteria. In this study of 20 patients the initial assessment was done by two methods namely global sinonasal symptoms severity using a 6cm visual analogue scale marked 1-7 at 1cm intervals and the 20 item sinonasal outcome test (SNOT). The assessments were made initially, after the third session of ultrasound therapy and finally after the sixth session. The authors claim that after six sessions 18 of the 20 patients improved and one of them ended up with acute sinusitis. Statistics were applied to SNOT scores and the p value ranged from 0.287 to 0.001. The study has concluded that therapeutic ultrasound is an acceptable treatment for chronic rhinosinusitis although it is accepted that the numbers were small and the study is not controlled. There is however no correlation between the severity of sinusitis and degree of improvement with ultrasound therapy. It would be interesting to know where this therapy stands in relation to the severity of the disease based on clinical findings and scanning and if this would be an avenue to pursue specially in cases of failed surgery.
Stress and Ménière’s disease
Reviewed by: Badr Eldin Mostafa
Nov/Dec 2010 (Vol 19 No 5)
Attacks of MD can be triggered by stress. However the cause-effect was not yet explored. In this article the authors used real-time PCR and western blotting for the expression and translocation of aquaporin-2 (AQP2) in the human endolymphatic sac of patients with MD. AQP2 is a vasopressin receptor and its overexpression in MD patients may explain the stress-related attacks. Vasopressin is one of the stress hormones, its elevation may induce V2R-cyclic AMP-PKA-AQP2 activation and endosomal trapping of AQP2 in the endolymphatic sac and lead to an acute attack. If such findings could be reproduced, specific therapy may be added to the armamentarium against MD especially in certain situations.
A useful flap for reconstruction in the head and neck
Reviewed by: Mrinal Supriya
Nov/Dec 2010 (Vol 19 No 5)
The keystone design perforator island flap was initially described by Felix Behan in 2003. This is a random pattern local elliptical flap with its long axis adjacent to the long axis of the defect. This is designed as an island based on axial perforators from the underlying structures with a width similar to the width of defect and length dictated by the size of defect. This was developed as an alternative to free flaps which are otherwise needed to close larger soft tissue defects following radical ablation anywhere in the body. This is based along the alignment of dermatome (Principally C2 and C3 dermatome in the head and neck area) with limited blunt dissection to preserve perforators. In the original article the author described use of this flap in more than 300 patients with only one case of partial flap necrosis giving a flap survival rate of 99.6%. In this article the authors describe their experience with this flap when used to reconstruct defects arising due to ablation of tumour in head and neck area in a small series of eight patients. All were elderly cases (mean age 80 years, range 67 to 95 years) and had extensive soft tissue ablation (mean defect size 45cm2, range 12-100cm2) for BCC or SCC in the head and neck area. Colour illustrations have been provided for all the cases and there is limited material provided describing the keystone flap. This seems to be a useful flap for reconstruction following extensive soft tissue ablation of skin cancers or advanced tumour requiring excision of extensive skin area. This could potentially be useful in cases with soft tissue loss following postoperative infective complications as well. The authors list reduced perioperative morbidity, shorter operating time and relative ease in mastering the technique as other benefits of this flap. However I am not sure its size would be enough for reconstruction of very large defect in the facial area. As it does not include bone, it would be unsuitable for cases needing composite reconstruction with osseous tissue. Free flap will remain the optimum graft in such cases. Tissue laxity is necessary for mobilising this flap and could be a limiting factor in patients with previous irradiation. However the authors do mention the limitations associated with the flap and indeed promote this flap as an alternative in selected group of patients. To get a better understanding of this flap interested reader would benefit from the first author's original paper published in ANZ J Surg in 2003. Overall this appears to be a very useful addition to the armament of the reconstructive surgeon faced with the problem of covering soft tissue defect in the head and neck area and deserves wider usage than is currently practised.
Better stability of prostheses with artificial extracellular matrices?
Reviewed by: Iordanis Konstantinidis
Nov/Dec 2010 (Vol 19 No 5)
This is another nice experimental study, from the well-known group of Dresden, on middle ear reconstructive surgery. This team has worked for many years on better coupling between the prosthesis and residual ossicles. Specifically in this study the authors implanted, on the footplate of Merino sheep, titanium footplate anchors coated with osteoinductive substances. Studies have shown that collagen-based matrices can induce and enhance bone formation and consequently increase implant stability. The idea of this study was to induce a controlled osseointegration on the footplate. The surface of each implant was modified by applying a collagenous matrix (collagen I or II) either with immobilised bone morphogenic protein (BMP-4) or transforming growth factor-ß. Polychrome labelling was used to assess new bone formation and remodelling during the study. At the end of the study, synchrotron radiation-based computed microtomography and histomorphometry were used to identify bone implant contact. Finally eight implants out of 46 ears enrolled in the study showed radiographical and / or histological evidence of integration by newly formed bone. Additionally ectopic bone formations were seen in another 21 specimens. One can argue about the non-impressive numbers, however this study presents the ability to induce a controlled osseointegration of titanium implants biologically activated with artificial extracellular matrices and this is a good start!
Stent fracture
Reviewed by: Badr Eldin Mostafa
Nov/Dec 2010 (Vol 19 No 5)
Endoluminal stenting is an alternative in the management of selected cases of tracheal stenosis. However stents have their own complications. A rare problem is stent fractures due to metal fatigue when subjected to torsional forces. This is a computed tomographic analysis of reconstructed CT scans of patients presenting with a fractured stent. The median time for fracture was 865 days. The measured bending angle for fracture was 19° bending angle of the tracheal central axis and a 44° maximal bending angle of the peripheral tracheal wall. This is a very interesting issue however the delayed occurrence of stent failure may be due to tissue / material interaction causing metal erosion rather than mere metal fatigue and torsional stressing. Both mechanisms may be at work but further studies may be needed to assess the effect of prolonged implantation of the stent material.
Endolaryngeal manifestations of myxofibrosarcoma
Reviewed by: B Viswanatha
Nov/Dec 2010 (Vol 19 No 5)
Sarcomas account for less than one percent of malignancies of the head and neck region. Myxofibrosarcoma comprises a spectrum of malignant fibroblastic lesions with variability in the amount of myxoid stroma and represents a distinct clinicopathologic entity that was described in 1977. Here, the authors have described a case of MFS of the right vocal fold in a 79 year old male patient. Endolaryngeal examination findings were suggestive of Reinke's oedema of the right vocal fold. The patient underwent a unilateral cordectomy and the tumour was resected with negative surgical margins. A unilateral swelling of the vocal fold suggesting a common Reinke's oedema turned out to be a very rare case of malignant myxofibrosarcoma. According o the authors this is the first reported case of myxofibrosarcoma of the vocal folds.
Voice changes during different phases of menstrual cycle and in postmenopausal woman
Reviewed by: B Viswanatha
Nov/Dec 2010 (Vol 19 No 5)
Voice is characterised by its frequency intensity and harmonics. The harmonics are hormonally dependent. The female voice evolves from childhood to menopause under the influence of hormones. Sex hormones fluctuations have a great impact on voice by affecting the female vocal fold histology and laryngeal function. This study was carried out to investigate the changes in voice due to the sex hormones, which will form the basis of a multidisciplinary approach to comprehensive and integrated understanding of premenstrual and menopausal female voice. In this study there were 35 healthy females in the reproductive age group and 20 females in the postmenopausal group. Patients were evaluated by a detailed history, laryngeal examination and acoustic analysis using a speech recorder and VAUGHMI software. In the experimental group fundamental frequency, frequency range, optimal frequency, harmonic to noise intensity ratio, maximum phonation duration, jitter and shimmer were analysed during different phases of menstrual cycle (that is menstrual phase, follicular phase, ovulatory phase, luteal phase and premenstrual phase). The postmenopausal females were subjected once to voice analysis at the time of initial presentation to the hospital. The present study compared phonoarticulatory characteristics with the help of computerised acoustic analysis between various phases of menstrual cycle in woman of reproductive age group and the base values were compared with that of a postmenopausal woman. This study has shown that voice quality is best in the menstrual phase and it is significantly poorer in postmenopausal females. This study suggests that hormone replacement therapy may be useful in the treatment of voice problems in females.
More about the nose and Parkinson's disease
Reviewed by: Badr Eldin Mostafa
Nov/Dec 2010 (Vol 19 No 5)
Olfactory dysfunction is a well documented feature of Parkinson's disease. In this article the authors compared the frequency of rhinorrhea between 34 Parkinson's disease (PD) subjects and 15 normal controls (NC) and explored relationships between rhinorrhea, clinical functions, and degree of nigrostriatal dopaminergic denervation using [(11)C]dihydrotetrabenazine (DTBZ) brain positron emission tomography imaging. Sixty-eight percent of PD subjects reported rhinorrhea of any cause compared with 27% (4 of 15) of NC (P=0.008). Rhinorrhea frequency remained higher in the PD group after excluding other nasal causes. There were no differences in demographics, nigrostriatal dopaminergic denervation, and clinical motor or nonmotor variables between PD subjects with and without rhinorrhea. Rhinorrhea is a common nondopaminergic feature of PD, unrelated to olfactory or motor deficits. PD can affect the nose is many ways both on the olfactory level on the functional level. The cause of this rhinorrhea should be further evaluated to determine its relationship to the disease and the possible therapeutic implications.
Pericranial flap for endoscopic skull base reconstruction
Reviewed by: Gauri Mankekar
Nov/Dec 2010 (Vol 19 No 5)
This paper from the Pittsburgh Group describes a novel technique for reconstructing the anterior skull base in selected cases. Their standard skull base reconstruction for endonasal procedures is a dural graft with a nasoseptal mucosal flap that is pedicled upon the posterior nasal artery. However, the flap may not be available for reconstruction due to prior surgery or involvement of the nasal septum by a sinonasal lesion. The authors describe 10 cases of a pericranial flap harvested using endoscopic techniques via small scalp incisions and then placed over the dural defect via a nasionectomy, that is a slit through the nasal bones performed through a 1cm glabellar incision. The frontal sinus tracts need to be opened laterally in order to avoid being obstructed by the flap. All of the cases had excellent healing with no evidence of postoperative CSF leakage. A temporoparietal flap for reconstruction is an alternative, but the authors found that they can be difficult to dissect, required at least a hemicoronal open incision, are distant from the anterior skull base, and require a transpterygoid dissection for transposition. Another very interesting report from the Pittsburgh Group along with their colleagues at North Carolina University.
Skull base ultrasonic bone curette
Reviewed by: Gauri Mankekar
Nov/Dec 2010 (Vol 19 No 5)
In this brief note, the authors describe their experience of the Sonopet ultrasonic bone curette and new dedicated endonasal hand-piece in 18 standard pituitary operations and nine extended approaches for either meningiomas or craniopharyngiomas. They found it easy to use and effective during the removal of the bone close to and covering the carotid and optic prominences. In one case there was a small tear of the dura. No cases of major neurovascular injury were observed. They conclude that it is a useful ancillary tool but its relative advantages and disadvantages compared to a drill utilising a diamond burr are not discussed.
The 4 year rule?
Reviewed by: Gauri Mankekar
Nov/Dec 2010 (Vol 19 No 5)
Neurovascular cross-compression of the cochlear nerve can lead to a 'curable' form of tinnitus. When detected and properly documented, vascular loop compression of the cochlear nerve can be surgically managed. In this study, twenty patients who underwent a microvascular decompression of the vestibulocochlear nerve for unilateral intractable tinnitus were evaluated by pre- and postoperative visual analogue scale for tinnitus intensity and tinnitus questionnaires for tinnitus distress. Of the 20 patients studied, 10 had improvements on their tinnitus visual analogue score intensity postoperatively, eight were unchanged, and two worsened. On the Tinnitus Questionnaire scores, seven of 13 patients improved and six of the 13 patients worsened. If decompression is performed before the end of the fourth year of tinnitus duration, a significant tinnitus intensity improvement can be obtained (P<.05 after four years, improvement cannot be obtained (P = .55). However, the tinnitus distress does not seem to decrease significantly. This may encourage us to order more and more MRIs for patients with unilateral looking tinnitus, looking not only for masses but also for vascular loops this should be as early as possible.
Obstructed tracheostomy tubes
Reviewed by: Angela Griggs
Nov/Dec 2010 (Vol 19 No 5)
Obstruction of a tracheostomy tube is always a worry for anyone caring for a tracheostomy patient. This short information article outlines the main causes of an obstructed tracheostomy tube. It covers the symptoms of respiratory distress and the issues of a dried mucous plug, over inflated herniated tracheostomy tube cuff, tracheostomy tube tip resting against the tracheal wall, a kinked tracheostomy tube and a displaced tracheostomy tube. For each cause it outlines the symptoms and management of the obstruction and considers prevention and after care. It highlights that the key issue in preventing obstruction is to closely monitor the patient for signs of respiratory distress. The article also includes a useful information box listing the equipment required at the bedside. One issue to consider when reading this article is that it is written from an American perspective and some terminology and practices are different from in the UK.
Collaborative care of the facial injury patient
Reviewed by: Stuart Clark
Nov/Dec 2010 (Vol 19 No 5)
This publication, number 2 from May 2010, concentrates on the mental health support and sociological characteristics of facial trauma patients in North America. They outline the characteristics of facial injury patients with reviews relating to the long-term concerns, substance use, partner violence, social supportand interventions that may help simultaneously with the physical and mental injury. Broadly the at-risk groups and the problems that they encounter mirror those that are seen in Western Europe.
Middle ear surgery - to image or not to image?
Reviewed by: Joanne Rimmer
Nov/Dec 2010 (Vol 19 No 5)
This edition of ORL is dedicated to ‘X-rays before middle ear surgery’, obviously a slightly controversial topic. This article discusses different middle ear pathologies and the indications and benefits of preoperative imaging for each. There are online guidelines for temporal bone imaging from the Association Française d’Otologie et d’Otoneurologie and the Société Francophone d’Imagerie Tête et Cou, which can be downloaded from http://www.orlfrance.org/article.php?id=20. The conditions covered include causes of conductive and mixed hearing loss with a normal tympanic membrane (otosclerosis, congenital absence of the oval window and superior semicircular canal dehiscence syndrome are discussed). Obviously chronic otitis media, with or without cholesteatoma, is discussed, along with possible complications thereof such as labyrinthine fistulae and tegmen anomalies. Conditions in which imaging is mandatory are covered; temporal bone trauma needs CT scanning while glomus tympanicum tumours need CT and possibly MRI depending on extent. The sensible conclusion is that even the best preoperative imaging does not replace surgical experience and technique and anatomical knowledge of the middle ear.
What needs a scan?
Reviewed by: Joanne Rimmer
Nov/Dec 2010 (Vol 19 No 5)
Another article about middle ear imaging, but perhaps slightly more helpful for those wanting an overview of when to consider a scan, when one is essential and when it may not be necessary. The authors cover ear malformations, inflammation including acute and chronic otitis media and associated complications, otosclerosis, trauma and tumours. They also discuss the options for revision cases.
Robotic thyroidectomy; is this really the future?
Reviewed by: James Barraclough
Nov/Dec 2010 (Vol 19 No 5)
Endoscopic and minimally invasive thyroid surgery are now routinely performed as day case procedures by our colleagues in North America having taken 10 years to evolve. It seems that the next step in thyroid surgery evolution is to use a robot and a remote site for the incision. The technique for the transaxillary approach for robotic thyroid surgery is described in relation to the Da Vinci surgical system. Once dissection through the axilla is made, various instruments for retraction are required to provide the space necessary for the robotic arms. The advantages quoted in this article are that the robot-operator interface provides excellent visualisation of the tissues with minimal tissue dissection around the thyroid itself, dexterity is better than that of a surgeon's hand and the scar produced can be hidden away from the eyes of the public. Aside from a comment in the summary of this article about unanswered questions regarding the benefits of this technology, there are no comments about the disadvantages. For this technology to become commonplace in the UK, it would need to provide advantages over current practice and it is not clear here what those may be. A large amount of tissue dissection (by hand) is required to gain access to the neck and this must have its own consequences. Assistants and an anaesthetist are required to work next to the patient so the operating room is not free of personnel. The driving force for this technology and approach is from the Far East where a neck scar is considered unsightly but this is not the case in the UK. The greatest issue is probably the cost which is not mentioned here but would include training, equipment and personnel charges. I am aware of centres in the UK beginning to utilise this technology but I would be surprised if this practice becomes commonplace within the NHS.
Balloon dilation Eustachian tuboplasty
Reviewed by: Rebecca Heywood
Nov/Dec 2010 (Vol 19 No 5)
Surgical management of Eustachian tube dysfunction is topical, with recent developments including laser and microdebrider Eustachian tuboplasty. Endoscopy of the Eustachian tube has also become possible as smaller and smaller endoscopes have become available. Balloon dilation techniques are becoming established as a therapeutic option in chronic sinonasal disease and here are introduced as a means of addressing Eustachian tube dysfunction. This study aimed to assess the procedure of balloon placement and safety aspects of Eustachian tuboplasty, particularly those relating to dilation of the bony Eustachian tube adjacent to the carotid canal, in a cadaveric model. The equipment was specially designed and comprised a balloon catheter and a microendoscope with channels for suction and balloon catheter introduction. The balloon catheter was thereby positioned in the cartilaginous and bony Eustachian tube of five cadavers. The procedure was carried out without technical hitches in all cases. CT scans were performed before, during and after balloon dilation and microsliced temporal bone histology was performed. CT scans and histological specimens were then assessed for evidence of mucosal and bony damage. No fractures or damage to the internal carotid artery could be demonstrated on CT, nor was injury to the internal carotid artery or bony Eustachian tube identified in histological specimens. However, microtears were evident within the cartilaginous Eustachian tube. The mucosa of the Eustachian tube was intact in all cases and post-dilation strictures should therefore be avoided. The authors comment on the altered tissue resistance characteristics in cadavers but still conclude that this technique is easy to perform and safe. It will be interesting to see the clinical outcomes following this procedure though the costs of balloon sinuplasty may preclude it from becoming commonplace.
Long-term results of hearing preservation surgery for vestibular schwannoma
Reviewed by: Rebecca Heywood
Nov/Dec 2010 (Vol 19 No 5)
The optimal management of patients with a small vestibular schwannoma and functional hearing remains a matter of controversy. Although many groups have published their data on hearing preservation surgery in the immediate postoperative period, there is little in the literature in the way of long-term hearing outcomes to compare to those after observation or radiotherapy. This paper from the University of Iowa assesses hearing up to five years after surgical excision of vestibular schwannoma via a middle cranial fossa approach. The main outcome measure used is the Word Recognition Score (WRS), which is based on speech discrimination scores (SDS) and does not have a PTA component, unlike the AAO-HNS and Gardner-Robertson scales. WRS grade I hearing (SDS>70%) was present in 43/49 (88%) of patients preoperatively, 42/49 (86%) postoperatively, and maintained in 38/42 (90%) of patients with more than two years’ follow-up and 23/26 (88%) with more than five years’ follow-up. The results do not look so good when AAO-HNS grade is considered; of 31/49 (63%) patients with AAO-HNS grade A hearing preoperatively, 16/31 (52%) had grade A hearing one month postoperatively and this grade was preserved in only 6/16 (38%) patients at the latest follow-up. Most of the change in grade was due to deterioration in PTA, not SDS. However the authors argue that the SDS is the most important factor in the determination of functional hearing and is often maintained even when the PTA deteriorates, and that the WRS should therefore be used preferentially to measure outcomes. They conclude that patients with initial postoperative hearing preservation tend to maintain it over five years and hearing deterioration is attributable to progressive bilateral SNHL in both ears. They therefore advocate surgery via a middle cranial fossa approach for young patients with small tumours as the best way of preserving hearing.
To do or not to do?
Reviewed by: Badr Eldin Mostafa
Nov/Dec 2010 (Vol 19 No 5)
Preoperative investigations are the norm prior to any surgery. However with increasing market driven medicine and cost reduction, only the strictest overheads are allowed. Tonsillectomy being one of the commonest ENT surgeries performed, the cost of preoperative lab tests may be staggering. This study included a literature search and a review of national databases estimating probabilities, costs, and utility data of preoperative screening. A 14-day Markov model evaluating three strategies: test all children for coagulation disorders; test only those children with a pertinent history; and perform no preoperative testing; was performed. Cost-effectiveness ratios were most sensitive to variation in the cost of postoperative care and the probability of postoperative bleeding. The strategy of non-testing was dominant in all sensitivity and was the most cost-effective strategy. This may help device strategies of preoperative evaluation restricting testing to children with documented coagulation disorders.
Management of communication breakdown during conversations with a hearing-impaired individual
Reviewed by: Roberta Buhagiar
Nov/Dec 2010 (Vol 19 No 5)
The area of conversational skills used with hearing impaired individuals has attracted considerable amount of research in the past and this article looks at a large conversation analysis study of interactional management by adults with a severe to profound hearing loss. The study is based on a qualitative methodology that looks at how conversational partners monitor the availability of the hearing impaired individuals to look and listen. Their conversational turns are timed to occur in such a way that the important parts of the conversation are easily understood by the hearing impaired conversational partner. Self-repair methods and other strategies are readily used by co-operative communication partners when there are problems with gaze availability. Even though misunderstandings do occasionally occur, the efforts made by the conversational partners mean that communication flows more easily. It is noted that these skills are also used in all other aspects of life and in doing so, attention is not brought to the fact that a person is hearing impaired. The main difference between communicating with a hearing impaired individual and communicating with someone who does not have any difficulty lies in the fact that the speaker usually keeps monitoring the level of availability to pick up information when speaking to someone with a hearing impairment.
Evaluating 3D endoscopic systems in skull base surgery
Reviewed by: Andy Hall
Nov/Dec 2010 (Vol 19 No 5)
This retrospective case series aims to evaluate the utility of a three-dimensional endoscopic system for non-pituitary skull base surgery in a tertiary care medical centre in Tel Aviv. A 3D imaging system involving polarising glasses and microscopes allows a stereoscopic view of the surgical field by presenting differing images to the left and right eyes simultaneously. The methodology evaluates the 3D system by focusing on ease of anatomical landmark identification in comparison to 2D visualisation. Additionally complication rates and interestingly adverse effects on the operating team were assessed. Thirty-six patients with a mixture of benign and malignant tumours were included with additional demographic and clinical characterisation provided. The results give us anatomical areas where the 3D technique was perceived by ‘operator consensus’ to be superior to the 2D technique for example sellar region, carotid prominence, fovea ethmoidalis and those where methods were perceived as equal to 2D technique for example middle turbinate, maxillary sinus and frontal sinus. The 3D technique was not deemed inferior to the 2D system at any point. Adverse effects to the surgical team – visual strains or headaches were apparent but facial discomfort was also mentioned. Overall this study has the feel of a preliminary exploration of 3D technology in skull base surgery with the authors clearly acknowledging the need for integration of performance parameters to establish an advantage over 2D techniques in the future.
Reconstruction in cervical spine osteoradionecrosis
Reviewed by: Andy Hall
Nov/Dec 2010 (Vol 19 No 5)
This case study describes a 57-year old man with osteoradionecrosis of the cervical spine and a fistula to the nasopharynx, secondary to radiation given for metastatic hepatocellular carcinoma. The authors elected for operative intervention following four months of antibiotics (IV and oral) as well as hyperbaric oxygen therapy and a curative liver resection. He was treated with debridement of the cervical spine and reconstruction of the nasopharangeal defect with a radial forearm free flap. At 22 month follow-up, the flap remains healthy with excellent function of speech and deglutition.
Speech & language therapy role in TEP closure
Reviewed by: Laith Tapponi
Nov/Dec 2010 (Vol 19 No 5)
Speech & language therapy role in TEP closureSurgical voice restoration via a TEP is one of the most significant developments in head and neck surgery in recent years. However, TEP closure (due to persistent leakage and so on) is rare and not as straightforward as its formation and the process can be time-consuming and complex. This study was carried out in South West England and South Wales and aimed to improve the success rate of TEP closure. The study concentrated on involving multidisciplinary working, making practice more evidence based, and problem solving wound healing issues in practice. Larger studies are required to fully understand the impact of radiotherapy, nutrition, reflux and surgery on outcomes. Therefore, a comprehensive assessment and measure taking prior to surgery is essentially needed via involvement of speech therapists to ensure the best possible outcomes for TEP closure.
More signs for acoustic neuromas
Reviewed by: Badr Eldin Mostafa
Sep/Oct 2010 (Vol 19 No 4)
T1 MRI sequences with gadolinium are considered the gold standard for detection of acoustic neuromas. However sometimes gadolinium may not be administered and the T2-weighted images are equivocal, especially when dedicated thin-section imaging of the IACs and temporal bones was not performed. In this article the authors retrospectively studied 187 consecutive patients who underwent imaging of the temporal bones for possible inner ear or IAC pathology over a one year period. They reviewed the films for abnormal increased FLAIR signal, increased intrinsic T1 signal, abnormal enhancement after gadolinium administration, and the presence of a mass lesion within the cerebellopontine angle, IAC, or inner ear. Twenty-five of 32 (78%) patients with schwannomas, restricted to the IAC and cerebellopontine angle, demonstrated associated increased FLAIR signal within the ipsilateral inner ear structures. The sensitivity, specificity, positive predictive value, and negative predictive value of inner ear FLAIR hyperintensity for a schwannoma were 80%, 95%, 78%, and 95%, respectively. This is a significant addition to the signs we should be looking for when screening for acoustic neuromas, especially when the original study comes back 'negative' against a high index of suspicion.
Delayed facial nerve decompression beneficial?
Reviewed by: Victoria Possamai
Sep/Oct 2010 (Vol 19 No 4)
Fisch and Esslen's recommendation that facial nerve decompression is only beneficial if carried out within 14 days is challenged in this study carried out in Korea. Ninety-one patients with severe / complete facial nerve paralysis (HB grade 5 or 6) + >90% denervation on ENoG and total denervation on EMG + prednisolone within three days of onset were offered surgery. Aetiologies were Bell's palsy, herpes zoster and trauma. Sixty opted to undergo surgical decompression of the nerve. Patients were divided into groups according to surgical timing after onset of paralysis: early (within 14 days), delayed (15-25 days), late (over 25 days). Outcome was measured by functional gain in HB grade. Unsurprisingly, the earlier the decompression was done, the better the result with the early group doing best. It was found that delayed decompression significantly improved functional outcome of patients compared to late decompression or medical treatment alone. The authors conclude that surgery, therefore, may be appropriate at this time interval from onset, and postulate whether the use of early steroids may be a relevant factor in extending the window for beneficial surgical treatment. A methodological concern is the lack of blinding of the researchers assessing outcome.
The Nacul suspensor system
Reviewed by: Furrat A Amen
Sep/Oct 2010 (Vol 19 No 4)
This is an interesting technique to correct the ptotic tip without the need for a formal rhinoplasty. An infraorbital and external nasal nerve block is performed. Then, a combination of a needle and microcannula is used to thread a Gore-tex filament through the septum just caudal keystone area. This Gore-tex filament is then threaded through the lower lateral cartilages on either side and is tied. This knot is then buried subcutaneously and the ends of the filament are cut. The technique is well illustrated with photos, and the results are excellent. It is certainly possible that the Gore-tex filament may extrude with time, depending on skin type. The follow-up is limited to eight months. If the author publishes good longer term results, it is a technique worth considering as a conservative treatment especially in the elderly.
Asthma and rhinitis as a uniform-airways disease
Reviewed by: Laith Tapponi
Sep/Oct 2010 (Vol 19 No 4)
This article examined 878 patients either with asthma or rhinitis or both. It concludes that patients with both asthma and rhinitis had less severe asthma attacks and more airway responsive, but worse rhinitis-specific quality of life, and more perennial allergy. The paper concluded patients with both diseases were under treated in 85% of cases; most ENT surgeons will agree with this.
Choice of medications in allergy
Reviewed by: Badr Eldin Mostafa
Sep/Oct 2010 (Vol 19 No 4)
A wide variety of drug classes are available for the management of allergic patients. However, not all are equally effective for specific symptoms. In this study, montelukast, azelastine, and budesonide were compared to determine the effect on individual, as well as total, symptom scores using the Rhinitis Severity Score (RSS). All three drugs were more effective than placebo. However, montelukast had the greatest effect of the three medications on reduction of ocular itching and throat or palatal itching. Azelastine's effect was greater than budesonide and montelukast for reduction of rhinorrhea. It would seem sensible to tailor the medications chosen for the patient according to his/her most prominent symptoms, rather than use a shotgun approach or restrict oneself to a preferred regimen.
How to manage hereditary angioedema in the long-term
Reviewed by: Laith Tapponi
Sep/Oct 2010 (Vol 19 No 4)
Treatment of hereditary angioedema in many parts of the world falls short. This article studies whether long-term prophylaxis is best with intravenous infusion over 15 minutes of C-1 esterase inhibitor, twice weekly or on demand therapy. As with all literature and article reviews, this treatment requires using a health professional for patient teaching and infusions can be quite time consuming, frustrating and inconvenient for the patient.Candidates for long-term prophylaxis are those with significant anxiety, more than one attack per month, previous ICU stay or laryngeal swelling and previous intubation. The aim is to get a better quality of life, be effective in decreasing the severity and frequency of the attacks and of course decrease the anxiety of those patients.
