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ACTA OTO-LARYNGOLOGICA

Implantable devices and large magnets – do they mix well?
Reviewed by: Bhaskar Ram
Vol 25 No 2
 

Although all brands are MRI safe at 1.5 T, the active middle ear implant system Vibrant Soundbridge (VSB), is special since it houses two magnets. These include a magnetic floating mass transducer (FMT) and an audioprocessor fixing receiver magnet which contribute to specific MRI-related side-effects. The study investigated the effects of MRI scanning on the VSB with an alternatively coupled FMT. All patients were asked to fill in a questionnaire for further evaluation. In four patients with the active middle ear implant system five MRI examinations were performed for different non-ear related indications. During the scanning, noise and subjectively perceived distortion of the implant were described. The hearing performance with the VSB was decreased in one patient which could be fixed by a surgical revision. This paper helps in counselling of patients regarding the possible side-effects regarding postoperative MRI scans. A study with larger numbers is awaited! 

Reference

MRI scanning in patients implanted with a round window or stapes coupled floating mass transducer of the Vibrant Soundbridge.
Renninger D, Ernst A, Todt I.
ACTA OTO-LARYNGOLOGICA  
2016;136(3):241-4.

AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY

Olfactory neuronal damage in sinusitis
Reviewed by: Edward Fisher
Vol 25 No 2
 

So many patients with nasal disorders have poor olfactory function, yet sometimes the nose may seem comparatively clear of conductive problems. This study postulated that neuronal damage in the olfactory apparatus would lead to a leakage of neuron specific enolase into the nasal secretions. They studied patients with chronic sinusitis, with and without polyps, and normal controls, including olfactory assessment as well as analysing secretions for neuron specific enolase. The higher the levels of this protein in the secretions, the poorer the olfactory function. Controls had lower levels than CRS patients, and polyp patients had higher levels than patients without polyps. What this means at a practical level, it is hard to say at this stage, but it does help to explain the multiple mechanisms of olfactory dysfunction in our patients.

Reference

Neuron specific enolase in nasal secretions as a novel biomarker of olfactory dysfunction in chronic rhinosinusitis.
Tysbikov NN, Egorova EV, Kuznik BI, et al.
AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY 
2016;30(1):65-9.

AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY

The microbiological environment of the paranasal sinuses
Reviewed by: Edward Fisher
Vol 25 No 2
 

This article reviews the ecology of the sinuses and tries to make sense of the confusing literature on the subject. This covers the details of molecular studies, particularly those which attempt to differentiate normal sinuses from those in patients with chronic rhinosinusitis. The real question is what constitutes a healthy microbial flora ‘community’ compared to an environment which encourages disease. Diverse organisms form the ‘normal’ inhabitants of the paranasal sinuses. Studies show that organisms regarded as ‘pathogenic’ can live happily among other commensals, in the absence of disease, so it is likely to be a question of what constitutes a healthy balance rather than the presence or absence of a particular organism. The concept of disruption of the healthy community of organisms as a precursor or part of the disease process is described. This area needs much more research, since so many of our current therapies are based on a too simplistic approach to the role of micro-organisms in sinus disease. Another paper in the same issue (pages 37-43) describes a particular study into postoperative changes and patient outcomes in relation to the microbial community in the sinuses and complements this review article very well, showing differences in diversity, abundance, prevalence and temporal changes. The journal issue editorial helps to put both papers in context. 

Reference

Microbiome of the paranasal sinuses: update and literature review.
Lee JT, Frank DN, Ramakrishnan V.
AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY 
2016;30(1):3-16.

AURIS NASUS LARYNX

Robot controlled mastoid surgery!
Reviewed by: Ravi Thevasagayam
Vol 25 No 2
 

This is a fascinating piece of work by a Korean team developing a human-robot collaborative control. Their model uses image guidance surgery to locate the drill tip’s position. Important structures can be highlighted – in this case the facial nerve. As the drill tip gets closer to the chosen structure, the drill movements become stiffer to give the operator feedback, until it appears that the operator will breech the target structure at which the actuators block the drill movement completely and alarm. The system was tested by allowing an engineer who was an untrained surgeon to drill five cadaveric temporal bones, who successfully avoided the nerve whilst damaging other structures. At the moment only two structures can be highlighted for protection although it seems likely that this number will increase. Obviously it seems unlikely that this will protect the nerve in the middle ear. Whilst I’m naturally a bit dubious about robotics at the moment and it seems to me that little will obviate the need for hours of temporal bone training and close supervised live operating, this seems like an exciting and potentially hugely useful addition to the mastoid surgeon’s armamentarium.

Reference

Semi-manual mastoidectomy assisted by human–robot collaborative control – a temporal bone replica study.
Lim H, Matsumoto N, Cho B, et al.
AURIS NASUS LARYNX
2016;43(2):161–5.

B-ENT

Assessing surgical tracheostomy skills
Reviewed by: Sunil Sharma
Vol 25 No 2
 

Surgical tracheostomy is an essential operation that trainees must be competent in. There is a lot of research currently looking into assessing trainees’ surgical abilities, particularly into assessments that can be used to demonstrate progress, so this article is very topical. In the UK, the Intercollegiate Surgical Curriculum Programme uses assessments such as procedure based assessments (PBAs), however critics suggest that it is difficult to demonstrate progress with this. This was a study from Saudi Arabia in which they developed the objective surgical tracheostomy skills (OSTS) tool. This comprised of 10 domains, each rated using a five-point Likert scale. There was also a global rating from unsatisfactory to excellent at the end. The OSTS tool was developed by otolaryngology consultants, fellows and specialists in medical education, and tested on 44 residents at varying stages of their training. There was good reliability and internal consistency, and its validity was established based on a significant improvement in senior resident scores compared to junior resident scores. There was good face validity with positive feedback from both assessors and trainees. An important limitation in this study was the lack of ability to assess inter-rater reliability, as only one assessor was present during any one procedure. This study provides an interesting assessment tool that could be incorporated into other training programmes, and could be replicated for other index ENT surgical procedures.

Reference

Tool for assessing surgical tracheostomy skills in otolaryngology residents.
Al-Qahtani KH, Alkhalidi AM, Islam T.
B-ENT
2015;11:275-80.

B-ENT

to say at this stage, but it does help to explain the multiple mechanisms of olfactory dysfunction in our patients. – EF Neuron specific enolase in nasal secretions as a novel biomarker of olfactory d
Reviewed by: Sunil Sharma
Vol 25 No 2
 

In this Bosnian study, the authors attempted to determine if air pressure, temperature and humidity had any effect on idiopathic epistaxis. The study took place over a three-year period and included 300 patients. A comparison was performed of meteorological data on the day of epistaxis (‘Day 0’) and on the first preceding day prior to epistaxis onset (‘Day -1’). All included patients had to be in the same city in Bosnia and Herzegovina on both days. The authors did note a peak incidence of epistaxis during the spring months (but this could be related to a peak of allergy symptoms during this period, which can exacerbate epistaxis). However, they did not find any meteorological trigger factors for epistaxis. The study is however limited by the fact that the temperatures, humidity and air pressures were measured outside, and may not reflect those that the patient was actually exposed to in their homes. Also, the arbitrary division of Day 0 and Day -1 means that in fact the weather conditions on the night before the onset of epistaxis (on Day -1) may have actually been the precipitating factors for onset of epistaxis. This study reinforces previous literature that particular weather conditions do not seem to be associated with the onset of epistaxis.

Reference

Idiopathic epistaxis and meteorological factors: case-control study.
Jelavic B, Majstorovic Z, Kordic M, et al.
B-ENT
2015;11:267-73.

HEAD AND NECK

Difficult consultations with HPV-positive oropharnyeal cancer patients
Reviewed by: Jonathan Hughes
Vol 25 No 2
 

The aetiological role of human papillomavirus (HPV) in oropharyngeal squamous cell carcinoma (OPSCC) is well established, and its incidence has massively increased over the last decade, whilst the incidence of HPV-negative OPSCC is declining. Although we know that HPV-positive OPSCC is associated with improved prognosis, the sexually transmitted nature of HPV infection brings potential stigma to the patient and anxiety to the head and neck cancer health professional inexperienced in discussing sexual behaviour with patients. This interesting preliminary study consisted of structured interviews of 15 health professionals involved in managing HPV-positive OPSCC patients regarding their experiences of explaining the causal role of HPV to their patients. Challenges were reported due to limitations in our knowledge about the virus and discomfort in talking about sexual health matters. Key messages were reported to form the basis of a successful consultation: 1) normalisation of HPV infection in the majority of sexually active people; 2) HPV infections associated with normal sexual behaviour and not promiscuity; 3) explanation that it’s the same virus associated with cervical cancer and HPV vaccination; 4) no need for change in patient behaviour and that infection was likely to have been acquired a long time ago; 5) good prognosis compared to HPV-negative cancers with de-escalation of treatment in many centres. The authors recommend learning within departments through feedback of experiences of health professionals (from all disciplines), communication skills workshops / courses and keeping up-to-date with the fast-moving story of HPV-associated OPSCC. 

Reference

Discussing a diagnosis of human papillomavirus oropharyngeal cancer with patients: an exploratory qualitative study of health professionals.
Dodd RH, Marlow LAV, Waller J.
HEAD AND NECK
2016;38(3):394-401.

INTERNATIONAL JOURNAL OF LANGUAGE AND COMMUNICATION DISORDERS

Team based learning in speech language pathology graduate courses
Reviewed by: Gauri Mankekar
Vol 25 No 2
 

According to the author of this article, the role of a speech language pathologist involves clinical problem solving in both diagnostic and treatment processes. Problem solving involves cooperative collaboration with clients and their parents. Therefore, in this pilot study, the author evaluates perception of course content to develop these skills in speech language pathology graduate courses. The study reports on the findings of educational outcomes and speech language pathology students’ perceptions of team based learning (TBL) in a communication disorders graduate course. TBL is an instructional method involving small groups, targeting cooperative problem solving skills. It enables the students to apply course concepts through teamwork and is followed by immediate feedback. The outcomes of the study suggest that the students perceived TBL as an effective instructional method which provided them with opportunities to apply course content in problem solving. The author recommends that future studies should evaluate the importance of this approach in other courses within the field and with more heterogenous student populations. 

Reference

Five heads are better than one: preliminary results of team-based learning in a communications disorder graduate course.
Epstein B.
INTERNATIONAL JOURNAL OF LANGUAGE AND COMMUNICATION DISORDERS
2016;51(1):44-60.

INTERNATIONAL JOURNAL OF LANGUAGE AND COMMUNICATION DISORDERS

Working with clients of communication disorders from culturally and linguistically diverse populations
Reviewed by: Gauri Mankekar
Vol 25 No 2
 

Speech language therapists (SLTs) deliver evidence based services worldwide for communication disorders to culturally and linguistically diverse (CLD) populations. They have to modify their approaches and tailor them to the needs of their students / patients. This article studies the responses of nine school SLTs in a diverse region of the USA to a semi-structured interview about how they modify their approaches, if at all, when interacting with culturally and linguistically diverse students and their families. The data analysis suggested four main factors faced by the SLTs: 1) language for communication with students and their families could be a barrier but also a bridge; 2) communicating through an interpreter was fraught with its own set of problems; 3) cultural differences had to be respected; 4) interacting with CLD students and their families was challenging but also associated with positive experiences. This article highlights the need for further research for culturally competent practices in the areas of assessment and intervention.

Reference

Working with culturally and linguistically diverse students and their families: perceptions and practices of school speech-language therapists in the United States.
Maul CA.
INTERNATIONAL JOURNAL OF LANGUAGE AND COMMUNICATION DISORDERS
2015;50(6):750-62.

INTERNATIONAL JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY

Carotid artery involvement with head and neck metastases
Reviewed by: Stuart Clark
Vol 25 No 2
 

This is a retrospective review of 27 patients radiologically diagnosed as having metastases involving the common or internal carotid arteries. All patients underwent a salvage neck dissection with surgical carotid peeling. Thirteen of the 27 achieved loco-regional control, five developed second primaries and 11 distant metastases. The survival time was noted to be poor regardless of regional control with the medial survival being 1.5 years and disease free survival 0.7 of a year. A two year disease free survival rate of 22% was observed. No patients in this review sustained the complication of arterial rupture however a small number of cases had previously had preoperative radiotherapy.

Reference

Clinical impact of radiographic carotid artery involvement in neck metastases from head and neck cancer.
Teymoortash A, Rassow S, Bohne F, et al.
INTERNATIONAL JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY
2016;45(4):422-6.

INTERNATIONAL JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY

Changes in airway dimensions after orthognathic surgery
Reviewed by: Stuart Clark
Vol 25 No 2
 

This is a systematic review of meta-analysis evaluating the effect of different types of orthognathic surgery on the cross sectional area and volume of the upper airway as assessed using CT or MRI. They found 28 articles of which only eight were thought to have a low risk of bias. They noted that there was no evidence to confirm that changes in the upper airway dimensions after orthognathic surgery predispose it to obstructive sleep apnoea. The aim of the review was to assess changes of the airway dimensions rather than initial final values. Overall they concluded that there was moderate evidence to unveil that the minimum cross sectional area of the upper airway increases significantly as does the total volume. There was a significant reduction in total volume after a maxillary advancement and mandibular setback as well as mandibular setback in isolation. This was based upon 3D imaging.

Reference

Upper airway dimensions in patients undergoing orthognathic surgery with systematic review and meta-analysis.
Christovan IO, Nisboa CO, Ferreira DMPT, et al.
INTERNATIONAL JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY
2016;45(4):460-71.

INTERNATIONAL JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY

What can the anterior cranial fossa fracture pattern tell us?
Reviewed by: Stuart Clark
Vol 25 No 2
 

This assessment involves 81 patients treated between two regional major trauma centres in the UK. Fifty sustained a predominantly anterior directed force and 31 a lateral impact. They found that anterior impacts reduce the incidence of fracture propagated beyond the anterior cranial fossa allowing it to act like a ‘crumple zone’. The lack of such a zone of lateral forces resulted in fracture propagation and transmission throughout the skull base, particularly into the middle of the posterior cranial fossa.

Reference

Applied anatomy anterior of the cranial fossa what can fracture patters tell us.
Stephens JR, Holmes S, Evans BT.
INTERNATIONAL JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY
2016;45(3):275-8.

INTERNATIONAL JOURNAL OF PEDIATRIC OTORHINOLARYNGOLOGY

Paediatric lymphadenopathy – helpful decision making
Reviewed by: Patrick Spielmann
Vol 25 No 2
 

The authors present a very helpful algorithm to manage cervical lymphadenopathy in children. The goal of managing children with inflamed lymph glands is to identify the rare malignant case and not over-investigate the vast majority of benign reactive swellings – a careful balance. The authors, working in a tertiary-referral centre, have produced clear evidence-based criteria to direct management and report results of >200 children managed according to it. The vast majority (85%) were diagnosed as benign / reactive and discharged at the first visit. They had not been re-referred in a five-year follow-up window, vindicating the decision to discharge. Only 2% eventually proceeded to excision biopsy based on the criteria. Although lymphoma would be the expected ‘malignant diagnosis’ not to be missed, no case was identified, the only malignancy being a sarcoma. Having clear evidence-based management criteria is useful for practising clinicians who see such children infrequently and trainees approaching post-graduate exams alike. I would recommend anyone working with children to get hold of the treatment algorithm. 

Reference

The validation of an algorithm for the management of paediatric cervical lymphadenopathy.
Locke R, MacGregor F, Kubba H. 
INTERNATIONAL JOURNAL OF PEDIATRIC OTORHINOLARYNGOLOGY 
2016;81:5-9.

JAMA FACIAL PLASTIC SURGERY

Are elective facelifts a good idea after head and neck cancer radiotherapy?
Reviewed by: Bilal Gani Taib
Vol 25 No 2
 

The aim of this study was to assess the safety of elective cervicofacial rhytidectomy following radiotherapy for head and neck squamous cell carcinomas (HNSCC). A greater proportion of HNSCC patients are infected with certain strains of the human papillomavirus, which causes more than half of all cases of oropharyngeal cancer. These patients frequently do not have the typical risk factors for HNSCC and are being cured. This cohort increasingly desire elective rhytidectomy following treatment as they are unhappy with their aesthetic outcomes following treatment. In this case control study there were 16 patients in the radiotherapy group and 16 in the control group who underwent elective cervicofacial rhytidectomy. Patients who received chemotherapy and radiotherapy were more likely to have complications (p=0.04) as were patients post radiotherapy who underwent rhytidectomy using a subcutaneous technique after (p=0.02). No major complications occurred in the control group but two major complications (12%) occurred in the case group (stroke and evacuation of a haematoma). Being older and the time from completion of radiotherapy and surgery did not show any correlation to complications. In conclusion, this study, albeit with small numbers, has highlighted that aesthetic facial surgery after radiotherapy is associated with an increased risk for complication compared with facial surgery without radiotherapy.

Reference

Cervicofacial rhytidectomy after radiotherapy for head and neck tumors.
Wudel JM, Novis S, Baker SR, et al. 
JAMA FACIAL PLASTIC SURGERY 
2016;18(1):9-14.

JAMA FACIAL PLASTIC SURGERY

Concussion and isolated mandible fractures – are we asking the right questions?
Reviewed by: Bilal Gani Taib
Vol 25 No 2
 

The mandible is one of the most commonly fractured craniofacial bones. A significant force is required to bring this about. Hence the authors hypothesised that concussion after a mandibular fracture is more common than the literature states. A case series of 16 patients with a mean age of 27.5 years were collected over a 12 month period. Patients were tested using the Military Acute Concussion Evaluation (MACE). A significant score was anything <25. Seventy-five percent of the fractures were sustained during assaults; half of all fractures involved the consumption of alcohol and 68% reported a loss of consciousness. Seventy-five percent (12/16) of patients with isolated mandible fractures met the criteria for a concussion in this study. These patients may benefit from being screened for concussion and referred to a concussion clinic. 

Reference

Incidence of concussion in patients with isolated mandible fractures. 
Sobin L, Kopp R, Walsh R, et al.
JAMA FACIAL PLASTIC SURGERY 
2016;18(1):15-8.

JOURNAL OF VESTIBULAR RESEARCH

How effective is vestibular rehabilitation in bilateral vestibular failure?
Reviewed by: Victor Osei-Lah
Vol 25 No 2
 

In patients with bilateral vestibular hypofunction (BVH), the outcome of vestibular rehabilitation is mixed. The aim of the study was to identify factors associated with outcome of vestibular rehabilitation (VR) in patients with BVH. A retrospective case notes review identified 69 patients diagnosed with BVH over a five-year period. BVH was diagnosed using bithermal caloric and rotatory chair testing. The outcome measures were visual blurring (oVAS), disequilibrium (dysVAS), dizziness induced by head movement (hmVAS), balance confidence scale (ABC), Disability Score, Quality of Life (TSI), Dynamic Visual Acuity (DVA), Dynamic Gait Index (DGI) and gait speed. As a group, improvement in all outcome measures except for Disability Score was identified. However the degree of improvement varied widely in individual patients (37.5% to 87.5%). Not all patients improved; in fact some had worse scores after VR. Several factors measured at baseline identified as potential factors associated with rehabilitation outcome included age, DGI, gait speed and intensity of disequilibrium. Older patients improved more than younger patients probably because of worse scores at baseline. Older patients had higher DVA scores at discharge. Lower (poorer) initial DGI scores were related to higher Disability scores at discharge. Initial gait speed correlated with DGI and gait speed at discharge which may be a reflection of the walking speed criteria that are part of the DGI score. As expected VR outcome was poorer in BVH compared with unilateral vestibular hypofunction. This study provides some guidance on prognosis of VR in BVF. Would the results be different if the definition of BVF was not based only on lateral semicircular function but on the function of all five vestibular receptors? 

Reference

Variables associated with outcome in patients with bilateral vestibular hypofunction: Preliminary study.
Herdman SJ, Hall CD, Maloney B, et al.
JOURNAL OF VESTIBULAR RESEARCH
2015;25:185-94.

JOURNAL OF VESTIBULAR RESEARCH

International classification of BPPV
Reviewed by: Victor Osei-Lah
Vol 25 No 2
 

In the past few years, the Bárány Society has made great strides in defining and classifying vestibular disorders along the lines of the international classification of diseases. This article addresses the diagnostic criteria for BPPV, the commonest cause of vertigo. The authors addressed the controversy surrounding terminology used to describe the vertigo and nystagmus of BPPV: ‘positional’ vs ‘positioning’. Whereas ‘positioning’ is more accurate, they agreed to preserve ‘positional’ in the definitions because of its ubiquitous usage. The paper reviews the epidemiology, pathophysiology and diagnosis extensively. They do not specifically address treatment. The characteristics of canalolithiasis and cupulolithiasis are well described. For BPPV of each of the three semicircular canals, the authors describe the key features of canalolithiasis and cupulolithiasis and how they should be annotated e.g. posterior canalolithiasis is designated pc-BPPV and the cupulolithiasis type, pc-BPPV-cu. Extensive comments and notes are given to clarify areas of controversy such as the features of apogeotropic and short arm horizontal canal BPPV. The authors emphasised the importance of testing for multi-canal BPPV. Guidance is provided on distinguishing BPPV from central disorders. The paper is worth a read for detailed information and references for the epidemiology and pathophysiology of BPPV.

Reference

Benign paroxysmal positional vertigo: Diagnostic criteria.
Von Brevern M, Bertholon P, Brandt T, et al.
JOURNAL OF VESTIBULAR RESEARCH
2015;25:105-17.

JOURNAL OF VOICE

Botulinum toxin injection for bilateral recurrent laryngeal nerve paralysis
Reviewed by: Christopher Burgess
Vol 25 No 2
 

All traditional surgical treatments for bilateral recurrent laryngeal nerve (RLN) paralysis are essentially a balance between maximising airway patency and ensuring adequate phonation / airway protection. This paper highlights the potential role of botulinum toxin (Botox) injection into the cricothyroid muscle bilaterally for the treatment of bilateral vocal fold paralysis to reduce obstructive airway symptoms. The patient population suitable for consideration of this intervention are those whose bilateral RLN paralysis results in an initial breathy dysphonia where the immobile vocal folds are in a relatively lateralised position. Over time, it has been noted that these patients’ dysphonia may improve but their airway may worsen due to unopposed action of the cricothyroid muscles. The clinical courses of three patients are reported who received Botox injections to their cricothyroid muscles to treat bilateral RLN paralysis following total thyroidectomies. Per side, 2.25-3.0 units were injected, and three to six separate injections had been performed a minimum of two months apart by the time of paper submission. Dyspnoea reportedly improved after each injection, with only minimal worsening of voice. Interestingly, two of the three patients did not experience recurrence of their dyspnoea eight months after their last injection, but whether this can be considered to represent long-term resolution is debatable. Clearly, a case series of three patients with largely subjective outcome measures is inadequate evidence for the benefit of Botox injections for bilateral RLN paralysis. Furthermore, the patient population who may benefit (stable airway, relatively lateralised vocal folds) will be a small subset of the total number of patients with bilateral RLN paralysis. Nevertheless, this intervention is certainly an interesting option for suitable patients with presumed bilateral RLN neuropraxia, given that the intervention is not permanent and does not preclude other therapeutic options in the longer term.

Reference

Cricothyroid muscle botulinum toxin injection to improve airway for bilateral recurrent laryngeal nerve paralysis, a case series.
Benninger MS, Hanick A, Hicks DM.
JOURNAL OF VOICE
2016;30(1):96-99.

NEUROSURGERY

Delayed facial palsy post vestibular schwannoma resection
Reviewed by: Gauri Mankekar
Vol 25 No 2
 

This article presents findings of a retrospective evaluation of 489 patients who underwent vestibular schwannoma surgery and developed delayed facial palsy. The authors define delayed facial palsy as deterioration of at least two HB grades between postoperative days five and 30. There were 368 patients with House- Brackmann (HB) grade I to III facial palsy which developed between postoperative day five and 30 included in the study. Most patients were observed to recover function within one month of onset. Patients with HB Grade III palsy on postoperative day five who later developed delayed facial palsy required longer recovery periods, often more than 60 days. The authors did not find evidence of steroid or steroids plus antiviral medication influencing recovery in those who received these medications compared to patients who did not. Patients undergoing gross total resections or a retrosigmoid approach were found to be at a higher risk of developing delayed facial palsy. The study suggests that additional nerve manipulation required in gross total resections and introduction of bone dust into the subarachnoid space during internal auditory canal drilling via the retrosigmoid approach may lead to an inflammatory response leading to delayed facial palsy. 

Reference

Incidence and risk factors of delayed facial palsy after vestibular schwannoma resection.
Carlston LP, Copeland WR III, Neff BA, et al.
NEUROSURGERY
2016;78(2):251-5.

NEUROSURGERY

Pituitary tumour associated headaches
Reviewed by: Gauri Mankekar
Vol 25 No 2
 

This longitudinal cohort study presents data with significant clinical implications for patients with headaches and the clinicians and surgeons who treat them. For the study, patients completed a self-administered survey on headache characteristics on initial presentation and after surgery of the pituitary gland. The study found that frequent, disabling headaches were common in patients with pituitary lesions, especially amongst younger women with a pre-existing headache disorder. Seventy-two percent of the patients reported headaches localised to the anterior region of the head. Forty-seven percent of the patients had reported prior diagnosis of migraine or other primary headache. Pituitary surgery was found to improve or resolve headache in the majority of patients with disabling headaches prior to pituitary surgery. According to the authors, pituitary headaches could be primary or secondary and the current ICHD criteria do not define the headaches adequately. Based on the findings of the study, the authors suggest a revision of the International Classification of Headache Disorders (ICHD) diagnostic criteria with addition of an additional diagnostic category for headache attributed to pituitary disease. 

Reference

Headache in patients with pituitary lesions: a longitudinal cohort study.
Rizzoli P, Iuliano S, Weizenbaum E, Laws E.
NEUROSURGERY
2016;78(3):316-23.

OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY – HEAD AND NECK SURGERY

Advancing the tongue in OSA surgery
Reviewed by: Suzanne Jervis
Vol 25 No 2
 

This article further delineates the options for hypopharyngeal OSA and describes the technique of genioglossus advancement to improve the tension in the tongue base. The authors take the reader through the relevant anatomy appropriate to the procedure and describe the technique as originally coined in 1984. They then subsequently walk you through the various alterations to this technique that have been described to avoid complications, most specifically the risk of mandibular fracture. They are supported with line drawings that aid the multitude of descriptions. Unfortunately, what becomes apparent is that there is no widely accepted technique with supporting evidence that demonstrates effectiveness of this sort of surgery. It suffers the same drawbacks as with hyoid suspension in that it is often combined with other surgical procedures for OSA, correcting other levels of collapse in addition. Case series are also small with varying definitions of surgical success. It still appears to be in the pioneering stage of development and with risks including bone necrosis and fracture, violation of dental roots and neurosensory changes. It is not recommended for the faint hearted! 

Reference

Genioglossus advancement for obstructive sleep apnea.
Wirtz N, Hamlar D.
OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY – HEAD AND NECK SURGERY
2015:26(4);193-6.

OTOLARYNGOLOGY – HEAD AND NECK SURGERY

Hypoglossal stimulation for OSA
Reviewed by: Thomas Jacques
Vol 25 No 2
 

Continuous positive airway pressure (CPAP) is a highly effective treatment for moderate-to-severe obstructive sleep apnoea (OSA), but suffers significantly from poor patient adherence. This paper reports the three-year outcomes of a prospective multicentre cohort study examining the effect of hypoglossal nerve upper airway stimulation (UAS) on OSA. This treatment is FDA-approved and deemed cost-effective in the USA. Patients with BMI >32 kg/m2 were excluded from the trial, along with those suffering from concurrent other sleep disorders, psychiatric disorders, or severe cardiac / pulmonary disease. All participants had an initial apnoea-hypopnoea index (AHI) of between 20 and 50 events/hr. Patients underwent implantation of a stimulating electrode on the distal hypoglossal nerve, connected to a pulse generator in the subclavicular region, and a respiratory effort sensor in the fourth intercostal space. The tongue base is thereby stimulated in synchrony with inspiration. Of 126 patients receiving the implant, only three required implant removal. Follow-up at 36 months was completed by 116 patients. Treatment response was defined a priori as a decline in AHI by >50%, to <20 events/hr. By this measure, 74% of patients achieved a treatment response. Mean AHI for the cohort declined from 32 initially to 11.5 at 36 months. Self-reported Epworth sleepiness scores and Functional Outcomes of Sleep Questionnaires (FOSQ) improved in a sustained fashion over the same period. Common adverse events included tongue abrasions from repetitive tongue movements over the dentition, and discomfort from electrical stimulation, although both declined significantly over the 36-month trial period. This longitudinal trial demonstrates the efficacy of this novel treatment for OSA, which merits further examination in controlled and comparative studies. The study is limited by its lack of a control group and significant individual differences, but UAS may represent a viable alternative in selected patients not tolerating CPAP. 

Reference

Three-year outcomes of cranial nerve stimulation for obstructive sleep apnea: the STAR trial.
Woodson BT, Soose RJ, Gillespie MB, et al.
OTOLARYNGOLOGY – HEAD AND NECK SURGERY
2016;154(1):181-8.

OTOLOGY AND NEUROTOLOGY

Cochlear implantation in SSD
Reviewed by: Anand Kasbekar
Vol 25 No 2
 

There are currently several trials for cochlear implantation (CI) in single-sided deafness (SSD) being undertaken to answer some of the questions this paper from New York raises. Who is best suited to receive one? What are their outcomes and how best can this be tested? The group have implanted 12 adult patients and four paediatric patients and assessed many more in making their conclusions. It is important to note that there are not sufficiently sensitive tests to demonstrate the subjective benefits that patients receive from CI in SSD in terms of improvement of localisation and speech understanding in difficult listening situations (in real-life situations). The study did not find any differences in localisation pre and post implant. Certain conditions the group state are absolute indications for a CI in SSD: 1) late stage Ménières disease. 2) “At risk” only-hearing ear, e.g. with an acoustic neuroma, implant the non-tumour deaf ear as a back-up in case the better hearing ear is deafened from the tumour. This also allays patient fears of turning completely deaf. 3) Paediatric progressive hearing loss, e.g. enlarged vestibular aqueduct. This is to prevent the untoward sequelae of long duration of deafness and total auditory deprivation. Current studies will inform us of the effect length of deafness has on CI outcomes in SSD and if there is a cut-off point or age. Overall a thought-provoking paper highlighting the challenges clinicians and patients face when deciding on a CI for SSD.

Reference

Single-sided deafness cochlear implantation: candidacy, evaluation, and outcomes in children and adults.
OTOLOGY AND NEUROTOLOGY
Friedmann DR, Ahmed OH, McMenomey SO, et al.
2016;37(2):e154-60.

OTOLOGY AND NEUROTOLOGY

Darn it! It’s going to take longer to get good at stapes surgery!
Reviewed by: Anand Kasbekar
Vol 25 No 2
 

Traditionally, it has been said the learning curve for a particular operation lies between 20 and 30 cases. In stapedotomy, a surgeon is deemed successful and perhaps competent if closure of the air-bone gap (ABG) is reached to within 10dB in more than 90% of patients. To put it another way, if the ABG is >10dB, the operation is seen as a “failure”. In reality we know this is not black and white but shades of grey… Anyhow, this paper suggests redefining that level, stating that the operation should be deemed as being successful if the ABG falls to within 15dB. As a fellow trying to get good at stapes surgery, that is welcome news, especially from a well-known otologist. The paper itself looked at the senior author’s experience of 204 stapedotomies (reverse Fisch technique) from 1999 to 2014. The article suggests that the senior surgeon performed all operations, although I hope that trainees performed some of the procedures! This of course would probably worsen results to some extent, and is probably a discussion for another day. Using more novel techniques of cumulative summation graphs (CUSUM) and the cumulative summation test for the learning curve (LC-CUSUM), a graph can be drawn to find out when the novice surgeon reaches competence and if he/she stays competent. Using the old definition of failure (>10dB ABG), the surgeon did not reach competence in 204 operations. Redefining failure as >15dB ABG meant that it took 43 operations to reach competence (longer than we traditionally thought). This has implications for training and also consenting purposes. This is a welcome study which encompasses several aspects of surgical training. You may want to see how your results compare and you will probably need a medical statistician to help! 

Reference

Outcomes in stapedotomy surgery: the learning curve redefined.
OTOLOGY AND NEUROTOLOGY
Watson GJ, Byth K, da Cruz M.
2015;36:1601–3.

OTOLOGY AND NEUROTOLOGY

The evidence for various treatments of autoimmune ear disease
Reviewed by: Anand Kasbekar
Vol 25 No 2
 

The difficulty with this disease entity is that it is a heterogeneous group of conditions affecting the ear and a widely accepted diagnostic criteria does not exist. It is therefore difficult to conduct a well controlled trial and this systematic review reflects the issue. For otolaryngologists this “voodoo” condition is poorly understood although we love to speculate on the aetiology, and even sometimes manage to convince our patients that we know what the cause of their hearing loss is. Steroids such as prednisolone are the mainstay of treatment and if this fails, most of us would give up. Others would throw the book (and the kitchen sink) at them. This well researched paper provides a brief summary of other treatments such as cyclophosphamide, methotrexate, TNF-apha inhbitors (Golimumab, infliximab, etanercept, rituximab), enoxaparin (Clexane), azathioprine and plasmapheresis. Do any of these agents work? Well, the evidence would suggest not unfortunately, although I am inclined to believe that this is a reflection of the difficulty in conducting studies to test efficacy of treatments and to identify subsets of patients with particular types of autoimmune disease. The important points to note are that: 1) if conducting a trial of patients with autoimmune disease, the patient must have had a trial of steroids to check that the aetiology is indeed autoimmune; 2) steroids may need to be continued for years to prevent (a quicker) hearing loss; 3) cochlear implantation is a viable option for those that are rendered bilaterally profoundly deaf with outcomes as good as matched controls. 

Reference

Systematic review of treatments for autoimmune inner ear disease.
OTOLOGY AND NEUROTOLOGY
Brant JA, Eliades SJ, Ruckenstein MJ.
2015;36:1585–92. 

RHINOLOGY

Nasal steroids do not cause ocular problems
Reviewed by: Suki Ahluwalia
Vol 25 No 2
 

This excellent, high quality and detailed systematic review from Australia dispels the myth propagated recently by some poorly designed studies that intranasal corticosteroids cause intraocular problems. A 40 year review of the usual databases found 665 articles and 19 were selected for this systematic review. Ten were RCTs with several thousand patients reported on in total. The articles variably reported outcomes of lens opacity / cataract formation, intraocular pressure measurements and glaucoma change, in patients including children using intranasal corticosteroids for proven allergic rhinitis and using no other form of steroid administration. Follow-up was up to two years. Various different intranasal corticosteroids had been used over this time period. This review found no difference in intraocular pressure or diagnosis of glaucoma in over 4000 patients in 10 RCTs treated with INCS. Furthermore five studies showed that intraocular hypertension and glaucoma were not worsened by INCS and finally no difference in lens opacity or new diagnosis of cataract in 3000 patients across six RCTs. Modern intranasal corticosteroids are slow release lipophilic compounds, 30% of the administered dose remains in the nose, with a high degree of glucocorticoid receptor affinity, low systematic bioavailability and the remainder swallowed is subject to first pass hepatic metabolism. Side-effects of this medication are minimal and there is certainly now quality evidence to demonstrate that they do not cause ocular problems. 

Reference

Intranasal corticosteroids do not affect intraocular pressure or lens opacity: a systematic review of controlled trials.
Ahmadi N, Snidvongs K , Kalish L, et al.
RHINOLOGY 
2015;53:290-302.

RHINOLOGY

Smoking and immunotherapy – does it worsen outcome?
Reviewed by: Suki Ahluwalia
Vol 25 No 2
 

This interesting study aimed to address the issue of smoking in patients who had their allergic rhinits treated by sublingual immunotherapy (SLIT). Assessment was with validated quality of life questionnaires. There were 163 patients recruited in Greece who had completed their SLIT therapy for allergic rhinitis. Data was then prospectively recorded on quality of life questionnaires which were completed before and after immunotherapy, smoking history was then correlated. The criteria for diagnosis of allergic rhinits and immunotherapy treatment is well documented here and the groups are well matched for comparison. Statistical analysis demonstrates that all patients, regardless of smoking status, show a significantly enhanced quality of life after treatment of their allergic rhinitis by SLIT. They therefore summarise that smoking should not be a contraindication to selecting allergic rhinitis patients for SLIT. 

Reference

Smoking effects on quality of life of allergic rhinitis patients after sublingual immunotherapy.
Katotomichelakis M, Tripsianis G, Daniilidi A, et al.
RHINOLOGY 
2015;53:325-31.

THE HEARING JOURNAL

Auditory neuropathy spectrum disorder
Reviewed by: Linnea Cheung
Vol 25 No 2
 

This is a concise summary of auditory neuropathy and current knowledge of the disorder through review of a recently published article. The terminology of this hearing disorder implies the site of the lesion is neural; however the characteristic electrophysical signature of the condition can occur in patients with pre or post synaptic lesions. The actual functional auditory ability of individual patients is varied. The term ‘auditory neuropathy spectrum disorder’ is now being adopted to reflect the heterogeneity of the causes, site of lesion and the auditory capability of individually affected patients. Several objective measurements hold promise in helping to identify the site of the lesion and thus helping to target treatment. Hearing aids can be beneficial for these patients, as can cochlear implantation, but the response is variable, particularly in patients with post-synaptic disorders. The article concludes by alluding to the mysteries that still surround the disorder – there is a challenge in accurately identifying the site of the lesion and in quantifying the degree or severity; furthermore there is a challenge in selecting and optimising the most appropriate intervention strategy for individual patients.  Clearly further studies into auditory neuropathy spectrum disorder are needed for the future. 

Reference

Mystery surrounds auditory neuropathy spectrum disorder.
He S.
THE HEARING JOURNAL
2016;69(3):33,36-7.

THE JOURNAL OF CRANIOFACIAL SURGERY

Does albumin have an effect on nasal polyposis?
Reviewed by: Stuart Burrows
Vol 25 No 2
 

Sometimes a short paper catches your eye! What causes chronic rhinosinusitis? What causes polyps? Fungi? Biofilms? Allergy? Maybe the lack of albumin? The two authors of this short paper present data that may suggest that the lack of albumin can enable tissue fluid to accumulate in the nasal lining contributing to the formation of nasal polyps. The idea is elegant and simple. They present data from 45 patients and 45 controls with and without polyp disease and their measurements of their albumin levels show a statistical difference between them. They relate not only albumin’s effects on osmotic pressure but also albumin’s nitric oxide carrying capacity to the possible pathogenesis of polyps. With so many causes postulated for sinus and polyp disease this may point to a further avenue for research. 

Reference

Albumin levels in patients with chronic rhinosinusitis with nasal polyps.
Karatas D, Yüksel F.
THE JOURNAL OF CRANIOFACIAL SURGERY
2015;26:e706-8.

THE JOURNAL OF CRANIOFACIAL SURGERY

Maternal angst
Reviewed by: Stuart Burrows
Vol 25 No 2
 

This paper confirms the anxiety that a mother experiences when their child undergoes surgery. The paper focuses on adenoidectomy and adenotonsillectomy for moderate to severe upper airway obstruction showing admirably how anxiety reduces following surgery. The authors recruited 66 mothers and assessed them using anxiety and depression scores. There was no difference in the levels of anxiety based on the sex of the child or if the child was over or under five years of age. The discussion points out that fathers experience less anxiety than mothers in relation to treatments their child undergoes. The study raises many points that are likely to be applicable across the board in surgery and highlights the stress that families are put under when they entrust us with their children. 

Reference

Effects of obstructive sleep apnoea in children as a result of adenoid and / or adenotonsillar hypertrophy on maternal psychologic status.
Ozbay I, Ozturk A, Kucur C, et al.
THE JOURNAL OF CRANIOFACIAL SURGERY
2015;26:2364-7.

THE JOURNAL OF LARYNGOLOGY AND OTOLOGY

A comparison of cold dissection, coblation and diode laser tonsillectomy
Reviewed by: Madhup Chaurasia
Vol 25 No 2
 

Excellence in tonsillectomy is based on the time taken, blood loss and rapid recovery with minimal pain. In this study, 120 children underwent tonsillectomy by three methods, namely cold dissection, coblation and diode laser dissection in three randomly allocated groups of 40 children in each. In cold dissection and laser methods, bipolar diathermy was applied for hamostasis whereas in the coblation method plasma wand set at four was used, although it appears bipolar diathermy was also applied in some patients. The pain and discomfort was recorded on a standardised Wong-Baker FACES pain scale. Results were statistically analysed and showed that coblation required least time, followed by diode laser method. Cold dissection took longest. Blood loss was minimal in the coblation method and maximum in cold dissection technique. In terms of postoperative pain and recovery, coblation method fared best. This is attributed to lower temperatures with minimal collateral thermal tissue damage. Pain after a week was maximum in the diode laser technique. The results of the study which is reasonably powered are comparable with those of previous reports but may be limited due to use of bipolar diathermy. However, the differences between each of the assessment factors in the three methods are minimal and the method applied should not ignore skills and facilities available and bear in mind the cost effectiveness. 

Reference

A randomised controlled trial of coblation, diode laser and cold dissection in paediatric tonsillectomy.
Elbadawey MR, Hegazy HM, Eltahan AE, Powell J.
THE JOURNAL OF LARYNGOLOGY AND OTOLOGY 
2015;129:1058-63.

THE JOURNAL OF LARYNGOLOGY AND OTOLOGY

Division of tongue tie helps breast feeding
Reviewed by: Madhup Chaurasia
Vol 25 No 2
 

The need for frenotomy in children with tongue tie is not universally accepted. It is however understood that among other problems, such as impaired speech, tongue tie impedes breast feeding possibly leading to early weaning. Therefore, with recent resurgence of breast feeding, the need for release of tongue tie has an added dimension. This study looks into breast feeding with and without division of tongue tie, using the Infant Breastfeeding Assessment Tool which has four domains, namely readiness to feed, rooting, fixing (latching on) and sucking pattern. Scores out of three in each domain add up to a maximum of 12 and have been used to assess the outcomes after surgical intervention and co-ordinated breast feeding support. Forty-two children participated in the study of which 36 underwent frenotomy and in this group, 29 mothers (81%) reported improvement in breast feeding. The results were better if frenotomy was performed in infants before the age of 30 days. Only one out of six mothers in the group not undergoing surgical intervention, but receiving continued support from infant feeding co-ordinator, reported improvement. Similar results are quoted from the literature. The authors accept that the numbers are small and telephone assessment could have been biased. However, the publication does emphasise the need for a very simple procedure, not even requiring anaesthesia, if done at an early age.

Reference

Tongue-tie division to treat breastfeeding difficulties: our experience.
Sharma SD, Jayaraj S.
The Journal of Laryngology and Otology 
2015;129:986-9.

THE JOURNAL OF LARYNGOLOGY AND OTOLOGY

Influence of Helicobacter pylori infection in otitis media with effusion
Reviewed by: Madhup Chaurasia,
Vol 25 No 2
 

Otitis media with effusion (OME) affects 20% of children and 10% have a recurrent problem. The incidence of Helicobacter pylori infection in children ranges from 15 to 46%. This study investigates how the presence of Helicobacter pylori infection affects treatment outcomes in children with OME. Of the 258 children diagnosed with OME, 134 (51.9%) were tested positive for Helicobacter pylori infection. These were randomly divided into a control group which received conventional treatment (amoxicillin-clavulanate for four weeks) and a study group which received triple therapy, namely clarithromycin, metronidazole and lansoprazole. In the H. pylori positive patients, results were significantly better in the study group treated with triple therapy than in the control group which received amoxicillin-clavulanate. A comparison between the groups with and without H. pylori infection, both treated conventionally, showed better results in the latter, suggesting adverse effect of H. pylori infection in the management of OME. The study provides an interesting link between two very prevalent conditions. 

Reference

Outcome evaluation of clarithromycin, metronidazole and lansoprazole regimens in Helicobacter pylori positive or negative children with resistant otitis media with effusion.
Mel-Hennavi D, Ahmed MR.
THE JOURNAL OF LARYNGOLOGY AND OTOLOGY
2015;129:1069-72.

THE LARYNGOSCOPE

Recovery rates in sudden sensorineural hearing loss
Reviewed by: Thomas Jacques,
Vol 25 No 2
 

Sudden sensorineural hearing loss (SSNHL) is most commonly idiopathic, and is seen relatively frequently in ENT practice. Recovery spans a period of around 1-2 months, and ultimate outcomes are highly variable, from complete recovery to no detectable hearing. Although the evidence for its use is not strong, administration of systemic and / or intratympanic steroid is standard practice. Reports of patient factors influencing recovery following SSNHL are mixed. The authors performed a retrospective regression analysis on the audiometric outcomes of 781 patients treated for idiopathic SSNHL, controlling for gender, age, pretreatment hearing, treatment delay and comorbidities. The results indicated significantly higher likelihood of significant recovery of hearing in: better pre-treatment hearing, prompter treatment, and absence of diabetes mellitus and hypercholesterolaemia. The study shows associations between various patient factors and the prognosis in idiopathic SSNHL, with data from a large sample of patients. This is helpful in risk-stratifying such patients, and also adds weight to the hypothesis that there is an angiopathic factor behind the condition. The cochlear blood supply is precarious, increasing its sensitivity to macro- and microangiopathy. 

Reference

Effect of comorbid diabetes and hypercholesterolemia on the prognosis of idiopathic sudden sensorineural hearing loss.
Lin CF, Lee KJ, Yu SS, Lin YS.
THE LARYNGOSCOPE
2016;126:142-9.

ACTA OTO-LARYNGOLOGICA

Does a labyrinthine fistula in cholesteatoma surgery lead to hearing loss?
Reviewed by: Bhaskar Ram
Vol 25 No1
 

Thirty-five patients with labyrinthine fistula related to cholesteatoma were studied retrospectively. All patients underwent CT scans and preoperative hearing tests 1-2 weeks prior to surgery (averaged at 0.5, 1, 2, 3, 4, 8 kHz). All 35 patients underwent mastoid surgery, 18 radical mastoidectomies, 16 canal wall down mastoidectomies with tympanoplasty and Bondy’s procedure. Postoperatively only 21 patients were followed up with postoperative audiograms. Twenty-five patients had fistulas of the lateral semicircular canal, four of the posterior semicircular canal, two of the superior semicircular canal and four with involvement of a semicircular canal and the vestibule and / or cochlea. After removal of cholesteatoma matrix from over the fistula, the defect was covered with temporalis fascia (in all cases including in the radical mastoidectomy group). In this group none of the patients had worse hearing, in spite of cholesteatoma matrix removal from over the fistula. Unfortunately only 21 patients were available for follow- up.