Hearing and analgesics
Reviewed by: Badr Eldin Mostafa
Sep/Oct 2010 (Vol 19 No 4)
It is a well known fact that aspirin use may be associated with hearing loss. However the effect of other analgesic agents on hearing is not well documented. In this study 26,917 men aged 40-74 years were followed up and the independent association between self-reported, professionally diagnosed, hearing loss and regular use of aspirin, non-steroidal anti-inflammatory drugs (NSAIDs), and acetaminophen was documented. During 369,079 person-years of follow-up, 3,488 incident cases of hearing loss were reported. Regular use of each analgesic was independently associated with an increased risk of hearing loss. For NSAIDs and acetaminophen, the risk of hearing loss increased with longer duration of regular use. Those who used aspirin regularly for 1-4 years were 28% more likely to develop hearing loss than those who did not use aspirin regularly; the risk did not increase further with longer duration of use. Those who used NSAIDs regularly for four or more years were 33% more likely to develop hearing loss than those who did not use NSAIDs regularly. The risk of four or more years of regular acetaminophen use also was 33% higher. The concomitant use of more than one class seemed to be additive especially NSAIDs and acetaminophen. This study sheds light on the risk to hearing from the regular use of analgesics (>2 times / week) especially in younger individuals. We should counsel our patients on the avoidance of regular analgesic use and monitor those who are forced to use them regularly.
Comparison of treatment results with Botulinium toxin A in essential palatal tremor in paediatric and adult patients
Reviewed by: Anurag Jain
Sep/Oct 2010 (Vol 19 No 4)
This is a case series of 10 patients with essential palatal tremors (EPT) in which the authors have reported the symptoms and findings as well as treatment outcomes with Botulinium toxin A (BTA) in these patients. EPT, also known as palatal myoclonus, is a rare condition characterised by repetitive, rhythmic and involuntary contractions of the palatal muscles (tensor and levator palati muscles) which cause objective clicking tinnitus in patients as can be observed by the examiner as well. This case series reports 10 patients (seven adults and three paediatric) with EPT seen over a four year period at the author's institution. The patients varied in ages from six to 68 years with equal sex distribution and duration of symptoms from one to 456 months. Tinnitus was present in all patients (unilateral or bilateral) with a frequency of the clicks varying from 30-100 per minute. All patients underwent endoscopic video recording, electromyography, tympanography and ear canal microphone recording. Five out of 10 patients with EPT opted for treatment with BTA. Two paediatric and three adult patients underwent BTA injections in the soft palate and this therapy was successful in all patients. However, in adults, the remission was shortterm (four to 32 weeks) but the paediatric patients achieved long-term remission. The authors concluded that the reason for this long-term remission of EPT in kids with BTA therapy is speculative, since the exact aetiopathogenesis is not yet known. However this study presents an argument for the use of BTA in children with EPT.
Lidocaine spray versus tetracaine solution for transnasal fibre-optic laryngoscopy
Reviewed by: Anurag Jain
Sep/Oct 2010 (Vol 19 No 4)
This is a prospective randomised controlled trial of 48 patients who were divided randomly into two equal groups in which 10% lidocaine and 2% tetracaine solutions were used respectively for topical anaesthesia prior to transnasal fibre-optic laryngoscopy (TFL). Outcomes in terms of discomfort experienced during the procedure were evaluated by the author by recording a visual analogue score, two hours following the procedure. This was then compared in the two groups and discomfort was found to be significantly less in the group which received 2% tetracaine as compared to the other group. The good things about this study are that a power calculation has been conducted prior to the study, and the outcomes have been evaluated by the appropriate statistical tests. However, there are some aspects which could have been clarified. Although the patients were randomised into two groups, no details have been provided as to how they were randomised. Also the title can be misleading as it suggests that 10% lidocaine spray was compared with 2% tetracaine solution soaked in surgical sponges. In fact the lidocaine spray was also sprayed on the sponges which were then applied topically in the nose. Although the outcomes suggest superiority of the tetracaine over lidocaine, a crossover study between these groups would be more convincing of the outcomes. Lastly, although the authors have recommended tetracaine as a safe and effective form of topical anaesthesia for TFL, its toxicity reports published in literature, as mentioned in the discussion makes the reader sceptical about using it in clinical practice, especially since so many safe and effective options are available.
Outcomes of septoplasty in young adults: the nasal obstruction septoplasty effectiveness study
Reviewed by: Anurag Jain
Sep/Oct 2010 (Vol 19 No 4)
Here the authors have reported the results of their prospective multicentre non-randomised observational study looking at the outcome of septoplasty, with or without turbinate reduction, using the 'Nasal Obstruction Symptom Evaluation scale' (NOSE) prior to and three and six months subsequent to the surgery.The authors have justified the use of this subjective patient symptom score to evaluate the surgical outcomes as according to them and as per the literature, rhinomanometry has little value in a clinical setting and sub-optimal test-retest consistency and does not correlate well with the patient symptoms. The authors have kept strict inclusion criteria for their studies, which excluded patients with other causes which may contribute to their nasal obstruction and other symptoms, thereby keeping the bias to the minimum. The final results included a total of 86 patients with a mean age of 22 years, which is much younger when compared to other published series and reflects an overall younger population in Tehran. The authors found that patients undergoing septoplasty with turbinectomy had earlier and greater symptomatic improvement than patients undergoing septoplasty alone. A greater success rate following the surgery in this study, when compared to other published series has been attributed to possibly a greater element of anatomically dependent nasal obstruction in younger patients as compared to possibly a greater element of dynamic causes for nasal obstruction in older patients. However I am not sure if it is a safe presumption to make, a fact which has been acknowledged by the authors. Overall this is a well conducted and well presented study.
CT evaluation of chemotherapy response
Reviewed by: Badr Eldin Mostafa
Sep/Oct 2010 (Vol 19 No 4)
The evaluation of tumour response to chemotherapy is critical in planning further management of patients. In this article the authors tried to validate a computerised segmentation system to estimate changes in tumour volume and percentage change in tumour volume, between the pre- and post-treatment scans. Manual and automatic estimation had a high correlation and this information can be used to calculate changes in tumour size on pre- and post-treatment scans to assess response to treatment in an easier less labour-intensive and less operator dependent way.
Balloons in the sinuses
Reviewed by: Joanne Rimmer
Sep/Oct 2010 (Vol 19 No 4)
Balloon sinuplasty is a relatively new technique but has been widely reported in the literature. These authors undertook a retrospective review of 30 patients with chronic rhinosinusitis who underwent balloon sinuplasty, with or without 'standard' functional endoscopic sinus surgery (FESS). Their technique of balloon sinuplasty is documented. They report excellent results with the balloon dilatation technique, but do not explain when or why FESS was used as well. One of their reasons for using balloon catheters is to be 'minimally invasive' and avoid FESS complications, so using it in addition to FESS, rather than instead of, seems to defeat this object. It is not clear how many patients had FESS, or how extensive it was, and it is therefore difficult to draw any real conclusions.
Fat injection can last
Reviewed by: Joanne Rimmer
Sep/Oct 2010 (Vol 19 No 4)
This is a prospective study assessing voice outcomes following vocal cord medialisation by two different methods. Isshiki type I thyroplasty has long been held up as the gold standard technique for long-term results. Autologous fat injection, on the other hand, is generally thought of as a temporary measure due to reabsorption of the fat over time. Here, 46 patients were treated with fat injection over a four year period, with 48 patients undergoing formal thyroplasty over the following three years. Their voices were recorded preoperatively and then at one, three, twelve and 24 months following surgery. Both groups showed significant improvement in voice parameters (jitter, shimmer and noise-to-harmonics ratio) at one month post-operatively. There was no difference between the groups, and this improvement was maintained over the two year follow-up period. At 24 months there was still no significant difference in voice parameters between the two groups. However, the injection group does have a higher revision rate (re-injection or thyroplasty), 20% compared to just two per cent in the thyroplasty group. That aside, this study provides good evidence that fat injection can provide stable long-term improvement in voice outcomes.
FEESST - a more detailed version of FEES
Reviewed by: Joanne Rimmer
Sep/Oct 2010 (Vol 19 No 4)
Larynx preservation surgery has obvious benefits in avoiding a permanent stoma, but patients are perhaps more likely to suffer problems with dysphonia and dysphagia compared to total laryngectomy. This paper follows seven patients who underwent supraglottic laryngectomy and three who had supracricoid laryngectomy; six also underwent radiotherapy while eight had a simultaneous functional neck dissection. All underwent fibreoptic endoscopic evaluation of swallowing with sensory testing (FEESST) as part of their swallowing rehabilitation programme. The addition of sensory testing to standard FEES allows assessment of laryngeal sensitivity and the laryngeal adductor reflex (LAR) using air pulse stimuli. The study was well-tolerated in all patients. The LAR was preserved in three of the ten patients: the two patients who did not undergo either radiotherapy or a neck dissection, and one patient who underwent neck dissection without radiotherapy. The LAR was delayed or absent in the remaining seven patients, and this was associated with severe aspiration. Residue was also higher in patients with an abnormal LAR. The authors reasonably (or unnecessarily) conclude that laryngeal sensitivity is reduced in patients who have undergone partial laryngectomy, particularly in those who also have a neck dissection or radiotherapy. They suggest FEESST may play an important role in planning and delivery of post-surgical swallowing rehabilitation, although how it improves on standard FEES is not clear.
Ingested foreign bodies in the thyroid gland?
Reviewed by: Joanne Rimmer
Sep/Oct 2010 (Vol 19 No 4)
Yes, apparently this really can happen! The authors present a case report of a woman presenting with throat pain, odynophagia, fever and a thyroid abscess; a 3cm wire bristle was evident within the right thyroid lobe on CT scan. This was found to be protruding from within the right piriform sinus on endoscopy. It was removed via the oesophagoscope and the thyroid abscess drained via a standard neck incision. A literature review revealed a further fourteen cases of foreign body migrating to the thyroid gland, including fish bones, chicken bones and metallic wires. Whilst plain radiographs identified the foreign body in eleven of fourteen cases, it was only picked up on CT in the other three. The moral of this slightly bizarre story is to have a high index of clinical suspicion, and examine your patients thoroughly. If there is not enough to go on to proceed with rigid endoscopy, then consider CT scanning if something does not seem quite right – who knows what you will find?
Post-nasal space biopsies - when to do?
Reviewed by: Joanne Rimmer
Sep/Oct 2010 (Vol 19 No 4)
Post-nasal space biopsies are required whenever there is unexplained soft tissue within the nasopharynx, and therefore have a very low sensitivity. Such a finding may be seen in patients presenting with any number of rhinological symptoms, yet, even with no risk factors for nasopharyngeal carcinoma, a biopsy is mandatory – no one wants to miss a cancer. The authors developed an objective endoscopic score to grade nasopharyngeal abnormality, potentially identifying a cut-off point for when biopsy is and is not required. Seventy-seven consecutive patients referred for nasopharyngeal biopsy were recruited, and a score sheet with 44 variables was developed. Each variable received a score of 0 (normal) or 1 (abnormal). Of the 77 patients, seventeen had nasopharyngeal carcinoma on biopsy, while 60 had benign or no disease. Patients found to have a malignancy scored significantly higher than those without, and no patient with a malignancy scored less than twelve. For patients with benign disease, 31% had a score of twelve or more that is, a false positive result based on this as a cut-off point (with a sensitivity of 100%). This study was undertaken in Hong Kong, so there is obviously a higher pick-up rate than other places in the world, and inter-rater variability has yet to be determined. However, once such issues have been resolved, and the score has been validated, it may offer an objective method of determining who needs a post-nasal space biopsy and who can be safely left alone.
Sialendoscopy
Reviewed by: Joanne Rimmer
Sep/Oct 2010 (Vol 19 No 4)
Sialendoscopy has been used in the diagnosis and treatment of major salivary gland disorders since 1990. Its use is ever increasing, with better optical systems and additional treatment methods. These authors performed a retrospective review of 83 patients who presented with symptoms of major salivary duct obstruction. Sixty glands (33 submandibular and 27 parotid) in 54 patients were evaluated with sialendoscopy. The technique is discussed, with a 100% success rate for being able to actually perform a diagnostic procedure. Two cases were normal. Sialolithiasis was found in 38 glands (28 submandibular and 10 parotid). Non-calcular obstructive disorders were seen in 15 glands, predominantly stenoses. There were occasional coexisting problems found, for example mucus plugs, in addition to another obstructive pathology. Mechanical or pneumatic lithotripsy was used to fragment the stones; a holmium:yttrium-aluminium-garnet laser was used in one case. The fragments were retrieved with forceps or a basket. The overall interventional success rate was 83%, with no complications. The authors advocate the use of sialendoscopy not only in sialolithiasis but in other salivary gland disorders as well.
Full thickness skin grafts and steroid injection - another attempt to deal with auricular keloids
Reviewed by: Christos Georgalas
Sep/Oct 2010 (Vol 19 No 4)
As everyone involved in facial plastic surgery knows, treating auricular keloids can sometimes give one this sinking feeling of waging an unwinnable war. The myriad of articles and suggestions usually only serves as further reinforcement of the extraordinary propensity of these lesions to recur. The introduction of intralesional steroids a few years ago seems to have improved the outcome of such patients, although the problem of dealing with the primary wound remains. Although a few series have introduced the possibility of using split thickness grafts or delayed reconstruction with some effectiveness, this is the first series describing the results of excision and immediate reconstruction with full thickness postauricular grafts and Kenalog (40mg/ml) injection. The authors present their series of 10 patients with significant in size auricular keloids (mean diameter 4.6, range 2-10cm) with a follow-up of almost a year. In all patients, the graft take was excellent and there was no evidence of recurrence, importantly, not only in the recipient but also in the donor site. One may challenge the wisdom of harvesting a donor graft from the postauricural sulcus thus creating the potential for a new keloid, as well as the limited follow-up, as keloids can recur after more than a year. However, this article does seem to provide good results (albeit with the caveats described above) and should certainly provide at the very least some room for discussion.
Unilateral or bilateral CI
Reviewed by: Badr Eldin Mostafa
Sep/Oct 2010 (Vol 19 No 4)
The case for bilateral cochlear implantation is now strongly getting hold in the otologic community. There have been numerous reports on the advantages of such a procedure for sound localisation and speech in noise perception. However there are some issues related to the double surgery, the preclusion of further benefit from newer implants. In this article the authors evaluated the performance measures of children's listening skills; parental-proxy valuations of the deaf children's health utility obtained with the Health Utilities Index Mark 3 and of their QOL obtained with a visual analogue scale. On average, bilaterally-implanted children performed significantly better than unilaterally implanted children on tests of sound localisation and speech perception in noise. However bilaterally- and unilaterally-implanted children did not differ significantly in parental ratings of health utility or QOL. These results may give us an insight of the true value of bilateral implantation from the beneficiary's point of view. It may curb a little bit our enthusiasm until we can reach better speech processing protocols or better performing implants to improve the real life outcomes as needed and evaluated by the patients and their caregivers.
Improving survival in early oral cavity carcinoma by adding radiotherapy
Reviewed by: Shabbir Akhtar
Sep/Oct 2010 (Vol 19 No 4)
Oral cavity squamous cell carcinoma (SCC) is a common problem worldwide. Despite recent advances in surgical techniques and addition of radiotherapy, the survival has remained static. The role of adjuvant radio and chemotherapy is well established in advanced stage (T3 & T4) SCC. However the patient may present with a lesion early in the course of his / her illness (T1 or T2).The role of adjuvant radiotherapy in the treatment of patients with T1-2 cancer is less well defined. Many of these patients with N0 neck undergo staging neck dissections. If the metastasis is limited to a single, less than 3cm node the patient will be upstaged to stage III but still routine use of adjuvant therapy will be controversial. Many clinicians consider limited regional spread as a good prognostic factor and will offer less intensive therapy, avoiding radio-chemotherapy related side-effects. In this excellent population based study, 1,539 patients were treated with surgery for T1-2N1. The main objective was to see a survival benefit in patients who, apart from surgery, also received adjuvant radiotherapy. Statistically, significant five year overall survival rate (41% for surgery alone versus 54% for surgery plus RT p<.001) was seen. This difference in survival was stronger in T2 versus T1 and in patients with oral tongue and floor of mouth carcinoma. The limitation of population based study, such as its retrospective nature, non-randomisation, no information about nodal control warrants multi-institutional prospective studies.
Killing cancer cells using Herpes simplex virus. Potential future avenues for young investigators
Reviewed by: Shabbir Akhtar
Sep/Oct 2010 (Vol 19 No 4)
Static survival rates of head and neck squamous cell carcinoma (HNSCC) cancer have led investigators to develop novel treatment options. The concept of infecting and killing cancer cells with attenuated Herpes simplex viruses sounds interesting and promising. The goal is improving local and regional control while minimising toxic effects. In this in vitro study, four human HNSCC cell lines were studied. All the four cell lines were infected with attenuated Herpes simplex viruses, whereas two cell lines were additionally exposed to the prodrug fluorocytosine. The idea of adding the prodrug was to assess its conversion to fluorouracil which has cytotoxic effects. Head and neck squamous cell carcinoma cells were 100% permissive to attenuated viruses. Virus caused more than 60% cell death six days after exposure. Fluorocytosine did not enhance cytotoxicity except in less-sensitive cell lines. From a clinical standpoint, these findings imply that viruses could be produced and released to infect and lyse cancer cells. As this was an in vitro study, these novel findings need further support from in vivo experiments to establish their potential application.
Paediatric lymphatic malformations; uncommon but complex clinical problem
Reviewed by: Shabbir Akhtar
Sep/Oct 2010 (Vol 19 No 4)
Lymphatic malformations are benign congenital abnormalities of the lymphatic system, thought to arise from disordered embryologic development. More than half of all lesions are found in the head and neck. Ninety percent of lymphatic malformations are diagnosed before age two years. Lymphatic malformations have traditionally been managed by observation, surgical excision but, over the last decade, sclerotherapy is also being increasingly used. Sclerosing agents include bleomycin, Ethibloc, pure ethanol and OK-432. Symptoms include visible nontender swellings, with cosmetic concerns related to soft-tissue masses, tongue protrusion, and bony deformity. These children may have functional issues, with speech difficulties, dysphagia, and dental problems. Recurrent infection, fluctuation of the lesion size, and recurrent bleeding of mucosal lesions may occur. Sudden enlargement may give rise to airway obstruction, requiring placement of a tracheostomy tube. Psychological sequelae can also arise as the child grows older and becomes increasingly aware of the lesion and the associated cosmetic issues. In this retrospective case series ninety-seven paediatric patients (aged one month to 16 years) diagnosed as having lymphatic malformations of the head and neck were studied. Follow-up ranged from three months to seven years. All of the patients underwent clinical and magnetic resonance imaging assessment. Treatment modality was selected according to disease location, cyst size, and parental preference. Treatments included surgery, sclerotherapy with OK-432 or with Ethibloc, and a combination of modalities. Isolated neck disease had an excellent outcome with either modality. Disease extending from the neck into adjacent anatomical structures like floor of mouth, tongue, and mediastinum required multiple treatments using combination of surgery and sclerotherapy. Treatment decisions should be made via a problem-based approach and should be individualised according to anatomical location, size and parental preference. Spontaneous improvement was documented in some children in this series, and patients may be observed provided that there is no significant associated compromise.
Pain is worse than palsy?
Reviewed by: Neil C Molony
Sep/Oct 2010 (Vol 19 No 4)
So it’s retrospective, cross-sectional even, but it’s a largish series from a major centre. This was a quality of life questionnaire (QoL) survey with replies from 101 operated Vestibular Schwannoma patients using the beloved, quite well validated, SF36 questionnaire, but also looking at a number of symptoms; headache, hearing, tinnitus, balance, pain, dry eyes and facial weakness. It compared replies from 59 patients operated via the retrosigmoid approach (RSA) and 42 via the translabyrinthine approach (TLA), with a mean follow-up of 5.9 years. Statistics are fair using t-tests with paired control data for symptom analysis. When present, pain (in the operated area as opposed to generalised / vertex headache) was the most disabling problem. About half had simple headaches and over 80% some balance problems though these generally did not impair life very severely. Tinnitus was more prevalent in those operated via the RSA, but a significant problem in less than 30%. Hearing loss by definition was total after the TLA approach but all but one RSA patient had significant loss and the grade of reported disability was not as different as I might have expected. Dry eye was quite common, very troublesome in 21% and poorly correlated to facial weakness. Facial palsy, while House-Brackmann grade 3 or more in at least 15 patients, was described as a problem only in eight, which seems surprising in comparison to our perception of this issue. An interesting general trend was that RSA patients were more limited by emotional problems than TLA patients. Women in general had slightly poorer function than men. In summary these patients do have impaired quality of life but pain in the operated site when present was the worst symptom, worse than facial palsy or hearing loss, so the patients’ perception of the main problem was perhaps not that a clinician would have anticipated – always worth knowing!
Changes in microbiology of complicated head-neck infections
Reviewed by: Iordanis Konstantinidis
Sep/Oct 2010 (Vol 19 No 4)
This is a nice retrospective Dutch paper dealing with 96 patients having complicated head-neck infections, requiring surgical intervention. 'Complicated' infection was defined as any infection with spread beyond the primary location. What the authors found is the need for aggressive surgery in children with ear infections or adults with complicated cholesteatomas (mortality rate 13%). The microbiology of ear infections in adults was Pseudomonas aeruginosa in 10% and anaerobes in 25% of cases. These results do not raise questions about empirical therapy with antibiotics. The most frequently used antibiotics (90% of patients) were amoxicillin-clavulanic acid, ceftriaxon, metronidazole, clindamycin or combinations including at least one of them. In general the predominant causative organisms for complicated head-neck infections were streptococcus pneumonia, beta hemolytic streptococci and Streptococci milleri. However, an interesting point was the positive cultures from six patients (various aetiology) for coagulase-negative staphylococci, which are resistant to the common used antibiotics. This is a fact that needs more attention in the future.
Pathology examination of adenotonsillectomy? Look better before surgery!
Reviewed by: Iordanis Konstantinidis
Sep/Oct 2010 (Vol 19 No 4)
This is another paper on this issue confirming that routine pathological examination in adenotonsillectomy is unnecessary. The authors assessed 589 adenoidectomy and 1,132 tonsillectomy specimens. The search for unexpected pathology in patients with benign indications for surgery found practically nothing. On the other hand, in 25 adult patients with clinical suspicion (asymmetry, ulceration and so on) the results showed 15 cases of lymphoma, one squamous and two undifferentiated carcinomas. However, a significant percentage of these patients 32% (8/25) had benign pathology. These results are in accordance with previous studies assessing adenotonsillectomy specimens. In children it seems to be clear that there is no need for pathology in routine adenotonsillectomy when clinical suspicion does not exist. However a high index of suspicion is needed in adults especially with clinical findings such as asymmetry, ulceration, positive lymph nodes or history of weight loss, night sweats and so on. Why not try for a European consensus on this issue?
Optimising intraoperative haemodynamics
Reviewed by: Rhodri C Costello
Sep/Oct 2010 (Vol 19 No 4)
This short communication builds on work previously done in major abdominal and orthopaedic surgery, where goal-directed volume expansion has resulted in shorter postoperative in-hospital stay and reduced complications. Appreciating the use of an oesophageal Doppler ultrasound to assess stroke volume and cardiac output is impractical in head and neck cancer surgery, the authors use a minimally invasive device called LiDCO Rapid. This derives stroke volume and heart rate from the patient's arterial pressure waveform, to guide fluid administration. The monitor displays beat-to-beat haemodynamic data which can be set to include blood pressure (systolic, mean, and diastolic), heart rate, stroke volume, cardiac output, systemic vascular resistance or pulse pressure variation (PPV). The authors describe their current fluid administration protocol, and explain how fluid boluses are given when the PPV rises to 10% or greater. This article reports the authors' early use of the LiDCO device, and they are planning on assessing the efficacy of their current protocol with a randomised, controlled, clinical trial, the results of which will make for interesting reading.
Visualising the invisible
Reviewed by: Rhodri C Costello
Sep/Oct 2010 (Vol 19 No 4)
This observational study, consisting of two series of 50 consecutive patients, compared the use of Lugol's iodine in obtaining clear resection margins in patients with oropharyngeal squamous cell carcinomas. The authors retrospectively reviewed their data for 50 patients (standard group) who had resection of a primary SCC of the oral cavity or oropharynx with curative intent, before introducing Lugol's iodine stain into their operative procedure and prospectively comparing the difference this made to the histologically clear margins. Thirty-two per cent of the standard group had intraepithelial neoplasia at the surgical margin compared to 4% after the introduction of Lugol's stain, with a significance of p=0.001, 95% CI 16-45. The authors discuss the promising future of optical spectroscopy and molecular markers for tumour extent. Concluding that Lugol's iodine is inexpensive, easy to use, proven of value in other mucosal sites and significantly reduces incidence of intraepithelial neoplasia at surgical margins. The authors concede that a trial is required, and comment that one has commenced with the end points being observation of clear histological margins and incidence of local recurrence.
Evaluation of hearing loss in non-explosive injuries of the ear
Reviewed by: Ahmed A Saada
Sep/Oct 2010 (Vol 19 No 4)
This is a prospective study of sixty-four consecutive patients who suffered physical blow to the ear resulting in tympanic membrane perforations. The aim of the study is to evaluate the incidence and pattern of hearing loss resulting from such trauma. The manuscript starts with an introduction differentiating between explosive and non-explosive blast injuries to the ear; explaining the mechanism of insult to the tympanic membrane. Subjects of this study underwent a thorough examination with consideration to their age, gender, side of injury, cause of injury and symptoms. Special attention was given to the location and size of the tympanic membrane perforation. Pure-tone audiometry was used to evaluate hearing threshold, with regular follow-up visits to assess the rate of healing. The results showed that anterior perforations accounted for 27% of the perforations, while posterior perforations accounted for 25% of cases. About 47% of the perforations involved adjacent portions of both anterior and posterior halves of the tympanic membrane. The authors categorised the size of the tympanic membrane perforations into: small, medium, large and very large. Seventy-four percent of the perforations were small in size and 13% occupied more than half of the entire tympanic membrane. Pure-tone audiogram showed that 33% of patients had no air-bone gap or sensorineural hearing loss, while 28% had mixed hearing loss. Moreover, spontaneous healing of the tympanic membrane perforations was associated with significant closure of the air-bone gap. The clinical significance of the present study lies in the fact that excellent recovery of conductive hearing loss can be expected in patients who sustained physical blow to the ear, whereas recovery of sensorineural hearing loss is less favourable. In all cases, an audiometric evaluation on the basis of exposure is well justified.
Reassessment of dizziness and vertigo in the elderly
Reviewed by: Ahmed A Saada
Sep/Oct 2010 (Vol 19 No 4)
This is an interesting prospective cross-sectional study that highlights the personal and health care burden of dizziness and vertigo in the community. Also, it aims to reassess the relationship of these symptoms with hearing loss and tinnitus. The manuscript starts with a good introduction about terminology of dizziness versus vertigo, with a mention of their incidence in the population over 65 years of age. The methods used included a set of questionnaires and auditory testing. The questionnaire is designed to cover a description of dizziness as well as the association of nausea, vomiting and tinnitus. The authors used the Dizziness Handicap Inventory which categorises the history taking into three dimensions: functional, emotional and physical aspects of dizziness. Hearing impairment was determined by pure-tone audiometry. The results showed 36.2% prevalence of dizziness / vertigo, 10% vestibular vertigo and 14.2% non-vestibular vertigo. Tinnitus and migraine symptoms were associated with dizziness / vertigo, while hearing loss was not. Although this study includes a large number of participants, the findings were based on self-reported dizziness symptoms obtained using a standardised questionnaire and not based on validated neuro-otologic examination. This observation clearly poses an important limitation in this study. Nevertheless, the findings reinforce published literature and highlight the burden imposed by dizziness in a significant section of the population. Accordingly, the problem of diagnosis and treatment of dizziness / vertigo should be regarded as a major healthcare issue.
The limits of transnasal endoscopic skull base surgery
Reviewed by: Susan A Douglas
Sep/Oct 2010 (Vol 19 No 4)
Endonasal endoscopic surgery has been facilitated by technological advances, a greater understanding of skull base anatomy and a multidisciplinary approach. There are, however, limitations on surgery imposed by anatomical factors, the histopathology and biological behaviour of disease, technical challenges of surgery, the special patient groups and the expertise of the surgical team. The anatomical restrictions can be divided into the sagittal and coronal planes. The optic nerves and internal carotid arteries are key anatomical structures identified in the sphenoid sinus. The sagittal plane extends from the frontal sinus to the body of C2 in the middle corridor. The coronal plane is subdivided in to anterior, middle and posterior coronal plane, corresponding to the cranial fossae. Some authors have shown that the limitations of the approach are size greater than 4cm, significant lateral tumour extension beyond the optic canals, encasement of neurovascular structures and brain invasion by malignant lesions. The authors emphasise that the surgical goals, when using an endoscopic approach, should be the same as those during open surgery. Other studies have shown that the lateral limitations of clival exposure were the medial pterygoid plate and the Eustachian tubes. During trans-odontoid surgery, the caudal exposure is limited by the nasal bones superiorly and the hard palate posteriorly. One of the most controversial topics is the management of sinonasal malignancies with skull base involvement. In properly performed surgery, the oncological principles do not need to be sacrificed in order to achieve complete resection with clear margins. A key point of discussion is whether endoscopic surgery allows for ‘en-bloc’ resection of tumours. Many intranasal tumours have a small area of tissue invasion, despite filling the empty spaces on the nasal cavity and paranasal sinuses. En-bloc excision of the entire tumour in not necessary; rather en-bloc excision of the area of invasion is performed. Tumour debulking is performed in order to gain access to the area of invasion. Although this violates the tumour, this does not violate normal tissue planes. There is no current evidence that debulking the tumour increases the risk of local recurrence.