Reference

A retrospective study on post-operative hearing of middle ear cholesteatoma patients with labyrinthine fistula.
Bo Y, Yang Y, Xiaodong C, et al.
ACTA OTO-LARYNGOLOGICA
2016;136(1):8-11.

AMERICAN JOURNAL OF OTOLARYNGOLOGY-HEAD AND NECK MEDICINE AND SURGERY

A spoonful of sugar… helps the operated sinuses calm down?
Reviewed by: Rohit Verma
Vol 25 No1
 

Ottoviano et al. present a prospective double-blinded RCT to assess the effect of a nasal gel containing silver sucrose octasulfate (Silsos Gel) on wound healing after endoscopic sinus surgery. The placebo used was a glycol gel. Thirty-four consecutive patients were included in the study. Exclusion criteria included those with previous sinus surgery or auto-immune disease. Endoscopic biopsies of the anterior ethmoid mucosa were taken at the time of surgery and 90 days postoperatively. Patients were assigned to the treatment gel or placebo, two sprays into each nostril BD for one month postoperatively. Patients were reviewed at 15, 30 and 90 days postoperatively. The Silsos gel group experienced a more rapid improvement as judged by Lund-Kennedy and SNOT-22 assessment, especially in the first 15-30 days postoperatively. The endoscopic appearance was also improved at day 90 postoperatively as compared to the placebo group. Histologically, there were fewer cells with abnormal cilliary morphology in the treatment group as compared to the placebo group at 90 days postop.  This study suggests that Silsos gel should be considered as an adjunct in the postoperative management of patients undergoing endoscopic sinus surgery in order to increase the rate of mucosal healing.

Reference

Silver sucrose octasulfate nasal applications and wound healing after endoscopic sinus surgery: a prospective, randomized, double-blind, placebo-controlled study.
Ottaviano, Blandamura S, Fasanaro E, et al.
AMERICAN JOURNAL OF OTOLARYNGOLOGY-HEAD AND NECK MEDICINE AND SURGERY
2015;36(5):625-31

AMERICAN JOURNAL OF OTOLARYNGOLOGY-HEAD AND NECK MEDICINE AND SURGERY

Salivary gland blues…
Reviewed by: Rohit Verma
Vol 25 No1
 

Intravenous methylene blue is a well-described method to assist in intraoperative localisation of parathyroid glands. The technique does come with challenges as anybody will know who has had to run adjacent to a theatre-bound trolley to ensure that the infusion starts preoperatively. This randomised trial involving 144 patients investigated the benefits of methylene blue during parotid surgery. The technique involves trans-oral cannulation of Stensen’s duct, ‘several minutes’ before surgery. The surgery types were divided into four groups; partial superficial, standard superficial, selective deep lobe and total parotidectomies. There were 70 cases where methylene blue was used and 74 without. Importantly 4/70 patients had total parotidectomy using methylene blue whilst 9/74 underwent total parotidectomy without methylene blue. There was a significant difference reported in rates of tumour recurrence and permanent facial nerve palsy, with higher rates in the non-methylene blue group (1.4% vs 6.7%). However it is not clear in what type of procedure these complications arose (i.e. total vs superficial parotidectomy) and what pathology was identified in these cases. The authors acknowledge that the non-methylene blue group did have a disproportionate number of procedures that inherently placed the facial nerve at greater risk. The lower rate of tumour recurrence may point towards methylene blue making it easier to identify the capsule of the salivary gland in order to facilitate complete excision. The authors suggest that methylene blue staining of the parotid gland does not increase the risk of complications, it may help to identify the nerve and does not compromise the subsequent histological diagnosis.

Reference

Methylene blue staining in the parotid surgery: Randomized trial, 144 patients.
Vaiman M, Jabarin B, Abuita R.
AMERICAN JOURNAL OF OTOLARYNGOLOGY-HEAD AND NECK MEDICINE AND SURGERY
2016;37(1):22-6.

AMERICAN JOURNAL OF OTOLARYNGOLOGY-HEAD AND NECK MEDICINE AND SURGERY

The middle way: treating idiopathic facial nerve palsy
Reviewed by: Rohit Verma
Vol 25 No1
 

Whilst the causes of recurrent facial nerve palsy are numerous, in many cases it may be idiopathic. There is no clear consensus on treatment of this condition and conservative management alone may condemn patients to gradually worsening facial nerve function after repeated attacks. This group reports on their series of 12 cases where they have undertaken facial nerve decompression via a middle fossa approach. They selected 18 patients with at least two episodes of facial palsy, 12 received surgery whilst six declined and were treated conservatively. In the operated group the internal auditory canal segment, meatal foramen, labyrinthine segment and geniculate ganglion were decompressed within three weeks. Those managed conservatively (control group) received oral prednisolone, 1 mg/kg/d for 10 days. The patients in the surgery group and the control group were followed up for 5.8 and 5.5 years respectively. Facial nerve function was assessed by the House–Brackmann facial nerve grading system. In the operated group, one patient had further episodes of facial palsy on the ipsilateral side, whilst in the control group, 4/6 had further episodes of ipsilateral facial palsy. The initial mean facial nerve function of the surgery group was HB 3.5 and of the control group was HB 3.7 After treatment, 11 patients in the surgery group recovered to Grade I or Grade II, amongst which six patients totally recovered. In contrast, only half of the control group recovered to Grade I or Grade II and the other three cases returned to Grade III or worse level due to further episodes of facial palsy. Hearing was preserved in all patients, and there was no severe complication. This study highlights an invasive, yet effective method to treat recurrent idiopathic facial palsy.

Reference

Idiopathic recurrent facial palsy: facial nerve decompression via middle cranial fossa approach.
Zhu Y, Yang Y, Wang D, Dong M. 
AMERICAN JOURNAL OF OTOLARYNGOLOGY-HEAD AND NECK MEDICINE AND SURGERY 
2016;37(1):31-3

AURIS NASUS LARYNX

Prognostic factors for myringoplasty
Reviewed by: Ravi Thevasagayam
Vol 25 No1
 

This retrospective study looked at the factors that were associated with a higher success rate for tympanic membrane perforation closure. The authors looked at 247 procedures. They compared the results of temporalis fascia versus tragal cartilage. The cartilage grafts had a higher successful closure rate. There was no significant difference in hearing results between these groups. The main factors associated with lower success rates were age (under 16 in this study), adenoidal hypertrophy and disease in the contralateral ear. No major surprises then, but this study seems to support the trend towards using cartilage grafts, particularly when the conditions are less favourable. 

Reference

Prognostic factors in type I tympanoplasty.
Mehti Salviz A, Ozlem Bayram A, Ali Alper Bayram A, et al.
AURIS NASUS LARYNX
2015;42:20-3

AURIS NASUS LARYNX

Risk factors for post laryngectomy fistula
Reviewed by: Ravi Thevasagayam
Vol 25 No1
 

This is a meta-analysis looking at the postoperative pharyngocutaneous fistula rates following total laryngectomy. The authors ended up with 34 studies with about 2500 patients. The most striking finding was that preoperative radiotherapy was a significant risk factor as well as positive margins and a postoperative haemoglobin of less than 12.5g/L. The authors also suggest tumour subsite (supraglottic v glottic) and T stage although these seem less clear cut. I wonder if the skill of the surgeon is a major risk factor particularly in view of the fact that the fistula rate ranged from 7.4% to 58%! One for another study perhaps. 

Reference

Pharyngocutaneous fistula after total laryngectomy: a systematic review and meta-analysis of risk factors.
Liang J-W, Li Z-D, Li S-C, et al.
AURIS NASUS LARYNX
2015;42:353-9.

B-ENT

BPPV duration as a predictor for therapy
Reviewed by: Sunil Sharma
Vol 25 No1
 

Benign paroxysmal positional vertigo (BPPV) is one of the most common vestibuar disorders encountered in the neurotology clinic. The majority of cases of BPPV are due to vestibuar lithiasis in the posterior semicircular canal, but there are reports of cases involving the lateral semicircular canal, or more rarely, the superior semicircular canal. There are excellent results in terms of resolution of symptoms with canalith repositioning techniques, but there is a group of patients who don’t respond to treatment, and require repeated manoeuvers, or who develop rapid recurrence of their symptoms after initial successful treatment. The authors in this Greek study attempted to determine if duration of BPPV had a prognostic impact on resolution of symptoms. They performed a retrospective study of all patients diagnosed with posterior semicircular canal BPPV over a three-year period, and split the patients into two groups; those who had BPPV of recent onset (<4 weeks, n=110) and those who had longer duration of BPPV at presentation (>4 weeks, n=121). The outcome of treatment was similar in both groups, but the rate of recurrence of symptoms was significantly higher in those patients with BPPV of longer duration (21.5% vs 10%). The authors postulate that the reason for the higher rate of recurrence may be due to the higher mean age of the group with BPPV of longer duration (58.2 vs 51.3 years), causing more extensive degenerative changes in the inner ear of the older patients. These findings may have implications in the follow-up for patients who report a longer duration of BPPV at initial presentation, as they may be more susceptible to recurrence of symptoms. 

Reference

Duration of benign paroxysmal positional vertigo as a predictor for therapy.
Balatsouras DG, Aspris A, Ganelis P, et al. 
B-ENT
2015;11:199-203.

BMC EAR, NOSE AND THROAT DISORDERS

Assessment of the incidence of LPR in the Greek population using the Reflux Symptom Index
Reviewed by: Gauri Mankekar
Vol 25 No1
 

Using the self-administered nine-item Belafsky Reflux Symptom Index (RSI) questionnaire, the authors of this article assessed the prevalence of laryngopharyngeal reflux (LPR) in the general adult Greek population as well as predisposing and associated factors for developing LPR. They found that the incidence of LPR in the Greek population was 18.8% without any statistically significant gender preponderance. The prevalence was high in the 50-64 age group. Smoking tobacco and consumption of alcohol was found to be associated with LPR. They did not find any other concomitant disease or medication to be related with LPR. This could be due to the small sample size of the population under study. The authors found RSI an easy and useful tool to assess for LPR in clinical practice. Similar epidemiological studies using the RSI may enable us to understand the aetiology, diagnosis of LPR and manage it better. 

Reference

Laryngopharyngeal reflux disease in the Greek general population, prevalence and risk factors.
Spantideas N, Drosou E, Bougea A, Assimakopoulos D.
BMC EAR, NOSE AND THROAT DISORDERS
2015;15(7): doi: 10.1186/s12901-015-0020-2.

BMC EAR, NOSE AND THROAT DISORDERS

CSOM in Mwanza, Tanzania
Reviewed by: Gauri Mankekar
Vol 25 No1
 

This is a prospective, cross-sectional study involving 301 patients consisting of farmers, students and employed professionals attending an ENT clinic in Mwanza, Tanzania. Of the 301 patients, 13 were HIV positive; 37.9% had some degree of conductive / sensorineural / mixed hearing loss; 16 required surgical debridement and five underwent mastoidectomy. Pseudomonas spp was the commonest gram negative isolate while Staphylococcus aureas was the commonest isolate amongst gram positive bacteria. Fourteen isolates were identified as methicillin resistant Staphylococcus aureus. The bacterial growth rate in this study was lower than in previous studies done in other countries and the authors postulate that this could be due to prior use of antibiotics and inability to perform anaerobic culture in the present study. They observed that those with positive HIV status and smokers respond poorly to treatment. They also observed that ignorance, home based treatment, cost of treatment, poverty and poor infrastructure contributed to prolonged duration of illness which contributed to disease complications such as hearing loss. This study adds to the existing literature on the epidemiology of chronic otitis media in the developing world.

Reference

Predictors of disease complications and treatment outcome among patients with chronic suppurative otitis media attending a tertiary hospital, Mwanza Tanzania.
Mushi MF, Mwalutende AE, Gilyoma JM, et al.
BMC EAR, NOSE AND THROAT DISORDERS
2016;16(1): doi: 10.1186/s12901-015-0021-1.

CLINICAL OTOLARYNGOLOGY

Is major ear surgery financially viable?
Reviewed by: Andy Hall
Vol 25 No1
 

It is difficult to ignore the present reality in the NHS that understanding clinical coding is perhaps of more relevance to the practising clinician than the human genome! Clinician engagement is becoming more essential to protect patient care and maximise potential service delivery and it is naturally important that ENT isn’t left behind. This retrospective financial analysis takes a single consultant experience over a two year period and looks to explore the variables that determine cost and profit for major ear surgery using real accountancy and theatre data. The overall complexity of the presently used ‘payment by results’ system is highlighted by the authors and the frequent disparity between the service delivered and the cost required to deliver that service is made clear. Only 21 out of 76 patient spells returned a profit with an overall net loss of £-1345.50 per patient. Most critically there was a strong relationship between overall theatre time and total costs. Only 6% of variation in earnings was due to factors other than theatre time or chance which appears staggering. As surgeons we will be subject to increasing analysis on profitability, therefore a greater understanding of the process is required. Driving forward accurate tariff remuneration is a key part of that process and articles such as this are an important step in the right direction. 

Reference

A break-even analysis of major ear surgery.
Wasson JD, Phillips JS.
CLINICAL OTOLARYNGOLOGY
2015;40:422-7.

CLINICAL OTOLARYNGOLOGY

Rhinosweetometry
Reviewed by: Andrew Hall
Vol 25 No1
 

An article that elicits a wry smile from the reader is worth drawing attention to particularly in the winter months. This account of brave self-experimentation is unlikely to lead to a future Nobel prize but nonetheless reinforces the important principle that we should always estimate the overall necessity of intervention against non-intervention in our surgical actions. Five popular sweets (mint, fruit or chocolate based) were placed in the right nasal cavity under the inferior turbinate of the author and the time taken to dissolve was recorded. All dissolved in under one hour although mint enthusiasts may be keen to know that a polo takes approximately fifteen minutes longer to dissolve than a tic tac! The authors suggest that if a paediatric nasal foreign body is clearly a sweet of the sugary / chocolate variety – a watch and wait approach is prudent in the first instance. This article is placed between a number of particularly worthy but intense articles based on statistics and immunology and for those who read Clinical Otolaryngology ‘cover to cover’ it provided a refreshing change in tone! 

Reference

Nasal Foreign Bodies: A Sweet Experiment.
Leopard DC, Williams RG.
CLINICAL OTOLARYNGOLOGY
2015;40:420-1.

CLINICAL OTOLARYNGOLOGY

The perils of poor postop blood pressure control
Reviewed by: Andrew Hall
Vol 25 No1
 

This retrospective case control study reviews 621 patients undergoing thyroid surgery over a 10-year period from 2002-2012 looking at postoperative haemorrhage rates. This potentially catastrophic complication warrants close analysis in order to best discern how it can be minimised. The benchmark incidence in high volume thyroid centres is 0.3-1%, while for this analysis the overall rate recorded was 2.57%. The principle independent risk factor for postoperative haemorrhage on the day of surgery after multivariate regression was found to be postoperative systolic blood pressure level. There was a 39% increase in risk of bleeding for every 10 point rise in systolic blood pressure over 170mmHg. (Odds ratio: 1.39; 95% CI= 1.09-1.8.) Regular blood pressure review and decisive action to control the systolic blood pressure in the early postoperative period would appear a wise recommendation. The authors do not presently suggest the best means of policing this parameter but this is an area of attention needing to be highlighted to nursing staff and junior surgeons alike. 

Reference

Postoperative systolic blood pressure as a risk factor for haematoma following thyroid surgery.
Morton RP, Vandal AC.
CLINICAL OTOLARYNGOLOGY
2015;40:462-7.

COCHLEAR IMPLANTS INTERNATIONAL

Can intraoperative electrically evoked auditory brainstem responses predict the outcome of cochlear implantation?
Reviewed by: Thomas Nikolopoulos
Vol 25 No1
 

Electrophysiology during cochlear implant surgery remains an issue of debate among the various centres. In the present study, the latencies and quality of the eABR waveforms from 74 adult implanted patients were analysed. In addition, four children with severe cochlear abnormalities were also reviewed. It was interesting to note that wave V in the mid- and low-frequency regions was the most robust and that significant latency shifts occurred in wave V from the low- to high-frequency regions. Although no correlations were found between waveform score, wave V–III interval, wave V latency, and MS-word scores, a negative eABR always predicted a negative outcome. The latter is associated with feelings of stimulation without actual hearing, very high levels in the tuning map postoperatively, and other negative parameters. Although the literature is more or less inconclusive, the results of this study support intraoperative electrophysiology taking into account the related limitations. 

Reference

Prognostic value of electrically evoked auditory brainstem responses in cochlear implantation.
Lundin K, Stillesjö F, Rask-Andersen H.
COCHLEAR IMPLANTS INTERNATIONAL 
2015;16(5):254-61.

COCHLEAR IMPLANTS INTERNATIONAL

Hearing preservation and device benefit following implantation of short or hybrid electrodes
Reviewed by: Thomas Nikolopoulos
Vol 25 No1
 

Hybrid or short electrodes have increasingly been used in the literature in order to combine electrical with hearing-aid stimulation. However, hearing preservation of the residual low-frequencies are of utmost importance in this attempt. The present study compared hearing preservation and performance of the device following the loss of residual hearing using a short electrode array and an even shorter hybrid implant.  It was very interesting to note that one year following implantation, 30% of patients with the Hybrid-L and 58% of patients with the CI422 lost residual acoustic hearing resulting in a profound hearing loss in the implanted ear. In contrast, mean CNC words in the implanted ear were 72% in the CI422 electrode group and 15% in the Hybrid-L electrode group at one year and the difference was statistically significant. The authors concluded that although shorter electrodes may have better rates of hearing preservation, the deterioration of speech understanding following the loss of residual hearing is greater in patients implanted with these electrodes. The whole situation is rather alarming, especially if we take into account the related cost-effectiveness and the fact that this study had only one year follow-up. 

Reference

Effects of loss of residual hearing on speech performance with the CI422 and the Hybrid-L electrode. 
Friedmann DR, Peng R, Fang Y, et al.
COCHLEAR IMPLANTS INTERNATIONAL 
2015;16(5):277-84.

DYSPHAGIA

Changes in swallowing function after thyroidectomy
Reviewed by: Roganie Govender
Vol 25 No1
 

Evaluation of functional impact following thyroidectomy tends to be focused on voice quality. The aim of this study was to document early (seven days postoperatively) and late changes (60 days postop) in swallowing function after thyroidectomy. A preoperative naso-endoscopic evaluation was performed to classify patients into groups of either normal laryngeal mobility (NLM: n = 39) or abnormal laryngeal mobility (ALM: n = 15). A FEES assessment of swallowing was performed at seven and 60 days post surgery, to evaluate four swallowing parameters: premature spill of food; laryngeal penetration; aspiration; post swallow residue / retention. Of the 54 patients included in this study, 87% with ALM and 44% with NLM demonstrated some dysphagia. Laryngeal penetration and aspiration occurred more frequently (33%) in the ALM group, particularly for liquids. For both groups, the most notable problem was post swallow retention – thick liquids and paste being worse than thin liquids. While swallowing abnormalities were more common in the early phase, they were found to persist (particularly problems with residue / retention) into the late phase regardless of laryngeal mobility. The authors also highlight that for the ALM group – even patients who demonstrated recovery of laryngeal movement by the late phase, continued to demonstrate abnormalities in post swallow residue. They postulate that perhaps the surgical access approach / cervical manipulation may account for these findings – citing studies using robotic techniques that report less impact on swallowing to support their argument.

Reference

Videoendoscopic evaluation of swallowing after thyroidectomy: seven and 60 days. 
Arakawa-Sugueno L, Ferraz AR, Morandi J, et al.
DYSPHAGIA 
2015;30:496–505.

HEAD AND NECK

Risk factors for TORS treatment failure in HPV-related oropharyngeal cancers
Reviewed by: Jonathan Hughes
Vol 25 No1
 

HPV-related squamous cell cancers are an increasingly common cause of malignancy in the oropharynx. There is evidence that these cancers are associated with a significantly improved overall survival compared to conventional HPV-negative tumours. The optimal treatment for such cancers is uncertain and deintensification therapeutic regimes are the subject of ongoing research. Some studies have shown that single modality treatment, including transoral robotic surgery (TORS), may be sufficient. It has also been suggested that surgical management may allow better patient risk stratification than radiotherapy, through evaluation of established risk factors such as extracapsular spread (ECS), and guide selection of adjuvant therapy in high-risk patients. This study, from a leading TORS centre, examined 114 patients with HPV-positive oropharyngeal cancer treated with an initial TORS resection (although many of the patients went on to receive adjuvant radiotherapy +/- chemotherapy) and analysed factors associated with treatment failure. A two-year 3.3% locoregional and 8.4% distant failure rate was reported. None of the established risk-factors for treatment failure, such as ECS or margin status, were found to be significant. Further research is needed with larger sample sizes and a clearer distinction between the treatment modalities, to determine the optimal treatment of HPV-related oropharyngeal cancer.

Reference

HPV-related oropharyngeal cancer: Risk factors for treatment failure in patients managed with primary transoral robotic surgery.
Kaczmar JM, Tan KS, Heitjan DF, et al. 
HEAD AND NECK  
2016;38(1):59-65.

HEARING RESEARCH

Otolith dysfunction in congenitally deaf adults
Reviewed by: Hannah Blanchford
Vol 25 No1
 

This paper helps to further define the profile of ocular and cervical vestibular-evoked myogenic potentials (o and c VEMPs) in patients with congenital profound sensorineural hearing loss (PSHL). It highlights the prevalence of otolith (saccular and utricular) dysfunction that exists in patients with PSHL, despite balance problems not featuring significantly in their case notes. The authors use cVEMP to assess saccular function and oVEMP as likely to represent utricular function. Twenty-nine patients (aged 18-63) with congenital bilateral PSHL and normal inner ear anatomy (defined by CT scan) and 20 healthy volunteers were included. The response rate in the PSHL group was 38.9% for oVEMPs and 44.4% for cVEMPs. It was 100% for the control group for both oVEMPs and cVEMPs. In the control group 10% showed abnormal calorics. In the PSHL group, 74.1% demonstrated an abnormality. The study demonstrated that utricular and saccular dysfunction appears to affect more than half of the adult cohort with congenital PSHL in addition to semicircular canal dysfunction. In comparison with the control group, of those patients with PSHL who did demonstrate the presence of oVEMPS and cVEMPS, many showed impairment of these responses: namely, abnormal thresholds, amplitudes and latencies. Interestingly, in the analysis of their medical records, neither patients nor doctors referred to any balance or vestibular dysfunction. The authors conclude that visual sensory system compensation may help ‘conceal’ the otolithic dysfunction in these patients. I would certainly be interested in future prospective studies which ask more specifically about functional balance abilities in patients with PSHL and wonder whether this is something we should be asking about more in the assessment of patients with hearing loss.

Reference

The hidden dysfunction of otolithic organs in patients with profound sensorineural hearing loss. 
Xu X, Ding C, Yu J, et al.
HEARING RESEARCH
2016;331:41-6.