Technical challenges – the important challenges are dural reconstruction and haemostsis. The workhorse used is the nasoseptal flap, which is pedicled on the posterior septal branch of the sphenopalatine artery. This provides a flap large enough to cover maximal dural defects, from the frontal sinus to the sella and from orbit to orbit. This flap may not, however, be as useful in the paediatric population and an anteriorly based pericranial flap can be elevated, via minimally invasive techniques, and placed intranasally without a craniotomy. Resources – technological resources involve the use of image guidance and intraoperative CT scanning. Of course the most important resource is a surgical team with proper training. This article is comprehensive and well written.
A new speech test to consider
Reviewed by: Veronica J Kennedy
Sep/Oct 2010 (Vol 19 No 4)
With the ever-increasing technological advances in hearing aids, it is useful to have reliable measures to assess how this benefits functional hearing ability or accesses the speech frequency range to aid communication. Clinical speech recognition assessment has been used for many years to assess the impact of a hearing loss and the benefit provided by hearing aids. Some of the tests used to assess speech recognition are discussed in the introduction of this paper, particularly their phoneme recognition and performance intensity (PI) functions. The paper looks at a computer-aided speech recognition test developed by Boothroyd (well known as a 'B' in the AB word list and BKB sentences). He had proposed that the use of PI functions could be useful to evaluate changes in hearing aid settings or in the assessment of speech perception over the tested individual's dynamic range. The aim of the paper is to use the Computer-Aided Speech Perception Assessment (CASPA) test to assess performance intensity functions for adults and children with normal hearing, in quiet and in noise. It also aimed to explore age-related differences to see if CASPA would be a clinically feasible tool for the audiological assessment of young children. CASPA had previously only been used in adults. Responses to lists of 10 CVC words, presented over a range of intensity levels, are entered into the computer. CASPA then uses computer-aided analysis to score the phoneme recognition across the intensity range tested in under five minutes rather than >15 minutes that it can take to do this tedious task. (The test in the study took 10 minutes to obtain PI functions across six intensity levels but the authors suggested that clinically it could be done in less time.) The age range of children in this study was between five and 12 years. As expected, age related differences were noted, with better word scores in the older children and adults. There were smaller differences in the phoneme scores. Although the children under eight years old had poorer phoneme recognition scores, there was less of a difference with the phoneme than with the word scores. Phoneme recognition was also less variable in noise. There were also smaller degradations of the phoneme than word recognition scores noted as the signal-to-noise ratio decreased across the age range showing that the use of phoneme rather than word scoring does minimise age-related differences in speech recognition. If CASPA is to be used as clinical tool, more work is needed to develop age-appropriate norms. However, this test could be a useful tool in the assessment of both adults and children.
Why noisy backgrounds are a problem with a high frequency hearing loss
Reviewed by: Veronica J Kennedy
Sep/Oct 2010 (Vol 19 No 4)
High frequency hearing loss, especially when it progresses into the frequency range associated with speech (<4kHz), frequently presents a problem with communication. As studies show mixed findings concerning speech perception in noise in individuals with a high frequency sensorineural hearing loss (HF SNHL) and the temporal impact of a HF SNHL, this Chinese study aimed to investigate this further. It used gap and amplitude modulation (AM) tasks to evaluate temporal resolution. A Mandarin version of HINT (hearing in noise test) was used to assess speech perception. The study participants were native Chinese speakers and had either normal hearing or a steeply sloping high frequency sensorineural hearing loss. Although the subjects tested had a high frequency hearing loss, a general trend of poorer temporal resolution was also noted in the low frequencies (<1kHz). In the AM detection task, when the noise-carrier with 1kHz cut-off was used, all the subjects showed elevated modulation depth thresholds compared with the normal hearing subjects. (The discussion did make note of another study using an animal model where, with a high frequency loss above 8kHz, sensitivity remained normal below this frequency.) The subjects with HF SNHL were also noted to be more sensitive to background noise. The overall performance in the speech assessment using HINT was also poorer in the subjects with a high frequency loss than with those with normal hearing. The larger impact of time compression on the HINT scores in the HF SNHL subjects suggests that there is a temporal factor involved although the study acknowledges that other factors apart from impaired temporal resolution contributed to the poorer scores. The effect of a high frequency hearing loss on central auditory plasticity, rather than just the impact of its reduced audibility, is considered and is an interesting read.
Confocal endomicroscopy imaging of oral and oropharyngeal tumours
Reviewed by: Owain R Hughes
Sep/Oct 2010 (Vol 19 No 4)
This paper presents the first published images of the oral cavity and oropharynx captured by confocal endomicroscopy (CE). The authors describe their experience of using a CE, which is a confocal microscope, miniaturised and incorporated into a conventional endoscope. Pentax have developed a system which is licensed for clinical use in the UK. Using CE, 475µm2 sections can be captured at 4µm increments, up to 250µm from the mucosal surface, in vivo. Two dimensional horizontal sections through the mucosa are projected onto a computer screen, in real time, delivering an ‘optical biopsy’ during surgery. The topical application of acriflavine hydrochloride stains cell nuclei, and intravenous fluorescein, which is routinely used for retinal angiography, attaches to serum albumin to highlight blood vessels. As fluorescein leaks through the vessel wall, cell cytoplasm and extracellular matrix are stained. Signs of malignancy were observed by CE as a disruption to the cell architecture and increase in the vascularity due to neo-vascularisation. The findings on CE correlated well with subsequent histopathological examination of biopsy specimens. This study was completed in adults without general anaesthesia. Further formal studies are required to evaluate the value of this technology in examining tumours of the upper aerodigestive tract under general anaesthesia. A particular problem with this technology, at present, is that it is very expensive to purchase, costing approximately £130k for the entire system.
High-performing teams
Reviewed by: Showkat Mirza
Sep/Oct 2010 (Vol 19 No 4)
This interesting article discusses the inspirational aspects on how to lead a high-performing team. The paper starts with how to hire staff; that is 'getting the right people on the bus'. A fundamental question when interviewing is where the candidate envisions themselves in five years' time. The differences between leadership and management are described, with leadership being about inspiration and management about manipulation. Other topics include staff meetings, taking time to do what's important, but not urgent, and having fun at work! The four simple rules of Toltec wisdom are given, always be impeccable with your word, do not take anything personally, do not make any assumptions and always try your best. A number of quotes and references for further reading are given.
Of posture and voice
Reviewed by: Badr Eldin Mostafa
Sep/Oct 2010 (Vol 19 No 4)
This study aimed at determining whether body movement is a side-effect of vocal effort or an integral part of communication effort behaviour. It involved twenty females with no postural or vocal disabilities. The subjects were asked to communicate with a listener, aiming to be understood under three different conditions designed to force them to make increasing vocal efforts under conditions 1 [weak vocal effort condition (WVEC)] and 2 [moderate vocal effort condition (MVEC)], the room was quiet (background noise: 44-48dB SPL) and the listener 4 and 10m away, respectively. Condition 3 [high vocal effort condition (HVEC)] was designed to force the subject to make a very high vocal effort: the listener was 10m away, and both the subject and the listener wore earphones with a 90db background noise. Objective voice data were collected by a dedicated workstation and Kinematic data were collected by an automatic motion analyser using passive body markers. This study highlights the co ordination between posture and voice during vocal effort. The movement which is associated with vocal effort is structured and involves the whole body. The amplitude and duration of the movement increase along with increasing vocal effort, and the movement anticipates phonation. The head movement may be involved in improving vocal efficiency, and the forward trunk bending may emphasise the energetic / effortful aspect of the communication. This work enhances the 'wholeness' of our specialty and how the different systems are all interconnected. Further research on the effect of different pathologies in one system on the other is now warranted.
Approaches to the skull base
Reviewed by: Badr Eldin Mostafa
Sep/Oct 2010 (Vol 19 No 4)
Although the title of the article and its abstract are very appealing, the content is rather disappointing. It is an overview of some approaches to the skull base including the pterional, frontolateral, transsphenoidal and suboccipital lateral approaches. These are classical approaches and the authors did not mention any of the more modern approaches which are now being standardised in both the otorhinolaryngological and neurosurgical literature. Each approach is briefly mentioned with a historical background (useful knowledge for those interested) and some case reports. The figures and illustrations are of high quality. However one would have expected more details, indications, contraindications complications and so on. Good reading within limits but a review should be more informative.
Role of HPV in head neck squamous cell carcinoma
Reviewed by: Gauri Mankekar
Sep/Oct 2010 (Vol 19 No 4)
In this retrospective study the authors conducted a literature review, along with a large meta-analysis, of HPV related head neck squamous cell carcinoma (HNSCC) to determine prevalence of disease and assess ramifications for survival and associated molecular biomarkers. They studied 5,681 cases of head and neck cancer, in whom they found a prevalence of HPV in 21.95%. The most prevalent genotype was HPV+ 16 in 86.7% patients. The risk of HNSCC amongst HPV 16 positive patients was 4.44 times that of HPV negative patients. Survival was better in HPV positive compared to HPV negative patients. HPV positive patients had a better response to radiotherapy compared to HPV negative patients. Also HPV positive patients had better response to chemo radiation than HPV negative patients. The authors confirmed that p16 immunohistochemical expression played a role as surrogate marker for HPV infection in HNSCC and predicts an improved survival outcome. The authors conclude that HPV+ tumours form an important subset of head and neck squamous cell carcinoma and it is necessary to find optimal therapy for them.
The relationship between myeloperoxydase level and bone destruction in patients with attico antral ear disease
Reviewed by: B Viswanatha
Sep/Oct 2010 (Vol 19 No 4)
This study was conducted to determine the effect of myeloperoxydase in the bone destruction in patients with chronic otitis media associated with cholesteatoma by immunochemical staining and to study the possible relationship between bone destruction by cholesteatoma and myeloperoxydase activity. In the study group there were 51 patients with squamosal type of ear disease and in the control group there were 30 patients with tubotympanic ear disease. During the surgical procedure, cholesteatoma tissue was removed from the study group and middle ear mucosa samples were taken from the control group. All histological slides were stained using monoclonal antibodies Ab-1. Myeloperoxydase positivism was monitored, while cytoplasmic staining was performed. Myeloperoxydase activity was either absent or observed at a very slight level in the control group and a moderate to intense level of activity was observed in the study group. The study showed different levels of myeloperoxydase activity with erosion of different structures in the middle ear cleft. The authors are of the opinion that preoperative myeloperoxydase level estimation may play an important role in the management of attico antral ear disease.
Do certain symptoms or signs predict a more complicated clinical course in paediatric retropharyngeal abscess?
Reviewed by: Mary-Louise Montague
Sep/Oct 2010 (Vol 19 No 4)
The authors of this retrospective study hypothesised that certain symptoms or clinical signs may be associated with a more complicated clinical course in patients with retropharyngeal abscess. Fifteen of 130 patients, under 18 years of age, with retropharyngeal abscess, were identified with a complicated clinical course, between 2002 and 2007, at a tertiary United States children's hospital. A complicated clinical course was defined as those patients who required admission to PICU, required more than one incision or drainage procedure or who had mediastinitis, internal jugular vein thrombosis or mycotic aneurysm. Eight children required more than one surgical procedure before the abscess resolved. Children with multiple abscess sites had a statistically significantly greater chance of requiring multiple procedures. Seven children presented with airway obstruction, necessitating admission to the PICU and / or intubation. All the patients requiring admission to the PICU presented with signs or symptoms of airway obstruction, compared to ten of the 115 with a smooth clinical course. The study, although limited by its retrospective design, suggests that patients with a complicated clinical course are more likely to present with airway obstruction or multiple abscess sites, than patients with a smooth clinical course. This may alert the astute clinician to earlier diagnosis and hopefully better outcomes.
The stress response in young children after adenoidectomy and adenotonsillectomy
Reviewed by: Mary-Louise Montague
Sep/Oct 2010 (Vol 19 No 4)
I have not before seen a study such as this prospective cohort study of 43 children aged two to seven years, which examines the stress response after adenoidectomy and adenotonsillectomy. It also examines whether child characteristics, of a behavioural and neurophysiological nature, can predict this stress response. Parents were asked to complete questionnaires about temperament, four weeks before surgery, about behaviour and sleeping problems four weeks before and six weeks after surgery, and about post-traumatic stress symptoms six weeks after surgery. Neurophysiological measurements (salivary cortisol and Respiratory Sinus Arrhythmia (RSA)) were performed four weeks before, directly after and six weeks after surgery. Results were compared with a control group of healthy children. Most children had more behavioural and emotional problems before surgery than the control group. After surgery there was an improvement in behaviour (75%) and sleep (68%), especially noticeable in boys. Post-traumatic stress symptoms were rare. An emotional temperament was associated with more behavioural problems before and after surgery, lower cortisol directly after surgery and lower RSA at follow-up. So adenoidectomy and adenotonsillectomy would appear not to be stressful for children. Rather they seem helpful for reducing pre-existing behavioural and emotional problems. Boys and girls react differently, with boys showing a better behavioural improvement after surgery. Individuals, from childhood onwards, respond differently to stress. I wonder how stressful it is for the parents or carers or indeed for adult patients undergoing tonsillectomy?
Energy psychology: yet another treatment for tinnitus
Reviewed by: Victor Osei-Lah
Sep/Oct 2010 (Vol 19 No 4)
Just as we thought we could not keep up with the myriads of proposed treatments for tinnitus, another one pops up! Thought field therapy (TFT) is a different psychotherapy approach that has been used to reduce or eliminate the emotional reactions associated with vertigo and chronic pain. Like acupuncture (but without the needles), it relies on the stimulation of specific energy (acupressure) meridians believed to be responsible for the negative emotional reactions. The author applies this therapy to two patients with troublesome tinnitus with a satisfactory outcome. The therapy involves identifying the emotional conflicts induced by the tinnitus, rating the severity of subjective distress in units (SUDS), assessment of muscle strength using applied kinesiology techniques (that is, verbalising negative statements such as 'I want to be miserable' produces greater muscle strength, the sort of 'psychological reversal' that is to be eliminated) and stimulating the meridians deemed to have the greatest muscle strength followed by tapping the meridians for the occipital lobe and the left and right hemispheres. The end-point is reached when the subject reports the absence of 'any negative emotional or psychophysiological states or sensations', a SUDS rating of zero. It was not clear how many sessions and / or duration of therapy was required. Although the author was at pains to stress how different this therapy is from other psychological interventions, there are some elements of CBT involved. The author rightly concludes by calling for research to compare TFT with other psychotherapy approaches. If you find TFT difficult to understand, you are in good company.
Enhancement strategies for transcranial magnetic stimulation
Reviewed by: Victor Osei-Lah
Sep/Oct 2010 (Vol 19 No 4)
The technique of repetitive transcranial magnetic stimulation (rTMS) has been touted as a promising tool for the treatment of tinnitus. It works by the application of an electric current via a coil. The electromagnetic field generated induces neuronal depolarisation in the cortical area(s) of interest. Although promising, a number of unresolved technical issues have hampered the use of rTMS in routine clinical tinnitus management. The authors provide an excellent review of the limitations of strategies that are being used to enhance the clinical utility of the technique. They address variations in site, frequency, intensity, mode and duration of stimulation, priming protocols, combination of targets for stimulation and pharmacological enhancements. The main conclusions are as follows: defining the target for stimulation is crucial, but they conclude that the jury is still out on the best imaging modality and coil placement; in initial responders, maintenance of tinnitus relief is better achieved by repeated sessions compared to a single session; the more chronic the tinnitus, the more non-auditory cortical areas are involved, therefore stimulation of both pre-frontal and temporal areas represent a promising enhancement strategy; burst stimulation is not superior to tonic rTMS and no currently used pharmacological enhancement (for example levodopa, pergolide) proved effective. This technique is however promising and clinicians should follow its development with interest.
Medicolegal decision making for noise-induced related tinnitus - the Belgian model
Reviewed by: Victor Osei-Lah
Sep/Oct 2010 (Vol 19 No 4)
The authors analyse the decision-making process used to ‘accept’ or ‘reject’ claims for tinnitus due to occupational noise-induced hearing loss (NIHL) in Belgium. The Decision-Making System (DMS) consists of an extensive set of 85 questions divided into four levels that eventually enable experts to arrive at a final decision as to whether the tinnitus is ‘a true component of the occupational disorder (noise-induced cochlear damage)’. The DMS was used in conjunction with detailed medical and occupational history and records, as well as detailed neurotological examination, behavioural and electrophysiological auditory assessment. Of the 113 claimants, 35 were accepted and were compensated 23 of whom were compensated solely for the tinnitus. Further insights into cochlear damage were gained by comparing the 35 subjects with NIHL-related tinnitus with 35 controls who also had NIHL but without tinnitus. The control group was significantly older, had a longer duration of noise exposure and had more pronounced hearing loss at 2 and 3kHz than the NIHL plus tinnitus group. A distortion product-gram notch at 3-4kHz was identified in 60% of the tinnitus group compared with the controls. This corresponded with the audiometric notch in the tinnitus group. The authors concluded that such a discontinuity in the tonotopic auditory pathway could facilitate tinnitus perception. They consider the DSM transparent and equitable.
Neuromonics tinnitus treatment
Reviewed by: Victor Osei-Lah
Sep/Oct 2010 (Vol 19 No 4)
Neuromonics device, a fairly new therapy, uses customised acoustic stimuli of soft music and wideband noise to achieve neural plasticity within the auditory system so as to minimise or abolish tinnitus-related symptoms. It targets both ‘the auditory and behavioural components involved in tinnitus perception’. In this two-year study, 47 tinnitus sufferers were given the device to use over a 6-8 month period. The majority of sufferers had had tinnitus for about five years. Initial assessment involved pure tone audiometry, tinnitometry and completion of the 26-item Tinnitus Reaction Questionnaire (TRQ). Subjects were divided into three groups: the ‘completed’ group (14), ‘active’ group – still undergoing treatment (18) and ‘incomplete’ group (15). Nine of the 15 of the third group found the device unhelpful and four reported worsening tinnitus. The treatment regime involved two phases, the main difference being the use of wideband noise in phase 1 only. Both phases include some form of counselling. In all groups, there was a significant reduction in TRQ scores, more so in the ‘completed group’, 75% of whom had 61.6% reduction (treatment was judged a success if a TRQ reduction of at least 40% was achieved). The authors conclude that Neuromonics is a useful device for treating tinnitus. Considering that part of the treatment involved some form of counselling and used white noise, in my opinion, it would be difficult to attribute their success solely to the device. Furthermore, tinnitus perception is dependent on several factors and many stressors that vary over time.
Transcranial cerebral sonography in neurotology
Reviewed by: Victor Osei-Lah
Sep/Oct 2010 (Vol 19 No 4)
Transcranial Cerebral Sonography – TCCS – (previously Tympanic Membrane Displacement – TMD) is a technique developed by the senior author. It measures tympanic membrane displacement as a reflection of the relationship between intracranial pressure changes and the perilymph via a patent cochlear aqueduct. A key advantage is that it is non-invasive and could be preferable to a lumbar puncture in the confirmation and monitoring of raised intracranial pressure. It has been used in the evaluation of a number of inner ear and intracranial disorders. The authors demonstrate the clinical utility with single case reports of specific neurotological conditions. In an adult presenting with headaches, pulsatile tinnitus and unilateral blurred vision due to sigmoid sinus thrombosis, TCCS aided diagnosis and monitoring of response to treatment. TCCS correctly diagnosed idiopathic intracranial hypertension (IIH) in an obese patient presenting with bilateral pulsatile tinnitus and bilateral low frequency sensorineural hearing loss. The patient responded to medications. Other conditions described were perilymph fistulae, Arnold Chiari Malformation and arrested hydrocephalus. Whereas in some of the cases presented TCCS was either diagnostic or confirmed abnormal CSF fluid dynamics, in most, the diagnosis was either already known, was made by other means or should have been clear from a good clinical history and examination. Although TCCS is a valuable addition to the neurootological diagnostic armamentarium, it’s likely to remain accessible only to large centres for the foreseeable future. It is not cheap!
Two different approaches to treat nasal polyps
Reviewed by: Badr Eldin Mostafa
Sep/Oct 2010 (Vol 19 No 4)
The medical management of nasal polyposis has always centred on the use of steroids. The authors compared the effects of oral glucocorticoids and doxycycline on symptoms and objective clinical and biological parameters in patients with chronic rhinosinusitis and nasal polyps. Methylprednisolone and doxycycline each significantly decreased nasal polyp size compared with placebo. The effect of methylprednisolone was maximal at week 3 and lasted until week 8, whereas the effect of doxycycline was moderate but present for 12 weeks. Both had different effects on various inflammatory mediators. This is an interesting approach as it may allow a 'steroid sparing' treatment in some selected (yet to be defined) cases and also the possibility of longer use of doxycycline (like the regimens used for acne) or a combination of both drugs in lower doses.
CT or plain x-ray; again?
Reviewed by: Badr Eldin Mostafa
Sep/Oct 2010 (Vol 19 No 4)
In this article the authors compared two views plain x-ray of the paranasal sinuses and a limited set CT in the evaluation of patients with asthma. The authors found (surprisingly!) that the information provided by CT is much more valuable than from plain x-rays. They conclude: 'As the determination of true sinus severity lesion impacts on asthma control, low-dose CT may replace PS plain X-ray and conventional CT to support better clinical decisions'. We are not in the 80s when this debate was still hot, the authors are all pulmonologists. Although to an ENT physician this is a non-issue, we still get referrals with a plain film and a report of maxillary sinusitis and the advice from the chest physician 'go treat your sinuses first'. We should communicate with our neighbours and inform them that a plain sinus film is not the standard of care any more but just a waste of resources.
Drugs for OSAS?
Reviewed by: Badr Eldin Mostafa
Sep/Oct 2010 (Vol 19 No 4)
This is a very stimulating article. The authors administered a combination of pseudoephedrine and domperidone to patients with obstructive sleep apnoea and followed them up with repeated nocturnal oximetry testing. The combination of domperidone and pseudoephedrine improved self reported snoring and sleepiness, and may have improved apnoeic episodes and sleep-related nocturnal oxygen desaturation in patients with obstructive sleep apnoea, provided the proportion of time spent asleep did not diminish. This combination may act on nasal obstruction, the sympathomimetic stimulant actions of pseudoephedrine and the antireflux actions of domperidone. Domperidone has also some central actions on the hypothalamopituitary axis. These complex actions may affect central sleep physiology. However pseudoephedrine may be contraindicated in hypertensive patients, those with glaucoma and prostatism (as many of OSAS patients are likely to have!). Although the measure used by the authors are way short of the gold standard, polysomnography, the results presented warrant a more detailed study on this drug combination which may give some hope to patients with mild to moderate OSAS.
Giant cell reparative granuloma
Reviewed by: Rhodri C Costello
Sep/Oct 2010 (Vol 19 No 4)
In this interesting paper the authors describe their experience with a 38 year old gentleman presenting with giant cell reparative granuloma (GCRG). The patient presented with a three year history of nasal obstruction, bloody discharge and epiphora, developing proptosis three months prior to consultation. Anterior rhinoscopy revealed a fragile obstructing mass with profuse watery discharge. CT and MRI imaging was performed, CT revealed an expansile soft tissue mass on the nasal cavity, with extension into the ethmoid sinuses, orbit and nasopharynx. MR imaging showed that opacification in the left maxillary and sphenoid sinuses was due to secretions and not due to soft tissue mass. Biopsy showed benign osteoclastic giant cells scattered in a cellular fibroblastic stroma – supporting the diagnosis of GRCG. Surgical excision was performed via lateral rhinotomy with extension to open sky incision. At one year follow-up the patient was free of recurrence. The authors discuss how GCRG is a rare, benign, granulomatous lesion most commonly arising in the mandible, maxilla, hand or foot. The lesion represents a reactive process rather than a true neoplasm. The authors discuss the history of GCRG, and a number of possible differential diagnoses. Discussion is made of the various potential treatment options.
Canal repositioning manoeuvre for BPPV without nystagmus
Reviewed by: Stephen J Broomfield
Sep/Oct 2010 (Vol 19 No 4)
It is not uncommon to encounter a patient with classical symptoms of BPPV who does not have nystagmus on positional testing. The aim of this study was to examine the effectiveness of canal repositioning manoeuvres in such cases of 'subjective BPPV'. Infrared video goggle examination was used to look for nystagmus in 850 patients presenting with clinical BPPV. Positional tests were used to identify posterior, lateral and anterior canal BPPV and were followed by the appropriate canal repositioning manoeuvre. A total of 140 (16.5%) patients were diagnosed with subjective BPPV, of whom 103 (73.6%) were 'cured' with canal repositioning on up to three occasions. This compared to a cure rate of 72% (612 / 850) in patients who exhibited nystagmus. Both groups had a recurrence rate of 8.7% after two years' follow-up. Whilst there are some methodological flaws with this study design, not least the lack of a control arm, it nonetheless raises an interesting question about how to manage a common clinical conundrum.
Effect of canalith repositioning procedures (CRP) in management of subjective benign paroxysmal positional vertigo.
Abdelghaffar H.
JOURNAL OF INTERNATIONAL ADVANCED OTOLOGY
2010;6:34-8.
A three dimensional presentation of cholesteatoma for trainees and patients
Reviewed by: Madhup K Chaurasia
Sep/Oct 2010 (Vol 19 No 4)
Learning cholesteatoma surgery is difficult because of the complex three dimensional anatomy with which the surgeon must be familiar. Likewise patients offered surgery for cholesteatoma, the symptoms of which may be minimal, often find it difficult to understand the serious complications which may be associated with this surgery such as permanent hearing loss, facial nerve paralysis and long-term dizziness. In this study the authors used an Amira software to reconstruct a three dimensional image from pre-operative CT scans of temporal bones. These were then used with trainees to highlight the complex anatomy and the surgical approaches. The three dimensional images of cholesteatoma in the temporal bone were also used to explain to patients the necessity for surgical intervention to avert spread of cholesteatoma and damage to vital structures. Three interesting cases are mentioned, one with a very small cholesteatoma and minimal symptoms, the second with a large cholesteatoma complicated by facial nerve paralysis and a third one with large cholesteatoma involving the labyrinth and causing dizziness. The authors state that this is an important tool both for training and obtaining informed consent in this complex surgery and its complications. Undoubtedly, this is a useful information method and unless the cost of software is forbidding which is unlikely, it should be introduced in all otological clinics.
An improved quality of life research tool to assess outcome of tonsillectomy in children
Reviewed by: Madhup K Chaurasia
Sep/Oct 2010 (Vol 19 No 4)
There is growing use of patient reported outcome measures to assess clinical effectiveness and quality of care around various surgical interventions. The National Institute of Health and Clinical Excellence has requested to issue guidance on ineffective treatments and has reported a lack of evidence to support tonsillectomy. This heightens the need for valid, sensitive reliable and parent reported outcome measure for paediatric throat disorders. In this study the authors have analysed the 16-item tonsil and adenoid health status instrument and modified it to a slightly abbreviated 14-item paediatric throat disorders outcome test. This was based on obtaining pre- and postoperative questionnaires by parents of children with throat disorders in a tertiary referral centre and a District Hospital. Children included were those with sore throats and obstructive sleep apnoea. The authors also studied a separate group of age matched healthy children. The items deleted from the original tonsil and adenoid health status instrument were direct cost of care and medications because prescriptions are free of charge and the questionnaire item regarding 'strep throat' infection which is little understood in the UK. The authors also suggest additional objective measurement of weight and height which could not be included in the 14-item paediatric throat disorders outcome test. It was noted that the 14-item paediatric throat disorders outcome test differed between children suffering from sore throats and healthy controls. Six months following surgical intervention parents reported improved scores. However the idea of the study was not to evaluate the effectiveness of tonsillectomy but to confirm the suitability of this outcome test to facilitate such research although the preliminary data in a small group of patients suggests a large benefit.
Arterial pseudo aneurysm following tonsillectomy – a rare but dreaded complication
Reviewed by: Madhup K Chaurasia
Sep/Oct 2010 (Vol 19 No 4)
The authors believe that several arteries around the tonsils can have variable courses and can be nipped in sutures or ligations. This can result in a haematoma and invasion by fibrous tissue leading to development of an aneurysm. A retrospective analysis of the case records of 8,837 patients who underwent tonsillectomy between 1988 and 2004 was undertaken and cases picked up using the words 'arteriography' and 'pseudoaneurysm'. The authors also studied 21 published cases of post-tonsillectomy pseudoaneurysms. It appears that the onset can be variable, extending in time to as much as 58 days following tonsillectomy. The external carotid artery is involved more often than the internal carotid artery, but the commonest one to be involved is the lingual artery which runs close to the inferior tonsillar pole. The diagnosis of post-tonsillectomy pseudo aneurysm is based on arteriography, ultrasound and computer tomography with contrast. Arteriography can be accompanied by embolisation which has limited success and even super selective embolisation may not always be successful. In some patients ligation of the injured vessel via an open transcervical approach had to be done. Arteriography can also reveal a normal finding and yet aneurysm may be discovered later after the procedure when the bleeding occurs. Ligature of external carotid artery can fail due to the presence of aberrant vessels. This article evokes awareness of a serious and potentially undetected condition not only in post-tonsillectomy bleeding but also in cases of unaccountable upper aerodigestive tract bleeding.
Can MRI screening for acoustic neuroma be rationalised?
Reviewed by: Madhup K Chaurasia
Sep/Oct 2010 (Vol 19 No 4)
Asymmetrical hearing loss is the commonest presentation of acoustic neuroma. Screening all these patients with MRI would undoubtedly pick up all the acoustic neuromas but, to avoid unnecessary screening, the criteria can be rationalised. The authors compared the audiometric data from 199 vestibular schwannoma patients with 225 non-tumour patients and tested eight screening protocols on all these patients. The presenting symptoms raised suspicion of acoustic neuroma in 86% of these cases. Audiogram types were studied and acoustic neuromas presented with a sloping or a high tone loss audiogram and flat type audiograms were second most common. Reverse slope and trough shaped audiograms were more common in non-tumour patients. It was noted that in patients with a better ear hearing level of less than 30 decibels the asymmetry was less and did not differ much from non-tumour patient; whereas in cases of acoustic neuroma with a better ear hearing level greater than 30dB the asymmetry was much more pronounced. The mean speech discrimination loss for suspect ears was 39% in vestibular schwannoma ears and 23% in non-tumour ears. The suggested criteria of a 20% inter aural discrimination loss difference had a sensitivity of only 50% and a specificity of 57%. Stapedial reflexes were not possible in all patients and therefore this parameter and lateralisation of tinnitus was not particularly helpful. Eight published protocols for screening were applied to this study and the sensitivity of the four most successful ones was 95-100% but the specificity was only around 50%. It was noted that the asymmetry was much more in major tumours, (exceeding 11mm) and these were detected earlier than smaller tumours. The author contends that to minimise the screening rate it would be best to not follow the criteria of asymmetry greater than 20dB at two neighbouring frequencies, but an asymmetry of greater than 15dB between 2 and 8kHz. This would allow a sensitivity of more than 90% and bring the screening rate down from 35 to 24%. Nevertheless, the author also maintains that one cannot rely entirely on any single strategy and one must continue to be guided by one's clinical intuition.
Do patients understand doctors' letters?
Reviewed by: Madhup K Chaurasia
Sep/Oct 2010 (Vol 19 No 4)
In the year 2000 National Health Service plans suggested that patients should receive copies of letters written by one doctor to another. In order that these letters from a specialist to a general practitioner or another doctor be objective and precise, it is difficult to avoid technical language and medical terms. Whether these letters would be understood by patients is quite another matter. In this study the authors have assessed the readability of these letters through assessment tools namely FLESCH reading e-score and FLESCH-Kincaid grade. The former assesses the ease with which a document can be read, depending on the length of sentences and the number of syllables in the words and the latter converts this reading ease score into a comparable US school grade reading level. In the retrospective phase of this study 295 letters from eight clinicians were evaluated. These produced a FLESCH reading ease score of 61.8 and the mean FLESCH-Kincaid reading grade was 9. After this initial phase the clinicians underwent some teaching to make these letters easier and then in the prospective phase of this audit another 301 letters were assessed. Unfortunately there was no significant difference in that the latter letters were not any easier to read! This therefore indicates that there might be a need to write separate letters to patients, which would be easier to read and comprehend. This is easier said but the doctor's time and staff requirement to double the existing exercise may not meet pockets of many Trusts!
Do retraction pockets impede epithelial migration?
Reviewed by: Madhup K Chaurasia
Sep/Oct 2010 (Vol 19 No 4)
Epithelial migration of the tympanic membrane is a recognised phenomenon, useful for clearance of debris and foreign bodies. Whether this occurs in a retracted but intact tympanic membrane has, according to this publication, not been studied although several studies have focused attention on perforated, grafted and open mastoidectomy cavity. In this study, a comparison is made of epithelial migration of the tympanic membrane between normal eardrums and those with various degrees of indrawing. A comparison was made between 40 patients with retracted tympanic membranes and 40 normal subjects. A dot of methylene blue was placed near the umbo and its movement picked up in periodic review, engaged with a micrometer attached to the microscope. Four grades of retraction according to Sade's system were studied. This did not include well formed pockets. There was no statistically significant difference in epithelial migration rate or pattern between the atelectatic and normal tympanic membranes, although in Grade 4 the epithelial migration rate was only 54.6 micrometers per day as compared to a rate of 64.7 micrometers per day in normal tympanic membranes. Well formed retraction pockets are not mentioned in this study. It is possible that the migratory rate deteriorates much more when pockets are formed, and the possible development of cholesteatoma occurs. It would also be useful to relate the migratory rate to the middle ear conditions such as negative middle ear pressure. This is particularly important because reduced migratory rate may well be a product rather than the pathogenesis of retraction pockets and possible cholesteatoma formation.
Eustachian tube evacuates, not supplies air in the middle ear
Reviewed by: Madhup K Chaurasia
Sep/Oct 2010 (Vol 19 No 4)
The common concept is that middle ear aeration is provided by air entering from the nasopharynx, through the Eustachian tube, into the middle ear. Based on earlier published reports by Buckingham et al., the authors have conducted an elaborate study to establish that the reverse is true. Three hundred and four middle ears were observed. These had myringotomy or perforation of the tympanic membrane. The patients selected were those who needed intratympanic drug administration or out-patient microscopic procedures. The findings were based on appearance / disappearance of air bubbles and movement of the fluid film inwards or outwards on swallowing. To overcome different reactions in different observation sessions, the reactions were categorised as 'types' and 499 such 'types' of 304 ears were studied statistically. It was noted 98% of normal ears showed spontaneous appearance of bubbles. Ears with SOM and chronic otitis media showed this phenomenon to a much lesser extent. Inward movement of the fluid film was observed much more often in normal ears than in those with SOM and chronic otitis media. Based on this study, the authors contend that there is no basis to support that the Eustachian tube lets in air through the nasopharynx, but actually evacuates it from the middle ear by a 'peristaltic' action. Inflammation and disease impair both production of air in the middle ear and its evacuation by the Eustachian tube. This article provides interesting reading and provokes thoughts applicable to many clinical situations where the flow in the Eustachian tube towards the nasopharynx may be impeded, such as bottle-feeding in infants. This also rationalises the insertion of a grommet, which would facilitate entry of air, enhancing the evacuating function of the Eustachian tube away from the grommet. Treatment of purely mucosal CSOM is particularly difficult. Is it because we do not fully understand the function of the Eustachian tube?!
Facial paralysis in children
Reviewed by: Madhup K Chaurasia
Sep/Oct 2010 (Vol 19 No 4)
There have been several publications on facial paralysis in adults but this study claims to be one of the few to analyse the causes and prognosis of facial paralysis in children. Twenty-four cases were studied, their ages ranging from three to 15 years with a mean of 11.3 years and the mean duration of follow-up was 9.2 months. The aetiology was trauma and infection (four patients each) and in 16 this was unknown (Bell's palsy). Electroneuronography was done in all these patients. Oral steroids were given to all children and three received Acyclovir. Those with delayed facial paralysis due to temporal bone fracture were treated with intravenous antibiotics and steroids. Of these patients, 91.6% recovered to Grade 1 and 2 House-Brackmann facial paralysis grades after six months. The role of Acyclovir is discussed and surgical intervention is recommended if the neuronal degeneration is more than 90%. It is also suggested that children recover quicker than adults. This is a rather short series but nevertheless provides useful reading.
Immunosuppressives for external auditory canal pruritus
Reviewed by: Madhup K Chaurasia
Sep/Oct 2010 (Vol 19 No 4)
Itching of ears is often a symptom associated with no clinical finding. The use of topical steroids for this is known but in the long term it can lead to thinning of the epidermis, decreased microvascularity and keratinocyte population. In this study the authors have suggested the use of pimecrolimus which is a new topical macrolide immunosuppressive agent. This has been used successfully in the treatment of skin conditions and it acts by preventing T cell activation and degranulation of mass cells. A comparison was made between two groups of patients, one receiving steroids and the other pimecrolimus. Assessment was made at the time of starting the treatment, three weeks later and finally in three months. It was found that there was a statistically significant difference between the itch symptom score at the time of starting the treatment and towards the end of it. There was a greater patient response in the pimecrolimus group but the difference was not statistically significant. The interesting aspect of this article is the use of itch severity scale and this is based on five factors namely the frequency of appearance of the itch, the nature of itching such as stinging or stabbing, the intensity of itching, disturbance of sleep and finally change of mood. A symptom score from 1-15 has been applied for statistical analysis. This is a subjective questionnaire. The study confirms the absence of clinical findings on examination of the external canal, an absence of systemic disease. The study is fairly elementary and does not take into account referred aural sensations and the possibility of nasal condition which can cause retraction of the tympanic membrane and a feeling of itching. However this does provide a basis for further study in this often intractable condition.
Rigid pharyngo-oesophagoscopy: is it safe as day case surgery?
Reviewed by: Madhup K Chaurasia
Sep/Oct 2010 (Vol 19 No 4)
Perforation after pharyngo-oesophagoscopy is an infrequent complication. A perforation rate of 1.2% has been reported, although difficult therapeutic procedures may increase it slightly. However, oesophageal perforation does carry a very high mortality rate of 10-40% and it is therefore important to be absolutely certain that it has not occurred before the patient is sent home. This brings into question the same day discharge because the onset of symptoms of oesophageal perforation is variable, timewise. In this multicentre study of 3,459 patients undergoing rigid pharyngo-oesophagoscopy 10 (0.29%) developed perforation. Perforation was suspected in nine of these patients intra-operatively and the onset of symptoms ranged from 1.5 hours to 36 hours. It is also interesting that three patients remained asymptomatic. The authors express concern that any protocol depending on symptoms developing within 24 hours is not absolutely foolproof. The answer suggested is that in cases where the procedure of pharyngo-oesophagoscopy was eventful and perforation is suspected a contrast swallow should be considered as a routine before discharging the patient home. Although this a common practice the message here is that this protocol should be followed even in patients without symptoms but eventful endoscopic procedure.
Sequential phase shift sound wave treatment for tinnitus – a new method
Reviewed by: Madhup K Chaurasia
Sep/Oct 2010 (Vol 19 No 4)
Tinnitus is a distressing symptom and we are all aware of the limitations of treatment with masking tinnitus, retraining therapy or other methods. The authors in this article believe that tinnitus originates in the brain, specific frequencies and volumes are generated and it is possible to reduce or modify the perceived sound wave with the phase shifted sequentially. This treatment is analogous to shooting a flight of geese with a shotgun instead of a rifle. An initial study involving 35 patients was undertaken to firm this concept. In this study there were two sham groups ‘a and b’ and the third group went through a six degree sequential phase shift sound wave delivery. The phase shift was related to the patient’s own perception of the frequency and intensity of the tinnitus. In the study group (c) 82% of patients reported a reduction of tinnitus by six decibels or more as compared with only 24% in the sham control groups a and b. This treatment was then offered to various centres across the world and the new report comprised 493 patents. Forty nine to 72% of patients had a reduction in tinnitus volume by six decibels or more. The treatment sequence was repeated three times a week and if the reduction in tinnitus is six decibels or more they were supplied with the treatment device for use at home. Further studies are required in this promising area of tinnitus management and more centres should be invited to take part.
Should intranasal steroid sprays be used daily?
Reviewed by: Madhup K Chaurasia
Sep/Oct 2010 (Vol 19 No 4)
Allergic rhinitis is a very common but not life threatening condition. The commonest treatment is the use of intranasal steroid sprays. Safe usage is a concern and factors which should be taken into account are systemic absorption, potency, binding affinity, distribution volume and half life. Mometasone has a low bio-availability and is therefore popular. In this study the authors have explored whether or not it is necessary to use this every day. Sixty patients with chronic allergic rhinitis were randomised. Cases with nasal polyps, sinusitis, asthma and previous steroid or other treatment were excluded. Thirty were instructed to use Nasonex once daily for six weeks and the other group was advised to spray daily for one week, every alternate day for one week and then on a self adjusted plan for four weeks. The patient symptoms score based on sneezing, stuffy nose and itching were graded 0-3 and scores were taken at the start and the end of the treatment. Acoustic rhinometry was also used to measure the nasal volume at the first visit and after completion of the treatment. It was noted that there was no statistically significant findings in the nasal scores between the two groups except on some days when the self adjusted dosage group recorded higher scores. Although the nasal cavity volume measured at the end of the study showed a marked improvement there was no statistically significant difference between the two groups. The authors therefore suggest that in order to avoid costs, a self-adjusted regimen should be adopted. This would indeed reduce costs and perhaps increase compliance, which can by no means be taken for granted with daily usage.
The use of antibiotics for acute tonsillitis in peritonsillar abscess
Reviewed by: Madhup K Chaurasia
Sep/Oct 2010 (Vol 19 No 4)
With increasing emphasis on infection control and appropriate usage of antibiotics to meet the objective and cost effectiveness, it is relevant to know what medication is used and the variation that exists in practice across the country. The authors aim to achieve this with a questionnaire based survey of 297 consultants. A single antibiotic, mainly Benzylpenicillin, used intravenously was preferred for acute tonsillitis by most consultants, whereas a combination of antibiotics was favoured for peritonsillar abscess. The difference was statistically significant. The commonest combination was Benylpenicillin with Metronidazole for peritonsillar abscess. Clarithromycin and Erythromycin was used in cases of Penicillin hypersensitivity. Very few respondents considered it necessary to seek microbiology advice. The duration of treatment was mainly a week and fewer clinicians used the antibiotics for a fortnight. It was also noted that use of Benylpenicillin alone after incision and drainage of a peritonsillar abscess was associated with a higher resolution rate and it is therefore questionable if two antibiotics need to be used. It would have been interesting to note if the use of stronger antibiotics such as Cefuroxime in combination or without would result in a shorter hospital stay for the patient and thus add to cost effectiveness in that dimension.
Laryngeal candidiasis in the outpatient setting
Reviewed by: Anurag Jain
Sep/Oct 2010 (Vol 19 No 4)
This is claimed to be the largest case series of laryngeal candidiasis patients published so far and includes 54 patients with this diagnosis. These cases were identified by a retrospective chart review at the Pacific voice clinic, University of British Columbia, Vancouver over a 10 year period. Most common presenting symptom was dysphonia (69%) followed by chronic cough (22%), shortness of breath (13%), sore throat (11%), globus sensation (6%), post nasal drip (4%) and haemoptysis (2%). Candida albicans was the commonest organism responsible and the majority of the patients were using inhaled coticosteroids for asthma. Oral fluconazole was the most effective treatment, curing 96% of the patients after the first course of treatment.
Role of intraoperative nerve monitoring of recurrent laryngeal nerve in high-risk thyroid surgery
Reviewed by: Anurag Jain
Sep/Oct 2010 (Vol 19 No 4)
This is a retrospective study in which the authors have compared the recurrent laryngeal nerve palsy rates between the high-risk thyroid surgery cases, who were monitored by nerve monitors, versus those who were not. High-risk thyroid surgery included surgery for thyroid cancer, Grave's disease, large and recurrent goitre. This study did not find any statistically significant difference in post surgical RLN palsy rates between the monitored and unmonitored groups and concludes that the visual identification of the RLN nerve by dissection is the best method to avoid nerve injury. It recommends a further multicentre prospective study to compare the role of RLN neuromonitoring in high-risk thyroid surgery. Since this study compares the palsy rates between the neuromonitored and unmonitored groups of the high-risk cases of thyroid surgery, it eliminates the possible bias due to case mix.
International classification of vestibular disorders
Reviewed by: Victor Osei-Lah
Sep/Oct 2010 (Vol 19 No 4)
Many in the neuro-otology community have been waiting for such a classification for years. Driven by the confusion created by the ‘lack of explicit and uniform criteria’ in defining various vestibular disorders and symptoms, The Bárány Society set up a committee in 2006 to develop an international classification of vestibular disorders (ICVD). Hopefully, the confusion over diagnoses such as ‘vestibular migraine’ as opposed to ‘vestibular Ménière’s’, ‘vestibular neuritis’ versus ‘cochleovestibular neuritis’, ‘labyrinthitis’, ‘acute peripheral vestibulopathy’ and so on would be removed. This, it is envisaged, will guide clinical research. Many will be familiar with the Diagnostic and Statistical Manual (DSM) in psychiatry and the International classification of Headaches (ICHD) in neurology. The first consensus document makes an excellent attempt to define and classify vestibular symptoms (ICVD-I: Classification of Symptoms v 1.0). After rightly distinguishing ‘vertigo’ from ‘dizziness’, the document identifies and defines four main categories of symptoms: vertigo, dizziness, vestibulo-visual symptoms and postural symptoms, each with well-defined sub-categories. It is still ‘work in progress’ and while the authors do not underestimate the task ahead, they would welcome comments from all. The next step, which the authors concede could take several years, will be to publish the final version of ICDV-I, while developing a classification of various specific vestibular disorders. At last the vestibular community can see the beginning of the end of many years of waiting for such a classification with the same degree of patience that they exact from their patients with a chronic vestibular disorder! I highly recommend this excellent but far from perfect document to the vestibular community.
International survey of vestibular rehabilitation therapists
Reviewed by: Victor Osei-Lah
Sep/Oct 2010 (Vol 19 No 4)
The Ad Hoc Committee of The Bárány Society set out to assess the training, educational background, referral patterns and sources and continuous professional development of those who deliver vestibular rehabilitation (VRT). They surveyed 133 therapists from 19 countries. Physical therapists (PT) – 117 – constituted the majority of professionals surveyed. There were 15 occupational therapists (OT) and one audiologist. The majority were from United States, Australia, Sweden and France with only three from the UK. Most of the respondents had entry-level degrees but apart from 47, the rest had additional Masters and / or Doctorates (especially in America). The key findings would not come as surprise to the vestibular fraternity. Eighty percent had no VRT training at entry level. Respondents acquired their knowledge from a variety of sources including during continuing education courses (69%), at work (26%), professional reading (14%), personal experience at work (14%), word of mouth (10%), graduate school or formal post-graduate education (6%), national conferences in their own disciplines at which a lecture was given (6%). Continuing Professional Education was achieved mainly through attendance of national and international courses / conferences but also from multidisciplinary meetings and the internet. The Committee seeks to develop recommendations for educational standards in VRT.
The role of vestibular evoked myogenic potentials (VEMP) in multiple sclerosis
Reviewed by: Victor Osei-Lah
Sep/Oct 2010 (Vol 19 No 4)
The diagnostic utility of vestibular evoked myogenic potentials (VEMP) continues to exercise the minds and efforts of clinicians and researchers. Originating mainly from the saccule, VEMP assesses the sacculo-colic pathways via the brainstem and parameters of its two main waveform complexes (p13n23 and n34p44) are used in diagnosis. This study uses VEMP to study the spatial dissemination of multiple sclerosis (MS) plaques. Forty-six patients confirmed relapsing-remitting MS patients with audiovestibular symptoms were divided into two groups: group 1 (22 patients) had MRI changes and group 2 (24 patients) had no MRI changes of MS. The authors report that 50% of the MS patients had p13n23 abnormalities and a delay in p13 latency signified vestibulocollic impairment. Of note, seven out of 22 patients with no MRI abnormalities had abnormal VEMP. Such patients may require more thorough investigations or close monitoring. The study also confirmed what is already known that the later n34p44 is cochlear in origin. They conclude that VEMP can be used to evaluate vestibulospinal tract abnormalities in MS patients presenting with balance problems.
A very rare unpublished complication of sulcus cyst surgery
Reviewed by: B Viswanatha
Sep/Oct 2010 (Vol 19 No 4)
This case report presents a vocal fold bridge (VFB) formation in a professional singer after surgical removal of a sulcus cyst as a sequel. VFB are rare benign pathologies and mostly coincidently discovered in direct laryngoscopy. The pathophysiology of VFB formation is not well established.In the present case, VBF formed as a sequel to sulcus cyst surgery and it had typical histopathologic features similar to that of primary VFB. The authors are of the opinion that a case of VFB arising as a sequel of phonomicrosurgical procedure is not reported in the literature and implicates the evidence of trauma in the aetiology.
Comparative study between injection laryngoplasty with large particle size hyaluronic acid and injection laryngoplasty with small particle-size hyaluronic acid
Reviewed by: B Viswanatha
Sep/Oct 2010 (Vol 19 No 4)
This randomised trial was undertaken with hypothesis that large particle size hyaluronic acid (LPHA) persists longer after injection and produces a more durable vocal result than small particle size hyaluronic acid (SPHA) after injection laryngoplasty (IL) for unilateral vocal cord paralysis (UVCP). The authors have done a prospective randomised single blinded trial to determine which hyaluronic acid (HA) particle size affects the durability of medialisation after IL for UVCP. Patients were randomised to undergo IL using large particle size HA or small particle size HA, and were blinded to which material was used. The voice handicap index at six months post injection was primary outcome measure and secondary outcome measure included vediostroboscopic findings, and objective acoustic and aerodynamic measures. The results of this study showed that the larger the particle size of LPHA makes this material more durable than SPHA for IL. The effect of medialisation using larger particle size HA is more than smaller particle size HA and can persist for six months or longer. As this procedure can be performed safely in office settings, the authors recommend it for temporary medialisation in patients with UVCP in whom medium-term improvement of six months or more is desirable.
Laryngeal electromyography in the management of patients with voice disorders
Reviewed by: B Viswanatha
Sep/Oct 2010 (Vol 19 No 4)
Laryngeal electromyography (LEMG) is a technique to assess the integrity of laryngeal muscles and nerves and it is a valuable adjuvant in the clinical management of patients with voice disorders. In this report, data analysis of 741 has shown that LEMG provides useful prognostic information regarding the likelihood recovery of satisfactory phonatory functions without surgery, following vocal fold paresis or paralysis. The present data has shown that visual assessment alone is inadequate to diagnose neuromuscular dysfunction in the larynx and the diagnosis based on vocal dynamics assessment and strobovideolarngoscopy are wrong in one-third of cases, based on LEMG results. Authors have shown the usefulness of LEMG in the clinical management of patients with voice disorders.
Polydimethylsiloxane injection laryngoplasty: an alternative to frame work surgery
Reviewed by: B Viswanatha
Sep/Oct 2010 (Vol 19 No 4)
This longitudinal prospective study, comprising of 15 patients with unilateral vocal cord paralysis, was done to document functional results and to compare objective and subjective voice measures after endoscopic laryngoplasty with injection of polydimethylsiloxane (PDMS). All patients underwent endoscopic injection of PDMS under general anaesthesia. Voice evaluation was done in all the patients, before surgery, after the procedure on the first or second postoperative day, after three months, and later every six months. The median follow-up was 21.7 months. All acoustic aerodynamics, perceptive and subjective evaluations showed a significant improvement. Functional results were found comparable to frame work surgery. The advantages of endoscopic laryngoplasty with injection of PDMS compared to framework surgery are:
1. No external incision is required,
2. Easy to perform,
3. Recovery of patient is faster.
PDMS particle size and its surface texture prevent material dislodgement and migration via lymphatics. Even in patients with paralysed cord in lateral position, PDMS injection has shown to improve vocal rehabilitation.The authors are of the opinion that endoscopic laryngoplasty with injection of PDMS is a safe and long-term option for treatment of unilateral vocal cord paralysis. They also suggest endoscopic laryngoplasty with injection of PDMS, as an alternative to framework surgery for treating patients with unilateral vocal cord paralysis.
Trigeminal neuralgia
Reviewed by: Badr Eldin Mostafa
Sep/Oct 2010 (Vol 19 No 4)
Neurovascular cross-compression is an accepted cause of trigeminal neuralgia. However the exact pathophysiology is still open to debate. The authors suggest a novel mechanism, bioresonance. When the vibration frequency of a structure surrounding the trigeminal nerve becomes close to its natural frequency, resonance of the trigeminal nerve occurs. The bioresonance can damage trigeminal nerve fibres and lead to the abnormal transmission of the impulse, which may finally result in facial pain. This may explain why some patients get symptoms, while others with the same anatomical configuration are symptomless. A further study on the pulse rate, flow or vessel wall characteristics may enable us to determine the resulting waves and thus help us in confidently diagnosing patients. It may also help in designing new therapeutic strategies.
Medical treatment of AN?
Reviewed by: Badr Eldin Mostafa
Sep/Oct 2010 (Vol 19 No 4)
This is a very limited study (two cases) on NF2 associated acoustic neuromas. Both were treated with bevacizumab; one for three months and the other for six months. This treatment induced regression of progressive vestibular schwannomas by more than 40% and substantially improved hearing in the patient treated for six months. Bevacizumab therapy may thus provide an effective treatment for progressive vestibular schwannomas in patients with NF2. However due to the extremely high cost of such therapy for the time being and the uncertain long-term control, it seems that it is not yet for tomorrow that we are going to offer our patients this type of therapy.
Endoscopic diving technique
Reviewed by: Showkat Mirza
Sep/Oct 2010 (Vol 19 No 4)
This short technical note describes a technique where a continuous flow of fluid occurs from the endoscope to aid both visualisation and the removal of lesions in the sellar, sinus cavity and clival regions. It is an established technique in regions of the body such as the bladder. The authors have used it in over 350 surgical procedures and have found it particularly useful in identifying small infiltrations of the cavernous sinus and in checking the integrity of the pituitary stalk, when instruments are introduced into the sella. Excellent colour photographs are included.
Oculomotor nerve: five segment classification
Reviewed by: Gauri Mankekar
Sep/Oct 2010 (Vol 19 No 4)
This study is a joint effort of well known neurosurgeons from different institutions. They performed endoscopic and microsurgical dissection of the oculomotor nerve following its entire course from the midbrain to the orbit. Fifty-nine human cadaver heads were used for the dissection. The nerve was exposed along its pathway via frontotemporal, frontotemoporo-orbitozygomatic and subtemporal transtentorial approaches. The endoscopic approach was performed in nine heads to visualise and compare the neurovascular relationships of the same areas from an infero-medial aspect. The authors have proposed a new anatomically and surgically oriented five segment classification of the oculomotor nerve: cisternal, petroclinoid, cavernous, fissural and orbital. Through the endoscopic approach the oculomotor nerve was exposed only in its proximal part (cisternal, petroclinoid and cavernous) and is more likely to be damaged only in an extended endoscopic endonasal approach. This article contributes to our understanding the anatomy of the skull base.
Sphenoid sinus pneumatisation
Reviewed by: Gauri Mankekar
Sep/Oct 2010 (Vol 19 No 4)
This is an anatomical study to examine various pneumatised extensions of the sphenoid sinus which may enable extended approaches directed through the sinus for removal of tumours in regions bordering the sinus, for example cavernous sinus, Meckel's cave, middle cranial fossa, planum sphenoidale, suprasellar region and clivus. The authors examined the sphenoid sinus and its surrounding structures in 18 cadaver heads and correlated the results with findings from 100 CT images of the sinus. They classified the sellar type of pneumatisation into six basic types based on the direction of pneumatisation: sphenoid body, lateral, clival, lesser wing, anterior and combined. Pre-operative imaging of the extensions of the sphenoid sinus helps to define the perisphenoidal neurovascular structures. The authors suggest that the recesses and prominences formed by pneumatisation of the sinus act as 'windows' opening from the sinus in different areas of the cranial base and may enable minimally invasive access to lesions in the corresponding areas.
Tinnitus intensity improves with microvascular decompression
Reviewed by: Gauri Mankekar
Sep/Oct 2010 (Vol 19 No 4)
The authors studied 20 patients who underwent micro vascular decompression of the cochlear nerve for unilateral intractable tinnitus. The pre and post-operative visual analogue scale for tinnitus intensity and tinnitus questionnaires for tinnitus distress were analysed before and after microvascular decompression. Ten patients had improvements on their tinnitus visual analogue score intensity postoperatively, eight were unchanged and two worsened. On the tinnitus questionnaire scores, seven out of 13 patients improved while six out of 13 patients worsened. The study concludes that microvascular decompression of the cochlear nerve can improve tinnitus intensity in selected patients if decompression is performed early, that is before the end of the fourth year although tinnitus distress does not seem to change.
Treatment of brain tumours with oncolytic viruses
Reviewed by: Gauri Mankekar
Sep/Oct 2010 (Vol 19 No 4)
This article reviews the concepts and development of viral therapy for brain tumours. Viral therapy uses either replication defective viruses (which do not multiply or propagate at the site of inoculation), or replication selective viruses (which divide in tumour cells, lyse them and their progeny propagate and kill neighbouring cells). Oncolytic viral infection seems to have promise as cancer therapy, based on viral killing alone. Also, virus-associated cell death may provide the stimulus to the system for initiating an anti-tumour immune response that has specificity and durability. Finally, the authors have reviewed how the immune modifying capacity of an oncolytic virus can be used to enhance a standard immunotherapy vaccine approach. Oncolytic viral therapy may offer a ray of hope for those who may suffer from malignant tumours in future and the development of a vaccine may prevent malignant tumours.