INTERNATIONAL JOURNAL OF LANGUAGE AND COMMUNICATION DISORDERS

Verbal memory and chronic speech and language disorders following stroke
Reviewed by: Gauri Mankekar
Vol 25 No1
 

Stroke is often associated with chronic language disorders like aphasia and apraxia as well as memory impairments. Studies have found that memory problems in stroke are often verbal memory disorders. This review article discusses the association between language and short-term and working memory impairments in aphasia as well as differential diagnosis of memory disorders and concomitant disorders like speech apraxia. In addition, the authors provide a critical appraisal of published treatments and outcomes. They suggest adopting specific protocols based on practice based evidence to assess short-term and working memory impairment in aphasic patients as part of the rehabilitation. This is an excellent review providing speech language therapists with practical knowledge on the assessment and treatment of short-term and working memory impairment in aphasia. 

Reference

Assessment and treatment of short term and working memory impairments in stroke aphasia: a practical tutorial.
Salis C, Kelly H, Code C.
INTERNATIONAL JOURNAL OF LANGUAGE AND COMMUNICATION DISORDERS
2015;50(6):721-36.

JOURNAL OF CRANIO-MAXILLO-FACIAL SURGERY

Sialendoscopy assisted excision of parotid stones
Reviewed by: Sunil Kumar Bhatia
Vol 25 No1
 

This is a retrospective paper from China that looks to assess the efficacy and safety of sialendoscopy with a combined transoral or transcutaneous approach for the removal of parotid stones. Sialolithiasis is known to be a cause for obstructive parotid conditions and account for a number of surgical procedures. Superficial parotidectomy is the generally accepted treatment of intractable obstructive disease. There are however the postoperative complications of facial nerve damage, facial hollowing, Frey’s syndrome and persistent postoperative pain. Any method that allows for the reductions of parotidectomy and the postoperative sequelae is a welcome addition to the surgeon’s armamentarium. This is a well written paper that is easy to follow and outlines investigation and surgery. Twenty-nine patients were diagnosed with parotid gland sialolithiasis; this was confirmed with ultrasound and computed tomography. All operations were carried out under local anaesthetic to confirm the presence of the stone and assess size / suitability for removal. If the movable stone was retrievable (as it was in nine patients) then it was removed. If the stone could not be retrieved as it was bigger than 3mm or impacted, a transoral procedure was carried out (15 patients), and if this failed then the siaendoscope was used to pinpoint the stone and a small cutaneous incision performed (five patients). Postoperatively sialenscopy was used to wash out,  inspect the gland, and insert a  stent. There were no postoperative complications. All patients had functioning parotid glands. This is also a good paper to read if one is contemplating starting a sialendoscopy service. There are good photographs and a discussion of sialendoscopy. The summary of discussion on sialendoscopy is particularly useful for exam preparation. 

Reference

Endoscopic-assisted gland preserving therapy for the management of parotid gland sialolithiasis: our preliminary experience.
Zheng L, Xie L, Zhijun W et al.
JOURNAL OF CRANIO-MAXILLO-FACIAL SURGERY 
2015;43:1650-4.

JOURNAL OF PLASTIC, RECONSTRUCTIVE AND AESTHETIC SURGERY

Treating keloid scarring with pressure clips following excision: does it work?
Reviewed by: Elinor Warner
Vol 25 No1
 

Keloid scars can pose a difficult management problem. Whilst not harmful in themselves they can be cosmetically unappealing and lead to social embarrassment and resulting isolation, and following surgical excision they often reoccur. Mechanical pressure is an adjuvant to surgical treatment that has been found to have some efficacy. Ear pressure clips have been devised to allow constant pressure to be applied to external ear keloids. Previous efforts have used clips made from methylmetacrylate which are not pressure adjustable. The team in the Netherlands followed up 88 patients who were using an adjustable custom made pressure clip (for up to 12 hours a day for 6-18 months) following keloid scar excision surgery and assessed for recurrence of keloid and patient satisfaction using the POSAS scale. The recurrence rate was 29.5%, compared to other studies showing 10-20% recurrence rate, however the authors argue that their prolonged period of follow-up (mean 6.5 years compared to 23 months), and findings of late recurrences (at three years) explain this difference. Recurrence rates in darker skin tones were significantly higher, fitting with available literature on this condition. Patient opinion, comfort, appearance and openness for retreatment were all significantly higher in the non-recurrence group, although there was no statistically significant difference in compliance and duration of treatment. There was also a significant improvement in all POSAS scores before versus after treatment. Overall almost 50% had some discomfort and / or itching, but no serious complications were recorded, making this adjustable device superior in terms of avoiding pressure sores and necrosis. Despite the authors’ enthusiasm for custom-made clips, this device is expensive and time consuming to make. The appearance is unsightly, it needs to be applied for up to 12 hours a day and causes discomfort one wonders if this is likely to be an agreeable and acceptable solution for these patients.

Reference

Efficacy of custom-made pressure clips for ear keloid treatment after surgical excision.
Tanaydin V, Beugels J, Piatkowski A, et al.
JOURNAL OF PLASTIC, RECONSTRUCTIVE AND AESTHETIC SURGERY 
2015;69(1):115-21.

JOURNAL OF VOICE

Voice outcomes following extended laser resections for laryngeal cancer
Reviewed by: Christopher Burgess
Vol 25 No1
 

It is now widely accepted that the oncological and voice outcomes following transoral laser microsurgery for early T1a glottic cancers are equivalent to, if not superior to, traditional radiotherapy. Voice outcomes following more extensive resections have not been as frequently investigated or reported however. This paper reviews the postoperative vocal outcomes from a cohort of patients who underwent European Laryngological Society (ELS) cordectomy types III-VI (resection into or beyond the vocalis muscle) for glottic cancers at a single institution. Eleven patients met the inclusion criteria, and outcomes were reported in terms of pre and postoperative voice handicap index (VHI) scores, maximum phonation time (MPT), and Grade and Breathiness scores. VHI was noted to worsen in the acute postoperative phase (up to four months after surgery) but had significantly improved compared to preoperative levels at long-term follow-up (greater than six months postoperatively). Grade and Breathiness also worsened in the short term but had returned to preoperative levels in the longer term. The only parameter that did not improve or return to preoperative levels was maximum phonation time. Three patients from the cohort underwent subsequent injection laryngoplasty or thyroplasty and are reported to have responded well. Although limited by small patient numbers and the retrospective nature of the study, the data from this paper certainly suggest that good long-term voice outcomes can be expected in the majority of patients who undergo extensive glottic soft-tissue resection for cancer. Such patients should be counselled preoperatively about the likelihood of an initial period of worsening of voice quality, and the potential requirement for laryngeal augmentation procedures in a small minority. 

Reference

Longitudinal voice outcomes following advanced CO2 laser cordectomy for glottic cancer.
Mendelsohn AH, Matar N, Bachy V, Lawson G, Remacle M.
JOURNAL OF VOICE
2015;29(6):772-5.

NEUROSURGERY

Novel balloon device to control cavernous sinus bleeding
Reviewed by: Gauri Mankekar
Vol 25 No1
 

In their Letter to the Editor, the authors suggest a draft for a novel balloon catheter device for sinus haemostasis during trans-sphenoidal surgery which is associated with uncontrollable sinus bleeding in 1-8% cases. Their proposed device has a single lumen tube which extends from the embedded end of the catheter to another terminal where a one-way check valve is located. They recommend that following adenoma surgery, the cavity should be filled with gelatin sponge, then the balloon device should be embedded in the cavity and the balloon inflated with air or water gently until haemostasis is achieved. The device could be removed on postoperative day seven transnasally. The letter also discusses current measures for controlling sinus bleeding including dexmedetomidine infusion; coagulating dural layers with angled bipolar coagulators; use of specially devised clip appliers and titanium clips; coil embolisation of intercavernous sinus; application of microfibrillar collagen haemostat or fleece coated fibrin glue and suturing of the medial wall of the cavernous sinus. 

Reference

Letter: An imaginary hemostasis device for sinus bleeding during transsphenoidal surgery. 
Tian C, Wang X, Wang X, Xiong W. 
NEUROSURGERY
2016;78(1):E160-1.

NEUROSURGERY

Reducing readmission rates after transsphenoidal pituitary surgery
Reviewed by: Gauri Mankekar
Vol 25 No1
 

This retrospective study provides an outpatient care pathway to screen and manage delayed hyponatremia which the study identified as the primary cause of readmission following transsphenoidal pituitary surgery. Of the 303 patients who were studied, 27 were readmitted within 30 days and 15 of the 27 patients had delayed hyponatremia. Other causes for readmission were diabetes insipidus, adrenal insufficiency, cerebrospinal fluid leak, epistaxis, cardiac arrhythmia, pneumonia, urinary tract infection and hypoglycemia. The authors recommend screening for hyponatremia within seven days of surgery as patients reach the nadir of their sodium levels around the seventh day postop. Earlier identification helps to manage the sodium levels on an outpatient basis with fluid restriction and salt supplementation and decreases the incidence of readmission. They also recommend using a corticosteroid-sparing protocol to decrease readmission rates for adrenal insufficiency. This study and similar others to follow highlight the importance of providing safe and cost effective health care in the modern era.

Reference

Delayed hyponatremia is the most common cause of 30 day unplanned readmission after transsphenoidal surgery for pituitary tumors.
Bohl MA, Ahmad Shah, Jahnke H, et al.
NEUROSURGERY
2016;78(1):84-90.

NEUROSURGERY CLINICS OF NORTH AMERICA

The increasingly favourable outcomes from endoscopic endonasal approaches for the management of pituitary adenomas
Reviewed by: Gentle Wong
Vol 25 No1
 

Historically, pituitary tumours have been surgically managed with an open, transcranial approach. Although this approach still has its merits in large intracranial adenomas, technological advancement has allowed smaller tumours to be debulked via a transseptal microscopic technique. These days, the endoscopic endonasal transsphenoidal approach is increasingly recognised as an equal parallel to the microscopic technique, with arguably more favourable intraoperative visualisation. The expertise of the ENT surgeon, with our greater understanding of the nasal anatomy, allows us to work with neurosurgeons to define the right indication for each pituitary tumour surgery and weigh in on each aspect of the multidisciplinary management. This review reaffirms that the endoscopic approach provides reasonable rates, favourable clinical outcomes and acceptably low complication rates. The commonest ENT-related complications include cerebrospinal fluid leak, sinusitis, epistaxis, and nasal septal perforation. 

Reference

Endoscopic endonasal extended approaches for the management of large pituitary adenomas.
Cappabianca P, Cavallo LM, de Divitiis O, de Angelis M, Chiaramonte C, Solari D.
NEUROSURGERY CLINICS OF NORTH AMERICA 
2015;26(3):323-31.

OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY – HEAD AND NECK SURGERY

Surgery for hypopharyngeal obstruction causing OSA
Reviewed by: Suzanne Jervis
Vol 25 No1
 

Surgical treatments for OSA are evolving with improved diagnostic accuracy of the level(s) involved. Where the collapsing segment lies below the soft palate, a variety of surgical techniques to correct the affected segment(s) are emerging. This article concentrates on one such procedure – the hyoid suspension, a procedure which originated from a patient with continued symptoms following UPPP, who subsequently underwent inferior sagittal mandibular osteotomy combined with hyoid myotomy and suspension. The technique that the article describes is a revision of the original, but instead of the hyoid being suspended superiorly, it is divided from the infrahyoid muscles and attached inferiorly to the thyroid cartilage with non-absorbable sutures. The technique is described adequately with accompanying line drawings. However, determining the effectiveness of this technique appears elusive. The reviewed literature includes a number of studies where the hyoid suspension procedure is performed as part of a ‘package’ of multilevel surgery. In addition, defining the outcomes for surgical success varies considerably across the studies (e.g. BMI, AHI and patient subjectivity) such that adequate comparisons are compromised. Where they have tried to isolate the procedure, ‘surgical success’ appears to be in the region of 45% and 52% and in 39 patients, six developed an infection, abscess or fistula (15%). It is likely that given the limited success and risk profile regarding fistula in particular, it may be a procedure to consider as a last option prior to tracheostomy in patients with severe OSA, rather than their first.

Reference

Hyoid suspension: hyothyroid and hyomandibular options.
Benoist LBL, van Maanen JP, de Vries N. 
OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY – HEAD AND NECK SURGERY
2015:26(4);178-82.

ORAL AND MAXILLOFACIAL SURGERY CLINICS OF NORTH AMERICA

Diagnosis of osteonecrosis of the jaw
Reviewed by: Deepak Chandrasekharan
Vol 25 No1
 

Although the management of osteonecrosis of the jaw is usually provided by colleagues in maxillofacial surgery, it is essential for ENT surgeons to effectively diagnose the various presentations of this condition. Affected bone that is exposed and necrotic may remain asymptomatic for prolonged periods with symptoms only developing when surrounding tissues are affected. This can include pain, tooth mobility, ulcers, mucosal swelling and erythema. One important presentation for ENT surgeons to recognise is that of chronic maxillary sinusitis with or without an oroantral fistula when the disease involves the sinus floor. A high index of suspicion is required in any patients taking antiresorptive therapy and in those with malignancies that may metastasise to bone. As well as a thorough history, imaging options include CT, MRI or bone scanning and a histopathologic diagnosis is also useful. The staging classification used by the American Academy of Oral and Maxillofacial Surgery spans from “at risk” to stage 0, 1, 2 and 3 with stage 3 being disease with extraoral fistula or involving the sinus floor. This is a helpful review with a broad coverage of the diagnostic tools for this complex and important condition. 

Reference

Diagnosis and staging of medication related osteonecrosis of the jaw.
Ruggiero SL.
ORAL AND MAXILLOFACIAL SURGERY CLINICS OF NORTH AMERICA
2015;27:479-87.

OTOLARYNGOLOGY – HEAD AND NECK SURGERY

Velopharyngeal insufficiency after adenotonsillectomy
Reviewed by: Thomas Jacques
Vol 25 No1
 

The authors retrospectively reviewed the clinical records of 320 paediatric patients who underwent either tonsillectomy, adenoidectomy or adenotonsillectomy, under a single paediatric ENT surgeon. Patients with pre-existing velopharyngeal insufficiency (VPI) were excluded, as assessed by preoperative testing for nasal air emission during phonation. This test was repeated postoperatively at three weeks, and again at five months if VPI was detected. Patients undergoing adenotonsillectomy were at a significantly higher risk of having VPI at three weeks postoperatively (13.6%). Adenoidectomy and tonsillectomy alone carried similar rates of early VPI (3.2% and 2.2% respectively). The majority of patients with detectable VPI were asymptomatic. Of those with clinical VPI at three weeks, 70% had normal nasal air emission tests at five months. This study is limited by its single-operator retrospective design, although the methodology was applied consistently, and the sample size was sufficiently large. The authors found that age, sex, adenoid or tonsil size, and surgical indication did not affect the risk of VPI. It demonstrates that the incidence of detectable VPI is relatively high, especially in adenotonsillectomy. However this is rarely a significant clinical problem, both because it is frequently subclinical, and also due to a high rate of spontaneous resolution. It also shows that VPI can occur with similar frequency after tonsillectomy or adenoidectomy, highlighting the importance of thorough informed consent in such cases.

Reference

Incidence and risk factors of velopharyngeal insufficiency postadenotonsillectomy.
Khami M, Tan S, Glicksman JT, Husein M.
OTOLARYNGOLOGY – HEAD AND NECK SURGERY
2015;153(6):1051-5.

OTOLOGY AND NEUROTOLOGY

Cochlear implanted children are more likely to have device failure if their balance function is impaired
Reviewed by: Anand Kasbekar
Vol 25 No1
 

We know that children with permanent hearing loss are more likely to have an associated balance problem. It is also thought that children with cochlear implants (CI) that fail do so because of an increased risk of falls and head injury, the falls presumably damaging the CI. The study itself looked at 35 children with CI failure compared to 165 children without failure. Children underwent a battery of vestibular tests (including calorics, vHIT, static and dynamic balance testing), and CI failures were significantly greater in children with vestibular impairment. If horizontal canal function was absent bilaterally, there was a 7.6 fold increased risk of CI failure. This study from Toronto advises us to refer our paediatric CI recipients to a paediatrician to identify those that have a vestibular impairment. Although the authors recognise that restoring vestibular input is not possible at present, future developments will allow such restoration (see work by Charley Della Santina at Johns Hopkins). We are reminded that identification of balance impairment can have a major impact on the management and counselling of the child and their family. 

Reference

Vestibular and balance impairment contributes to cochlear implant failure in children. 
OTOLOGY AND NEUROTOLOGY
Wolter NE, Gordon KA, Papsin BC, Cushing SL.
2015;36:1029-34.

RHINOLOGY

Thalidomide in HHT
Reviewed by: Suki Ahluwalia
Vol 25 No1
 

An interesting paper from a specialist centre in the Netherlands regarding the use of thalidomide in HHT patients. The St Antonius hospital has 1238 patients with HHT and 1% of these use thalidomide. The aim was to assess the benefits, objectively and subjectively and also the side-effects. Five years of records yielded 12 eligible patients taking 50-100mg of thalidomide daily for this cohort study, which has been designed with a view to a larger trial. Data was collected by questionnaire with patients asked general health questions to detail the severity of their HHT before, three months into and currently or just before stopping use. Data was also collected on duration and frequency of nose bleeds and also on number of blood transfusions. Most patients seem to have benefitted although more than half stopped treatment due to side effects, in particular, neuropathy, pain and oedema, skin reactions and general malaise. This paper highlights that thalidomide is only beneficial to a certain cohort of patients with this disease and probably should only be commenced in specialist centres with the necessary expertise to continue the assessment and supervision of these patients. Knowledge of the side-effects appears important also, since this would seem to be a major factor with patients.

Reference

Follow-up of Thalidomide treatment in patients with Hereditary Haemorrhagic Telangiectasia.
Hosman AE, Westermann CJJ, Snijder R , et al.
RHINOLOGY 
2015;53:340-4.

THE HEARING JOURNAL

Infant mental health and hearing loss
Reviewed by: Linnea Cheung
Vol 25 No1
 

This interesting editorial explores an aspect in the field of research dedicated to promoting healthy social and emotional development and the prevention and treatment of mental health problems in very young children. Since babies learn through primary attachment relationships with their caregivers, it is thought that the interaction creates an environment of safety for them to develop. Therefore, disturbances in this emotional connection could impair development in social and emotional functioning. This is of importance in babies with hearing loss as parents may struggle to connect with their child, believing they cannot hear their voices, whilst also grieving the diagnosis of hearing loss and being overwhelmed by the wealth of hearing technologies offered. The editorial gives a 10-point question guide when observing the interaction between children with hearing loss and their families to help encourage a better relationship and possibly a better hearing outcome, and thus may enhance the service we can provide. 

Reference

The powerful influence of infant mental health on hearing loss.
Wolfe J, Smith J, Elder T, Roberts E.
THE HEARING JOURNAL
2015;68(12):19,22,24-25.

THE HEARING JOURNAL

Leisure listening does not affect the hearing of young people
Reviewed by: Linnea Cheung
Vol 25 No1
 

The existing literature highlights concerns regarding the possibility of leisure activities involving listening to music on portable music players causing hearing loss. However, there is much speculation regarding actual effect. This article outlines a project involving young persons aged between 11 and 35 years of age and by using a detailed hearing health history and comprehensive audiometric evaluation, the information was used to create an estimate of individuals’ cumulative lifetime noise exposure. The measures appear to accurately estimate the true situation in terms of levels of noise exposure. A set of hearing threshold reference levels was produced from previous surveys of normative hearing thresholds for people aged 12 to 35 years in two, five and 10 year steps at fractiles and the results of those in this study group were compared against them. The results are contrary to those expected: no measurable change in threshold levels with respect to age in this group. In fact, the hearing thresholds appear to remain within normal ranges. In addition, there was no statistically significant relationship between cumulative noise exposure and hearing thresholds. Perhaps, therefore, this is an issue that is not as widespread as has been previously feared.

Reference

Leisure noise and the hearing health of young people.
Williams W.
THE HEARING JOURNAL
2015;68(12):28,30.

THE JOURNAL OF CRANIOFACIAL SURGERY

Anatomy for extended sinus surgery
Reviewed by: Stuart Burrows
Vol 25 No1
 

In the world of image guidance and pushing the boundaries of what can be achieved endoscopically the assessment and understanding of preoperative imaging is critical for success. This paper highlights the anatomical variations in the pterygopalatine and sellar regions. The authors have used CT angiography to image the skull base and sinuses of 118 patients and undertaken multiplanar reconstructions for their analysis. Their aim was to document the location of the pterygopalatine fossa and its associated communicating canals based on useful landmarks. The paper offers lots of measurements and describes variables and the relationship between key strictures. The main take home message is that there is huge variation and detailed assessment of each patient individually is vital. What the paper does offer is a good overview of the structures and it works well as an instructional paper. 

Reference

Location of pterygopalatine fossa and its relationships to the structures in sellar region.
Cheng Y, MD, Xu H, et al.
THE JOURNAL OF CRANIOFACIAL SURGERY
2015;26(6):1979-82

THE JOURNAL OF CRANIOFACIAL SURGERY

Otoplasty equals happiness
Reviewed by: Stuart Burrows
Vol 25 No1
 

There are frequent criticisms of procedures that are viewed as cosmetic therefore of no benefit to health. Here a German group have looked at the benefit of otoplasty on quality of life. They point out that ‘beautiful people have an advantage in many areas of life’. Here they present data from 81 patients who underwent surgery during an 18-year period. They utilised well recognised validated scoring systems, such as the Glasgow Benefit Inventory (GBI), to show that there is a significant quality of life improvement following otoplasty. They have gone on to show that the improvement is comparable to other ENT and urological procedures that have published GBI data. There is an undoubted need to produce data to justify what we do in health systems that are looking to cut resources. ENT often encompasses treatment for conditions that are not life-saving or life-extending but life enhancing. The paper highlights the WHO statement that quality of life encompasses ‘mental and social wellbeing not merely an absence of disease…’

Reference

The psychological and psychosocial impact of otoplasty on children and adults.
Papadopulos NA, Niehaus R, Keller E, et al.
THE JOURNAL OF CRANIOFACIAL SURGERY
2015;26:2309-14

THE JOURNAL OF LARYNGOLOGY AND OTOLOGY

Influence of atmospheric conditions on post tonsillectomy secondary haemorrhage
Reviewed by: Madhup Chaurasia
Vol 25 No1
 

Haemostasis in epistaxis and a good few other conditions outside the field of otolaryngology seem to be affected by the weather. It is generally thought that dry and hot environment encourages secondary post tonsillectomy haemorrhage. Variations in water vapour pressure, but not humidity has been correlated with post tonsillectomy bleeding. The studies so far have been short and variables have been multiple. It appeared that carrying out such a study in Darwin, Australia, where variations in humidity and water vapour pressure rather than temperature create  ‘dry’ and ‘wet’ seasons, would help to elucidate specific effect of these variables. Of the 941 patients who underwent tonsillectomy, 74 (7.7) had secondary haemorrhage. This was higher in older children and males. However, no difference was found between ‘wet’ and ‘dry’ seasons, nor months with low or high water vapour pressure. The variance in temperature could not be determined because of minimal changes of temperature over the year in Darwin. The study also evokes the concept that variations noted in previous studies relate to changes in temperature rather than humidity or water vapour pressure. Although no definitive findings have emerged from this study, the authors have interestingly pointed towards confounding influences possibly affecting secondary post tonsillectomy bleeding, such as use of air-conditioning and different methods used for the operation. Using these variables, future studies may be quite informative and useful. 