Absorbable packing after sinus surgery
Reviewed by: Joanne Rimmer
Sep/Oct 2010 (Vol 19 No 4)
Synechiae formation is the most common post-operative complication following endoscopic sinus surgery. Abrasions, destabilisation of the middle turbinate and inadequate medialisation of the middle turbinate at the end of the procedure may all play a part in post-operative scarring. The authors report a randomised single-blind controlled trial, evaluating the effect of an absorbable packing material in the middle meatus, on the rate of post-operative scarring. Fifty-three patients undergoing endoscopic sinus surgery (with or without polypectomy) were included. A commercially available hyaluronic acid / carboxymethylcellulose dressing (Seprapack (Genzyme, Cambridge, MA., USA) was placed into the middle meatus of one side in each patient; the other side was left unpacked. Endoscopy was performed at each visit at one, two, four and eight weeks post-operatively, and the presence of synechiae, mucosal oedema, crusting and residual packing was documented. The patients completed visual analogue scores (VAS) to assess congestion, crusting and the amount of saline douche used. There was no difference in the amount of synechiae formation in each side after eight weeks, although there were fewer at two weeks. Patients reported less nasal congestion in the packed side at four and eight weeks, although this difference was not significant. The small trial size is discussed, and while the patients were blinded as to which side was packed, the surgeons were not. Whether this affected their post-operative assessment is not clear, but further trials are required before this becomes an evidence-based standard of care.
Laryngeal closure after CVA
Reviewed by: Joanne Rimmer
Sep/Oct 2010 (Vol 19 No 4)
The authors report 45 patients with intractable aspiration and dysphagia secondary to a cerebrovascular accident (CVA) who were treated with laryngotracheal closure and cricopharyngeal myotomy. Whilst laryngotracheal separation and 'typical' laryngeal closure have been used in these cases, they produce a blind-ending subglottic cavity in which secretions can pool and stagnate. The authors describe their technique of combining laryngotracheal closure with cricopharyngeal myotomy to allow maximal recovery of swallowing function and the eradication of aspiration with minimal side-effects. It essentially involves suturing the true and false cords together and placing a strap muscle flap into the subglottic cavity thus created. They report 100% success in eliminating aspiration, and varying degrees of swallowing improvement in all patients, to a normal oral intake in some. A permanent tracheostome was created in all, and no tracheostomy tubes were required. The benefits as compared to other techniques are touched on, but laryngectomy as a treatment is not mentioned at all, nor is post-operative voice (or lack of it). The authors do conclude that this should be used in select patients only, but it certainly may be something to think of if all other avenues have been exhausted.
Using an LMA for difficult airways
Reviewed by: Joanne Rimmer
Sep/Oct 2010 (Vol 19 No 4)
A retrospective review was performed to illustrate the usefulness of a laryngeal mask airway (LMA) for ventilation of patients with difficult airways undergoing laryngoscopic procedures. Patients had a history of difficult intubation or were predicted to be a difficult airway. All underwent airway procedures using a flexible laryngoscope or bronchoscope. It was also possible to use a flexible laser fibre through the biopsy channel of the bronchoscope, allowing five of the six patients studied to undergo laser treatment to laryngeal or tracheobronchial lesions. There were no complications, airway-related or other. Obviously such use of an LMA (with or without laser) needs to be done in a planned setting in a controlled environment with an experienced airway anaesthetist and surgeon.
An overview of lithotripsy
Reviewed by: James Barraclough
Sep/Oct 2010 (Vol 19 No 4)
The indications for lithotripsy, with regards to salivary calculi, are set out clearly in this article. The most frequently used extracorporeal shock wave lithotripsy utilises an electromagnetic energy source that is minimally invasive and can be used on an outpatient basis, without anaesthesia. The authors highlight mounting evidence for its efficacy as a first line intervention. They stress that ultrasound analysis is essential and sialography is commonly needed before the procedure, but that good results are gained for parotid stones, intraductal locations and stones with a diameter of less than 7mm. Lithotripsy is also commonly now used in combination with the emerging technologies, highlighted elsewhere in this series of articles. It is interesting to note that, despite the American readership of this journal, lithotripsy for salivary glands is not available in the USA due to FDA approval application costs, whereas it is widely available in Europe.
Cough is related to reflux in a number of ways
Reviewed by: James Barraclough
Sep/Oct 2010 (Vol 19 No 4)
The presence of gastric contents within the upper oesophagus and upper airway has been established as one of the causes for a number of laryngeal symptoms. This article describes recent research into this area with regards to the relation with cough. It was previously assumed that acidic reflux caused chronic cough, due to localised irritation, but it appears that there is growing evidence that non-acidic reflux (such as with bile and pepsin) may also have a significant role to play. This may go some way to explain the lack of improvement in some patients with demonstrable reflux, in whom PPIs do not improve their cough. In addition, there is also evidence to indicate that the presence of distal oesophageal acidification can increase the reflex cough sensitivity to non-acidic and even exogenous agents. In further detail, the author quotes results from manometry testing that suggests only a weak association of coughing events with refluxing of acid. This goes some way to explaining the poor correlation of cough symptoms and reflux symptoms. There then follows a discussion regarding treatment therapies available for reflux associated cough, including evidence for PPIs, alginates and prokinetics. Surgery should be reserved for patients with medically resistant symptoms. However, the series quoted commonly mention that cough only has a moderate likelihood of benefiting form surgery. Behavioural, laryngeal hygiene and drug compliance issues also play a part in this multifaceted problem and so it is likely to create a challenge for some time to come.
Some respite for the unexplained cougher
Reviewed by: James Barraclough
Sep/Oct 2010 (Vol 19 No 4)
Patients in whom a chronic cannot be explained have created a challenge for many clinicians. This interesting article investigates the possible reasons for an unexplained chronic cough and includes a concise algorithm to work through when faced with a patient in whom many investigations have been unhelpful. Then follows insightful comments as to why some patients may have had certain conditions crossed off the potential differential diagnosis list. For example, silent reflux associated with cough can take up to six months of treatment with intensive medical therapy to resolve an associated cough. The author suggests that the number of truly unexplained coughers is less than 10% of the total of chronic coughers. The potential mechanisms for this group of patients include an overly sensitive cough reflex, coexisting autoimmune disease and a different airway histopathologic profile (where the cough itself may be the cause of the lymphocytic inflammation). A number of treatment options have been postulated including a self limited trial of opiates, nebulised local anaesthetics, gabapentin and amitriptyline with variable and unconvincing results. What is clear is that a multidisciplinary approach is needed.
Strictures and stones...
Reviewed by: James Barraclough
Sep/Oct 2010 (Vol 19 No 4)
This article delivers a concise overview of past, current and future options available for the radiologically and endoscopically guided management of benign salivary duct obstruction. A number of possibilities for stricture dilation are described including salivary balloon ductoplasty with radiological guidance or endoscopic guidance under local anaesthesia. Cutting balloons are now available that have small microtome blades mounted along the balloon itself. Practicalities of the use of such techniques are described, together with some of the common pitfalls encountered. The authors quote series of patients where ductoplasty was feasible in 87% to 95% and an improvement in symptoms was achieved in 92% to 96%. Re-stenosis rate was quoted at just over 5%, with a mean interval of 31 months. Endoscope technology is improving, allowing for smaller fibres and higher quality images. In addition, this has lead to the production of microinstruments that can be used in conjunction with small endoscopes, such as retrieval baskets, graspers, microforceps and balloon catheters. The authors go on to describe gland-preserving surgery, with endoscopic assistance, to move the stone, so that a small intraoral incision can be made for stone removal.
Treatment algorithms
Reviewed by: James Barraclough
Sep/Oct 2010 (Vol 19 No 4)
This is a helpful resume of the previous articles and provides a practical, stepwise approach to the management of benign salivary gland obstruction. It highlights the position and size of stones likely to benefit from various methods of removal. It goes on to describe options available for ductal problems, from distal to proximal, including the intraparenchymal ductal system. The algorithms are also illustrated and these may be of help to anyone who is interested in managing patients with these problems.
Efficacy of Montelukast as monotherapy for persistent allergic rhinitis?
Reviewed by: Annabelle CK Leong
Sep/Oct 2010 (Vol 19 No 4)
Montelukast is a leukotriene receptor which is usually used in the treatment of allergic rhinitis only after firstline options of antihistamines and intranasal corticosteroids have been exhausted. This double-blinded randomised controlled trial compared a group of patients given 10mg montelukast tablets with a placebo group, and subsequently analysed the improvement in quality of life with a 28-item questionnaire covering nasal and eye symptoms and effects on work and sleep. There was a statistically significant difference between the two groups, suggesting that montelukast is effective therapy by itself for persistent cases of allergic rhinitis. However, these results have to be interpreted cautiously as patients with asthma, those who had used systemic or topical corticosteroids in the previous month or were on antihistamines, were excluded, which could mean that those included in the study had far less severe allergic rhinitis to begin with!
Posterior semicircular canal dehiscence
Reviewed by: Rebecca Heywood
Sep/Oct 2010 (Vol 19 No 4)
This is the first reported series of patients with symptomatic posterior semicircular canal dehiscence (PSCD) in the recent preponderance of literature on dehiscent semicircular canals. Twelve patients (2-67 years) with hearing loss from the Children's Hospital Boston were found to have PSCD on high-resolution CT. As with other third mobile window conditions, there was a wide range of auditory and vestibular symptoms. Chronic disequilibrium was the most common complaint. Other symptoms encountered were similar to those of superior SCD and included autophony, pulsatile tinnitus, aural fullness. Most patients had a mixed hearing loss, though pure conductive and sensorineural losses were present. All patients had normal stapedial reflexes and tympanometry. Two cases had iatrogenic dehiscence following acoustic neuroma removal and mastoid surgery. Seven of the other 10 cases had dehiscence along the caudal portion of the canal into a high riding jugular bulb. This series shows a marked preponderance (10 / 12 patients) for right sided disease, which the authors explain by the fact that right dominant jugular venous drainage is more common. Of note, these subjects were selected by hearing loss and thus are not necessarily representative of all PSCD patients. There is obviously a long way to go to explaining the spectrum of disease, from completely asymptomatic dehiscence to severe vertigo and hearing loss. They also demonstrate suprathreshold responses in 2 / 12 patients and suggest that this should be considered a suspicious finding for labyrinthine dehiscence. PSCD should be included in the differential diagnosis of atypical hearing and vestibular symptoms.
Steroids for vestibular neuritis
Reviewed by: Rebecca Heywood
Sep/Oct 2010 (Vol 19 No 4)
It seems logical that corticosteroids should have a beneficial effect on vestibular neuritis as for other acute cranial nerve neuropathies. Nevertheless, steroid therapy for vestibular neuritis has not received the attention from the UK ENT community that it has for facial nerve palsy, or sudden sensorineural hearing loss. This may be because patients are frequently managed by GPs and many recover symptomatically without treatment. However, it is widely acknowledged that permanent canal paresis occurs and symptoms persist in some patients. This systematic review and limited metaanalysis attempts to address the effect of early steroid treatment on clinical parameters and caloric paresis. Only four randomised controlled trials, comparing steroids started within five days of onset of symptoms with placebo, were identified. The proportion of patients with complete caloric recovery at one and 12 months was significantly better with steroids, compared to placebo. One of the four studies evaluated caloric results at one month only, without baseline values or long-term follow-up. Only one study evaluated clinical recovery; this showed no significant difference in recovery at one, three or six months between the two groups. In conclusion, the authors suggest that, while steroids improve caloric outcome, they do not improve clinical outcome. This should be interpreted with caution, since the only study to look at clinical effects had a small sample size and unclear randomisation. As with most meta-analyses, in this age of evidence based medicine, it seems that there really is no evidence! And further well designed RCTS are needed…
Viral entry to vestibular system via palatal taste receptors
Reviewed by: Rebecca Heywood
Sep/Oct 2010 (Vol 19 No 4)
A viral aetiology for vestibulopathy has recently been postulated and histopathological correlates support the presence of viral DNA in the vestibular ganglia of affected individuals (although it is present in some unaffected individuals too…). Here a possible route for passage of viruses is demonstrated. A small variable component of the nervus intermedius (NI) has previously been shown to travel within the superior vestibular nerve, separate from the major part of the NI, and joins the facial nerve later (the vestibulofacial anastomosis (VFA)). This study demonstrates ganglion cells associated with this part of the NI, which receive afferent taste fibres from the palate, via the greater superficial petrosal nerve (GSPN). The VFA and ganglion were identified in 32 of 160 sectioned human temporal bones (the small yield is attributed to section thickness). Ganglion cells were situated within, or intimately related to, the vestibular ganglion in all cases, but no direct neural connection could be found to it. Furthermore, a neural pathway tracer chemical applied to the cut end of the GSPN in four rats was identified in cells within the vestibular ganglion, adjacent to the facial nerve and NI. The authors postulate that neurotropic viruses, such as herpes, may enter palatal taste receptors in the newborn and subsequently travel to the NI ganglion cells, which, although not neurally connected to the vestibular nucleus, provide access for infectious proteins to the vestibular nerve, via tight junctions and satellite cells. Reactivation of the virus may then manifest as a vestibulopathy later in life.
Where do I speak from?
Reviewed by: Roberta Buhagiar
Sep/Oct 2010 (Vol 19 No 4)
Person-centred care (PCC) has become one of these 'hot button' topics within the healthcare system. This article defines PCC as having a primary focus on the person as opposed to the task, recognising and valuing personal knowledge and experience as well as the person's autonomy and competence in terms of decision making and problem solving related to both physical and emotional needs. PCC may improve therapy outcomes, client satisfaction, and perceived quality of care, as well as address aspects of evidence-based practice. Results from this pilot study suggested that current approaches to clinical supervision and grading may play a role in reducing the amount of PCC provided. Clearly, further study is needed before the utility of these objectives can be established.
The future of person-centered care in voice clinics
Reviewed by: Laith Tapponi
Sep/Oct 2010 (Vol 19 No 4)
Person-centred care (PCC) has become one of these 'hot button' topics within the healthcare system. This article defines PCC as having a primary focus on the person as opposed to the task, recognising and valuing personal knowledge and experience as well as the person's autonomy and competence in terms of decision making and problem solving related to both physical and emotional needs. PCC may improve therapy outcomes, client satisfaction, and perceived quality of care, as well as address aspects of evidence-based practice. Results from this pilot study suggested that current approaches to clinical supervision and grading may play a role in reducing the amount of PCC provided. Clearly, further study is needed before the utility of these objectives can be established.
Anterior skull base surgery in paediatric and young adult patients
Reviewed by: Andy Hall
Sep/Oct 2010 (Vol 19 No 4)
This is a single-institution retrospective cohort study in a tertiary care academic cancer centre, reviewing anterior skull base surgery over a thirty-two year period in patients under the age of twenty-one in relation to that of 'adult' patients. This group were found to be much less likely to suffer from any comorbidity than adult patients. They found a higher percentage of patients with sarcoma histology (53%) in comparison to adult patients and, as such, 74% of this cohort were found to have received neo-adjuvant chemotherapy prior to surgery. The overall CNS complication rate is demonstrated to be less in the young adult population. A trend is shown for improved three year survival for patients under the age of twenty-one, postulated to be due to the more favourable pathological profile of disease (with fewer cases of squamous cell carcinoma or sinonasal mucosal melanoma etc). The authors recognise the importance of longer term follow-up in assessing any sustained difference in survival. Prospective multi-institutional data will be required to truly assess outcome data, while the increasing use of endoscopic resection techniques also questions the overall relevance of the review data.
Bullet-induced syncope
Reviewed by: Andy Hall
Sep/Oct 2010 (Vol 19 No 4)
This describes a fascinating case of a gun-shot wound through the left face resulting in the lodging of a bullet in the right jugular foramen. Following the acute non-surgical management of his injuries the patient returned to work however he soon became troubled by attacks of sudden unprecipitated syncope. It was postulated these were a direct result of direct irritation of cranial nerves IX and X. A transcervical transmastoid surgical approach to the jugular foramen allowed removal of the bullet and, following this, the patient was able to resume full active military service.
Light at the end of the tunnel
Reviewed by: Andy Hall
Sep/Oct 2010 (Vol 19 No 4)
This paper reports the introduction of endoscopic transsphenoidal resection techniques at a single centre comparing it to microscopic transmucosal approaches in a concurrent case control manner. In what the authors describe as 'pseudorandomisation', the availability of specific ENT surgical assistance determined the choice of technique with 51 in the endoscopic arm and 46 in the microscopic arm. Independent of this selection process, the two groups appear well matched. Crucially, the authors recognise the importance of determining whether the perceived advantages of endoscopy translate into discernable patient benefit. Interestingly, on this basis, they focus on a likely learning curve in their complication rate with this technique, dividing the endoscopic arm into 'early', 'middle' and 'late' cohorts. The authors demonstrate a statistically significant reduction in the complication rate for both CSF leak (from 41% to 6%) and diabetes insipidus (35% to 6%) between the early and late cohorts that they attribute to this learning curve. There is a need for multi-centre pooled analysis to reach any definitive conclusion but the concept of minimising the learning phase where possible is an important one in any advancing surgical technique.
Quality of life following endonasal skull base surgery
Reviewed by: Andy Hall
Sep/Oct 2010 (Vol 19 No 4)
This paper attempts to evaluate the impact of endonasal skull base surgery on quality of life. It has previously been felt that an endonasal approach avoids the morbidity of a transcranial / transfacial approach and offers potential of a faster recovery. The study looked at 51 patients, examining quality of life outcomes using the anterior skull base questionnaire, a site specific quality of life assessment tool along with the (SNOT)-22 questionnaire, providing a symptom score related to sinonasal function. Overall, patients demonstrated a good to very good Quality of Life score following the endonasal approach on the anterior skull base questionnaire. Interestingly, 27% of patients had a SNOT-22 score of 4.0 or greater, indicating a severe problem related to a loss of smell or taste. This disparity indicates some of the difficulties faced by studies looking at quality of life outcomes.
Temporal bone CSF leaks: a case series
Reviewed by: Andy Hall
Sep/Oct 2010 (Vol 19 No 4)
This is a retrospective case series of cerebrospinal fluid leaks of temporal bone origin at Mount Sinai Hospital in New York. Eight of these were spontaneous and six had CSF leak from an encephalocele discovered during chronic ear surgery. The authors describe a transmastoid surgical approach, initially in all, but with additional exposure required in three cases in the form of minicraniotomy and middle fossa craniotomy. Primary surgical repair was successful in all six chronic ear surgery patients and six out of the eight patients with spontaneous leaks. The authors clarify that selection of surgical repair for middle fossa defects remains a matter for individual judgement, with the available literature reflecting individual surgeon experience. In light of this, the article provides a useful summary of surgical management of temporal bone CSF leaks, with an emphasis on preoperative collaborative planning by experience skull base otolaryngologists and neurosurgeons.
Mandibular advancement splint in an edentulous patient
Reviewed by: Showkat Mirza
Sep/Oct 2010 (Vol 19 No 4)
Traditionally oral appliances for snoring and obstructive sleep apnoea (OSA) require enough teeth in good periodontal condition for device stability. The authors describe one of the few cases in the literature of a modified splint in an edentulous patient with severe OSA. The apnoea / hypopnoea index reduced from 98 to 15 with the device. Suitable illustrations are included.
Effect of loratidine / montelukast in allergic rhinitis
Reviewed by: Laith Tapponi
Jul/Aug 2010 (Vol 19 No 3)
This paper offers safe and effective relief for nasal congestion, the most common and bothersome symptom of allergic (seasonal or perennial) rhinitis. It is always interesting and thought provoking to see how otolaryngologists deal with everyday 'bread and butter' ENT problems. The authors concluded in this extensive prospective study of 1,095 patients that a combination of loratidine and montelukast was as efficacious as pseudoephidrine than placebo on nasal congestion. However, patients treated with L / M and placebo experienced more favourable safety, tolerability profile and lack of association with the potential for abuse compared with pseudoephidrine.
How crustaceans can help us in FESS surgery
Reviewed by: Edward W Fisher
Jul/Aug 2010 (Vol 19 No 3)
Chitostan is a polymer based on chitin (present in insects and crustaceans) and is available as a gel for potential use in surgery. Studies on sheep models have been encouraging and this study examines the use of the gel in ESS cases. With pressure on surgeons to perform surgery on a day case basis and to limit the number of follow-up appointments, anything that helps control bleeding and limits adhesion formation has to be a good thing. This randomised controlled trial of chitostan in ESS cases looked at 40 cases and found impressive improvements in haemostasis times and adhesion formation in the gel cases compared to controls. The figures suggest that the improvements are clinically relevant rather than just being statistically significant. This sounds more promising than some previous commercially available materials.
Staphylococcus predominant in sinusitis biofilms
Reviewed by: Edward W Fisher
Jul/Aug 2010 (Vol 19 No 3)
This detailed study looked at a group of rhinosinusitis patients and compared sinus tissue with patients who were having sinus access procedures for non-inflammatory conditions. FISH (fluorescence in situ hybridisation) was used to analyse the specimens, looking at the pattern of bacteria with a laser scanning electron microscope. This study found no biofilms in the control sinus samples but found bacterial biofilms in 36 out of 50 patients (72%) and the predominant bacterial colonising was Staphylococcus aureus. Eleven out of 50 cases had characteristic fungal biofilms and there were cases in which both fungal and bacterial biofilms coexisted. The importance of biofilms in ENT infections (CRS, tympanostomy tube infections, chronic tonsillar infections for example) seems to be in the ascendancy.
Sticky mucus in sinusitis cases
Reviewed by: Edward W Fisher
Jul/Aug 2010 (Vol 19 No 3)
The study of stickiness of mucus and the effects on its ability to flow (mucus rheology) has been tantalisingly interesting but practically difficult, usually involving the use of labour-intensive and expensive biological methods – such as the frog palate model. This study examines a group of patients with sinus disease and in some cases before and after nasal surgery and in the outpatient clinic. The method used for analysis of mucus is the 'cone and plate rheometer', measuring 'dynamic viscosity' and 'elasticity'. Clinical information was collected and measured using CT (Lund-Mackay score) and SNOT-20 for symptoms. The results are presented in an opaque fashion and the absence of a control group makes it hard to find meaning in the figures presented. However, it is apparent that disease severity and dynamic viscosity / elasticity are correlated, much as expected. Improvement in these figures correlated with improvement in postoperative clinical data in one case. The study has a long way to go to give truly meaningful figures, but this study seems to be more of a preliminary report to establish the range of expected figures from this in vitro method.
Two holes are not better than one
Reviewed by: Edward W Fisher
Jul/Aug 2010 (Vol 19 No 3)
This very impressive paper looked at nearly 9,000 outpatients and examined their noses for so-called accessory ostia of the maxillary antra and looked for mucosal recirculation (between natural and accessory ostia) and other signs of inflammation. The major statistic is that a tiny proportion of non-sinusitis cases had accessory ostia (0.48%) whereas a fair proportion of the sinusitis cases had an accessory ostium in the posterior fontanelle (19.3%). They conclude that the presence of an accessory ostium predisposes to inflammation and that the term 'accessory ostium' (with its implication of a helpful or at least neutral ventilation hole) should be discarded.
HPV and tonsillar carcinoma
Reviewed by: Joanne Rimmer
Jul/Aug 2010 (Vol 19 No 3)
There has been an increase in the incidence of tonsillar carcinoma over the past 20 years, and human papillomavirus (HPV) has been implicated in the literature as an aetiological factor. Previous studies have shown that HPV-positive tonsil cancers have tended to occur in younger patients with a lower incidence of smoking and alcohol consumption than the 'traditional' head and neck cancer patient. Prognosis in these patients has been reportedly better. This group reviewed 48 patients with tonsillar carcinoma, and found that 35% were HPV-positive tumours. In contradiction to previous reports, they found no significant difference between JPV-positive and HPV-negative patients with regards to age, smoking or alcohol intake. Perhaps more significant was the lack of a significant difference between the two groups' prognosis. Whilst HPV-status is not routinely looked at in the UK, it has been used as a prognostic indicator to inform clinician and patient decision-making. There is no obvious explanation for the differences (or lack thereof) in this study compared to previous work, and further work is needed for clarification, particularly if HPV-status of tumours is to have any further clinical relevance.
Awake airway surgery
Reviewed by: Badr Eldin Mostafa
Jul/Aug 2010 (Vol 19 No 3)
Surgery for tracheal stenosis is a delicate compromise between anaesthetic airway support and the surgical access. In this prospective, clinical feasibility study 20 patients with upper tracheal stenosis were managed through cervical epidural anesthesia and conscious sedation, and atomised local anesthetic. No intraoperative intubation or jet ventilation was required. Outcome measures were ease of surgery, observer-rated functional result, early (less than 30 days) complications, and patient-reported satisfaction. There were no early complications and only one patient required nasotracheal intubation. There was also no reported short-term recurrence. In the authors words 'all patients indicated that they would be happy to repeat the procedure'. It would seem to be useful to add a similar comment from the anesthetists and surgeons as well. However, it may be a good alternative for high risk patients who cannot be properly ventilated once they are asleep or paralysed.
Bone anchored hearing aids in children
Reviewed by: Shabbir Akhtar
Jul/Aug 2010 (Vol 19 No 3)
Criteria for bone-anchored hearing aid (BAHA) use are profound unilateral sensorineural hearing loss (USNHL), in the setting of a normal-hearing contra lateral ear. In the paediatric population, two-stage surgery is often performed to allow proper time for osseointegration. Evidence suggests that children with profound USNHL perform poorly in school, display learning difficulties, and have behavioural problems relative to their normal-hearing peers. Adult patients using the BAHA have shown increased understanding of speech in noise and increased patient satisfaction. On the other hand, the use of the BAHA in children remains controversial. According to these authors its role in children has not been explored previously. The study included 23 children, five years and older. Results of the Hearing in Noise Test (HINT) and the Children's Home Inventory for Listening Difficulties (CHILD) questionnaires were compared before and after surgery. Although the authors have shown improvement in both outcome measures after treatment, no statistical test is applied and we are left with a question whether this difference is significant or not. They have reported a complication rate of 17%, mainly skin related. Although there are reports of BAHA use in children under three years, this is fraught with high risks of complication. Most of the literature suggests surgery after four years, as was the case in this study. One of the measures of success of a BAHA in a child is the number of hours / days per week that the child wears his / her BAHA. This was not assessed in this study.
Update on bone-anchored hearing aids in pediatric patients with profound unilateral sensorineural hearing loss.
Christensen L, Richter GT, Dornhoffer JL.
ARCHIVES OF OTOLARYNGOLOGY-HEAD & NECK SURGERY 2010;136:175-7.
A new endoscope for outpatient biopsies?
Reviewed by: Neil C Molony
Jul/Aug 2010 (Vol 19 No 3)
This is what I would tend to call a 'technical paper' in that it describes initial use of a new instrument to solve old problems. The Japanese authors devised and tested a new semi-flexible endoscope, in which the coil could be bent by hand to a shape looking suitable for a given patient, prior to using it in the same way as a rigid transoral endoscope with a biopsy channel. This was tried on six patients, all very virtuous with ethical approval! It proved good for visualisation and photographic recording, and tumour biopsy in all locations, but not successful in removing vocal cord polyps due to angulation difficulties. It was also effective for foreign body removal, such as removing fishbones. As an instrument it looks interesting, and certainly it is desirable to allow more biopsies in clinic with images for documentation and avoid general anaesthetic endoscopies. I am not clear how well the instrument would stand up to the various decontamination requirements, and with a biopsy channel, it could not have disposable sheaths. If it goes into more widespread production, I certainly would be interested, though adding suction might be an advantage.
NPC into the prevertebral or parapharyngeal space? Give chemotherapy!
Reviewed by: Neil C Molony
Jul/Aug 2010 (Vol 19 No 3)
This is a retrospective study from Taiwan of 105 patients, but asking new questions of existing practice from recent data. The aim was to find if three factors gave a poor prognosis in NPC (nasopharyngeal carcinoma). These were: firstly, invasion of the prevertebral space; secondly parapharyngeal invasion; and thirdly large tumour volume. Assessment of these areas was by MRI scan. This unit routinely gave radiotherapy to all newly diagnosed NPC cases, with concurrent and adjuvant chemotherapy to advanced cases, defined as T2-T4. This did not, of itself, automatically mean chemotherapy for all three groups listed, though some such patients would have had it, if staged as T2-T4. This allowed retrospective comparison of these as risk factors. The presence of two of these was defined as giving 'high risk' of poor outcome for the study. Analysing data found patients with two of these three had a statistically significant reduction in three-year metastasis free survival, and nearly significant (p=0.9) reduction in three year recurrence-free survival. Assessment was by repeat endoscopy and biopsy, with imaging if it seemed clinically needed. This seems reasonable, as does use of MR to measure tumour extension into these relatively inaccessible proposed high risk areas. The conclusion is that these three areas do indicate high risk of recurrent or aggressive disease and therefore it recommends giving such patients chemotherapy, and perhaps indicates the limitation of any classification system in defining the spread of a cancer.
Bayesian belief networks and electrical impedance studies of thryoid nodules
Reviewed by: Peter Radford
Jul/Aug 2010 (Vol 19 No 3)
This interesting paper tackles two research topics, both of which may impact on the management of thyroid nodules. The key element of this paper is to see whether an electronic Bayesian Belief Network can help guide management of thyroid nodules, showing indeterminate cytology on fine needle aspiration (FNA). Two hundred and sixteen patients with thyroid nodules, already scheduled for diagnostic hemi-thryoidectomy, were recruited and data of ultrasound, fine needle aspiration and scintigraphy were collated with other patient factors. One interesting extra bit of data added was what is currently only a research-level investigation, thyroid Electrical Impedance Study (EIS) - a method championed by this research group but currently not in wide use. These data were correlated with the post-operative histopathology data. Ninety percent of these data were inputted into the electronic Bayesian Belief Network to generate predictive models, with different conditional independence assumptions for each aspect of the data. These models were then tested, with 10% of the data withheld from the model, to test accuracy. The generated model gave positive and negative predictive values for malignancy of 83% and 79% respectively. Sensitivity and specificity of 82% and 77% for malignancy were also achieved. The authors hope that, with further testing, a web based model will be available to help guide clinicians on management of thyroid nodules and potentially save patients from having a diagnostic hemi-thyroidectomy, an operation not without risks. It is important to note that the sample population had clinically earned a diagnostic hemi-thryoidectomy already and a wider population of thyroid nodules may lead to altered predictive values. Another note is the use of the thyroid Electrical Impedance Study, a diagnostic test not as yet widely used, but with potential diagnostic value. The paper does provide the starting point for further testing and may develop a potentially very useful management tool.
Vestibular system helps to regulate cerebral perfusion
Reviewed by: Rebecca Heywood
Jul/Aug 2010 (Vol 19 No 3)
In recent years it has been proposed that the vestibular system may contribute to human adaptation for the maintenance of cerebral perfusion and blood pressure in the upright position, previously thought to be controlled mainly by cerebral autoregulation and cardiovascular reflexes. This study carried out by Harvard Medical School and NASA seeks to further define this role and postulates involvement of the otolith organs in the regulation of cerebral perfusion. Healthy adults were subjected to two motion protocols at different frequencies to elicit vestibular activity. Pitch tilt (moving the body nose up or nose down relative to the horizon) in a tilt chair stimulated both otolith organs and semicircular canals. Translation (movement in a single axis of motion) in a variable-radius centrifuge in the dark removed visual cues of orientation and stimulated the otolith organs only; subjects were spun at a constant rotational velocity in the centrifuge for five minutes prior to translation such that the semicircular canals no longer sensed angular acceleration. Of note the pitch tilt experiments were not carried out in the dark and only 18 out of 24 healthy subjects completed the experiments. Variation in cerebral blood flow velocity with frequency, direction and tilt angle position was demonstrated which could not be fully accounted for by fluctuations in blood pressure and end-tidal CO2. The changes were similar with or without semicircular canal stimulation, consistent with a role for otolith organ mediated activity in cerebral blood flow regulation. The findings raise interesting questions regarding the contribution of vestibular hypofunction to postural imbalance. Future work in the clinical arena may direct therapies for postural hypotension, for example in age related vestibular impairment. A fascinating article which also caught the eye of the media, this adds a small part to a much bigger picture.
Vestibular effects on cerebral blood flow.
Serrador JM, Schlegel TT, Black FO, Wood SJ.
BMC NEUROSCIENCE 2009;10:119.
Dexamethasone to the rescue for mice with olfactory nerve trauma!
Reviewed by: Carl Philpott
Jul/Aug 2010 (Vol 19 No 3)
This paper depicts an animal study conducted to look at the differences in severity between a mild nerve transaction and a severe nerve transaction on a immunohistological basis and then look for evidence that dexamethasone modulated this effect in the severe cases. They used a Teflon blade to produce a mild injury and a steel blade to produce a severe one at the cribriform plate where the olfactory nerves enter the bulbs. After seven weeks, the dexamethasone modulated mice showed there was a significant reduction in the proliferation of injury-associated tissue formation compared with the saline controls. There were also significant decreases in the number of GFAP-positive cells and CD68-positive cells that are associated with the inflammatory response. Although this paper does not give any indication of the poor mice's olfactory function long term as conceded by the authors, it does suggest that early use of dexamethasone in patients with these injuries may prevent significant neuronal damage and possibly protect some function.
Cochlear implantation and quality of life
Reviewed by: Thomas Nikolopoulos
Jul/Aug 2010 (Vol 19 No 3)
Quality of life in cochlear implantation is a relatively new issue in relation to the usual outcome measures of speech perception and speech production. This qualitative study aimed to gain a deeper insight into the effects of cochlear implants on recipients' lives, as perceived by the recipients themselves. To obtain this insight, the authors used four open-ended questions. One hundred and seven adult patients from two Norwegian implant centres were invited to take part in the study. Of these, 74 returned completed questionnaires (69%). Recipients perceived that they had got 'a new life' with the implant. Contributing to this global category of effects were four other categories. These concerned subjects' interactions with the world around them, experience of themselves, ability to hear the world around them and finally certain device-related issues. Overall, psychological well-being was improved. The authors concluded that their questionnaire might prove a useful tool in the follow-up of patients. However, open-ended questions have certain weaknesses and all outcome measures should be evaluated with regard to reliability and validity.
Effects of cochlear implants: a qualitative study.
Rembar S, Lind O, Arnesen H, Helvik AS.
COCHLEAR IMPLANTS INTERNATIONAL 2009;10:179-97.
Facial palsy after cochlear implant surgery. A challenging complication
Reviewed by: Thomas Nikolopoulos
Jul/Aug 2010 (Vol 19 No 3)
Facial nerve palsy following cochlear implant surgery is one of the most challenging complications. Apart from the functional, aesthetic and emotional concerns, it can raise important medico legal issues. The authors reported a case of facial palsy on the fifth postoperative day, that was combined with increased IgM antibodies to HSV. The patient was treated mainly with methyl prednisolone and valacyclovir. With physiotherapy, the patient had a full recovery in two months. In general, delayed facial palsy may be attributed to neural oedema, vasospasm and viral reactivation. The authors suggested that manipulation of sensory branches of the facial nerve and chorda tympani may have reactivated the virus and therefore they recommend extreme caution during surgery, in order to avoid facial nerve trauma, with proper irrigation to lower the risk of neural oedema. All these precautions seem reasonable and should be exercised. However, we cannot be entirely certain that the virus caused the facial palsy and also that surgical manipulations reactivated the virus.
Intra-operative imaging during cochlear implant surgery. Is it necessary?
Reviewed by: Thomas Nikolopoulos
Jul/Aug 2010 (Vol 19 No 3)
Imaging during cochlear implant surgery seems attractive, as it may confirm proper electrode array insertion in challenging cases. The authors reported two unusual cases of cochlear implant (CI) surgery. In the first case, a two-year-old child was bilaterally implanted. After introduction of the array in the right side, Neural Response Imaging (NRI) was performed and a neural potential was found only on two apical electrodes. Radiological intra-operative assessment with antero-posterior trans-orbital plain films showed the electrode array in the superior semicircular canal. The electrode array was removed and reinserted correctly. In the second case, a 72-year-old man underwent left cochlear implantation for sensorineural profound deafness of unknown origin. NRI showed the presence of neural potential on three tested channels. In this case, as routinely employed since 2006 in the authors' cochlear implant centre, an intra-operative static fluoroscopy test revealed the electrode array in the superior semicircular canal. The electrode array was removed and reinserted correctly. The authors concluded that the intra-operative radiological assessment is helpful during CI surgery, especially when there is any doubt about correct electrode insertion. This is true, although plain films may not be very clear in some cases.
The transmeatal approach: results in 131 patients
Reviewed by: Thomas Nikolopoulos
Jul/Aug 2010 (Vol 19 No 3)
The transmeatal approach (TMA) is an alternative to the classical approaches in cochlear implantation. It is an open-tunnel technique that differs from the closed transcanal non-mastoidectomy approaches. The TMA involves creating an open transcanal tunnel starting from the annulus superior to the chorda tympani laterally towards the suprameatal region. Then, through the open tunnel, a bony groove is created in the bone underneath the length of the external auditory canal (EAC) to protect the electrode from extrusion through the EAC. The authors reported the use of this approach in 131 patients (115 consecutive paediatric and 16 adult) between May 2004 and December 2007. During two to 46 months of follow-up there were a few complications and no electrode extrusion. However, this is a rather short follow-up as complications in cochlear implant surgery may be encountered many years after the operation. Moreover, some surgeons may be concerned with some details of the new technique (for example the electrode array is covered with cartilage and bone pate).
Tuning the cochlear implant. Not always easy!
Reviewed by: Thomas Nikolopoulos
Jul/Aug 2010 (Vol 19 No 3)
Appropriate tuning of the device is of paramount importance in cochlear implantation. However, difficulties and challenging cases are not rare. The programming of the speech processor involves measurement of electrical threshold and 'most comfortable loudness' (MCL) levels on each electrode. However, when the derived 'map' is activated the perception is often too loud or too soft. In this situation, adjustments of MCL settings are usually made in order to achieve a comfortable percept. The present study examined the range of volume control adjustments in 24 cochlear implant users. Volume control settings varied from 36% to 126% with a mean of 84.3% (SD = 20.4%). Additionally, the output compression function ('maplaw') was adjusted to test whether this alternative manipulation could result in a comfortable percept. It was found that this could be achieved satisfactory, with maplaw values ranging from 10 to 2,000. It therefore seems that in certain cases maplaw adjustments may be needed (for example when a cochlear implantee is complaining that environmental sounds are too loud and speech is not).
Nasal packing after sinus surgery
Reviewed by: Susan A Douglas
Jul/Aug 2010 (Vol 19 No 3)
This well written article examines the purpose of nasal packing after endoscopic sinus surgery (ESS), as well as the types of available packing. Nasal dressings are used to prevent postoperative haemorrhage, decrease adhesion formation and prevent lateralisation of the middle turbinate. This is important because the most frequent complication of ESS is adhesion formation (occurring in 36% of patients). Adhesion avoidance begins with attention to the surgical techniques to meticulously spare mucosa. Removable dressing – these tamponade bleeding surfaces, activate the coagulation cascade and act as a barrier to the formation of adhesions. The devices include balloon tamponade devices, ribbon gauze soaked in Vaseline, polyvinyl acetate sponge (Merocel; Medtronic Xomed, Jacksonville, FL, USA). Removable dressings are associated with adverse effects; patients describe removal of these packs as the worst part of the ESS experience. Removal may also be associated with bleeding, trauma to the nasal mucosa as well as complications such as septal perforation, turbinate necrosis, toxic shock syndrome, aspiration and foreign body reactions. Absorbable dressings – there are a number of dressings including blood based products, animal, plant and synthetic based biomaterials. The blood-based products include Fibrin glue (Quixil; Omrix Co., Brussels, Belgium) and Floseal (Baxter International Inc., Deerfield, Illinois, USA). Both have been shown to have haemostatic properties but adverse effects on wound healing have been noted. The use of blood-based products also raises concerns regarding transmission of disease (HIV or hepatitis) and antibody formation as well as a 1.7% risk of developing a serious bleeding disorder. Animal based biomaterials include hyaluronic acid-based products including Merogel (Medtronic, Xomed). Two published articles do not demonstrate any difference in adhesion formation compared to Merocel as a control. The routine use of animal based products may risk transmission of disease such as Creutzfeldt-Jacob. Synthetic products include oxidised regenerated cellulose (Surgicel Nu-knit; Ethicon Inc.). This has been shown to be equally effective for control of haemorrhage but there are no studies on wound healing. Synthetic material such as polyurethane foam (Nasopore; Stryker Canada, Hamilton, Canada) is a new material and no potential for antibody formation. A recent study compared this to a vinyl glove finger and there was no significant difference with regards to pain, pressure, and blockage, swelling or bleeding. The article discusses two newer materials; microporous polysaccaride hemosphere (MPH; Medafor Inc., Minneapolois, Minnesota, USA) and Chitosan. MPH has been compared to Floseal in animal studies and there was no evidence of poor wound healing with MPH. In patient studies, MPH has shown excellent haemostatic properties. Chitosan is prepared from Chitin, a polymer found in a large number of natural sources. This is an effective haemostatic agent. In patient studies Chitosan gel has been shown to improve intraoperative haemostasis, and result in significantly fewer adhesions.
How reliable is frozen section during glottic trans-oral laser surgery?
Reviewed by: Owain R Hughes
Jul/Aug 2010 (Vol 19 No 3)
This paper presents a retrospective review of 97 patients undergoing trans-oral laser cordectomy for cancer. The purpose of the study was to determine how well intra-operative frozen section analysis of the tumour margin predicted subsequent histological analysis of the specimen's margins. The results demonstrate that intra-operative frozen section agreed with histological examination of paraffin fixed specimens about 95% of the time. This has led the authors to conclude that frozen section is a reliable, cost-effective method to assess margin status, preventing systemic second look surgeries, when used during trans-oral laser surgery.The weakness of this paper is that the reader is not given details of the decision-making that determined how the surgeon chose to perform frozen section. There are times when the tumour is well circumscribed and its histological margin can be predicted accurately from its macroscopic appearance. At other times the tumour margin is difficult to assess intra-operatively; it is in these situations that an intra-vital method of determining the tumour margin becomes very useful. The authors also highlight some of the problems with taking frozen sections; namely that its accuracy is determined largely by good communication between the surgeon and pathologist. The surgeon takes the biopsy and takes responsibility for making a clinical decision, based on the histological interpretation, which is the responsibility of the pathologist. This separation of responsibilities clearly introduces the potential for error. What is required is a method by which the surgeon is able to image the histological extent of the tumour intra-operatively. This is the future, but is not yet a reality in routine surgical practice.
Strategic plan
Reviewed by: Showkat Mirza
Jul/Aug 2010 (Vol 19 No 3)
The article features in an issue devoted to the business aspects of facial plastic surgery. The physician may be focused primarily on clinical issues and patient care, but the practice of facial plastic surgery is often a small business and it is becoming increasingly more challenging to operate at a profit. This paper looks at the process of developing a business plan, to bring clarity and objectivity to the assessment of practice goals and market dynamics. The steps, from defining the mission of the practice to specific short and long-term goals, are outlined. In this time of increasing financial pressures, this paper may be of particular interest to clinicians.
Eat up your vegetables
Reviewed by: Stuart Clark
Jul/Aug 2010 (Vol 19 No 3)
This is a prospective paper from Spain evaluating the behavioural and clinical risk factors on the prognosis of 146 patients with newly diagnosed oral cancer. Patients were interviewed prior to treatment, one year following diagnosis, and a further review one year later. They concluded that a high vegetable intake before diagnosis and to a lesser extent after diagnosis was independently associated with reduced risk of recurrence. Concerning fruit, a high intake before and after diagnosis was associated with a better prognosis although was thought not to be statistically significant. The explanations for these findings were either that diets rich in fruit and vegetables were associated with a generally better diet and therefore overall nutritional status or that the components of fruit and vegetables produced a protective local effect possibly by modifying the oxidative state of transforming cells. They also fuond a strong association between diagnostic delay and poorer prognosis. The authors accept there are significant limitations to their study particularly concerning a lack of statistical power and bias.
Clearing blood clots blocking ventilation tubes
Reviewed by: Mary-Louise Montague
Jul/Aug 2010 (Vol 19 No 3)
Ventilation tube insertion is the most commonly performed surgical procedure in children. Ventilation tubes can become blocked, after insertion, for a number of reasons. Bleeding is frequently a cause of this blockage. The aim of this ex vivo experimental study was to determine the efficacy of common solutions used to dissolve blood clots blocking ventilation tubes, of differing lengths and diameters. Ear models mimicking the external auditory canal, tympanic membrane and middle ear space were constructed and ventilation tubes inserted and blocked with blood clots. Test solutions including saline (control), 3% hydrogen peroxide, white vinegar, Floxin otic drops and Ciprodex otic drops were applied to the blood clots and the time taken for clearance was recorded by microscopic visual confirmation. T-tubes had higher odds of unblocking than collar button tubes. Vinegar and 3% hydrogen peroxide were more effective than antibiotic drops in clearing the blood clots. Interestingly, the antibiotic drops were not significantly more efficacious than controls. The authors acknowledge that their study cannot address the issue of pain with contact of both vinegar and hydrogen peroxide on middle ear mucosa because of the ex vivo design of the study. Furthermore the study was not blinded, with the first author conducting the application of all agents and microscopic examinations. Nonetheless patient factors are eliminated by the ex vivo design allowing for uniformity in implementation of the experiment.
Could surgical treatment of subglottic haemangioma become obsolete?
Reviewed by: Mary-Louise Montague
Jul/Aug 2010 (Vol 19 No 3)
Treatment options for subglottic haemangioma have evolved over the years, from tracheostomy, to endoscopic laser ablation, to injection and intubation and, finally, open excision. More recently propranolol has been shown to be effective in treating cutaneous haemangioma alone. It has also been shown to be effective, in conjunction with other treatment modalities, for cutaneous haemangioma with concurrent subglottic haemangioma. Judging from the success of treatment, in this case report from Great Ormond Street Hospital for Children, London, UK, the surgical treatment of isolated subglottic haemangioma could well become obsolete. The authors describe the treatment of an isolated subglottic haemangioma, filling 95% of the airway, in a four month old child, with propranolol alone without side-effects. The Great Ormond Street Hospital guidelines for propranolol therapy in such cases are described in detail, including dosing schedule, pre-treatment assessment and work-up, monitoring during initiation of therapy and longer term dosing schedule. This would serve as a most useful protocol for paediatric otolaryngologists making this diagnosis, in the future, at other centres and is certainly one I will adopt in my practice. The authors note that the advantages of propranolol therapy for subglottic haemangioma – namely non-invasive, rapid onset, avoidance of tracheostomy, avoidance of prolonged steroid therapy, avoidance of manipulation of subglottic tissues, avoidance of prolonged periods of intubation, low complication rate and inexpensive – far outweigh the disadvantage of the need for detailed pre-treatment work-up and monitoring, whilst on treatment, and the potential side-effects of propranolol itself.
Does the addition of erythropoietin to radical radiotherapy affect survival, anaemia or fatigue in head and neck cancer?
Reviewed by: Annabelle C K Leong
Jul/Aug 2010 (Vol 19 No 3)
Tumour response to radiotherapy in patients with pre-existing anaemia is less effective than in patients with normal haemoglobin. Many previous studies have demonstrated that anaemia is a significant predictor of negative response to radiotherapy in different types of cancer, including head and neck cancer. This suggests that correction of anaemia during radiotherapy might improve survival and local control. However, the use of erythropoiesis-stimulating agents such as Epoetin-alfa is controversial based on unfavourable outcomes or neutral effects in previous trials. This was a prospective randomised controlled trial of 301 patients assigned to either radiotherapy with, or without, epoetin-alpha for 12 weeks. Although Hb levels increased from baseline with epoetin-alfa, there was no significant difference in disease-free survival between the two groups, nor any difference in tumour outcomes, cancer-related treatment anaemia or fatigue. Evidence of improved survival after epoetin use in patients undergoing radiotherapy in head and neck cancer is therefore lacking.
Effects of autologous serum in tympanic membrane perforations
Reviewed by: Stephen J Broomfield
Jul/Aug 2010 (Vol 19 No 3)
This paper is an example of an experimental study with results that do not reach statistical significance and yet still hold some interest. The study builds on previous work examining the role of tissue factors in healing of tympanic membrane perforations. The authors created bilateral perforations of the tympanic membranes of a series of 20 rats using a needle. Autologous serum was prepared and one drop applied daily to each rat's left ear. The right ear was untreated and therefore acted as a control. After a further two weeks, a histopathologic examination of both ears was made. Outcome measures included the perforation closure rate, measured thickness of the tympanic membrane, and an assessment of the fibroblastic reaction, neovascularisation and inflammation of the tympanic membrane. The authors note a trend towards better healing in every category in the serum-treated group but were unable to demonstrate statistical significance, and recommend further studies in this area.
Can nurses triage otolaryngology referrals?
Reviewed by: Madhup K Chaurasia
Jul/Aug 2010 (Vol 19 No 3)
It is traditional that consultants should triage otolaryngology referrals. Considering that 15% of all GP referrals are to otolaryngology, this can be time consuming but also time wasting due to non availability of the consultant. In this interesting study, the authors compare triaging done by senior consultant, another consultant, an ENT trained nurse, a non-ENT trained nurse and two each of SHOs, FY2s and specialist registrars on same referrals. It was noted that the trained nurse had close agreement with the senior consultant. They also agreed with the other consultant and with specialist registrars. The untrained nurse and junior doctors marked more patients as urgent, but on a retrospective review no really urgent case was downgraded as soon or routine. The study therefore supports the role of nurses in triaging. This may save valuable time and expensive consultant resources for something which can be done in alternative ways as is the practice in some other specialities.
Conservative management of vestibular schwannoma
Reviewed by: Madhup K Chaurasia
Jul/Aug 2010 (Vol 19 No 3)
With better methods of diagnosis, vestibular schwannomas are picked up much earlier than they were in previous decades. Present imaging also allows a better assessment of growth of these tumours and, based on this, not all tumours need to be resected. In this exceptional presentation on conservative management of vestibular schwannoma, comprising 490 tumours (327 of sporadic and 163 NF2 tumours), the authors have studied various aspects which seems to influence the rate of growth and thus help in deciding whether or not these should be removed surgically. The tumours were classified as intrameatal and intracranial, the latter if they extended beyond the internal auditory meatus and the size was graded from 1 to 4 depending on the longest axis measurement of the intracranial component of the tumour. Statistical analysis was applied to assess the growth rate and frequency of growth in both sporadic and NF2 tumours, which vary from 1.1mm to year in sporadic tumours to 1.7mm a year in NF2 tumours. The intervention rate was 100% up until 1992, but, in this study, approximately two thirds of the tumours in both the sporadic and the NF2 group did not require surgery. This decision was also helped by the small size of tumour, lack of growth, long history, patient preference, co-morbidity and presence of only minimal symptoms. Larger sporadic schwannomas showed greater tendency to grow than their neurofibromatosis counterparts and conservative treatment is not recommended for intracanalicular schwannoma larger than 15mm. The decision is more complex for NF2 tumours, which are often bilateral. It is also interesting that the growth rate is inversely proportional to the age at detection for neurofibromatosis, but this is not the case in sporadic tumours. The article provides interesting reading and has useful statistics to be presented to an anxious patient when the acoustic neuroma is discovered.
Does methylprednisolone help in the control of tinnitus?
Reviewed by: Madhup K Chaurasia
Jul/Aug 2010 (Vol 19 No 3)
Control of tinnitus is difficult and results of various studies on therapeutic interventions vary considerably. In the study, the authors assess the efficacy of intra-tympanic methylprednisolone against a placebo in a single-blinded, controlled trial. Seventy patients were randomised to receive either a placebo (normal saline) or intratympanic methylprednisolone as an out-patient procedure. Patients with chronic ear disease, otosclerosis and retrocochlear pathologies were excluded. Self-related tinnitus loudness score and a tinnitus severity index were used to assess the results, comparison being made pre- and post-operatively and also between the placebo and methylprednisolone. There was no improvement in the average total tinnitus severity index score in both groups on comparison of pre- and post-treatment results. There was also no statistically significant difference between the post-treatment tinnitus severity score between the drug and the placebo groups. There was an improvement in self-related tinnitus loudness score pre- and post-operatively in both groups but, again, there was no difference in the post-treatment score between the drug and the placebo groups. Therefore, contrary to a couple of other studies mentioned, the results indicated no improvement in tinnitus after injection of methylprednisolone. The authors are aware of the limitations of this study and the impeding factors may have been poor diffusion of methylprednisolone into the inner ear. It is also contemplated that most patients had presbycusis and that improvement in this sub-group is often difficult to achieve. However, no significant complications and no hearing loss have been reported in this study. In view of this, and the fact that good results have been reported in other studies, this trial should not preclude further trials of this nature considering that tinnitus can often be extremely distressing.
Intratympanic methylprednisolone injections for subjective tinnitus.
Topak M, Sahinyilmaz A, Ozdoganoglu T, Yilmaz HB, Ozbay M, Kulekci M.
JOURNAL OF LARYNGOLOGY AND OTOLOGY 2009;123:1221-5.
How to reduce follow-ups in an ENT emergency clinic
Reviewed by: Madhup K Chaurasia
Jul/Aug 2010 (Vol 19 No 3)
An emergency ENT clinic is now a feature of many departments across the country. This helps to receive patients spontaneously, lessens out-of-hours work, and immediate and effective treatment is provided. However, if these patients continue to keep coming, these clinics can cease to be useful. In this published audit, the authors picked up patients who required to be seen more than twice in the ENT emergency clinics and most of these cases had otitis externa. The junior doctors who ran these clinics were asked to discuss all patients wanting a third visit with an ENT consultant or a specialist registrar. A protocol was devised for the treatment of this particular condition and instructions visibly placed at strategic points in the clinic. The protocol was also passed over to succeeding junior rotations. The prospective arm of the audit revealed a 70% reduction in the number of excess clinic appointments and a 22% reduction in the total number of ENT emergency clinic visits. These findings were statistically significant. Repeat follow-ups waste resources and this example could be applied to many other situations such as dizziness, chronic sinusitis, following ear surgery and likewise.
Uses of diffusion-weighted magnetic resonance imaging in otolaryngology
Reviewed by: Madhup K Chaurasia
Jul/Aug 2010 (Vol 19 No 3)
This review article provides good reading on advances in magnetic resonance imaging and its applications in more precise diagnosis in otolaryngology. The authors explained the fundamentals of magnetic resonance imaging and how diffusion-weighted imaging uses pulse magnetic fields of varying strengths, direction and time intervals to activate the protons in water molecules. Essentially, tissues which have increased permeability due to disease allow greater movement of water molecules. The technique uses the concept of parent diffusion coefficient, which can be applied to a spectrum of pathological conditions. Diffusion-weighted MRI is valuable in the diagnosis of cholesteatoma and its combination with CT scanning, according to one report, has reduced the rate of second look operations from 62% to less than 10%. The specificity and sensitivity of this technique in the diagnosis of petrous bone cholesteatomas is 84% and 87% respectively. It has been found to be very accurate in the prediction of facial nerve course in the temporal bone. There are also applications of diffusion-weighted magnetic resonance imaging in head and neck cancer. It has a sensitivity and specificity of 98% and 88% respectively in distinguishing between malignant and benign lymph nodes, the apparent diffusion coefficients being higher in the former and also in poorly differentiated cancers where a technique also allows differentiation between post-treatment tissue changes and tumour recurrence with a sensitivity and specificity at 84% and 90% respectively. There are fewer false positives than in PET. However, the diagnosis of head and neck abscess has an accuracy of only 50% and the technique is not particularly useful in salivary gland tumours. This is, indeed, a useful development, possibly saving unnecessary surgery in chronic ear problems or suspected but unconfirmed cancer recurrence.
Diffusion-weighted magnetic resonance imaging: its uses in otolaryngology.
Doshi J, Jindal M, Chavda S, Irving R, Dee R.
JOURNAL OF LARYNGOLOGY AND OTOLOGY 2009;121:1199-1203.
Systematic review comparing the treatment outcomes between laser resection and radiotherapy in the cases of early glottic cancer
Reviewed by: Anurag Jain
Jul/Aug 2010 (Vol 19 No 3)
Early glottic cancer (T1, T2) constitutes around 75% of all cases of laryngeal cancers and carries a good prognosis because of early symptoms and low risk of lymphatic spread. Transoral endolaryngeal surgery (TOL), radiotherapy and partial laryngectomy are all accepted treatments for early glottic cancer, however there is some controversy regarding the best treatment. This is currently decided by a multidisciplinary team and is guided by patient choice. Although there is some evidence in the literature which compares the treatment outcomes, following these treatment modalities, no systematic review has been performed comparing radiotherapy with TOL. In this study the authors have performed a systematic review, comparing the treatment outcomes for early glottic cancers (T1, T2) using local disease control, overall survival, laryngectomy-free survival and post treatment voice quality as the main outcome measures. Using two different reviewers and the a priori criteria for inclusion, 26 eligible retrospective studies were identified. These constituted a total of 7,676 patients with 2,571 treated with TOL and 5,105 with radiotherapy. This review found no significant difference between the two treatment modalities, for local control and laryngectomy-free survival but did favour TOL surgery for overall survival. There was no objective difference in voice quality following these two treatment modalities; however there was a trend towards superiority for radiotherapy. There are a few flaws in the included studies which have been acknowledged by the authors. Finally, other factors, such as patient wishes and convenience, duration of treatment, cost and the possibly of recurrent disease, should be carefully considered before making a final decision regarding which choice of treatment.
Virtual Endoscopy: our next major investigative modality?
Reviewed by: Anurag Jain
Jul/Aug 2010 (Vol 19 No 3)
In this article the authors have highlighted virtual endoscopy (VE) and its role as an investigative tool in nasal and paranasal sinus conditions. It has already displayed endoluminal pathology in the colon, trachea, bronchial tree, blood vessels and so on. The raw data acquired from helical computed tomography is post-processed, using a volume rendering technique, which allows dynamic navigation within a lumen using a fly-through feature. Although the role of VE is promising, especially in planning surgery and for teaching purposes, it has its own disadvantages. Although the authors have referred to it as a, 'non-invasive imaging tool', it does involve radiation exposure to the patient and hence is invasive. Since, by the time a patient undergoes a CT scan, they would have already undergone diagnostic nasal endoscopy in the clinic, the role of VE in providing any extra diagnostic information to the surgeon is debatable, especially given its limitations in providing the images in greyscales and its inability to differentiate secretions from soft tissue mass. Furthermore, proper training requirement of ENT surgeons in using this technique and infrastructure and cost requirement may limit its use.