Reference

(Ton)silly seasons? Do atmospheric conditions actually affect post-tonsillectomy secondary haemorrhage rates?
Cadd B, Rogers M, Patel H, Crossland G.
THE JOURNAL OF LARYNGOLOGY AND OTOLOGY 
2015;129:702-5.

THE LARYNGOSCOPE

Surgical voice restoration after laryngopharyngectomy
Reviewed by: Thomas Jacques
Vol 25 No1
 

Voice restoration is one of the key rehabilitative steps after laryngectomy or total laryngopharyngectomy (TLP). Patients who undergo TLP require reconstruction – increasingly commonly with microvascular free flaps. Despite their advantages in terms of fistula rates and swallowing outcomes, these flaps can be associated with “wet”, less intelligible voice quality compared to typical transoesophageal speech (TES). The authors aimed to compare the functional voice outcomes between patients who had undergone TLP, using two commonly used free flaps: radial forearm flap (RFF) and jejunal free flap, and patients with traditional TES following laryngectomy alone. They collected quality-of-life data using validated questionnaires and voice recordings of standardised vocal tasks, from a total of 40 patients. Voice recordings were analysed objectively (software) and subjectively by trained and non-trained listeners. No significant difference in pitch, length of phonation or amplitude was found between the three groups. Listeners judged post-laryngectomy TES superior to both groups of post-TLP patients in almost all parameters, including rate, dynamics, effectiveness, fluency, wetness etc. There was no significant difference between the two methods of free flap reconstruction. Quality-of-life measurements mirrored these findings. This study is limited by small sample size, but is a rigorous examination of voice-related outcomes in major head and neck surgery, with a methodology that would extend well to larger studies. It provides more reliable evidence that free flap reconstruction may lead to inferior voice outcomes, but highlights that two commonly-used techniques are equivalent in this regard, aiding clinical decision making.

Reference

Tracheoesophageal voice after total laryngopharyngectomy reconstruction: jejunum versus radial forearm free flap.
Deschler DG, Herr MW, Kmiecik JR, et al.
THE LARYNGOSCOPE
2015;125:2715-21.

AMERICAN JOURNAL OF OTOLARYNGOLOGY

Deep space neck infections – salivary gland as source is commoner in elderly patients
Reviewed by: www.ncbi.nlm.nih.gov/pubmed/25630849
Online Only
 

Whilst deep space neck infections (DNI) can originate from many sources, dental and salivary glands are commonly the culprit. This paper details 44 patients treated for deep space neck infections originating from salivary gland and compares them to a previously published cohort of 191 cases of DNI originating from non-salivary gland. The patients were treated at a single centre over 11 years. The mean age of the salivary gland group was 62 years. In 38 out of 44 cases, the submandibular gland was the source of sepsis, the parotid was the source in six out of 44. In patients with DNI from a non-salivary gland source, mean age was 44.5 years. In 103 out of 191 cases, the sepsis stemmed from a dental origin, 53 from an oropharyngeal origin. The remainder came from infected cysts, hypopharyngeal lesions, with five out of 191 cases from other ascertained ENT sources of sepsis. Odynophagia was a less common complaint in salivary gland sources of sepsis (53.9% vs 29.6%). Patients with salivary gland sources were older, had more co-morbidities and required surgical intervention in 47.7% of cases, this is compared to surgical intervention being required in 69.1% in non-salivary DNI. This last result is not statistically significant but the authors suggest that it does suggest a trend. Mean hospital stay was 8.2 days. This paper highlights that in elderly patients, a salivary source of sepsis in DNI is more common than in younger patients. This may be due to several factors including increased use of xerogenic medications such as anti-depressants, beta-blockers, Alzheimer’s disease medications and diuretics. In addition age-related atrophy of salivary gland tissue, especially in the sub-mandibular gland, makes sepsis more likely. The authors report that analysing their entire cohort suggests that a salivary gland source of DNI is present in 19% of cases. 

Reference

Deep neck infections originating from the major salivary glands

Favaretto N, Fasanaro E, Staffieri, et al.

AMERICAN JOURNAL OF OTOLARYNGOLOGY-HEAD AND NECK MEDICINE AND SURGERY

2015;36(4):559-64.

B-ENT

Pharyngocutaneous fistula after total laryngectomy
Reviewed by:
Online Only
 

Pharyngocutaneous fistula (PCF) after total laryngectomy is a serious complication post-surgery, and can lead to prolonged hospitalisation, adding delays in postoperative chemoradiotherapy. This Turkish retrospective study looked at 166 patients who underwent total laryngectomy for laryngeal cancer, although it is not clear what time period this was over. They looked at 32 individual risk factors thought to contribute to the development of PCF post laryngectomy. In summary, they found that age >61 years, diabetes, preoperative radiotherapy, preoperative tracheostomy, low postoperative albumin and haemoglobin levels, and postoperative infection (evidenced by temperature >38 degrees), were considered to have a statistically significant effect on the development of PCF by multivariate logistic regression analysis. They also found an association of advanced disease on T staging, concurrent bilateral neck dissection, T-shaped pharyngeal closure and presence of postoperative depression with PCF, although it is not clear whether there could be confounding factors associated with this. Their incidence of PCF (19.2%) was comparable to previously published literature. This paper provides a comprehensive review of one institution’s experience with PCF, and reinforces the idea that preoperative nutritional and psychiatric support, regulating metabolic parameters postoperatively, and concurrent flap reconstruction helps to reduce the incidence of PCF.

Reference

Pharyngocutaneous fistulae after total laryngectomy: analysis of the risk factors and treatment approaches.
Kilic C, Tuncel U, Comert E.
B-ENT
2015;11:95-100.

COCHLEAR IMPLANTS INTERNATIONAL

A new modified double-flap technique for cochlear implant surgery
Reviewed by: Thomas Nikolopoulos
Online Only
 

The authors retrospectively assessed 342 implantees with a minimum of five years’ follow-up who had been implanted using a lazy S-shaped post auricular incision with a modified double-flap technique. From the notes, postoperative wound complications and any other adverse events were identified and tabulated. According to the authors’ classification major complications included flap necrosis, wound infection requiring surgical intervention, and wound dehiscence with or without implant exposure. On the other hand, minor complications were considered as swelling over the implant and superficial wound infections managed conservatively. The authors reported a mean surgical time of less than 90 minutes and only four minor wound complications in all 342 implantees with none lost to, at least, five years’ follow-up. Two weeks was the standard time elapsed between surgery and fitting. The outcomes are more than encouraging. However they should be interpreted with caution due to the retrospective nature of the study. 

Reference

The outcome of our modified double-flap technique for cochlear implantation: a case series of 342 consecutive patients.

Alzoubi F, Oda H, Omari AA, Al-Zuraiqi B.

COCHLEAR IMPLANTS INTERNATIONAL 

2015;16(2):95-9.

COCHLEAR IMPLANTS INTERNATIONAL

Does post-meningitic cochlear obliteration affect impedance and charge of the implant?
Reviewed by: Thomas Nikolopoulos
Online Only
 

Implantation in children deafened by meningitis may be very challenging due to obliteration or ossification of the cochlea. This study aimed to assess impedance values and charge consumption in such cases and evaluate if they are affected by the degree of the obliteration / ossification. Forty-nine implanted children deafened by meningitis and 43 implanted children deafened by other causes were compared. The results revealed that subjects had significantly higher impedances in comparison to the controls, although the degree of ossification did not seem to influence them. This is rather odd and not expected. Either the number of subjects was too small which did not allow the difference to be revealed or there is another explanation that we cannot identify. The two groups were comparable in charge consumption. However, when children with grade 2 ossification were compared to the controls, a statistically significant difference was found. Interesting study, although it seems that larger numbers would allow more valid conclusions.

Reference

Cochlear implantation in children with bacterial meningitic deafness: The influence of the degree of ossification and obliteration on impedance and charge of the implant.
Durisin M, Büchner A, Lesinski-Schiedat A, Bartling S, Warnecke A, Lenarz T.
COCHLEAR IMPLANTS INTERNATIONAL 
2015;16(3):147-58.

COCHLEAR IMPLANTS INTERNATIONAL

Does trainee participation in cochlear implant surgery affect operative times?
Reviewed by: Thomas Nikolopoulos
Online Only
 

The role of surgical education is a very sensitive issue in spite of the obvious need and the obligation of doctors to pass on their knowledge and experience to the next generation. This study is very interesting as it assesses whether trainee participation, among other factors, influences operating room time in cochlear implant surgery. Retrospective in nature, the study reviewed the notes of 455 unilateral cochlear implantations. The average surgical time was found to be two hours and a half, whereas the average total operating time was found to be three hours and 10 minutes. The presence of trainees was associated with a significant difference in surgical time, although trainee involvement did not significantly increase total operating time. Surgeon identity was also a time determinant, whereas patient age, gender, American Society of Anesthesiologists classification, and paediatric designation were not found to have any predictive role. Although interesting, the study’s major weakness was no assessment of the time or the exact role of the trainees involved in surgery. Nevertheless, training is an obligation and not an option if we want health systems to maintain high quality.

Reference

Influence of trainee participation on operative times for adult and paediatric cochlear implantation.
Puram SV, Kozin ED, Sethi RKV, Hight AE, Shrime MG, Gray ST, Cohen MS, Lee DJ.
COCHLEAR IMPLANTS INTERNATIONAL 
2015;16(3):175-9.

COCHLEAR IMPLANTS INTERNATIONAL

Which factors affect music involvement in implanted children’s everyday life?
Reviewed by: Thomas Nikolopoulos
Online Only
 

During the last few years, cochlear implantation research has included music. Processing strategies and rehabilitation teams are now interested in music appreciation by implantees, as speech perception and production are no longer the only issues or targets. The present study aimed to assess the patterns of musical participation and whether family affects it. The parents of 32 implanted children were asked to complete a questionnaire in relation to the musical involvement of their implanted child and the other sibling (if one existed). The latter comparison was very interesting as it revealed that there are no differences between implanted and normally hearing children in the same family with regards to musical involvement. In relation to family influence, families who enjoy and spend a greater amount of time involved in music tend to have children who also engage more actively in music. Despite the weaknesses of the present study (very long and not validated assessment measure, small numbers of subjects), it gives a fresh insight into what affects music involvement of implanted children. 

Reference

Family involvement in music impacts participation of children with cochlear implants in music education and music activities.
Driscoll V, Gfeller K, Tan X, See RL, Cheng HY, Kanemitsu M.
COCHLEAR IMPLANTS INTERNATIONAL 
2015;16(3):137-46.

DYSPHAGIA

Marshmallows for swallowing assessments!
Reviewed by: Roganie Govender
Online Only
 

The complaint of ‘food sticking in my throat’ is one many of us will have heard several times in clinical practice. The authors of this study report the prevalence of this symptom to be between 5-8% in the general population over 50 years of age. They suggest that very little research has been done to determine how accurately patients are able to identify the location of the problem, the characteristics they describe or how best to assess this symptom. They undertook a retrospective analysis of 141 videofluoroscopic swallow studies that were performed on patients reporting this symptom. All were carried out at a single institution following a similar protocol. They found that in 76% of patients (107/141) an explanatory cause was found on videofluoroscopy. This was defined as a clear restriction (stop of bolus flow) of the swallowed material. Of the patients with a clear identified cause, only 5% did not sense the food sticking when it occurred. Only one fifth of patients (20% of 141) who complained of food sticking in the throat actually had an explanatory cause localised to the pharynx or upper oesophageal sphincter. The restriction was most often demonstrated in the oesophagus. The explanatory cause was classified as ‘physiologic’ in 85% of cases and  ‘anatomic’ in 15%.  Cricopharyngeal bar was the most frequent non-obstructive abnormality. A non-masticated marshmallow was the best swallow material to identify this problem, which is often undetected if only fluids (barium alone) are used during the assessment. The take-away message seems to be that a significant proportion of patients who report this symptom, are likely to demonstrate an explanatory cause. This may only be observed if the correct swallow material is used, and if the assessment includes the full length of the oesophagus. 

Reference

‘Food sticking in my throat’: videofluoroscopic evaluation of a common symptom.
Madhavan A, Carnaby GD, Crary MA.
DYSPHAGIA
2015;30:343-8.

HEARING RESEARCH

Role of cochlear implants in the management of incapacitating tinnitus in patients with unilateral hearing loss
Reviewed by: Faiz Tanweer
Online Only
 

This is an interesting paper on patients with unilateral hearing loss and incapacitating tinnitus. The present study was conducted on 23 patients who had a cochlear implant for unilateral hearing loss including patients with single sided deafness (SSD). Most of the patients had hydrops, trauma or sudden deafness. In these patients tinnitus was persistent for more than two years and had not improved with conventional treatment. Tinnitus was most likely due to cochlear deafferentation in these patients. All patients were followed for about eight years and pre and postoperative tinnitus questionnaire and VAS loudness score were noted. SSD patients reported tinnitus suppression as a primary benefit, perhaps secondary to restoration of sensory input. In the UK, NICE does not recommend cochlear implant for unilateral hearing loss, but perhaps associated incapacitating tinnitus can be an indication, as proven by the long term results of this study. 

Reference

Cochlear implantation as a long-term treatment for ipsilateral incapacitating tinnitus in subjects with unilateral hearing loss up to 10 years. 
Mertensa G, Bodta MD, Heyninga PVD.
HEARING RESEARCH 
2016;331:1-6.

INTERNATIONAL JOURNAL OF LANGUAGE AND COMMUNICATION DISORDERS

Quality of life measurement tools in children with speech and language difficulties
Reviewed by: Gauri Mankekar
Online Only
 

The authors of this paper reviewed various quality of life measurement tools which are used to assess the effects of speech and language difficulties in children and adolescents. Measuring quality of life outcomes in children with these difficulties is not easy due to the heterogeneity in impairments and several targets during intervention. However, due to the increasing demands of policy makers, quality of life measurements are becoming important as they help decisions during resource allocation. Most of the studies use generic QoL measures and five studies used preference based QoL such as 16D/17D, HU13, EQ5D and QWB-SA. The authors found that of the several measures used, HU13 generated the most relevant estimates despite the fact that the weights for this measure were generated with adults.

Reference

Measuring quality of life in children with speech and language difficulties: a systematic review of existing approaches.
Gomersall T, Spencer S, Basarir H, Tsuchiya A, Clegg J, Sutton A, Dickinson K.
 INTERNATIONAL JOURNAL OF LANGUAGE AND COMMUNICATION DISORDERS
2015;50:(4)416-35.

INTERNATIONAL JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY

Maxillary osteotomy stability
Reviewed by: Stuart Clark
Online Only
 

This systematic review assesses inferior repositioning of the maxilla six months after surgery. Two articles were identified with a total of 22 patients. The repositioning was of a mean of 3.2 to 4.5mm anteriorly and 0.1 to 1.8mm posteriorly. Six months after treatment there was a mean relapse of 1.6mm anteriorly and 0.3 posteriorly. They acknowledge the various procedures that may be involved in trying to reduce the relapse of this unstable procedure. Inevitably the variables involved in this surgery and the limited sample size resulted in the statement that no significant conclusions could be determined. 

Reference

Stability of Le Fort I maxillary inferior repositioning surgery with rigid internal fixation: a systematic review.

Convens JMC, Kiekens RMA, Kuijpers-Jagmain AM, Fudaleg PS.  

INTERNATIONAL JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY 

2015;44:609-14

INTERNATIONAL JOURNAL OF ORAL and MAXILLOFACIAL SURGERY

Safe distances in the infratemporal fossa
Reviewed by: Stuart Clark
Online Only
 

This analysis from China involved 50 enhanced CT datasets to reconstruct the skull, internal carotid artery and the internal jugular vein. The anatomical routes of these vessels were related to the styloid process, height of the pterygoid plates, distance from the pterygoid processes and the most prominent part of the zygomatic arch. The distances from the pterygoid processes to the internal carotid artery were 31mm and 34mm inferiorly and superiorly and 51mm from the zygomatic arch to the medial pterygoid plate. Head posture was noted to have an effect. 

Reference

Surgical safety distances in the infratemporal fossa; three-dimensional measurement study.
Guo YX, Sun ZP, Liu XJ, Bhandari K, Guo CB.  
INTERNATIONAL JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY 
2015;44:555-61.

JAMA OTOLARYNGOLOGY HEAD AND NECK SURGERY

Incidental thyroid nodules: should we observe or operate?
Reviewed by: Suki Ahluwalia
Online Only
 

Thyroid nodules are extraordinarily prevalent, detected by physical examination in 7% and by imaging studies in 67% of the population. Although most of these nodules are benign, up to 20% are found to be malignant on excision. It’s a very difficult decision for a clinician to offer surgery or observation for such incidental thyroid nodules. The precise reasons for the increased incidence of thyroid cancer are difficult to determine. Increased use of diagnostic imaging capable of exposing subclinical disease is considered the most likely explanation. More than half of the cases detected incidentally through imaging can be labelled as low risk cancers. There is much uncertainty about the benefits of surgical intervention for low-risk thyroid cancers, especially papillary thyroid cancer. The number of thyroidectomy procedures performed to treat thyroid cancer in the United States has risen by 60% over the past 10 years. Thyroidectomy usually requires hospital admission and carries a 1- 6% risk of complications, including hypoparathyroidism and recurrent laryngeal nerve injury. Two recent large observational studies from Japan offering patients with low-risk thyroid cancer (papillary microcarcinoma) the choice of thyroidectomy or active surveillance suggest that small papillary thyroid cancer may never progress to cause symptoms or death. These studies provide an opportunity for the medical community to start a dialogue among all stakeholders about novel management approaches for these incidentally detected cancers. The costs and psychosocial implications of prolonged surveillance versus current accepted treatment of surgery also need to be assessed. With time, molecular markers may add more objective measures by providing a better understanding of the biology and behaviour of individual cancers. Until these studies are completed, patients must be objectively and supportively presented with all possible management options. 

Reference

Incidental thyroid nodules and thyroid cancer: considerations before determining management .
Tufano RP, Noureldine SI, Angelos P. 
JAMA OTOLARYNGOLOGY HEAD AND NECK SURGERY
2015;141(6):566-72.

JAMA OTOLARYNGOLOGY HEAD AND NECK SURGERY

Voice after posterior cordotomy: we think voice is bad, patients think it’s better!
Reviewed by: Suki Ahluwalia
Online Only
 

Bilateral vocal fold immobility (BVFI) is a condition that can affect voice with an impact on quality of life (QOL). Surgical trauma from damage to bilateral recurrent laryngeal nerves, such as from previous thyroid, parathyroid, or mediastinal surgery are common causes of bilateral vocal fold immobility. Treatment options are surgical and include posterior cricoid split with graft, posterior cordotomy, medial arytenoidectomy, total arytenoidectomy, tracheostomy, or a combination of these procedures. Posterior cordotomy first described in 1989, involves using a laser to make a transverse cut in the posterior aspect of the more immobile vocal fold. This allows the incised vocal fold to shorten and displace anteriorly, increasing the size of the posterior glottis airway to improve air flow through the glottis. Posterior cordotomy is commonly combined with medial arytenoidectomy, which destroys the vocal process and medial arytenoid cartilage to create more space posteriorly. Complications with posterior cordotomy are rare; however, because it is a destructive procedure, patients may complain about voice changes. In this study subjective and objective voice outcomes were studied following posterior cordotomy with medial arytenoidectomy in patients with BVFI. Retrospective medical record review of 15 patients was performed. Mean follow- up was 2.6 months. Subjective voice outcome was assessed using Voice-Related Quality of Life (VRQOL). For objective voice outcome the Consensus Auditory Perceptual Evaluation of Voice (CAPE-V) instrument was used. While postcordotomy patients had a dysphonia that was noticeable to voice professionals, most patients in this study subjectively felt as though their voice improved after surgery. The results of this study support that posterior cordotomy with medial arytenoidectomy may offer patients improved or unchanged voice quality of life, (VQOL) despite the decrease in overall voice severity perceived by professionals. The findings in this study may help better counsel patients with BVFI considering posterior cordotomy and medial arytenoidectomy. Current preoperative counselling includes discussion of the balance between improved breathing through a larger glottic airway and the subsequent reduced voice quality and volume. While the patient’s voice may lessen in quality and volume to others, there is a good possibility that he or she may feel as though the voice has improved or not changed after surgery. This study does have limitations, it is a small retrospective study with a relatively short follow-up.

Reference

Voice outcomes following posterior cordotomy with medial arytenoidectomy in patients with bilateral vocal fold immobility.
Hillel AT, Giraldez L, Samad I, Gross J, Klein AM, Johns MM. 
JAMA OTOLARYNGOLOGY HEAD AND NECK SURGERY
2015;141(8):728-32.

JOURNAL OF CRANIOFACIAL SURGERY

Salt in surgical simulation
Reviewed by: Stuart Burrows
Online Only
 

Cheap, easily accessible and realistic methods of reproducing surgery through simulation are the ideal. Here a group from Tokyo, Japan report on a method of producing 3D printed skulls and mandibles to use for simulated surgery. A high resolution CT scan forms the basis for the model. They then use a 3D inkjet printer to print using salt to produce bone and tissue and can highlight structures such as nerves, vessels and teeth by colouring the salt. They are able to control the hardness and viscosity of the model to bring it close to that of human bone. Studying the characteristics of pig rib, their salt model and a resin model, they found similar load-deflection characteristics between the pig rib and salt model compared to the resin model. They report a cost of about one fifteenth that of current modelling techniques and this could provide an economically efficient model for simulated surgery and training. In the current context of the drive to find simulated training methods this would appear to be an advance in enabling training and possibly practising a procedure prior to surgery. 

Reference

Salt as a new colored solid model for simulation surgery.
Okumoto T, Sakamoto Y, Kondo S, Ogata H, Kishi K, Yoshimura Y.
THE JOURNAL OF CRANIOFACIAL SURGERY 
2015;26: 680–1.

JOURNAL OF VOICE

Voice therapy is an effective treatment for presbyphonia
Reviewed by: Christopher Burgess
Online Only
 

The quality of an individual’s voice often declines with age. This deterioration occurs firstly as a result of vocal fold atrophy secondary to histologic alteration of the vocal fold mucosa as well as atrophy of the laryngeal musculature. Phonatory efficiency is additionally reduced through a decrease in lung elasticity, vital capacity and respiratory strength. Surgical interventions that have been utilised for presbyphonia include medialisation thyroplasty and injection laryngoplasty. Functional improvements are however reported to be modest with these procedures. In this paper, 16 patients with presbyphonia (age range 65 to 81 years) were treated with voice therapy comprising vocal function exercises. Multiple outcomes were assessed for this intervention group including pre- and post-treatment voice quality on the GRBAS scale, acoustic analysis and voice handicap index-10 (VHI-10) scores. Stroboscopic examination was also employed to assess the normalised mucosal wave amplitude (NMWA), normalised glottal gap (NGG) and bowing index. The same outcomes were assessed for a historical control group of six patients with the same diagnosis who did not receive any intervention. Following voice therapy, significant improvements were noted in GRBAS and VHI-10 scores in the intervention group as well as stroboscopic examination findings (with the exception of the bowing index). No significant improvements were noted in historical control outcomes. The results of this small, retrospective study would suggest that vocal function exercises are an effective form of treatment for presbyphonia, and are likely to achieve their effect through improvement in laryngeal muscular functioning. As such, the paper would tend to support a management strategy of voice therapy as a first-line treatment for presbyphonia, with surgery reserved only for cases resistant to such treatment.