Topographic organisation of auditory cortex not as straightforward as we thought
Reviewed by: Rebecca Heywood
Jul/Aug 2010 (Vol 19 No 3)
The widely accepted concept of tonotopic organisation of the auditory cortex is founded on experiments carried out with techniques with poor spatial resolution. In this study two-photon Ca2+ imaging of functional responses in the mouse auditory cortex was used to image single cells and thereby acquire a high resolution picture of neuron to neuron organisation. Fluorescent dyes sensitive to changes in calcium concentration and thus neuronal activity were injected in to the auditory cortex of anaesthetised mice. Pure tones of different frequencies and broadband noise of varying intensities were presented. Subthreshold stimuli, depolarisation spikes and inhibitory responses were detectable and so mean change in fluorescence of a cell from the baseline over all time frames during the stimulation period was calculated. Individual cells responded to a specific frequency maximally (characteristic frequency). They were also shown to have a 'best intensity'. Although gross tonotopic organisation was illustrated, there was local heterogeneity in the tones represented among neighbouring individual cells. Topographic mapping in response to intensity was not demonstrated. Clusters of neurons were noted to respond at subthreshold level to a specific sound though only some cells within the cluster depolarised. Therefore it seems that while many cells receive the same input their outputs vary widely, affording rapid adaptation in response to variations in the acoustic environment. The authors point out several limitations of the study; mean change in fluorescence does not account for timing of individual depolarisation spikes, which may also convey information about the stimulus. Furthermore, the degree of tonotopic and intensity representation depends on the depth of anaesthesia of experimental animals as well as differences between species. Nevertheless this study sheds new light on the function of the auditory cortex and opens avenues for further research.
'Q-tip': an easy solution to retraction in endonasal endoscopic surgery
Reviewed by: Gauri Mankekar
Jul/Aug 2010 (Vol 19 No 3)
The use of retractors during surgery is very important. However, it is difficult to use retractors during an endonasal endoscopic approach through the restricted nostril passages. The ideal retractor, used during endoscopic endonasal procedures, should be thin, should not block the minimal nasal space, should be long enough to reach the cranial base and smooth enough to avoid tissue damage. The authors describe a practical alternative, the 'Q-tip' retractor, for endonasal retraction. The Q tip retractor offers an easy, low cost solution, is freely available and is effective in retracting or protecting neurovascular tissue, that descends into the operating field. The authors have provided additional information about surgical technique using the Q tip and suggest that it may take a little practice to get used to these simple retractors!
Endoscopic craniocervical decompression
Reviewed by: Showkat Mirza
Jul/Aug 2010 (Vol 19 No 3)
This paper from the renowned Pittsburgh Group is an anatomic study evaluating the surgical access to the craniocervical junction using three endoscopic approaches: endonasal, transoral and transcervical. Adequate lower clivus and craniocervical decompression was achieved using the endonasal and transoral approaches but not with the transcervical approach. In the transnasal approach it can be difficult to remove the odontoid in cases in which the C1-C2 junction is below the horizontal level of the hard palate but the authors found that the base of the odontoid can be below the hard palate as long as a tangential line from the inferior aspect of the nasal bone to within 3 to 5mm from the base of the surgical resection does not cross the posterior hard palate. The 3 to 5mm excess is possible by the use of an angled drill. An interesting discussion and comments are given including the reduced morbidity such as velopharyngeal insufficiency with the transnasal approach. An article of interest to those specialising in anterior skull base surgery.
Fluorescein to identify vital structures during mastoidectomy
Reviewed by: Gauri Mankekar
Jul/Aug 2010 (Vol 19 No 3)
Risk of facial nerve injury is the biggest challenge of mastoid surgery. This article, written by neurosurgeons, describes a novel technique to identify the facial nerve and semicircular canals during mastoid surgery. The authors cannulated the major neck vessels in four cadavers. Then the mastoid cortex was removed and indocyanine green was injected into the vessels. The sigmoid sinus, facial nerve and semicircular canals were skeletonised, using drilling guidance provided by the fluorescence. As the mucosa is well vascularised, it shines after the injection of indocyanine, while the bone, which is not vascularised, does not shine. Thus, the fluorescence guides the drilling, displaying air cells which are safe to remove. However, during live surgery, the dye may get washed out before the surgeon reaches the vital areas, while in the presence of inflammation or tumour invasion, the mucosa will enhance more and make identification of facial nerve and the canals easier. The authors have recommended this technique to residents in training.
Infratemporal fossa tumour removal with endoscope
Reviewed by: Gauri Mankekar
Jul/Aug 2010 (Vol 19 No 3)
The authors have described endoscopic exposure of the infratemporal fossa, by combining endonasal and Caldwell-Luc approaches, in four formalin fixed cadavers. Complementing this cadaver study, they describe the use of this approach in a patient for resection of a trigeminal schwannoma, in the infratemporal fossa. Due to the complex anatomy of the infratemporal fossa, the authors suggest a step-wise progression. In the first stage, they performed endonasal transmaxillary exposure and in the second stage, they performed endonasal transmaxillary exposure via the Caldwell-Luc approach. The lateral limits of their exposure were the ramus of the mandible; the osseous skull base and foramen ovale superiorly and the distal upper cervical internal carotid artery posteriorly. The authors recommend this less invasive approach in the surgical management of juvenile nasopharyngeal angiofibromas, trigeminal schwannomas with extra-cranial extension and biopsy of malignant lesions in the infratemporal fossa. This requires both an endoscopic sinus surgeon and a neurosurgeon with cranial base oncology experience as part of a multi-disciplinary team. Soon we may not need an external approach for most infratemporal fossa tumours!
Transsphenoidal ultrasound for residual tumour diagnosis
Reviewed by: Gauri Mankekar
Jul/Aug 2010 (Vol 19 No 3)
Residual tumour masses are common after trans-sphenoidal surgery. This article describes real time identification of the amount of tumour removed in transsphenoidal surgery, with the help of ultrasound. The authors performed intrasphenoidal and intrasellar ultrasound during trans-sphenoidal surgery in nine patients with pituitary microadenomas, to identify residual tumour masses. They used small, side-looking, high frequency, ultrasound probes with long probe tip, measuring 3x4mm, to identify important neurovascular structures and for resection control and identification of normal pituitary tissue. The authors believe that image resolution of ultrasound is far superior to what can be achieved with current clinical MRI technology, although there is a significant learning curve. Interpreting ultrasound images is different from axial, saggital and coronal views of the sella, as seen on MRI. Also, in comparison to MRI, the time taken for intra-operative ultrasound is shorter and it is easier to bring ultrasound into the operating theatre than to build MRI equipped operating theatres. They conclude that small, intrasellar, ultrasound probes can be further improved to become a flexible tool in trans-sphenoidal surgery.
Head-neck vascular anatomy and its variants
Reviewed by: Gauri Mankekar
Jul/Aug 2010 (Vol 19 No 3)
In this article, the authors have described the normal anatomic features and common and uncommon vascular variants that may affect cross-sectional image analysis and angiographic diagnosis of the 'vascular highway' beginning with the origins of the great vessels at the aortic arch and extending through the skull base. Amongst several cases innumerated, the authors describe the case of a five year old child with nine days' post tonsillectomy massive oral bleeding. His CCA arteriogram revealed a pseudoaneurysm of the superior thyroid artery with a contrast collection in the inferior aspect of the operative bed. The pseudoaneurysm was successfully embolised with n-butyl cyanoacrylate. They conclude that understanding normal and variant vascular head-neck anatomy is critical for accurate diagnosis and development of safe and effective treatment strategies. Localisation, anticipation of vascular supply and knowledge of potential collaterals and dangerous anastomoses are important precursors to patient management.
Paediatric otoplasty
Reviewed by: Susan A Douglas
Jul/Aug 2010 (Vol 19 No 3)
This article examines the various techniques used in otoplasty. The authors describe the difficulties that patients experience including ridicule, which may lead to social phobias. Protruding ears are commonly due to an underdeveloped antihelical fold (two thirds of cases) or an excessive amount of conchal bowl cartilage (one third of cases). The article describes the preoperative assessment, including measurements taken from the helical rim to the scalp and mastoid, which are compared with the other side. The goal of surgery is to produce the ideal auriculocephalic distances described. The authors provide excellent photographs and diagrams of the surgical technique. This involves excision of post auricular skin and soft tissue excision, as well as the Furnas suture-only technique for conchal bowl setback. They also describe the use of Mustarde sutures to correct the antihelical fold. The early complications of the procedure include haematoma formation, cellulitis, perichondritis or necrosis of the cutaneous flap. The late complications include keloid formation, suture extrusion, post auricular webbing and a poor cosmetic result. This is a well-written article but there is little detail given to the cartilage scoring techniques.
Paediatric otoplasty.
Ambro BT, Lebeau J.
OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY, HEAD AND NECK SURGERY 2009;20:206-9.
The future for intranasal medications
Reviewed by: James Barraclough
Jul/Aug 2010 (Vol 19 No 3)
This interesting article describes the current research that is progressing to develop ways that intranasal medications can be better delivered to penetrate the nasal mucosa. The authors describe that there is little evidence that low volume devices deliver medications well into paranasal sinuses especially before surgical intervention. They go on to illustrate ways that medications can better penetrate the nasal mucus which forms a barrier. Mucoadhesive particles, mucus penetrating particles and mucoactive particles (surfactants) may increase drug delivery. This may be aided by mucociliary clearance and not only steroids but targeted antimicrobials, anti-inflammatories may be developed with these new agents to improve mucosal absorption. No patient data is given for specific medications but this is clearly a developing field.
Dehiscent canals again
Reviewed by: Liam M Flood
Jul/Aug 2010 (Vol 19 No 3)
That diagnosis of Superior Semicircular Canal Dehiscence (SSCD) continues to appear in new guises in the literature. Autophony, the disturbing perception that one's own voice is too loud, is often attributed to Eustachian Tube Dysfunction, recruiting deafness, especially secondary to hydrops, or, all too often, a psychological disturbance in the sufferer. It is however increasingly recognised as yet another manifestation of this flourishing diagnosis of SCCD. As recently as 1998 this was first reported; now few otology journals lack another case series in each issue. We all know about the imbalance, the sound induced vertigo, the spurious air bone gap, hearing one's own pulse or even one's eyeballs moving! These authors have derived an autophony index; a five item scale based on the Tinnitus Reaction Questionnaire (TRQ9) and applied it, with the SF-36 Health Survey, to 19 patients with SCCD. The survey was conducted pre and three months after canal repair. All but one had autophony before surgery. Thirteen sufferers showed complete and immediate relief post operation. One apparent failure was due to persisting contralateral SCCD and one actually showed worsening, ultimately attributed to a patulous Eustachian tube. The scanners will be swamped to catch up with decades of missed diagnosis one fears!
Long-term hearing preservation during watchful waiting of small acoustic neuromas
Reviewed by: Rebecca Heywood
Jul/Aug 2010 (Vol 19 No 3)
Opinion varies widely on the optimal management of vestibular schwannoma, with a greater tendency to operate on small tumours in the USA than in the UK, where a watchful waiting policy is more frequently adopted. In order that surgery on a small tumour is successful, hearing outcome after surgery should be superior to that following conservative management. This study aims to assess the long-term hearing results after a period of watchful waiting. All patients registered in the Danish national database for unilateral vestibular schwannoma, who were managed by a 'wait and scan' policy over a 33 year period, were included. Nearly all patients had a small tumour (_20mm). Nine hundred and thirty-two patients, with at least two complete pure tone and speech audiograms available, were included in the study and followed up for at least five years in 40% and 10 years in 11% of patients. Of those with 100% speech discrimination at diagnosis, 87% maintained good hearing (speech discrimination _70%). In 59% of patients the AAO-HNS class of hearing was unchanged from diagnosis, during the observation period. The general trend illustrated is that, the better the speech discrimination at diagnosis, the smaller the magnitude and the slower the rate of decline in hearing with watchful waiting. The overall rate of hearing preservation was comparable to that of surgery. This study, hence, supports selection of patients with good speech discrimination at the time of diagnosis for a watchful waiting approach, as it is likely they will maintain good hearing spontaneously.
Long-term hearing preservation in vestibular schwannoma.
Stangerup SE, Thomsen J, Tos M, Caye-Thomasen P.
OTOLOGY & NEUROTOLOGY 2010;31:271-5.
Resin temporal bones for surgical training
Reviewed by: Rebecca Heywood
Jul/Aug 2010 (Vol 19 No 3)
It would seem that French ENT trainees are also afflicted with increasingly limited opportunity to dissect cadaveric temporal bones and reduced surgical exposure time. Surgical simulation is becoming more commonplace. This group describes the development of resin temporal bones, made by rapid prototyping (RP). This is a technique widely used in manufacturing, whereby a machine constructs a physical object in multiple layers, by reading a computerised image; in this case HRCT scans of seven cadaveric temporal bones. Coloured acrylic was injected into the models to aid identification of landmarks during dissection. The technique was validated by comparing positional relationships between structures in the prototypes with the cadaveric temporal bones on CT and during anatomical dissection. No statistically significant difference was found in dimensions, though there were problems relating to seepage of coloured acrylic, imprecise representation of ossicles and permeability of small cavities. There is no mention of cost. This technique may be useful for preoperative simulation of surgery for challenging cases. The authors comment that the texture of the resin during drilling was comparable to that of cadaveric temporal bones, but the resistance of the bone was lower. Pettigrew plastic temporal bones, well known to many UK trainees, are often criticised for having a different 'feel' to a real bone and are felt to be useful for learning anatomy, but are not a replacement for cadaveric temporal bones. By the end of this paper I decided that RP resin bones also have a long way to go!
Vascular loops and hearing loss
Reviewed by: Liam M Flood
Jul/Aug 2010 (Vol 19 No 3)
This is a retrospective study of 58 MRI scans, prompted by asymmetric sensorineural hearing loss. It seeks a correlation between vascular loops of the Anterior Inferior Cerebellar Artery (AICA) and ipsilateral deafness / tinnitus. Loops are all too common, but their significance is determined by either the degree of penetration into the Internal Auditory Canal (IAC) or the proximity to the vestibulocochlear nerve. In the former system, the Chavda Classification, loops are graded from Type I (not entering the IAC) to Type III (extending more than half the length of the IAC). The second grading scale looks more at what the vessel loop is actually doing, that is the degree of contact with the nerve bundle, as A-D. Category A is no contact, B is adjacent, C is a loop passing between the facial and VIII nerve and D is contact displacing the nerve. Type I loops, those never entering the canal, were seen in 83% of symptomatic and 76% of asymptomatic ears. Type II, entering the canal only superficially, appeared in 17 and 21% respectively. Type III loops, extending to the lateral end of the IAC, were only found in symptomatic ears (3%). It hardly takes statistical analysis to show that there is no relationship here. Similar results emerged, looking at degree of compression, even with the most extreme, Type D loops, actually displacing the nerves. Class C, the loop passing between VII and VIII, did show a statistically significant association with hearing loss (31% of symptomatic and 15% of asymptomatic ears). Mind you, if you study enough variables, something will eventually crop up, by chance. That is how p values work! Neurosurgical enthusiasm to treat trigeminal neuralgia or hemifacial spasm associated with vascular loops has not yet extended to treatment of hearing loss. This is a small low-powered study but it adds to the often contradictory literature that largely fails to show any association between AICA loops and vestibulocochlear symptoms.
'X' marks the spot
Reviewed by: Carl Philpott
Jul/Aug 2010 (Vol 19 No 3)
As any rhinologist would tell you, the key to reducing the chance of recurrence, when excising an inverted papilloma, is determined by finding the origin of the lesion and clearing the site of any residual cells. Therefore, anything which helps to identify this pre-operatively and to plan the procedure (especially where open techniques might be required) is clearly welcome. Enter the 'osteitis sign'. The authors have looked at the coronal reformats (1mm slices) of CT scans of 24 patients diagnosed histologically with inverted papilloma and correlated this with the intra-operative findings. The degree of osteitis seen in the scans was graded as subtle, intermediate or obvious, with intermediate being the baseline reference. There was some apparent blinding in the assessment, although this was not entirely clear from the paper. In three cases there was no obvious osteitis sign, but in the remainder there were seven obvious, 10 intermediate and four subtle cases with correlation to the origin surgically in all but one case (95%). The authors claim to have not performed any revisions or additional procedures on these patients, based on using this sign to plan the surgery. Clearly, individuals involved with managing these tumours need to become familiar with recognising these signs and test the correlation for themselves. The authors have recommended window settings of W = +1800 and C = +350. Maybe a discussion point for your next radiology meeting?
Predicting the site of attachment of sinonasal inverted papilloma.
Bhalla RK, Wright ED.
RHINOLOGY 2009;47:345-8.
The advance of the balloon in the management of sinus disease
Reviewed by: Carl Philpott
Jul/Aug 2010 (Vol 19 No 3)
The use of balloon catheters in sinus surgery is an up and coming interventional technique which is gaining increasing popularity and has made the transition from a procedure requiring fluoroscopic guidance to one that can now be performed in the outpatient clinic. There is clearly an issue of correct patient selection here and, in this study, the authors have chosen to use this new technology on a patient presenting with acute frontal sinusitis. Although this is a simple case report of one patient with acute frontal sinusitis, it does draw attention to the procedure, which only the passage of time and reporting of long-term cases series will accept or refute as a viable alternative to conventional endoscopic techniques, given the varied and sometimes complex anatomy of the frontal recess.
Turbinate grafts for CSF leak repairs
Reviewed by: Carl Philpott
Jul/Aug 2010 (Vol 19 No 3)
This paper reports the combined results of a Brazilian-Italian collaboration, over 10 years, where 125 cases of CSF leaks were repaired using an inferior turbinate graft as an overlay technique. The description of the technique in this paper appeared a little brief, with no diagrammatic or photographic representation of the procedure itself. Nonetheless, they report a success rate of 94% at first attempt. The failures appeared to be patients with high BMIs and / or diabetes and three of them occurred within three days of the procedure, the others leaking after several months. Most of the defects repaired were less than 2cm in size and were due to spontaneous, iatrogenic or traumatic causes. Interestingly, the delayed leak recurrences were repaired using an underlay technique. Whilst there are a number of different techniques described for repairing CSF leaks, this one certainly represents a viable option with sufficient exposure and training in the technique.
Endoscopic treatment of cerebrospinal fluid leaks with the use of lower turbinate grafts: a retrospective review of 125 cases.
Cassano M, Felippu A.
RHINOLOGY 2009;47:362-8.
Current concepts in face-lift operation
Reviewed by: Mrinal Supriya
Jul/Aug 2010 (Vol 19 No 3)
This is an excellent article, written by an experienced plastic surgical team, involved in carrying out facial cosmetic surgery. In the tradition of ‘how we do it’, this article describes the ‘composite face-lift technique’ which is a deep-plane musculocutaneous flap lift. This differs from conventional deep-plane face lift in providing a superior-medial vector of pull (as opposed to superior-lateral) and involves arcus marginalis release and septal reset. The authors feel that these two distinguishing features result in a more harmonious appearance, without giving an obvious surgical appearance. Rather than discussing the basic details of face lift surgery, this article is geared towards more advanced complex techniques. It states the indications, technique and postoperative care of this procedure and would be of interest to any surgeon who is involved in carrying out facial cosmetic surgery. The illustrations accompanying the text are excellent – the postoperative outcome is truly remarkable! Sceptics are welcome to see the amazing impact this surgery can have on the facial appearance and this paper underscores the skill and experience of the authors (even after accounting for the likelihood that these pictures are probably ‘best outcome’ cases). Though brief, the descriptions are explanatory enough for easy incorporation by someone who is well conversant with traditional face-lift surgery. This edition of this respected journal further highlights the ongoing refinement of facial cosmetic surgery and would be of interest to surgeons practising in this field.
Aiding a decision for excision: quality of life outcomes and vestibular schwannoma surgery
Reviewed by: Andy Hall
Jul/Aug 2010 (Vol 19 No 3)
The management of vestibular schwannoma is now increasingly focused on exploring outcomes related to the patient's perspective of his/her treatment. This prospective observational study uses quality of life assessment tools to directly compare conservative management with microsurgical excision in those with a new diagnosis of vestibular schwannoma, at a single tertiary centre. An assessment of the quality of life of 18 'wait and scan' patients was compared with 17 patients who opted for microsurgical excision of their vestibular schwannoma. The SF-36 and Glasgow Benefit Inventory (GBI) were used at baseline and one month, three months and six month periods. Overall, there was no significant difference in overall quality of life alteration (GBI total score) between microsurgery and conservative management. The authors do, however, note an improved overall quality of life score of patients at six months after microsurgery (relative to their pre-operative score) as a new finding of their research. They, sensibly, temper this with the acknowledgement of the lack of randomisation and the inevitable bias this may cause within their small sample. The study is an interesting step in the right direction to evaluate this issue, but without the patient size and follow-up length to influence meaningful change in practice.
Ménière’s disease: a well known theory refuted?
Reviewed by: Victoria Possamai
May/Jun 2010 (Vol 19 No 2)
In 1968 Shucknecht proposed that episodes of vertigo were caused by ruptures of Reissner's membrane caused by raised endolymph pressure. The subsequent mixing of potassium rich endolymph and perilymph causing paralysis of afferent nerve activity. The authors of this paper suggest that if this were indeed the pathological process occurring, a significant deterioration in hearing should be expected during an attack, as cochlear as well as vestibular function would be affected. Patients with Ménière’s disease (+ EcochG and 'definite Ménière’s' in AAOHNS scale) were fitted with a hearing aid system allowing them to measure their own hearing thresholds. They were asked to do this three times a day for eight weeks, and to try to record their hearing thresholds during an attack of vertigo. Six patients were able to achieve this. The audiograms recorded did not show any evidence of deterioration in thresholds during an attack. The authors conclude that these findings do not support the 'rupture theory', suggesting that alternative theories need to be considered and developed.
Topical mitomycin C (MC) and 5-fluorouracil (5FU) prolong myringotomy patency
Reviewed by: Victoria Possamai
May/Jun 2010 (Vol 19 No 2)
Incisional myringotomies without tube placement heal within several days. If it were possible to increase this time to several weeks this may be adequate to treat serous otitis media and negate the need for ventilation tubes. There have been several animal studies finding that MC and 5FU delay myringotomy healing. This is the first study to compare the two agents. Radiofrequency assisted myringotomies were carried out bilaterally on 40 rats. Gelfoam soaked in the test solution (20 x MC, 20 x 5FU) was then applied topically for 10 minutes to the right ear, whilst saline soaked gelfoam was applied to the left side. Mean patency time was 4.85 weeks in the MC group, 3.90 weeks in the 5FU group and 1.30 weeks in the controls. The difference between both treatment groups and controls is statistically significant, but not that marked between the two treatment groups. Otorrhea developed in a significant proportion of treatment group ears (15-20%) and there is concern about the possible ototoxic effects of these agents. The authors therefore state that further testing is needed before considering the use of these agents in human ears.
A safe long term treatment for allergy
Reviewed by: Badr Eldin Mostafa
May/Jun 2010 (Vol 19 No 2)
The daily question physicians are asked by their allergy patients: is long-term treatment safe? This seems a very pertinent question. This was a multicentre, parallel-group, double-blind, double-dummy, randomised study. It included 1,095 subjects with documented history of seasonal AR and positive skin-prick test to a prevailing aeroallergen. They were treated for 15 days with fixed-dose combination loratadine/montelukast, pseudoephedrine, or placebo. The change in quality of life from baseline nighttime and daytime nasal congestion and peak nasal inspiratory flow were assessed. L/M and PSE were significantly more effective than placebo. There were no significant differences between L/M and PSE for any efficacy analysis including improvement in the quality of life. Subjects treated with L/M experienced a similar incidence of total adverse events versus placebo and a lower incidence of total adverse events versus PSE. Nasal decongestant activity of L/M was significantly higher than that of placebo and similar to that of PSE in symptomatic AR subjects. These findings are quite interesting as the safety profile of both loratadine and montelukast are far better than pseudoephedrine and have fewer contraindications and precautions of use.
D and D
Reviewed by: Badr Eldin Mostafa
May/Jun 2010 (Vol 19 No 2)
Patients with dementia develop dysphagia some time during the clinical course of their disease. However the pattern of dysphagia differs between the different causes of dementia. In patients with Alzheimer disease (AD) impairment was more in oral transit delay whereas patients with vascular dementia (VaD) showed more deficits in bolus formation and mastication of semisolid food, epiglottic inversion, and silent aspiration. These results could indicate that the swallowing disorders of the AD group may result from sensory impairment in relation to dysfunctions in the temporoparietal areas, whereas the swallowing disorders of VaD group may primarily be caused by motor impairments due to disruptions in the corticobulbar tract. This is an important study as it may guide further therapeutic and rehabilitative manoeuvres in order to improve the nutritional status of the patients and prevent pulmonary complications from silent aspiration.
Nasal sprays get into the middle meatus better after FESS
Reviewed by: Edward W Fisher
May/Jun 2010 (Vol 19 No 2)
This study proves something that was taken to be self-evident, but is nonetheless helpful to have proven by science. Forty nasal cavities were studied in patients about to have FESS and the delivery to the middle meatus of a nasal steroid spray was judged by placing a neurosurgical patty in the middle meatus and examining it after drug delivery. The rise in drug administration was statistically significant and likely to be clinically significant. This is encouraging for those who have always believed that this was part of the benefit of FESS to control rhinosinusitis.
Beware cervical osteophytes
Reviewed by: Joanne Rimmer
May/Jun 2010 (Vol 19 No 2)
This is a case report highlighting the dangers of cervical osteophytes, particularly in cases of diffuse idiopathic skeletal hyperostosis (DISH). An 84-year-old man presented with progressive dysphagia, and examination revealed a midline mass of the posterior pharyngeal wall that partially restricted right vocal fold movement. A CT scan showed large anterior cervical osteophytes but also noted a 4cm hypopharyngeal mass within the pyriform sinuses and in contact with the right arytenoid. Biopsies were taken during an uneventful endoscopy, and showed only polypoid squamous mucosa (it was eventually felt to be a reactive soft tissue mass secondary to osteophytes). However, the patient represented one week later with moderate airway distress, and was found to have significant oedema and granulation tissue at the biopsy site, with bilateral vocal cord paresis. He required a tracheostomy, and several weeks later underwent resection of the osteophytes by the neurosurgeons via an anterolateral transcervical approach. The discussion centres on the causes of airway compromise in such patients, and recommends a combined surgical team approach to such cases. Perhaps they should also warn of the dangers of biopsy as a precipitating factor for acute airway compromise?
From BAHA to cochlear implant
Reviewed by: Joanne Rimmer
May/Jun 2010 (Vol 19 No 2)
Bone-anchored hearing aids (BAHA) can be useful in aiding patients with predominantly conductive hearing loss, and are sometimes used in single-sided deafness. Their application in mixed hearing loss is also documented, and it was this application that is addressed in this review. Specifically, the authors wanted to see what cut-off point there might be for BAHA use, and when to consider changing to a cochlear implant. The five patients, reviewed retrospectively, had all been fitted with a BAHA. The authors report this initially closed the air-bone gap almost completely in all patients, and even seemed to have an effect on the sensorineural component of their hearing loss. With further deterioration of that component, however, the BAHA became ineffective and the patients all underwent cochlear implantation. The authors feel that an implant is indicated when the mean sensorineural loss is 70dB HL or greater, or when the speech recognition score at 65dB SPL with a BAHA is less than 40%. Whilst their numbers are small, it is interesting that patients with otosclerosis may do less well with a cochlear implant than those with other causes of hearing loss, perhaps due to cochlear involvement. Perhaps the key message is that the presence of a BAHA does not preclude implantation in the future if the hearing loss changes with time.
Yet another tonsillectomy method...
Reviewed by: Joanne Rimmer
May/Jun 2010 (Vol 19 No 2)
Another journal edition, another method of taking out tonsils! This time it is the turn of microdebrider intracapsular tonsillectomy, which is being compared with monopolar diathermy. Apparently the microdebrider has been shown to reduce postoperative pain, recovery time and haemorrhage. This study aimed to refute claims that microdebrider intracapsular tonsillectomy has a higher intraoperative blood loss. A prospective study was carried out and included 57 children who underwent intracapsular tonsillectomy and 51 patients who had diathermy tonsillectomy. Intraoperative blood loss was measured. There was a statistically significant difference, with greater blood loss in the microdebrider group. The authors do not feel this difference is clinically significant (based on total blood loss), and in fact give various reasons for the apparent exaggeration of blood loss in the microdebrider group. Their conclusion is that we should not be discouraged from using this technique based on the amount of intraoperative blood loss. I am sure there are many reasons why surgeons would be wary of using this technique, and I am afraid that their study does little to change this.
If you haven't had a CSF leak yet...
Reviewed by: Neil C Molony
May/Jun 2010 (Vol 19 No 2)
This is a useful study and I think very honest. It reviews 14 years of endoscopic sinus surgery looking for patterns and causes of cerebro-spinal fluid leaks needing surgical repair. One hundred and forty-four of 6,908 cases had CSF leaks, but of these 92 were spontaneous or in cancer resections, and 20, of the iatrogenic 52 from non-tumour surgery, were not the department's own cases. They were hence not possible to analyse, retrospectively, from the notes for finding 'faults'. This left 32 patients, and, of these, in two thirds of cases the leak was apparent at initial surgery. Leaks were commoner when operating on the right, the harder side to access when operating right-handedly. The commonest site was the root of the middle turbinate, in the anterior ethmoid region, and senior trainees who had already performed over 100 FESS procedures had the highest rate of leaks(14 of the 32); a 'learning curve' effect perhaps reflecting becoming more daring with growing experience, before sufficiently knowing one's limits! Frontal sinus aditus leaks (five of 32) were generally seen with the most senior surgeons, who are more likely to undertake these cases, but may not be 'scared enough' when operating in this area. Repairs were mainly with mucoperiosteum and glue, though four of 32 needed a second repair, one requiring an external approach. The message? Respect the learning curve effect as you become more familiar with a technique, always respect the frontal area, and watch for any leak, as immediate repair is preferable.
Wide dilution steps for threshold testing
Reviewed by: Carl Philpott
May/Jun 2010 (Vol 19 No 2)
Threshold testing has already been shown to be the most sensitive form of olfactory testing and both phenethyl alcohol and 1-butanol have been utilised in existing commercially available smell test kits such as Sniffin' Sticks. This study sets out to compare the two odours and test whether using small or large dilution steps makes a difference to the results achieved. Using 116 subjects with a ratio of 3 normosmic to 1 hyposmic patients, the authors showed that there was no significant difference in the results achieved with the two odours in either group of patients, that is they could still be distinguished. Further to this, the wider dilution step showed that the test could be completed 25-30% faster in the pathological group. This would clearly suggest that having wide dilution steps in either odour is the way forward in olfactory threshold testing.
Can cochlear implantation leave intact otoacoustic emissions in 'auditory neuropathy'?
Reviewed by: Thomas Nikolopoulos
May/Jun 2010 (Vol 19 No 2)
The so called 'auditory neuropathy' is characterised by the presence of otoacoustic emissions and / or cochlear microphonics suggesting normal outer hair cell function in conjunction with absent or grossly abnormal auditory brainstem responses. This disease is often associated with particularly poor response to amplification and poor speech discrimination is not rare. Cochlear implantation has been shown to be an option in affected patients. However, cochlear implantation is supposed to affect the outer hair cell function and abolish otoacoustic emissions. This paper reports a case of successful cochlear implantation and preserved otoacoustic emissions in a child suffering from 'auditory neuropathy'. Although the paper is not very clear and some important details are missing, and the 'hearing preservation' technique was not used in this case, the concept of preserving otoacoustic emissions following cochlear implantation in cases with 'auditory neuropathy' is very interesting.
Can we convert Bamford, Kowal and Bench (BKB) sentences to Arthur Boothroyd (AB) words in quiet and vice versa in cochlear implant patients?
Reviewed by: Thomas Nikolopoulos
May/Jun 2010 (Vol 19 No 2)
This paper describes the relationship between the scores obtained in the Bamford, Kowal and Bench (BKB) sentence test and the Arthur Boothroyd (AB) word test in quiet for a group of 71 cochlear implant users. Each subject was tested at the same appointment and in the same environment during routine clinical appointments at the South of England Cochlear Implant Centre. Using rationalised arcsine transformation and a linear regression calculation, conversion tables were produced from BKB to AB and from AB to BKB scores. The relationship between scores obtained from the two tests was highly significant. Although the statistics were in favour of the close relationship of these two tests and the conversion tables may be of use in cochlear implant centres and by audiologists, there are several issues that should be taken into account. For example a 9% score on AB word test relates to 48% on BKB sentences and 80% on AB word test relates to 100% on BKB sentences, as the authors make it clear in the discussion. Moreover, floor and ceiling effects are also important. It seems that such conversions (from one test to another), although feasible, may be invalid if the differences of these tests and what exactly they measure are not taken into account.
Cochlear implantation in children with keratitis-ichthyosis-deafness (KID) syndrome:benefits and risks
Reviewed by: Thomas Nikolopoulos
May/Jun 2010 (Vol 19 No 2)
Keratitis-ichthyosis-deafness (KID) syndrome is a rare syndrome, associated with mutation of the connexin-26 gene, affecting skin, hair, vision and hearing. The ichthyotic involvement of the ear canal epithelium and the associated non-erosive keratosis obturans complicate hearing assessment and aid fitting. The tendency to eczematous dermatitis and otitis media is an additional problem with cochlear implantation. The authors implanted three children with (KID) syndrome. The open-set outcomes were satisfactory. However, they faced several problems with regard to otitis externa and otitis media. All cases required additional medical or surgical management. The authors suggest that cochlear implantation can be effective in these patients. However, there is no long follow-up in these three cases. Parents should be prepared for the risks and the significant additional problems that should be managed in special centres with very close follow-up.
Implantable hearing devices. Can multifrequency tympanometry assess the middle ear mechanics?
Reviewed by: Thomas Nikolopoulos
May/Jun 2010 (Vol 19 No 2)
The authors used multifrequency tympanometry to assess middle ear mechanics after implantation of two types of implantable hearing aids. A total of 34 patients were included in the investigation; 19 of them were fitted with the Otologics system and 15 with the MED-EL Vibrant Soundbridge system. With the Otologics recipients, measurements were made preoperatively and both two months and at least 12 months postoperatively. Measurements involving the MED-EL patients were taken at least 12 months postoperatively. For all measurements, the non-implanted contralateral side was used as a control. Preoperatively, the resonance frequency of the Otologics patients was 904.3±218.2Hz for the implanted side and 907.1±161.8Hz for the non-implanted side. Postoperatively, a significant increase (p<0.01) compared with the preoperative value and the control side was observed after two months: 1111.3±234.7Hz, as opposed to 823.8±274.5Hz on the contralateral side. After 12 months, the resonance point was restored to approximately the preoperatively measured values: 975±55.3Hz (implanted side) and 901.3±207.1 (control side). The resonance frequency in the Symphonix patients, as measured after at least 12 months (on average, 35 months), was 1006.3±269.5Hz on the non-implanted side and 900.1±249.3Hz on the implanted side. The authors suggest that the resonance frequency on the implanted side was higher than on the control side. However, the difference was not statistically significant. Finally, the authors recommend monitoring following the implantation of active hearing systems in order that conclusions can be drawn regarding the adequacy of the coupling of the actuation driver to the ossicular chain. However, the post-operative changes in the middle ear cannot be excluded in the first follow-up intervals as the reason for resonance frequency change and the long-term intervals did not show any significant changes.
New approach to cochlear implantation. Keyhole surgery?
Reviewed by: Thomas Nikolopoulos
May/Jun 2010 (Vol 19 No 2)
The authors following the general trend for minimally invasive surgical approaches propose a limited access 'keyhole' cochlear implantation (CI) surgical technique. The surgery employs a 15-18mm diameter C-incision on the rear of the auricle. The implant is retained in a snug pericranial pocket. A bony retention well is avoided. Minimal mastoid cell clearance is used. Through a standard posterior tympanotomy the electrode array is inserted in scala tympani. The authors claim that this surgical approach is brief, atraumatic and well suited to small infant cases. They have used this approach in 315 sequential routine CI cases from 1997-2007 and they claim that the complication rates compare favourably with past reports. These outcomes of the present series question the use of larger incisions and implant retention wells. However, some complications seem to be high enough, especially the migration rate. The authors suggest that current implant designs should be modified for better adaptation to the cranial contours in order to limit adverse events.
Epithelial tumours of the lacrimal gland
Reviewed by: Stuart Clark
May/Jun 2010 (Vol 19 No 2)
This is a retrospective review of 22 patients who presented with epithelial neoplasms of the lacrimal gland. Sixteen of these were benign all of which were pleomorphic adenomas. Of the six malignant neoplasms, three were adenoid cystic carcinomas. Benign tumours were treated by local excision with no recurrence. The treatment of the malignant tumours varied. The benign tumours presented as painless slow growing swellings causing proptosis and infra medial displacement of the globe. The mean time from complaint to diagnosis was three years. Usually there was no neurological disturbance or pain. There may be restricted ocular motility. A rapid onset of swelling was strongly suggestive of a malignant neoplasm, with the mean time to diagnosis being six months.
Prognostic factors for free-flaps
Reviewed by: Stuart Clark
May/Jun 2010 (Vol 19 No 2)
This paper from The Netherlands retrospectively analysed 150 patients who had free-flap surgery for head and neck defects. They found that medical complications were associated with an AA score of 3, and male gender as prognostic factors. Surgical complications were associated with an operation time exceeding ten hours and female gender. A variety of flaps were used, the majority of which were the radial forearm. The surgery was all for malignancy the vast majority of which was squamous cell carcinoma. It is a little arbitrary as to what was regarded as a medical or surgical complication. It does not address those where a complication could be inter-related and therefore medical as much as surgical.
Late results of stapedotomy
Reviewed by: Steven J Broomfield
May/Jun 2010 (Vol 19 No 2)
Late deterioration of hearing after stapes surgery is a well recognised phenomenon and is the subject of this paper from the Netherlands. The authors present the long-term results of 46 patients with otosclerosis operated on by a single surgeon. The initial outcome of surgery was improvement of the average air-bone gap (ABG) from 30.2 to 7.1dB. The average pre-operative bone conduction level of 21.8dB remained stable at 19.8dB after surgery. At the time of longterm follow-up 10 to 21 years (mean 14.3 years) later, the average ABG had stayed at 9.3dB whilst the average bone conduction had fallen at a rate of 0.6dB per year to 32.8dB (unfortunately the authors do not give a range for these averages nor any frequency specific data). This rate of deterioration is similar to that found in other studies, and the authors postulate that it may be due to presbyacusis, advancing cochlear otosclerosis, or a combination. It might have been interesting to compare these results to a group of patients with otosclerosis treated with hearing aids alone over a similar period. Nonetheless, the take-home message is that patients should be made aware of this late deterioration at the time of their initial surgery.
National Hearing Screening Programme (NHSP): protocols and results
Reviewed by: Madhup K Chaurasia
May/Jun 2010 (Vol 19 No 2)
Early diagnosis and intervention hold the key to successful rehabilitation of children born with permanent hearing loss. Neither the health visitor distraction test screening nor the targeted neonatal hearing screening provide satisfactory identification of these children which is why NHSP was introduced and is now well established in the UK. NHSP at this centre yielded 54 children with bilateral hearing impairment of greater than 40dB HL from a screening population of approximately 44,000 over a four year period. TEOAE screening was done as an initial test followed by automated ABR in referred cases. Initial screening was done within four weeks, 75% of babies requiring further testing were covered in two months and the rest within three months. The programme also used age standardised data regarding speech and language development and social function and through 'early support programme common monitoring protocol' involving local teachers of the deaf and parents and thus compared these children with normal subjects. Children with mild to moderate hearing loss had normal age related scores. Those requiring cochlear implants showed initial delay but later progressed. Hearing aids were fitted within four weeks of diagnosis and seven had cochlear implants from 18 to 28 months of age. It is highlighted that 22 deaf children would not have been picked up by targeted screening programme. Attention is drawn to the possibility of auditory neuropathy and early implantation should take note of this. Also, children with normal screening results can develop deafness in the immediate years that follow. Although the results are encouraging, NHSP should also take into account unilateral hearing loss and children with this problem should not be discharged as per the existing protocol.
The relevance of polysomnography in the diagnosis of OSA in young children
Reviewed by: Madhup K Chaurasia
May/Jun 2010 (Vol 19 No 2)
It is understood that 12% of children snore and 0.7 to 1,8% have obstructive sleep apnoea. Undiagnosed obstructive sleep apnoea can cause problems in the immediate post operative period after tonsillectomy. There is also increasing evidence that children with even mild sleep breathing disorders (AHI less than 5) develop cardiovascular and neurocognitive changes. This study compares the efficacy of clinical evaluation and paediatric sleep questionnaire with complex polysomnography. In this study, clinical evaluation yielded sensitivity of 68.4 and specificity of 59.5. The sensitivity was increased though only slightly by applying the paediatric sleep questionnaire. The predictive value of pulse oximetry was assessed but it proved that this method is not a substitute for polysomnography as it failed to diagnose seven children with OSA (AHI>5) confirmed by polysomnography. This is because repeated arousals, registered by polysomnography are often missed by pulse oximetry. The study also showed that the diagnostic algorithm which gives an indication of the risk associated with OSA failed to identify such children, one of them with AHI as high as 39! The study exposes the inadequacy of commonly available diagnostic tools for OSA and emphasises the need for polysomnography.
Closure of dural defect post trans-sphenoidal surgery: a new technique
Reviewed by: Gauri Mankekar
May/Jun 2010 (Vol 19 No 2)
The incidence of CSF leakage post-trans-sphenoidal surgery is common. It results from inadequate repair of a CSF fistula created at the time of the primary operation. The authors developed a new technique for dural suturing with fascia graft using specially devised suture tying micro-instruments and report on their success rates in twenty-one consecutive patients who underwent suprasellar tumour removal. Of the 21 patients, 16 patients' large dural defects were closed with fascia graft suture for CSF leak during or after extended trans-sphenoid surgery and in five patients the defect was closed after a traditional trans-sphenoid surgery. In this article, Ahn et al. have elucidated their technique with excellent diagrams about suturing the dural defect in a restricted space using rectus abdominus muscle or fascia lata with specially devised micro-instruments. None of their patients developed a CSF leak postoperatively. During their learning curve the duration of their surgery reduced from nine hours to approximately one hour!
Hearing preservation in vestibular schwannoma surgery using image guidance and endoscope
Reviewed by: Gauri Mankekar
May/Jun 2010 (Vol 19 No 2)
In this anatomic study, Pillai et al. attempted to preserve hearing using navigation system and endoscope during exposure of the internal auditory canal via the retrosigmoid approach in ten whole fresh cadaver heads. In the retrosigmoid approach hearing loss, despite preservation of the cochlear nerve, can result from labyrinthine injury of the posterior semicircular canal and / or common crus during drilling of the posterior wall of the internal auditory meatus as there are no anatomic landmarks to identify these structures. Based on their study, the authors recommend frameless navigation using high-resolution CT scanning and permanent bone implanted reference markers to maximise safe drilling of the IAC without violating the labyrinth, leaving behind a small segment of the lateral IAC exposed. Further exposure of the fundus with removal of the schwannoma can be achieved with an angled endoscope avoiding cerebellar retraction, cochlear nerve and labyrinthine injury. This technique when moved from the laboratory to the operating room could contribute to improving the effectiveness and safety of retrosigmoid approach for removal of vestibular schwannomas.
Transphenoidal encephaloceles
Reviewed by: Showkat Mirza
May/Jun 2010 (Vol 19 No 2)
Transsphenoidal encephaloceles are rare and usually managed by a multidisciplinary team that may include the otolaryngologist. Patients have a protrusion of the dural sac through a sphenoid bone defect into the pharynx which tends to progress over time and therefore surgery is recommended. The surgical treatment remains a challenge because of the encephalocele's relationship with structures such as the hypothalamus, pituitary gland and optic pathway. Unlike more anterior encephaloceles where the stalk can be amputated and dural edges closed, a similar approach with sphenoid encephaloceles risks loss in vision and endocrinopathies. The authors describe their experience of five surgical cases (parents refused surgery in one case) over an 11 year period. Three patients had a transoral, transpalatal microscopic approach and two had a transnasal microscopic approach. The procedures are described with the sac being reduced and some illustrations are included. The sphenoid bony defect was repaired with human deantigenic bone or demineralised human bone matrix. Further details regarding the operative technique would have been useful. Preoperative symptoms remained stable or improved in all of the patients after surgery. Two patients experienced a palatal dehiscence. No mortality was recorded.
Embolisation for head-neck tumours
Reviewed by: Gauri Mankekar
May/Jun 2010 (Vol 19 No 2)
Endovascular procedures are accepted modality of treatment for cerebrovascular diseases and neoplasms of the head and neck. Over the years, the procedures have become less invasive and more effective. Sekhar et al. describe their experience with these procedures over 3.5 years for 18 convexity tumours, 42 skull base lesions, 19 intrinsic brain tumours and 23 extracranial neoplasms which were embolised. The procedures often but not always resulted in reduced intra-operative bleeding and enhanced tumour removal and there were no major complications. The authors caution that knowledge of potentially dangerous anatomoses between the EC and IC circulations is essential to minimise risk of cranial nerve palsies, blindness or neurologic deficits. They conclude that an interdisciplinary approach and treatment in high volume centres are vital to obtain maximal benefit for patients.
Stereotactic radiotherapy in the head and neck
Reviewed by: Badr Eldin Mostafa
May/Jun 2010 (Vol 19 No 2)
Advances in the management of locally advanced head and neck cancer (HNC) have been focused on treatment intensification, including concomitant chemoradiotherapy, biological agents, and combining surgery with chemoradiotherapy. Despite these improvements, locoregional recurrence still constitutes the main pattern of treatment failure. Locally recurrent primary HNCs that have already received a full course of EBRT present a specific therapeutic challenge due to limited management options. In most cases, the normal surrounding tissues have approached close to accepted radiotherapy tolerance doses. Any additional EBRT dose required to achieve sterilisation of persistent tumour carries a significant risk of treatment-related morbidities.This article focuses on the use of stereotactic body radiotherapy for treatment of HNC as a boost after conventional external-beam radiotherapy, and also as reirradiation in recurrent or second primary HNC. Dose fractionation schema varied, from single doses of 14, 16, and 18 Gy, to fractionated doses of 36 Gy in 6 fractions, to 48 Gy in 8 fractions 2-3 times weekly. Radiation toxicity included Grade 1-2 mucositis in all patients with oropharyngeal or laryngeal lesions. The role of SBRT in HNC is an emerging treatment option for locally advanced and recurrent HNC as a radiosurgical boost or a form of highly focused reirradiation therapy. Phase I data shows that SBRT for HNC is a feasible treatment option with promising local control rates, although additional studies are needed to determine optimal patient selection, dose fractionation, and timing of therapy compared with other treatment strategies such as conventional radiotherapy, surgery, and chemotherapy. This may be finally a way out from our frustration as physicians when facing patients with recurrent lesions to whom we are utterly helpless.
New techniques for thyroid surgery
Reviewed by: Susan A Douglas
May/Jun 2010 (Vol 19 No 2)
The authors have described a series of novel surgical techniques, some of which have been facilitated by new technology. The authors state that these techniques have transformed the way that modern thyroid surgery is done. The original technique described by Theodore Kocher in the late 19th century has changed. These changes include preoperative techniques such as preoperative endoscopy, which allows identification of unanticipated laryngeal findings with improved diagnosis and alteration of the surgical plan where necessary. Immediate postoperative endoscopy allows the surgeon to develop and improve his/her surgical technique. The authors mark the patient in the 'holding area', while the patient is awake and upright. This ensures that the incision is in an optimal location. There is also minimal or no neck extension. The authors feel that neck extension may cause unnecessary posterior cervical neck pain, which is eliminated by avoiding hyperextension. They have also found that hyperextension make identification of the recurrent laryngeal nerve more difficult. With a neutral head position the nerve appears more 'wormy' in configuration and is therefore easier to identify. The use of a glide scope for intubation of the patient allows accurate placement of the endotracheal tube (as an image of the position of the scope is projected onto a screen). This allows laryngeal nerve monitoring during surgery by ensuring that the surface electrode is placed against the vocal cords and reduces the risk of recurrent laryngeal nerve injury. Regarding intraoperative techniques, the authors do not lift subplatysmal flaps. A horizontal skin incision is made through skin, subcutaneous tissues and platysma muscle to expose the strap muscles. This minimises the dissection required and the tissue trauma. The authors describe other techniques such as the use of atraumatic elevators and avoidance of clips sutures and drains. The harmonic device is used to ligate the superior pole and allow faster dissection with reduced risk of injury to the external branch of the superior laryngeal nerve. The strap muscles are closed with a single figure of eight suture to avoid a haematoma deep to the strap muscles. The authors also routinely give calcium supplements postoperatively in lieu of testing in order to treat those who become transiently hypothyroid. The procedure is done on an outpatient basis. This is a well-written article describing some relatively new techniques in thyroid surgery. It is well worth reading if one performs thyroid surgery. These tips may help to reduce perioperative morbidity and make surgical techniques more time efficient.
Contralateral hearing changes after mastoid surgery
Reviewed by: Christopher J Webb
May/Jun 2010 (Vol 19 No 2)
This prospective study compared distortion product otoacoustic emissions (DPOAE) in patients undergoing mastoid surgery. The non-operated ear was the subject under investigation. The trial consisted of a treatment group undergoing mastoid surgery (n=13) and a control group undergoing Tympanoplasty type 1 (n=5). In the control group there was no significant difference from baseline in any patient. In the treatment group there was an apparent drop in 2 and 4kHz DPOAEs immediately after surgery, which improved at 24 hours and then dropped again at one week and four weeks post-surgery. The reason for saying apparent drop is that no confidence limits are mentioned, so although the mean DPOAE appears to drop the actual significance cannot be judged from this study with small numbers of patients.
Mechanical treatment of palatal snoring
Reviewed by: Christopher J Webb
May/Jun 2010 (Vol 19 No 2)
A Swiss patient invented a device to cure his own snoring. The device is in essence a bent piece of plastic coated wire which is hooked onto the upper lip and then runs intraorally across the hard palate and is bent up behind the soft palate bringing it forwards and stenting it. This device is known as the Velumount. In patients with palatal snoring it has been proven to reduce the snoring index, the Epworth Sleepiness Scale score, and in patients with sleep apnoea it reduced the Apnoea-Hypopnoea Index. All reductions were highly significant. The side-effects of the device are a tendency to rhinolalia, a risk of nasal regurgitation of fluids if desired in the night, and a foreign body sensation if the device is bent too strongly. As a mandibular advancement prosthesis is proven to be effective in tongue base snoring it would seem that the Velumount could be useful in palatal snorers.
Oral tolerance and autoimmune deafness
Reviewed by: Christopher J Webb
May/Jun 2010 (Vol 19 No 2)
Antibodies directed at inner ear proteins are known to result in sensorineural deafness. This paper used a substance called β-tubulin, which has similar amino acid sequences to a protein in the guinea pig inner ear, to stimulate an antibody response resulting in deafness. Prior to immunisation with β-tubulin the guinea pigs were split into five groups. One group was fed oral saline, one group received ovalbumin and the remaining three groups were given 20, 30 or 200μg of β-tubulin orally. All groups were fed daily for five days and then immunised on day seven. Hearing was evaluated before the study commenced and after the immunisation. Animals given saline, ovalbumin or 200μg of β-tubulin all experienced a significant hearing loss, however guinea pigs receiving 20 or 30μg of β-tubulin did not have a significant change in hearing. Immunologically cytokines associated with inflammation (interferon gamma – IFN-γ) were suppressed whilst protective cytokines (interleukins 4, 5 and 13 and transforming growth factor beta) were upregulated. The upshot of this study is that it is theoretically possible to protect against autoimmune inner ear disease by administering sufficient low dose oral antigens to prevent immune activation against the inner ear protein. The next challenge would be to develop such oral antigens and secondly to find out the other consequences of fiddling with the immune system.
Beyond endoscopic rhinology
Reviewed by: James Barraclough
May/Jun 2010 (Vol 19 No 2)
This article provides a comprehensive review of the current and future developments of how endoscopic interventions in rhinology are starting to incorporate intraoperative imaging. Endoscopic advances have provided rhinologists with excellent imaging but only in two dimensions, whereas the addition of radiological guidance can provide a third dimension. The authors describe the technologies available, including multidetector CT, MRI, 3D fluoroscopy and image guidance techniques in good detail. They also provide evidence that the outcomes of using these technologies are in keeping with current more widely used techniques. Access to pituitary lesions, unusual anatomy and difficult endoscopic procedures are suggested areas where these technologies may have some advantages. They do acknowledge that there are drawbacks including expense, a learning curve and space issues. It is also worth noting that the results they quote do not provide convincing evidence of significant morbidity reduction. However, this is an interesting read if only to gain insight into what our American colleagues are beginning to practise.
CT of otosclerosis
Reviewed by: Liam M Flood
May/Jun 2010 (Vol 19 No 2)
High resolution CT (HRCT) of the temporal bone reminds us that otosclerosis is truly otospongiosis, with focal lesions appearing hypodense rather than sclerotic. This is a prospective study of 209 ears suspected of otosclerosis, undergoing HRCT prior to tympanotomy. Of these, 84.2% were classified as positive for otosclerotic lesions and, in all stapes fixation was confirmed. Of the 15 ears with negative scans, four showed malformation and one a fracture of the stapes rather than otosclerosis. Footplate problems at surgery for example floating, occurred more frequently in the absence of positive CT findings. HRCT sensitivity for OS was 95.1% and foci involving the otic capsule, internal canal or round window accurately predicted sensorineural loss. The indication for imaging and irradiation in the study is unclear and it is largely based on known OS sufferers, rather than control group. The resulting illustrations are excellent however.
Does side matter?
Reviewed by: Liam M Flood
May/Jun 2010 (Vol 19 No 2)
This study, from Grenoble, France, compares outcomes for stapes surgery on right and left ears. Most surgeons have a dominant hand / eye and might have a preference for one particular side in ear surgery as a result. Is this borne out of a retrospective analysis of results of surgery for otosclerosis? The authors reviewed 894 patients almost equally divided as to side of surgery, with three operators over 32 years. Patients were subdivided according to pre-op air-bone gap (ABG) and, further, on pre-op bone conduction (BC), for analysis of results. Outcome was judged according to change in ABG and BC at four months post-op. They especially sought any sensorineural loss, of at least 10dB post operatively. Results for right and left ears were indistinguishable and, for the 19 showing post-op sensorineural loss, they were also equally divided. The discussion suggests that 'side preference' is greatest amongst the less experienced surgeons, this indeed proving the only statistically significant finding in this study. Of any random sample, 11% of us are left handed and may well start preferring left ear surgery. Somewhere a learning curve kicks in and this preference fades. In expert hands anyway, this does seem justified.
Explaining the complex vestibular system in a simple way
Reviewed by: Roberta Buhagiar
May/Jun 2010 (Vol 19 No 2)
The authors describe in detail both the peripheral and central vestibular anatomy and physiology of the vestibular system. These pathways have been well documented previously in the literature but the schematic representations used in this article help understand these complex pathways in a more simple manner. The authors concentrate on describing the vestibule-ocular reflex (VOR) in detail since understanding the VOR and its anatomy and physiology helps the reader understand both the normal and abnormal eye movements. This in turn helps understand the effects these abnormal eye movements have in patients with unilateral vestibular dysfunction and benign paroxysmal positional vertigo. The plasticity of the vestibular system is mentioned and linked to vestibular compensation – a topic which has attracted a lot of research through the years. This review links the normal function of the vestibular system to the processes that may underlie recovery from dysfunction.
Paranasal sinus development in children judged by Magnetic Resonance
Reviewed by: Edward W Fisher
Sep/Oct (Vol 20 No 4)
This study of 2,025 patients is a useful database for researchers and clinicians who deal with children. The authors analysed scans in children aged 0-18 years who were imaged for conditions that could reasonably be disassociated from nasal disease and had no history of nose or paranasal sinus disease. All of the patients had magnetic resonance scans (1.5 Tesla) and from these scans detailed measurements of the paranasal sinuses were made (dimensions and volumes). While this has all the appeal of a railway timetable to read in sequence, it is of great potential usefulness in interpreting scans and assessing disorders of the sinuses in children, as well as providing a useful bank of information for researchers in the field. Sinus anatomical variations are well described due to the size of the population studied.
When one ear is as good as two
Reviewed by: Veronica J Kennedy
Real-ear to coupler difference (RECD) is undoubtedly a useful clinical tool in optimising hearing aid fitting. It allows a more individual-specific fit than using averaged age-appropriate corrections and, in the ideal world, takes just minutes to perform. In the real world, however, especially with children, getting patients to sit still, not wriggle or move their head during the procedure can be an unwelcome challenge in a busy clinic. This study looked at RECDs across a range of adults, school-age children and pre-school children who used hearing aids and compared right and left ear measurements. A previous study had noted that the difference between ears was less than 3dB in 90% of the adults tested in a laboratory-based study. Although there was one adult who showed a difference between ears of 8dB for unexplained reasons, generally the results in this trail coincided with the above lab-based results. As expected, RECD values in preschool children are higher because of smaller external ear canal volume. In the adults tested, a RECD roll off was noted at the higher frequencies, probably because of a longer sound bore in the adult ear moulds. Overall, the mean differences between the right and left ear were reported as small and not statistically significant. It is also worth noting the finding that, in children, generally the difference between the measured RECD and published predicted values was larger than when using the measured RECD from the opposite ear. The recommendation of the paper is that it would be more accurate to use a single measured RECD for both ears of preschool children than to use the predicted data for the unmeasured ear.