Reference

Multidimensional analysis on the effect of vocal function exercises on aged vocal fold atrophy.
Kaneko M, Hirano S, Tateya I, Kishimoto Y, Hiwatashi N, Fujiu-Kurachi M, Ito J.
JOURNAL OF VOICE
2015;29(5):638-644.

NEUROSURGERY

Active intervention in small schwannomas associated with higher incidence of long-term hearing loss
Reviewed by: Gauri Mankekar
Online Only
 

This article represents collaborative data of hearing outcomes from tertiary centres in Norway and the United States. They studied data of patients with less than or equal to 3cm vestibular schwannoma who underwent observation, primary microsurgery and Gamma Knife surgery between 1998 and 2008. At 7.7 years mean time after initial treatment, using the Hearing Handicap Inventory for Adults (HHIA) and the Tinnitus Handicap Inventory, patients were mailed a survey. Of the 79% of the patients who responded to the survey, more than 75% had non-serviceable hearing at follow-up. The study results showed that durable hearing was preserved only in those patients who were observed and did not undergo any treatment. Treatments in any form, either microsurgery or Gamma Knife surgery were associated with hearing loss and the incidence was highest in patients who underwent surgery. This data is worth considering for neuro-otologists treating vestibular schwannomas.

Reference

Long term auditory symptoms in patients with sporadic vestibular schwannoma: an international cross-sectional study.
Tveiten OV, Carlson ML, Goplen F, Vassbotn Flemming, Link MJ, Lund-Johansen M.
NEUROSURGERY
2015;77:218-27.

NEUROSURGERY

Gamma Knife surgery for persistent or recurrent trigeminal neuralgia
Reviewed by: Gauri Mankekar
Online Only
 

Treatment of trigeminal neuralgia continues to be challenging. The treatment options include pharmacotherapy, or failing this, surgical options like microvascular decompression (MVD), radiofrequency ablation, pencil beam convolution and Gamma Knife surgery. The authors of this article have presented a series of 54 patients who were treated with Gamma Knife surgery (GMS) for recurrent trigeminal neuralgia after microvascular decompression and other ablative procedures. Seventy-eight percent of patients experienced initial pain relief and 44% maintained long-term pain relief without pain medication. Additionally, GMS after MVD was well tolerated without increased incidence of complications. The authors also report that their long-term outcome in this group was similar to that of patients undergoing GMS as primary treatment. This article provides evidence that GMS provides a safe option for treatment of persistent or recurrent pain after MVD.

Reference

Decreased probability of initial pain cessation in classic trigeminal neuralgia treated with Gamma Knife surgery in case of previous microvascular decompression: a prospective series of 45 patients with a > 1 year of follow-up.
Tuleasca C, Carron R, Resseguier N, Donnet A, Roussel P, Gaudart J, Levivier M, Regis J.
NEUROSURGERY
2015;77:87-95.

NEUROSURGERY

Surgery of vestibular schwannomas with peritumoral oedema
Reviewed by: Gauri Mankekar
Online Only
 

This is an interesting retrospective study evaluating peritumoral oedema on magnetic resonance images and correlating it with the intra-operative tumour characteristics and outcome. The study results found that vestibular schwannomas with peritumoral oedema were associated with greater incidence of hypervascularity and so had a higher incidence of postoperative tumour bed haemorrhages. The presence of peritumoral oedema however did not correlate to the degree of tumour adhesion and was not associated with more radical tumour removal. The long-term outcome of facial nerve function and hearing was similar in vestibular schwannoma patients with and without peritumoral oedema. The authors report that despite the increased vascularity, the surgical resection and dissecting the arachnoid plane was not more difficult. However, this aberration may be due to the fact that the senior author is very experienced! Surgeons with less experience are likely to find the resection of vestibular schwannomas with peritumoral oedema more challenging.

Reference

Prognostic significance of peritumoral edema in patients with vestibular schwannomas. 
Samii M, Giordano M, Metwali H, Almarzooq O, Samii A, Gerganov VN.
NEUROSURGERY
2015;77:81-6.

OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY – HEAD AND NECK SURGERY

Describing the most useful OSA assessment?
Reviewed by: Suzanne Jervis
Online Only
 

This article sets out to comprehensibly describe drug induced sleep endoscopy and its role in determining the level of obstruction in patients with OSA. The advantages described include the fact that other techniques, including Muller’s manoeuvre, have significant variation in assessor reliability and struggle to accurately demonstrate the true level(s) of obstruction. Drug induced sleep endoscopy is the closest to the true sleep state and also has the advantage of assessment during it with regards airway manoeuvres and mandibular splints etc. Another advantage includes the assessment being performed in real time with pulse oximetry. However, sleep endoscopy has not yet been directly evaluated against other OSA assessments. Despite this the authors extensively describe the indications (usually moderate to severe OSA and failed CPAP) and technique so that it can be reproducible. Propofol is the drug of choice and they provide guidance on the level of sedation that is to be achieved. A particularly helpful table is where the authors describe the endoscopy findings against the severity of OSA but also the possible CPAP alternatives from a surgical perspective. They convincingly argue the point that although sleep induced endoscopy may not accurately reflect a true sleep state, it is certainly considered the most useful assessment tool currently employed by sleep centres. A thorough and detailed article especially for those considering undertaking it as part of their OSA assessment. –

Reference

Drug-induced sleep endoscopy.
Kohn JL. Gillespie MB.
OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY – HEAD AND NECK SURGERY
2015;26(2):66-73.

OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY – HEAD AND NECK SURGERY

Surgical options for children with OSA
Reviewed by: Suzanne Jervis
Online Only
 

This paper looks at the surgical management of OSA in children and approaches the method of patient selection initially. They discuss the role of polysomnography in that it is part of the AAOHNS criteria in those patients with OSA symptoms and obesity, trisomy 21, craniofacial abnormalities, neuromuscular disorders etc., or if symptom correlation is poor with no co-morbidities. However, it is often underutilised due to time and resources therefore overnight pulse oximetry is commonly used instead. In the context of symptoms suggestive of OSA and a positive oximetry result, the positive predictive value is very high at 97%. Once selection has taken place and the obstruction level identified, surgery in children can then take the format of adenotonsillectomy, palate or pharyngeal surgery, tongue base surgery, nasal surgery or laryngomalacia surgery. The authors outline the benefits of adenotonsillectomy in lymphoid hyperplasia [treatment success in 59-82% (AHI<5)] and summarise the various techniques that may be employed to remove them or reduce their volume. Suturing the anterior and posterior tonsillar pillars together reduces the AHI but fails to resolve the OSA. In tongue base surgery, lingual tonsillectomy has been performed in children with laser or radiofrequency ablation and lingual hypertrophy is commonly found in obesity and trisomy 21. Tongue base suspension has also been described in children. Inferior turbinate reduction can be undertaken, often with coblator or microdebrider and laryngomalacia surgery can sometimes help if it is a contributing factor in OSA. This article is a useful overview for the surgical alternatives to children with OSA. 

Reference

Surgical management of sleep-disordered breathing in children.
Qualls H, Rimell F.
OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY – HEAD AND NECK SURGERY
2015;26(2):100-4.

THE JOURNAL OF LARYNGOLOGY AND OTOLOGY

An office procedure to close small tympanic membrane perforations
Reviewed by: Madhup K Chaurasia
Online Only
 

Various methods have been described for closure of small tympanic membrane perforations, ranging from paper patching to use of fibrin glue. The procedure needs to be non-invasive and cost effective. Use of Terdermis to close perforations of all sizes has been described in this article. Terdermis has two layers - a collagen layer which is made to slide under the rim of the perforation, the margins of which are freshened. The silicon layer sits on the meatal side of the tympanic membrane, the two layers thus ‘sandwich’ the rim of the perforation and allow the material to be lodged quite stably. After seven days, the outer silicon layer is peeled off and epithelialisation of the eardrum defect is expected to have closed the perforation. The procedure is repeated if tympanic membrane perforation has not closed. The study involved a total of 19 patients. After initial operation, 14 out of 19 perforations closed. Middle and large sized perforations required repeat procedures. The success rate was 0 for perforations which were wet, suggesting the method does not work in cases of extensive otorrhoea, because the sponge acts as an artefact. The procedure takes little time, costs less and does not require post auricular incision. The only disadvantage is that the silicone layer has to be peeled off. The method could be a useful office procedure and comparisons should be made with published results of other such methods. 

Reference

Clinical study of transcanal closure of tympanic membrane perforations using collagen sponge.
Tamae A, Komune S.
THE JOURNAL OF LARYNGOLOGY AND OTOLOGY 
2015;129(S2):S21-6.

THE JOURNAL OF LARYNGOLOGY AND OTOLOGY

Epley Manoeuvre: number of times it is required and its diagnostic value
Reviewed by: Madhup K Chaurasia
Online Only
 

Benign paroxysmal positional vertigo is a common condition but if inadequately treated or wrongly diagnosed, can prolong the distressing symptoms of momentary dizziness, nausea and visual disturbances which can be due to other causes and deteriorate quality of life. Studies on the subject of BPPV hitherto have not addressed the number of times the Epley manoeuvre is required to get rid of BPPV. In this article, the authors present a review of treatment of 70 patients diagnosed with BPPV and offered the Epley manoeuvre in the first appointment and then repeatedly in four weekly follow-up appointments until they were asymptomatic and had negative Dix-Hallpike tests. Forty-seven percent of these patients were asymptomatic after one treatment and 84% required three of fewer treatments to become asymptomatic. The authors emphasise the diagnostic role of the Epley manoeuvre, in that if the condition is not cured after three treatments, the diagnosis of BPPV should be questioned and further investigations carried out. The possibility of migraine should be considered. The study highlights the effective role of this simple and non-invasive management technique, which if used repeatedly if required, can not only cure the disease but also help in choosing other avenues for a diagnosis. 

Reference

How many Epley manoeuvres are required to treat benign paroxysmal positional vertigo?
Hughes D, Shakir A, Goggins S, Snow D.
THE JOURNAL OF LARYNGOLOGY AND OTOLOGY 
2015;129:421-4.

THE JOURNAL OF LARYNGOLOGY AND OTOLOGY

How well are we managing epistaxis cases?
Reviewed by: Madhup K Chaurasia
Online Only
 

Epistaxis constitutes 34.5% of all emergency admissions to otolaryngology departments nation-wide. Presently there are no detailed consensus guidelines for this commonest emergency, and there is tremendous variation of practice. Quite often, non-ENT trained doctors manage this emergency. This paper reviews practice of epistaxis management in six hospitals in the UK with regard to set standards aiming at a 100% target in terms of appropriate practice of managing epistaxis. This involves initial examination and attempt at nasal cautery to avoid hospital admission, early surgical or radiological intervention to avoid prolonged nasal packing and post-bleeding nasal examination to evaluate underlying causes and consider further treatment or evaluation to identify relevant pathology. The survey revealed that there was poor documentation of nasal examination and junior staff were not complying with the universally accepted minimum standard of written communication. Only 9% of patients received surgery or embolisation. Of all cases eligible for surgical or radiological intervention, the proportion of those receiving this varied from 12.5 to 28% which is remarkably low. This may have been due to non-availability of senior staff. The length of stay averaged 1.9 days. A suggestion is made for having designated centres for epistaxis but the idea verges on idealism rather than practicality. Epistaxis is the commonest emergency which can present with extreme urgency and affects mainly the elderly. It should be manageable locally and provide the basics of otolaryngology emergency service for which any consultant should be available and able to handle it. 

Reference

A multi-centre audit of epistaxis management in England: is there a case for a national review of practice?
Hall AC, Blanchford H, Chatrath P, Hopkins C.
The Journal of Laryngology and Otology 
2015;129:454-7.

The Journal of Laryngology and Otology

Influence of smoking on vocal fold polyps
Reviewed by: Madhup K Chaurasia
Online Only
 

A vocal fold polyp is a benign lesion related to phonotrauma which induces upregulation of inflammatory processes and histological changes can occur in the epithelium and lamina propria. Whether smoking produces additional or enhanced changes is the subject of this study. Twenty-nine patients presenting with vocal fold polyps were divided into smoking and non-smoking groups and various parameters, ranging from duration of hoarseness to histopathological features were compared with statistical analysis. It was observed that smokers presented much later than non smokers, presuming it was just laryngitis. The mean polyp size was larger in smokers. Smokers had more keratinising features. Atypia was not seen in non-smokers but 35% of smokers showed this change. Cigarette smoking was associated with higher rate of laryngopharyngeal reflux. Smokers also had thinner basement membrane which has been explained by upregulation of inflammatory process producing more malleoproteinases which may promote membrane digestion and dissolution. This is an important step in progression from carcinoma in situ to microinvasive carcinoma. Hyaline generation was greater in smokers. All these results were statistically significant. The study confirms superadded injurious effects of smoking on vocal fold polyp that is already altered by phonotrauma and offers enhanced caution on smoking. 

Reference

A comparative histopathological study of vocal fold polyps in smokers versus non-smokers.
Effat KG, Milad M.
THE JOURNAL OF LARYNGOLOGY AND OTOLOGY 
2015;129:484-8.

THE JOURNAL OF LARYNGOLOGY AND OTOLOGY

Use of topical steroids and antibiotics, compared to systemic antibiotics in the treatment of acute rhinusinusitis
Reviewed by: Madhup K Chaurasia
Online Only
 

Acute rhinusinusitis is mainly initiated by viral infections. Bacterial infection is usually superadded. The inflammatory cascade upregulates the pro-inflammatory mediators resulting in pain, nasal obstruction and nasal discharge. Local application of steroids and antibiotics could provide a higher concentration of these agents at the affected site and there are lesser side-effects compared to use of systemic anitibiotics. With these concepts, the authors carried out a randomised, controlled and prospective study on 40 patients presenting with acute rhinusinusitis, one group receiving topical steroids (dexamethsone 0.053%) with topical antibiotic (ofloxacin 0.26%) and the other group receiving only oral antibiotic (amoxicillin 90mg/kg). The control of symptoms was assessed with a questionnaire using VAS, eight, 24 and 48 hours after initiation of therapy and finally on the tenth day. Using statistical analysis, it was noted that pain was initially better controlled in the topical therapy group. This was also the case with nasal discharge. Nasal obstruction was equally reduced in both groups initially. After ten days, nasal discharge lingered a bit more in the topical therapy group. Control of bacterial presence was also assessed by taking swabs on the first and tenth day, but results of this do not seem to be conclusive. The authors contend that in cases of uncomplicated rhinusinusitis, topical therapy including steroids is relatively more effective. It is not clear whether these patients were hospitalised, because otherwise eight and 24 hourly observations could be onerous. If hospitalised, these patients might as well have received intravenous antibiotics to make hospitalisation worthwhile. 

Reference

Comparative study of the efficacy of topical steroid and antibiotic combination therapy versus oral antibiotic alone when treating acute rhinusinusitis.
El-Hennawi DM, Ahmed MR, Farid AM, Al-Murtadah AM.
THE JOURNAL OF LARYNGOLOGY AND OTOLOGY 
2015;129:462-7.

THE JOURNAL OF LARYNGOLOGY AND OTOLOGY

What causes delays in head and neck cancer treatment?
Reviewed by: Madhup K Chaurasia
Online Only
 

This article identifies which factors are responsible for delays in cancer management by a retrospective case-control series study, statistically comparing two groups, each of 50 patients, one receiving timely treatment and the other breaching set targets. It was observed that age, site and stage of cancer and treatment modality was not associated with delay. However, administrative issues such as outlying location of the hospital of initial consultation and patients not initially being seen by a multidisciplinary team member were important factors causing delays. The authors therefore emphasise the importance of timely communication between clinicians inside and outside the ENT head and neck cancer and maxillofacial units. Initial referrals to these units for obvious benefits, such as rapid triage, imaging and histology would reduce delays. Pathways need to be refined and dedicated slots for investigations should exist. Delays occurred particularly in patients with cancer of unknown primary and this is due to the number of investigations required. An interesting comparison is made with delays occurring in the USA. The time between agreement of a treatment plan and commencing it is longer there, but the time between first appointment and initiating the treatment is less, indicating that the access to diagnostic and staging investigations is much quicker in the UK but the therapeutic intervention gets delayed. It was also observed that advanced disease is treated more quickly in the UK. 

Reference

Factors associated with delays in head and neck cancer treatment: case controlled study.
Nash R, Hughes J, Sandison A, Stewart S, Clarke P, Mace A.
THE JOURNAL OF LARYNGOLOGY AND OTOLOGY 
2015;129:383-5.

INTERNATIONAL JOURNAL OF LANGUAGE AND COMMUNICATION DISORDERS

Efficacy of interventions for stuttering: literature review
Reviewed by: Gauri Mankekar
Vol 24 No 6
 

This is the first part of a two-article review of the efficacy of different modalities of treatments used for treatment of stuttering / stammering. In this article, the authors describe their efforts to identify and quantify evidence on various interventions used to treat developmental stuttering amongst all age groups. They conducted a literature search for articles reporting non-pharmacological modalities for developmental stuttering and evaluated study quality using a tool for considering risk of bias. They found that most of the interventions are likely to benefit at least some of the patients with stuttering. However, they also found that the response to these treatments varied vastly depending upon individuals and could be maintained with all types of interventions, although less so with feedback and technology interventions. This article is an exhaustive literature review encompassing all types of interventions and their efficacy in all age groups, compared to other studies which restrict themselves to either specific age groups or specific treatment modalities.

Reference

The state of the art in non-pharmacologic interventions for developmental stuttering. Part I: a systematic review of effectiveness.

Baxter S, Johnson M, Blank L, et al.

INTERNATIONAL JOURNAL OF LANGUAGE AND COMMUNICATION DISORDERS

2015;50(5):676-718.

INTERNATIONAL JOURNAL OF LANGUAGE AND COMMUNICATION DISORDERS

Impact of lingual pumping in Parkinson’s patients with dysphagia
Reviewed by: Gauri Mankekar
Vol 24 No 6
 

Dysphagia in Parkinson’s disease (PD) is one of the most important causes of mortality in these patients. Swallowing difficulty in Parkinson’s disease is associated with lingual pumping or festination, anterior escape, premature loss of bolus, oral and pharyngeal retention, multiple swallows, laryngeal penetration and aspiration. The authors of this article evaluated the impact of lingual pumping on the oral and pharyngeal phases of swallowing using videofluoroscopy to observe 10 swallows of barium of different consistency and volume in 69 patients with PD. They found that lingual pumping or lingual rocking was associated with loss of bolus control, unstable organisation of the food bolus, pharyngeal food retention and uncoordinated swallowing leading to aspiration. This was more noticeable with food of thicker consistencies. They recommend changing the consistency of food and / or volume of food or adoption of tools to facilitate better organisation of food bolus to decrease morbidity and mortality in PD patients. The article provides swallowing therapists information to improve their management of PD patients with dysphagia. 

Reference

Swallowing disorders in Parkinson’s disease: impact of lingual pumping. 

Argolo N, Sampaio M, Pinho P, et al.

INTERNATIONAL JOURNAL OF LANGUAGE AND COMMUNICATION DISORDERS

2015;50(5):659-64.

JAMA OTOLARYNGOLOGY HEAD AND NECK SURGERY

Predictors of complications in patients undergoing oral cavity cancer surgery
Reviewed by: Suki Ahluwalia
Vol 24 No 6
 

Surgical management of oral cavity cancers is complex, frequently involving extensive resections and complicated reconstructions. Quantification of risk in an individual patient may allow surgeons to more effectively identify patients at higher risk of complications and develop strategies for prevention, timely recognition, proactive management and informed consent from the patient. In this study from Memorial Sloan Kettering Cancer Center authors retrospectively reviewed medical records of 506 patients. Thirty-six variables were tested as potential predictors of complications. Nomogram was developed to detect which patients are at higher risk of developing complications. Six variables including body mass index (BMI), comorbidity status, preoperative white blood cell count, preoperative hematocrit, planned neck dissection, and planned tracheotomy had highest predictive value. Authors have developed a statistical tool that accurately estimates an individual patient’s risk of developing a major complication after surgery for oral cavity squamous cell carcinoma.

Reference

Individualized risk estimation for postoperative complications after surgery for oral cavity cancer.

Awad MI, Palmer FL, Kou L, et al.

JAMA OTOLARYNGOLOGY HEAD AND NECK SURGERY

2015; 141(11):960-8.

JAMA OTOLARYNGOLOGY HEAD AND NECK SURGERY

Shoulder function in patients undergoing neck dissection: its effects on work and leisure activities
Reviewed by: Suki Ahluwalia
Vol 24 No 6
 

Shoulder dysfunction is common after neck dissection and includes shoulder pain, limited abduction and scapular winging. Modifications of the radical neck dissection were designed to limit morbidity, however, even with accessory nerve-sparing neck dissections, shoulder dysfunction can be seen. Shoulder syndrome is thought to be multifactorial. The extent of dissection in level II and V causes shoulder morbidity, but the effects of radiation therapy and chemotherapy when added adjuvantly to surgery remains questionable. In this study 167 spinal accessory nerve sparing neck dissections were evaluated. Their data suggest that increased treatment, either in the form of increased surgical dissection or use of radiation therapy and / or chemotherapy is correlated with poorer shoulder function and quality of life. Importantly, poorer shoulder function appears to confer disability with respect to leisure activities and employment status after neck treatment. This study has confirmed the fact that shoulder dysfunction is common after neck dissection and adjuvant therapy; what they failed to asses was effect of physiotherapy on shoulder dysfunction. It’s high time that multiple randomised studies should be carried out to better quantify the minimum duration and intensity of physiotherapy necessary to improve shoulder function after neck dissection. 

Reference

Association between multimodality neck treatment and work and leisure impairment: a disease-specific measure to assess both impairment and rehabilitation after neck dissection.

Gallagher KK, Sacco AG, Lee JS, et al.

JAMA OTOLARYNGOLOGY HEAD AND NECK SURGERY

2015; 141(10):888-93.

JOURNAL OF CRANIO-MAXILLO-FACIAL SURGERY

An overview of microsurgical reconstruction of the head and neck worldwide
Reviewed by: Sunil Kumar Bhatia
Vol 24 No 6
 

Microsurgical reconstruction is an integral part of the treatment following ablation for malignancy or trauma. Currently there are no clear treatment guidelines following tumour resection. This was recognised a few years ago and in 2008 various collaborative groups were founded as the German-Austrian-Swiss workgroup on tumours of the head and neck region – DOESAK. This group initially addressed questions on this topic in German speaking Europe in 2011 and later further refined and revalidated the questions in the rest of Europe in 2014. This is the third phase with the DOESAK questionnaire distributed worldwide. Thirty-eight units from Germany, Austria and Switzerland, 65 from remaining Europe OMFS departments and 226 units worldwide responded to the survey. There is wide agreement on the commonly used flaps and a trend towards primary bone reconstruction. However, that is where similarities end and as expected there is no uniform concept regarding osteosynthesis of bone transplants, microsurgical techniques, and supportive medication and postoperative monitoring protocols. In addition while microsurgical reconstruction is the gold standard in Europe, worldwide only every second unit has accesses to this technique. This is an interesting paper that proves different microsurgical protocols work in various situations.

Reference

Microsurgical reconstruction of the head and neck region: current concepts of maxillofacial surgery units worldwide.

Kansy K, Mueller AA, Mucke T et al.

JOURNAL OF CRANIO-MAXILLO-FACIAL SURGERY 

2015;43:1364-8

JOURNAL OF CRANIO-MAXILLO-FACIAL SURGERY

Facial reconstruction with polyethylene implants
Reviewed by: Sunil Kumar Bhatia
Vol 24 No 6
 

Planning reconstructive surgery for complex craniofacial defects challenges even the most experienced of surgeons. In most cases surgery is undertaken to improve anatomical functioning. However the anatomical structure of these regions is also critical to facial aesthetics and patient satisfaction depends on both function and the aesthetic results of surgery. It is then sometimes necessary for onlay grafting with alloplastic or autogenous material. Benefits of autogenous material include relative resistance to infection and relative ease of incorporation into new bone, absence of a foreign body reaction and reduced extrusion. However there can be unpredictable resorption, displacement and donor site morbidity and prolonged surgical time. Alloplastic material may not be freely available and can be expensive. They are associated with low morbidity rates, but this is site and material dependent. Polyetheretherketone (PEEK) is considered to be the gold standard of alloplastic material for the construction of patient specific implants for various reasons. However a major disadvantage is the cost. Porous polyethylene e.g. Medpore is an alloplastic material which has been around for a while and has been used to repair defects in the maxillofacial skeleton. This is a long term retrospective study from the Netherlands. It was designed to review the indications, results and complications of patients treated in a single unit with porous polyethylene implants. Sixty-nine high-density porous polyethylene implants were used in 40 patients (22 women and 18 men) between January 1996 and December 2013. All patients had preoperative CT scans to image the initial defect; implants were fixed with osteosynthesis screws. Follow up period was time of surgery to January 2014. Results showed an unsatisfactory appearance in 10.1% and then 8.6% removal of implants removed due to infections and fistulae. It is difficult to accept the conclusions of this study, suggesting the overall complications being very low. The authors however also accept the limitations of this study being retrospective and having multiple variables such as different operators and technique not taken into account. It is however a very good read to revise the pitfalls of alloplastic reconstruction of the maxillofacial skeleton. 

Reference

Porous polyethylene implants in facial reconstruction: outcome and complications.

Ridwan-Pramana A, Wolff J, Raziei A et al.

JOURNAL OF CRANIO-MAXILLO-FACIAL SURGERY 

2015;43:1330-4.

JOURNAL OF CRANIO-MAXILLO-FACIAL SURGERY

Postop follow up of oral squamous cell carcinoma: a new protocol
Reviewed by: Sunil Kumar Bhatia
Vol 24 No 6
 

Oral and oropharyngeal cancers together are the sixth most common malignancy in the world, with an increasing incidence of oral squamous cell carcinoma (OSCC). The recurrence rate of OSCC is reported to be approximately 10-26%. About two-thirds of all recurrent tumours occur within 2-3 years of initial treatment. Recurrent disease or subsequent metastasis within the first 18 months after primary surgical resection worsens the five year survival rate of patients by about 20.5%-27.6%. Whilst close follow up is suggested, recognising recurrent disease can be challenging partly due to anatomical distortion, fibrosis, bleeding, oedema, inflammation and possible infection. There is also no international consensus or guidelines on either clinical or radiological follow up with detailed post treatment protocols. This is an interesting paper from Germany; the authors attempt to establish an algorithm for follow up based on a review of the literature, existing guidelines and their institutional protocols. They recommend a follow up with clinical and radiological components. An initial CT is recommended six weeks postoperatively and then once every 12 weeks for the first six months alternating with clinical review only, every third month in year two, twice a year in year three and four and finally once in year five. This is a total of 10 CT scans over the five years. If there is any ambiguity a PET is ordered. Ultrasound has limitations of imaging deeper structures and while MRI as a modality is discussed, it is not part of the regular protocol. This is an interesting paper and reveals practice of medicine elsewhere. The follow up recommendations of the National Comprehensive Cancer Network (NCCN) guidelines for head and neck cancer are physical examination and history every 1-3 months for the first year every 2-6 months for the second year, every 4-8 months in years 3-5 and imaging in the first six months post treatment. The modality of imaging is not however specified. These are similar to NICE guidelines. It is an interesting viewpoint and well written paper. 

Reference

Loco-regional recurrence after surgical treatment of oral squamous cell carcinoma: proposals for follow up imaging based on literature, national guidelines and institutional experience.

Loeffelbein DJ, Eiber M, Mayr P et al.

Journal of Cranio-Maxillo-Facial Surgery 

2015;43:1546-52.

JOURNAL OF VESTIBULAR RESEARCH

Horizontal nystagmus: vestibular neuritis or lateral canal BPPV?
Reviewed by: Victor Y Osei-Lah
Vol 24 No 6
 

A horizontal nystagmus due to lateral canal (LSC) BPPV that is present in the upright position, that changes direction with head turn in the horizontal plane has been termed ‘pseudo-spontaneous nystagmus’ (PSN) because it mimics that of vestibular neuritis. The key features of PSN seen during the head pitch test (HPT) are defined as, “The PSN beats toward the healthy side in geotropic LSC BPPV and toward the affected side in apogeotropic LSC BPPV. It increases with the head bent 30 backward, disappearing when the head is bent 30 forward (neutral position), and reverses its direction when the head is additionally inclined forward to 60”. The aim of the study was to determine the incidence of LSC BPPV in 273 patients diagnosed with vestibular neuritis at the emergency department. The HPT was positive in 56 patients (37 geotropic and 19 apogeotropic). Further positioning tests, seated supine position and head roll while supine tests, confirmed the diagnosis of LSC BPPV in all 56 patients. What is more, all responded to appropriate particle repositioning manoeuvres! It is interesting how a simple test such as the HPT can confirm LSC BPPV, timely effective treatment and the avoidance of expensive investigations and hospital admission. 

Reference

Lateral canal BPPV with pseudo-spontaneous nystagmus masquerading as vestibular neuritis in acute vertigo: a series of 273 cases.

Asprella-Libonati G.

JOURNAL OF VESTIBULAR RESEARCH

2014; 24:342-349.

JOURNAL OF VESTIBULAR RESEARCH

Perception of verticality during attacks of Ménière’s
Reviewed by: Victor Y Osei-Lah
Vol 24 No 6
 

Ménière’s disease (MD) affects the cochlea and all peripheral vestibular receptors. The perception of verticality, a function of the utricle, is evaluated by the subjective visual vertical (SVV) test. The authors studied SVV in two groups of MD patients: a) first ever documented episode and b) recurrent MD, patients with previously documented episodes. There were nine and 12 patients respectively. In both groups, spontaneous nystagmus, audiogram and SVV were assessed during an acute attack and one week after an attack. Spontaneous nystagmus and SVV were characterised as either irritative or paretic. Caloric test, head impulse and head shaking tests were added at one week. In 78% and 75% of cases, the SVV during the acute attack was pathological in the first and second group respectively but the difference was not statistically significant. In the first group, SVV correlated with the canal abnormality in less than half of cases, the others showing SVV deviation to the healthy ear. In all seven subjects the pathological SVV had normalised at one week. The SVV was found to be persistently abnormal in most patients with recurrent MD. The authors concluded that otolith dysfunction is present in acute MD attacks, including the first ever attack and the deviation of SVV is often irritative (in > 40% of cases) i.e. deviation towards the healthy ear: this they called ‘maculo-canal dissociation’.

Reference

The first attack of Ménière’s disease: A study through SVV perception, clinical and pathogenetic implications.

Faralli M, Lapenna R, Mandalà M, et al.

JOURNAL OF VESTIBULAR RESEARCH

2014;24:335-42.

JOURNAL OF VOICE

Spasmodic dysphonia – is greater awareness needed?
Reviewed by: Christopher Burgess
Vol 24 No 6
 

Spasmodic dysphonia (SD) is a focal dystonia of the laryngeal musculature. Previously considered to be a rare disorder, it has more recently been suggested that SD is in fact not rare but is frequently misdiagnosed or undiagnosed. This paper would appear to provide further evidence in support of the latter viewpoint. One-hundred-and-seven patients with SD managed at the Emory University Voice Center in Atlanta, Georgia were surveyed about their experiences with the condition. Of the study population, 80% were female with an average age of symptom onset of 45 years. A delay in diagnosis was a common experience – it took this cohort on average over four years (53.2 months) to be diagnosed with SD after first going to a physician with vocal symptoms. Furthermore, patients consulted with four different physicians before receiving the correct diagnosis. Over 30% of patients were initially prescribed a medication other than botulinum toxin to treat their symptoms, including 15.6% of patients who were prescribed anxiolytics and 9.4% who were prescribed acid reflux medication. Two major factors that hinder the early diagnosis of SD are the lack of objective diagnostic criteria and the absence of a specific diagnostic test. Until these issues are addressed, the authors argue that earlier diagnosis of this condition requires greater clinician awareness of the typical presenting features of spasmodic dysphonia at both primary and secondary care levels. One potentially helpful clue identified in this study may be the presence of a pre-existing extra-laryngeal dystonia – nearly a quarter of the study cohort reported a second dystonia other than SD, with cervical dystonia being the most common; 2.6% reported having writer’s cramp. 

Reference

Diagnostic delays in spasmodic dysphonia: a call for clinician education.

Creighton FX, Hapner E, Klein A, et al.

JOURNAL OF VOICE

2015;29(5):592-4

NEUROSURGERY

Endoscope assisted removal of jugular foramen schwannomas
Reviewed by: Gauri Mankekar
Vol 24 No 6
 

This article, written by a renowned surgeon with extensive experience in removal of jugular foramen and skull base lesions, describes a new classification for jugular foramen schwannomas (JFS) and a template for selection of surgical approach for endoscope assisted removal. For this retrospective study, tumour extension, extent of tumour resection, cranial nerve outcome, approach-related morbidities and tumour recurrence in 16 patients with JFS were evaluated. The surgical approach was chosen depending upon the pattern and extent of tumour growth, extent of bone destruction in CT scans and the patient’s neurological status. The authors were successful in removing the entire tumour, even when there was an intraosseous extension, with the help of endoscope-assisted dissection. They also describe excellent results with lower cranial nerve preservation due to the use of the endoscope. This is another vindication for the mighty endoscope which is improving results of surgery in difficult to dissect skull base regions.

Reference

Surgical treatment of Jugular Foramen Schwannoma: surgical treatment based on a new classification.

Samii M, Alimohamadi M, Gerganov V.

NEUROSURGERY

2015;77:424-32

NEUROSURGERY

Evidence based guidelines for ONS treatment in occipital neuralgia
Reviewed by: Gauri Mankekar
Vol 24 No 6
 

Occipital neuralgia (ON) can flummox otolaryngologists especially when it follows mastoid surgery. The paroxysms of sharp, electrical pain originating from the occiput can extend along the posterior aspect of the scalp and even up to the mastoid. Although the aetiology of the pain is unknown, it can result from compression or trauma to one or more of the nerves in the distribution of the greater, lesser or third occipital nerve. The authors of this article are part of the multidisciplinary task force consisting of volunteer neurosurgeons and pain management specialists who formulated evidence based guidelines for the use of occipital nerve stimulation (ONS) for the treatment of patients with medically refractory ON . They reviewed the various treatment options for ON via a systematic literature search describing outcomes of interventions which include neuropathic agents, local anaesthetic / steroid / botulinum injection, dorsal root ganglionectomy, neurectomy, decompression, neurolysis, posterior rhizotomy and occipital nerve stimulation (ONS). Nine articles met their inclusion criteria, although none of the studies described in the articles included patient populations specific to medically refractory ON. Based on the results of the data derived from the literature review, the task force recommends the use of ONS as a treatment option for patients with medically refractory ON. They also acknowledge the need for prospective comparative studies to determine the usefulness of ONS in the long-term, as well as the difficulty in conducting double blind trials as the treatment of ONS depends on the producing paresthesia detected by the patient in the affected region.

Reference

Occipital nerve stimulation for the treatment of patients with medically refractory occipital neuralgia: Congress of Neurological Surgeons systemic review and evidence based guidelines.

Sweet JA, Mitchell LS, Narouze et al.

NEUROSURGERY

2015;77:332-41.

NEUROSURGERY

Identifying CN IX and X using endotracheal tube electrodes
Reviewed by: Gauri Mankekar
Vol 24 No 6
 

This clinical study describes the possible usefulness of endotracheal tube electrodes in monitoring vocal cord function during cerebellopontine angle surgery in 20 patients. Lower cranial nerves, especially IX and X are at risk of injury during skull base surgery although the risk is low in vestibular schwannoma and trigeminal neuralgia surgery. For the study, the authors used intravenous non-depolarising cisatracurium to enable endotracheal intubation following total intravenous anaesthesia with propofol and remifentanil. Subsequently, no other neuromuscular blocking agent or volatile anaesthetic was administered. Modified endotracheal tubes with four electrodes placed above the cuff were used for endotracheal intubation. Needle electrodes were also placed in the masseter muscle, orbicularis oculi, oris, soft palate surrounding the uvula, the trapezius and the anterior aspect of the tongue. Bipolar motor stimulation of motor rootlets in the CPA led to simultaneous recording of compound motor action potential (CMAP) from both surface and soft palate electrodes. The authors found that there was high inter-individual but low intra-individual variability in the amplitude and latencies of vocal cord CMAPs. In two patients, vocal cord CMAPs were lost during surgery and were associated with postoperative hoarseness and dysphagia. With more data being published, endotracheal tube electrode monitoring may become de rigueur in identifying vocal cord motor rootlets in the CPA / skull base and functional impairment during skull base surgery. 

Reference

Endotracheal tube electrodes to assess vocal cord motor function during surgery in the cerebellopontine angle.

Romagna A, Rachinger W, Schwartz C, et al.

NEUROSURGERY

2015;77:471-8.

NEUROSURGERY CLINICS OF NORTH AMERICA

CSF leak – endoscopic or open repair?
Reviewed by: Gentle Wong
Vol 24 No 6
 

Cerebrospinal fluid (CSF) rhinorrhoea is well known to the ENT surgeon. It commonly occurs secondary to a predisposing event such as accidental or iatrogenic trauma. When it occurs spontaneously, it can be associated with benign intracranial hypertension. The commonest CSF leak sites are located in the anterior cranial fossa, namely the ethmoid roof, the olfactory groove and the sphenoid sinus roof. The initial management paradigm of CSF leak is partially dependent on the root cause of the predisposing event. Ultimately though, all persistent cases of CSF leak should undergo surgical repair. Historically, these defects have been repaired via an external approach; increasingly however, endoscopic approaches are proving popular. Whichever technique is chosen, one of the fundamental factors underpinning success is localisation of the leak site. Access to both high-resolution CT and MRI imaging increases sensitivity for detecting the leak to almost 97%. CT cisternography is rarely used due to low sensitivity. The availability of perioperative adjuncts such as intra-thecal fluorescein and image-guidance system may further improve the confidence of the surgeon. This review concludes that most leak sites can be successfully repaired endoscopically, with potentially much lower morbidity. Frontal sinus defects are traditionally repaired externally, but the advancement of the 45 and 70° angled telescopes have made possible repair of certain frontal sinus leaks. The final frontiers for endoscopic repair currently are at an extreme superior or lateral location of the frontal sinus, beyond the reach of current instruments. 

Reference

Endoscopic endonasal repair of spontaneous and traumatic cerebrospinal fluid rhinorrhoea.

Gonen L, Monteiro E, Klironomos G, et al.

NEUROSURGERY CLINICS OF NORTH AMERICA

2015;26(3):333-48.

NEUROSURGERY CLINICS OF NORTH AMERICA

How should I excise sinonasal tumours, open or endoscopic? En bloc or piecemeal?
Reviewed by: Gentle Wong
Vol 24 No 6
 

Sinonasal tumours often present late because initial symptoms mimic benign disease. They tend to produce more unilateral nasal symptoms, and patients with advance disease often describe paraesthesia and other cranial neuropathies. They only account for approximately 3% of upper aerodigestive malignancies. Squamous cell carcinoma (SCC) is the commonest, followed by adenoid cystic carcinoma, and adenocarcinoma. Mucosal melanoma, olfactory neuroblastoma, and sinonasal undifferentiated carcinoma are all rare. Surgery for sinonasal malignancies has traditionally been via open techniques. However, there is an increasing paradigm shift in endoscopic resections utilising the principles of tumour disassembly and negative margins. Proponents argue that transoral laser surgery and Mohs micrographic surgery, which are similar examples of effective piecemeal resection, yield good results so why not sinonasal piecemeal resection? Opponents speculate that oncological integrity would be compromised by piecemeal resections, but this has now been disputed with evidence demonstrating patients who undergo piecemeal open resections have same outcomes as those with en bloc resections. The endoscopic technique is also more likely to produce lower morbidity, such as cosmesis, speech and swallowing. Hospital stay is also likely to be shorter. Endoscopic technique shows much promise, but there are occasions where this is contra-indicated. Open approaches are still better when there is orbital disease, or skin or palate involvement, or where disease is lateral or superior to carotid / optic nerve. Therefore, surgeons must be prepared to switch to the appropriate procedures if negative margins cannot be obtained endoscopically.

Reference

Surgical techniques for sinonasal malignancies.

Farag A, Rosen M, Evans J.

NEUROSURGERY CLINICS OF NORTH AMERICA

2015;26(3):403-12.

OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY – HEAD AND NECK SURGERY

Clinical assessment in OSA
Reviewed by: Suzanne Jervis
Vol 24 No 6
 

This paper divides the assessment up into anatomical (nasal and oropharyngeal), endoscopic and imaging. It points out the salient features to look out for in OSA patients with regards the nasal valve and also oropharyngeal anatomy, with tonsil hypertrophy grading being indicative of OSA (type IV). Mallampati classification is described with useful colour images and the Friedman scoring system is explained as a combination of palate-tongue position, tonsil size and body mass index (BMI), to gauge predictors of success of uvulopalatopharyngoplasty (UPPP.) Both the Fujita and Moore classification systems describe the level of obstruction. Interestingly, the authors debate the use of Muller’s manoeuvre, citing the surrounding conflicting literature regarding its use in predicting the level of obstruction and hence the success of UPPP. They also describe the use of CT or MRI in the context of obstruction level, evaluating the cross sectional areas of the nasopharynx and oropharynx. Interestingly, despite acknowledging the radiation dose of a 3D cone beam CT, it appears to be commonplace within this particular sleep centre in Mississippi, USA. Pharyngometry and critical closing pressure is also described by the authors as a simple and effective way of determining OSA, although it is still to be combined with other data such as neck circumference and BMI to predict OSA severity and surgical response. Sleep endoscopy is left to the following article but one seems a little unclear overall as to which assessments and investigations they favour as a sleep centre. Perhaps an example of a patient journey through their clinic may have been more illustrative and useful to those setting up services with an interest in assessing these patients.

Reference

Airway evaluation in obstructive sleep apnea.

Kowalczyk DM, Hardy ET, Lewis AF.

OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY – HEAD AND NECK SURGERY

2015;26(2):59-65.

OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY – HEAD AND NECK SURGERY

Medical trends in sleep disordered breathing
Reviewed by: Suzanne Jervis
Vol 24 No 6
 

This duo provide an eloquent outline of sleep disordered breathing in general, with particular emphasis on the medical impact and associations of the condition. The increasing prevalence of the condition is described, with increasing worldwide obesity, increased association of cardiac and metabolic comorbidities and rising use of opioid analgesics for chronic pain as the main culprits. It also serves as an excellent reminder of the reasons behind treatment, with studies showing increased likelihood of car accidents, mortality, excessive healthcare utilisation, and multiple areas of comorbidity. Specifically, the frequency of apnoeas and associated hypoxaemia can predict new cardiovascular disease, in particular with regard to recurrent atrial fibrillation and sudden cardiac death. In addition, the UK has demonstrated that treatment of OSA in diabetics significantly improves diabetic control, health status, and costs when compared to those who remain untreated. They then go on to concisely describe the four main medical therapies: positive pressure therapy; weight loss; pacing (phrenic / hypoglossal nerves); and oral devices. They remind us of the poor compliance of CPAP (50%) and that in some cases nocturnal oxygen therapy may be appropriate. If the apnoeas appear to be position related then restricting sleep positions may also be helpful. A useful medical overview of the topic, which is always beneficial from a surgeon’s perspective.

Reference

Current medical concepts in obstructive sleep apnea.

Pusalavidyasagar S, Iber C.

OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY – HEAD AND NECK SURGERY

2015;26(2):52-8

ORL

Mitomycin in adjuvant treatment of laryngotracheal stenosis
Reviewed by: Zi Wei Liu
Vol 24 No 6
 

Laryngotracheal stenosis (LTR) is a difficult condition to manage, and the effectiveness of surgical treatment is limited by the tendency of scar tissue to reform. Mitomycin has been used as a controversial adjuvant to surgical treatment for many years. Drawbacks include limited evidence of efficacy, the practicalities of administering a cytotoxic drug and the theoretical risk of malignant transformation. The authors of this paper describe a retrospective series of patients with LTR undergoing endoscopic surgery with (n = 30) or without adjuvant mitomycin (n = 41), applied for four minutes intraoperatively on a pledget. Overall, the mitomycin patients had a longer period between procedures compared to those in the non-mitomycin group. The patients who received multiple applications of mitomycin also had a longer symptom-free period between procedures than those who only had a single application. There is a lower incidence of patients undergoing emergent airway procedures in the mitomycin group, although it is not statistically significant. Although this is a retrospective case series, the authors do account for some confounding factors by removing patients with incomplete data, and no one received concurrent steroid injections. They do comment that the patients were selected for mitomycin if they were likely to require multiple airway procedures. The mitomycin group comprised mainly of patients with subglottic stenosis whereas the non-mitomycin group had a larger variety of airway pathology such as epiglottic and glottic lesions. Further randomised or well controlled cohort studies are required to shed light on this difficult clinical entity. 

Reference

The efficacy of mitomycin C in the treatment of laryngotracheal stenosis: results and experiences with a difficult disease entity. 

Reichert LK, Zhao AS, Galati LT, et al. 

ORL 

2015;77:351-8

OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA

Do I need Google maps in here?
Reviewed by: Sheneen Meghji
Vol 24 No 6
 

Image guidance surgery (IGS) has grown in popularity. This review article discusses its application in endoscopic sinus surgery (ESS). IGS technology has vastly improved with smaller, more mobile platforms that are easy to set up and use. IGS allows validation of anatomy prior to operating, especially in revision ESS. Additionally, it improves spatial orientation, is useful in teaching and training and may reduce the stress of the operating surgeon. In 2010 it was reported that whilst IGS was accessible to 95% respondents in the USA it was only used in 18% of ambulatory cases. In complex or revision ESS, usage is more variable. Interestingly, one study reported that trainees trusted the navigation system 90% of the time and were more likely to take risks if using IGS whilst operating. It is imperative to remember that image guidance has a target error of up to 2mm. It should therefore be used as a guide and not relied upon exclusively when making intraoperative decisions. As ESS complications are rare, it is difficult to assess if IGS reduces these complications.  Studies to date have not seen any significant benefits from IGS use. In conclusion current research does not support IGS routinely and states that it does not provide medicolegal accountability. It does however improve the knowledge of patients’ surgical anatomy and may lead to more complete and time-efficient operation. It should be used on a case-by-case basis, in the best interests of the patient and not be solely relied upon by the user.

Reference

Does image guided surgery reduce complications?

Ramakrishnan VR, Kingdom TT.

OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA

2015;48(5):851-9.

OURNAL OF VESTIBULAR RESEARCH

New diagnostic criteria for Ménière’s disease – an international consensus
Reviewed by: Victor Y Osei-Lah
Vol 24 No 6
 

Most readers are familiar with the American Academy diagnostic criteria for Ménière’s disease (MD) but a significant minority will be aware of other criteria from Japan and Korea. This new effort is a collaboration between these three bodies and the Barany Society, as part of the latter’s attempt to classify vestibular disorders (ICVD), making the criteria truly international. There are only two categories: definite and probable MD. Definite MD is characterised by a) two or more spontaneous episodes of vertigo each lasting 20 minutes to 12 hours, b) audiometrically documented low to medium frequency sensorineural hearing loss in one ear, defining the affected ear on at least one occasion before, during or after one of the episodes of vertigo, c) fluctuating aural symptoms (hearing, tinnitus or fullness) in the affected ear, d) not better accounted for by another vestibular diagnosis. Probable MD is defined as: a) two or more episodes of vertigo or dizziness, each lasting 20 minutes to 24 hours, b) fluctuating aural symptoms (hearing, tinnitus or fullness) in the affected ear, c) not better accounted for by another vestibular diagnosis. Of note, documented hearing loss is no longer a requirement for probable MD. The authors make a distinction between vertigo (the sensation of self-motion when no self-motion is occurring or the sensation of distorted self-motion during an otherwise normal head movement) and dizziness as defined by International Classification of Vestibular Disorders (ICVD). Key differential diagnosis such as vestibular migraine, autosomal dominant low frequency sensorineural hearing loss, TIA and autoimmume inner ear disease are addressed in this paper. It is worth a read.

Reference

Diagnostic criteria for Ménière’s disease

Lopez-Escameza JA, Carey J, Chung W-H, et al.

JOURNAL OF VESTIBULAR RESEARCH

2015;25:1-7.

RHINOLOGY

Pyriform turbinoplasty
Reviewed by: Shabbir Akhtar
Vol 24 No 6
 

This article describes a new operative technique to improve nasal airflow, the pyriform turbinoplasty. This specifically addresses the lateral part of the nasal valve where there may be impingement into the airway in select patients. This corresponds to the area over the “shoulder” of the inferior turbinate and directs airflow towards the middle meatus. A mucosal flap is raised and the frontal process of the maxilla and part of the lacrimal bone are resected, thereby improving the flow of air toward the middle meatus, without damaging mucosa. Clinical photographs of the technique are within the paper. The authors have reconstructed the nasal cavity using mapping software from CT scans of one patient and then built a model using ANSYS engineering simulation software. Using the principles of computational fluid dynamics, the velocity of air travelling through the nose has been simulated using fluid and known parameters have been included. This has then been repeated postoperatively. Simulated flows demonstrate that after surgery, there is a more uniform and improved airflow, although not necessarily faster. Ventilation in the main areas is improved without altering the pattern of airflow significantly. This is an interesting concept and one would hope due to the resection of bone, may provide long-term results. I’m sure these patients will be followed up and look forward to seeing the clinical results. 

Reference

The effect of “Pyriform Turbinoplasty” on nasal airflow using a virtual model.

Simmen D, Sommer F, Briner HR, et al.

RHINOLOGY

2015;53:242-8.

THE JOURNAL OF CRANIOFACIAL SURGERY

Identifying early flap failure
Reviewed by: Stuart Burrows
Vol 24 No 6
 

The holy grail of flap monitoring is an easy, reliable and predictive method to identify impending compromise. Does this paper provide it? Various methods have been used to improve our ability to monitor the viability of a flap and here the use of skin prick glucose measurement is used. The authors present their method of measuring skin prick blood glucose at 0, 6, 12, 24 and 48 hours postoperatively and compared these results with clinical assessments and overall flap failure. The study included 127 flaps and the data presented is comprehensive with good methodology. They have calculated that a blood glucose value of 62mg/dL provided an overall diagnostic accuracy of 87%. The paper does include pedicled as well as free flaps and data from non-head and neck flaps. How applicable the study is when the data is limited to the 25 head and neck free flaps remains to be seen. The results provide an interesting benchmark for further studies but do not provide help for the buried head and neck reconstructive flap where skin prick monitoring is not possible. 

Reference

Diagnostic accuracy of blood glucose measurements in detecting venous compromise in flaps.

Bashir MM, Tayyab Z, Afzal S, Khan FA.

THE JOURNAL OF CRANIOFACIAL SURGERY 

2015;26(5):1492-4

THE JOURNAL OF CRANIOFACIAL SURGERY

Identifying early flap failure
Reviewed by: Stuart Burrows
Vol 24 No 6
 

Like Zorro, the head and neck surgeon leaves their mark. No more so than during parotid surgery. Various modifications have been put forward modifying the classic Blair incision. This latest modification camouflages the pre-tragal scar by running it on to the crus of the helix and then posteriorly along the tragus, then continuing as the traditional Blair from the lobe into the neck. In the paper they present data from 12 patients showing their assessment of the postoperative aesthetics of the scar and the sufficiency of access. The proposed technique offers an interesting new possibility to avoid visible facial scars. As suggested by the authors the combination of a facelift style incision with their technique may offer the optimal aesthetic result. The authors consider that their modified approach can be safely applied for various lateral approaches to the parotid gland pharynx, and even the cranial base. 

Reference

Modification of Blair approach with a modified endaural component to access the parotid region.

Olarte HF, Gomez-Delgado A, Rivera-Guzman A.

THE JOURNAL OF CRANIOFACIAL SURGERY

2015;26(6):1972-4

THE JOURNAL OF LARYNGOLOGY AND OTOLOGY

Are upper respiratory symptoms and macroscopic changes in children always due to gastro-oesphageal reflux?
Reviewed by: Madhup Chaurasia
Vol 24 No 6
 

In children, symptoms such as chronic cough, wheezing, stridor, voice changes, persistent asthma and dental erosion are often presumed to be due to gastro-oesophageal reflux and empirical treatment with PPIs is offered. Usual investigations, such as a barium meal, gastroscopy and a 24-hour pH monitoring confirm gastro-oesophageal reflux but whether this is causing extra-oesophageal symptoms or producing changes in the larynx and pharynx is not something to be taken for granted. In this study, the authors investigated children with laryngeal symptoms and detected presence of pepsin in tracheal aspirate, done at the time of laryngobronchoscopy. They found a significant correlation of the presence of pepsin in the trachea with positive laryngopharyngeal findings such as interarytenoid oedema, obliteration of vocal folds, posterior commissure hypertrophy and ‘cobblestone’ mucosa. These laryngo-bronchoscopic changes were not associated with positive standard tests for gastro-oesophageal reflux. Detection of pepsin in the trachea was associated with croup and cystic fibrosis. The message given here is that presence of pepsin in the trachea and not gastro-oesophageal reflux causes the macroscopic changes noted on laryngobronchospy. If pepsin is absent, these changes may well be due to other conditions that may require alternative investigations such as allergen testing.

Reference

Correlation between laryngobronchoscopy and pepsin in the diagnosis of extra-oesophageal reflux.

Krishnan U, Paul S, Messina I, Soma M.

THE JOURNAL OF LARYNGOLOGY AND OTOLOGY

2015;129:572-9.

THE JOURNAL OF LARYNGOLOGY AND OTOLOGY

Does teaching affect patient satisfaction?
Reviewed by: Madhup Chaurasia
Vol 24 No 6
 

Teaching practice on real patients has several advantages in terms of lower costs and genuine clinical material but it is often a concern that using real patients for undergraduate teaching may result in patient dissatisfaction and many patients would prefer not to have medical students learning with them. The study explores these concepts with a direct comparison between a group of patients (case patients) seen by undergraduates and then findings confirmed by a teacher, followed by discussions on management and another group in which patients were seen in the normal way by residents in specialist training (control patients). Prior to this, the undergraduates had been tutored in the specialty which included methods of examination. The patients were then asked to grade variables in their encounter with the physicians, such as behaviour, professional skill, interaction and quality of healthcare provided. There was no significant difference in these variables, only more time was spent with the case group patients. The study has limitations due to the small sample size but it illustrates that using real patients does not diminish patient satisfaction or quality of healthcare provided. Patients can therefore be used for teaching undergraduates without any major reservations. 

Reference

Use of real patients in teaching ENT diseases to undergraduate students and its effects on patient satisfaction: cross sectional survey.

Lofgren E, Alikoski S, Hannula S, et al.

THE JOURNAL OF LARYNGOLOGY AND OTOLOGY

2015;129:666-9

THE JOURNAL OF LARYNGOLOGY AND OTOLOGY

Guidelines for management of orbital infections
Reviewed by: Madhup Chaurasia
Vol 24 No 6
 

Orbital infections predominantly affect the paediatric population and complications can be very serious. The cellulitis can be preseptal or orbital and the abscess can be confined within the periosteum or extend into the orbit. Cavernous sinus thrombosis can complicate the condition. The purpose of this study was to review the practice of management of orbital infections at a tertiary referral centre, compare it with the management described in the literature and establish guidelines for safe management. In the retrospective review of management of 54 children at a tertiary centre over a four year period and in the 17 articles reviewed from the literature, there were wide variations in practice. There seemed to be no fixed pattern for a multidisciplinary approach with ophthalmologists, radiologists and microbiologists. There were wide variations in use of culture and sensitivity to picking up infecting organisms which over time have changed from haemophilis influenzae to strains of streptococcus, staphylococcus and MRSA.  CT scans, done in half of patients, did not necessarily follow from high risk indications. Based on these findings, a definitive protocol has been established which appears to be logical and is followed widely. Aspects which the protocol clarifies include the immediate need for ophthalmology review, obtaining cultures from blood, conjunctiva and nose, prompt intravenous antibiotics, topical nasal steroids and close monitoring with regard to vision. The need for immediate CT scans and discussion with a microbiologist has been established. The article offers helpful guidance, applicable at all centres, to avoid serious complications of this condition.

Reference

Orbital infections:five year case series, literature review and guideline development.

Atfeh MS, Khalil HS.

THE JOURNAL OF LARYNGOLOGY AND OTOLOGY 

2015;129:670-6

THE LARYNGOSCOPE

Botox application for drooling shrinks salivary glands
Reviewed by: Thomas Jacques
Vol 24 No 6
 

The large majority of sialorrhoea (drooling) in paediatric patients is managed conservatively. However in severe cases, often where there is associated developmental delay or a motor disorder, medical and surgical techniques can be used to decrease salivary flow. Botulinum toxin injection is used increasingly for this purpose, with high efficacy and favourable side-effect profile when compared to anticholinergic medications or salivary gland excision. The authors of this case control study used ultrasound to assess the size of major salivary glands which were regularly injected with Botox (22 children), versus healthy controls (38 children). Assessment was by a blinded trained sonographer. There were no adverse events associated with Botox injection. Salivary glands that had received regular Botox injection were significantly smaller than those of normal controls, correlating with clinical outcomes. The study showed that Botox injection leads to changes in the size of the submandibular and parotid glands in a paediatric population, although it is not known what the cellular mechanism for this change is. It remains unclear whether the change is permanent or transient. The authors conclude that Botox injection is effective and safe, and should be considered first-line therapy for sialorrhoea in children, before irreversible surgical procedures are considered.

Reference

Effect of recurrent onabotulinum toxin A injection into the salivary glands: an ultrasound measurement.

Cardona I, Saint-Martin C, Daniel SJ.

THE LARYNGOSCOPE

2015;125:E328-32

THE LARYNGOSCOPE

Margin control using optical techniques in head and neck surgery
Reviewed by: Thomas Jacques
Vol 24 No 6
 

Emerging optical techniques such as high-resolution microendoscopy (HRME) are currently being examined for their reliability in discriminating benign from neoplastic epithelium. These techniques may offer the potential to detect the margin of an upper aerodigestive tract tumour in a non-invasive manner, allowing targeted biopsy, and even margin control during resection. Research is currently at an early stage. HRME entails the topical application of proflavine as a fluorescent contrast agent, followed by the use of a fibreoptic probe, placed on the mucosal surface, which transmits an image to a tablet device. The authors of this study conducted a feasibility study to determine the sensitivity and specificity of HRME. Multiple blinded reviewers evaluated HRME images of patients with squamous cell carcinoma, with sensitivity and specificity of 96% and 95% respectively compared to gold-standard histopathology. Real-time interrogation of tissue to detect malignancy is an exciting emerging field. The technology reviewed in this article is however currently hampered by the ability only to examine very superficial tissues, and artefacts created by inflammation, keratin debris, bleeding and other factors. 

Reference

Operative margin control with high-resolution optical microendoscopy for head and neck squamous cell carcinoma.

Miles BA, Patsias A, Quang T, et al.

THE LARYNGOSCOPE

2015;125:2308-16.

AMERICAN JOURNAL OF OTOLARYNGOLOGY-HEAD AND NECK MEDICINE AND SURGERY

No soup for you…! Early identification of postoperative perforation increases the success of conservative management
Reviewed by: Rohit Verma
Vol 24 No6
 

Iatrogenic perforation of the hypopharynx or cervical oesophagus is a well-recognised life-threatening complication. Previous studies have demonstrated that conservative management with broad-spectrum antibiotics and withholding oral feeding may avoid morbidity associated with surgical repair. This study addresses when conservative management should be employed and when this strategy may delay definitive management making the situation more complex. Twenty-eight adult patients with iatrogenic hypopharyngeal or cervical oesophagus perforation confirmed by imaging or endoscopic visualisation from a single centre were analysed, spanning 1994-2014. Fourteen patients were managed conservatively, whilst 14 were initially managed surgically with procedures ranging from neck drainage, chest drainage, mucosal closure, muscle flaps or combinations of these procedures. Six patients failed conservative management but were successfully treated after surgical salvage intervention. Univariate analysis identified that patients who failed conservative therapy were more likely to be demonstrating systemic toxicity, had eaten between injury or for whom >24 had passed between injury and identification of the injury. This has lead to the authors producing a simple algorithm stressing the importance of early intervention and identification of systemic toxicity as key features to guide management. Patients who have eaten following injury are recommended for immediate surgical intervention to prevent delay in management.

Reference

Management of cervical esophageal and hypopharyngeal perforations.

Zenga J, Kreisel D, Kushnir VM, Rich JT. 

AMERICAN JOURNAL OF OTOLARYNGOLOGY-HEAD AND NECK MEDICINE AND SURGERY

2015;36(5):678-85.

AMERICAN JOURNAL OF OTOLARYNGOLOGY-HEAD AND NECK MEDICINE AND SURGERY

Patient reported outcomes improve if antibiotic choice is directed from endoscopic culture results in chronic rhinosinusitis
Reviewed by: Rohit Verma
Vol 24 No6
 

The use of antibiotics in chronic rhinosinusitis (CRS) has been established as part of the EPOS guidelines, as has the role of taking swabs for microbiology culture. There has not been much literature however on whether tailoring antibiotics in response to culture and sensitivity has an impact on patient reported outcomes. In this retrospective study, the authors reviewed 105 adults with CRS who had nasal swabs taken using an endoscopic assisted technique. SNOT-20 outcomes were recorded. Mean age was 46.3, with mean 1.9 endoscopic sinus surgical procedures each (0-8). Empirical antibiotic therapy was commenced in 55 cases, most commonly using Co-Amoxiclav (21), quinolones (14) and clarithromycin (12). The most common pathogens grown from culture were S.aureus (29%), P.aeruginosa (24%) and MRSA (11%) Antibiotic therapy was changed in 81 patients in response to culture results, with Doxycycline, Quinolones or Trimethoprim initiated most commonly. Mean duration of therapy was 2-3 weeks. SNOT-20 outcomes were recorded pre- and post-treatment. Statistically significant change in total SNOT-20 scores and all four subdomains was noted, with improvement being clinically meaningful in the rhinologic subdomain (−  1.10, p < 0.0001). Repeat purulence was only noted in five cases (4.8%). Multivariate regression analysis demonstrated that concurrent use of oral steroids was independently associated with improvement in the rhinologic subdomain (p = 0.0041). This study highlights that empiric prescribing of antibiotics may be sub-optimal and not in keeping with maximal medical therapy. Clinicians should therefore consider taking culture swabs as part of their routine practice to guide antibiotic therapy. 

Reference

Endoscopic culture-directed antibiotic therapy: impact on patient symptoms in chronic rhinosinusitis.

Jiang ZY, Kou YF, Batra PS.

AMERICAN JOURNAL OF OTOLARYNGOLOGY-HEAD AND NECK MEDICINE AND SURGERY

2015;36(5):642-6.

B-ENT

Middle ear pressures with different anaesthetic agents
Reviewed by: Sunil Sharma
Vol 24 No6
 

The use of appropriate anaesthetic agents is essential to avoid complications during middle ear surgery. This Turkish study attempted to identify whether intravenous (IV) anaesthetics (propofol) or inhalational agents (sevoflurane) cause more variations in middle ear pressures. The authors performed a prospective study of 57 ASA I-II patients between the ages of 18-65 years, who were not undergoing otological operations. The patients were randomly allocated to either the propofol (P) group or sevoflurane (S) group according to the anaesthetic agent that they received intraoperatively. Baseline tympanometry was recorded before anaesthesia was introduced, and then repeated at 5, 10, 15 and 30 minutes post induction of anaesthetic agent. All post-induction middle ear pressures (MEP) were higher in the S group than baseline, whilst there was no difference between the post-induction MEP values and baseline in the P group. All post-induction MEP values were significantly higher in the S group than the P group (p < 0.05). These results reinforce previous studies that suggest that IV anaesthetic agents (such as propofol) are more reliable than inhalational agents (such as sevoflurane) in middle ear surgery.

Reference

Middle ear pressure changes with sevoflurane and propofol-remifentanil.

Dogan M, Duger C, Uysal IO, et al.

B-ENT 

2015;11:219-22.

B-ENT

Surgery in the only hearing ear
Reviewed by: Sunil Sharma
Vol 24 No6
 

In this study the Turkish authors attempted to investigate how quality of life was impacted in patients who underwent surgery for chronic otitis media in their only remaining hearing ear (OHE). Some surgeons view this as high risk due to the potential for hearing loss post surgery in the OHE. However, if the patient is left untreated, hearing can further deteriorate, and there is a risk of further complications. The authors performed a retrospective study, and 23 patients with OHE who underwent middle ear surgery were included. Only 15 of these patients regularly attended follow up for at least two years. There were no complications, and all ears dried up postoperatively. In terms of hearing outcomes, in five patients there was an air-bone gap gain of >20dB, in seven patients a gain of >10dB, in two patients no significant change, and in one patient there was a deterioration of -2dB. One might expect that when operating on patients with OHE the surgeon may be more cautious in disease removal, resulting in a higher rate of recurrence, but the results from this study would not suggest that this is the case. Although there were only a small number of patients included in this study, the

results suggest that surgery can be safely performed in patients with OHE with good results, improving the patient’s quality of life, if performed by an experienced otologist with modern techniques and instruments. Furthermore, if hearing does deteriorate post-surgery, there are options for hearing rehabilitation such as cochlear implantation. 

Reference

Chronic otitis media surgery in the only hearing ear.

Kalcioglu MT, Cetinkaya Z, Toplu Y, et al.

B-ENT

2015;11:223-7

COCHLEAR IMPLANTS INTERNATIONAL

Do the modern multiple microphones with beamforming facility really help implantees?
Reviewed by: Thomas Nikolopoulos
Vol 24 No6
 

In this study the authors aimed to assess the benefit beamforming multiple microphones provide to implantees. Speech reception thresholds were assessed in different situations; fixed masking noise from eight loudspeakers around the subject at 0°, ±45°, ±90°, ±135°, and 180° azimuth or from five loudspeakers positioned at ±70°, ±135°, and 180° azimuth. In the third test set-up, an additional roving noise was added to the six loudspeaker arrangement. The results revealed that beamforming multiple microphones made a difference and the most significant effect was seen in the six speaker roving and fixed noise conditions. The authors concluded that in difficult and noisy environments, the new microphone beamforming facilities do help in speech perception. An interesting study encouraging further improvements in beamforming microphones in order to improve listening in noise and in situations where implantees complain of poor listening perception. It remains to be seen if this benefit is significant in real life situations as perceived by the implantees themselves.

Reference

Speech reception threshold benefits in cochlear implant users with an adaptive beamformer in real life situations.

Geibler G, Arweiler I, Hehrmann Ph, et al.

COCHLEAR IMPLANTS INTERNATIONAL 

2015;16(2):69-76.

COCHLEAR IMPLANTS INTERNATIONAL

Is auditory frequency discrimination related to speech recognition in implantees?
Reviewed by: Thomas Nikolopoulos
Vol 24 No6
 

Why do two identical implantees perform differently? This fundamental question has not yet been answered despite the extensive research in the field. The authors attempted to clarify the issue, or at least approach it, assessing the association between deficits in auditory frequency discrimination and speech recognition in deaf adults with cochlear implants. The study included 36 subjects; 20 adults with cochlear implants and 16 controls (normal-hearing adults). For research purposes the authors divided the implantees into two groups, proficient and non-proficient users (10 in each group). The comparison outcomes revealed that the normal-hearing controls outperformed the non-proficient implantees with regard to auditory frequency discrimination but they did not outperform the proficient implantees. Moreover, the statistical analysis found a significant relationship between speech recognition and frequency discrimination. This is very interesting although the authors themselves admit that no causal link can be established from the present study. Closer inspection of the results reveals that the statistically significant association is true only for the lower frequency of 500Hz. 

Reference

Deficits in auditory frequency discrimination and speech recognition in cochlear implant users 

Turgeon C, Champoux F, Lepore F, Ellemberg D.

COCHLEAR IMPLANTS INTERNATIONAL 

2015;16(2): 88-94.

FACIAL PLASTIC SURGERY

The initial management of nasal trauma
Reviewed by: Sunil Kumar Bhatia
Vol 24 No6
 

Fractures of the nose are the most common facial fractures and reported to be the third most common fracture of the human skeleton. Nasal trauma can lead to obvious or more subtle loss of function or form and cosmetic compromise. Untreated it can lead to immediate or longer term issues. The overall goal of treatment is to restore the nose to its original state and minimise need for further surgery or intervention. The management of nasal trauma has remained controversial and challenging through the ages, with even Hippocrates mentioning it 2000 years ago. This article written by an ENT surgeon from the USA details the assessment of nasal trauma and provides a simple algorithm based on the clinical picture and other published guidelines. It is easily followed and the paper itself is easy to follow. Well illustrated and step wise, it provides an excellent discourse on the examination. There is also an important section on paediatric nasal trauma. A review of the instrumentation and treatment techniques is described, this is brief, but does provide some insight to the surgical techniques. It is an excellent paper for anyone revising or merely brushing up on a common problem that is easily sub optimally assessed. 

Reference

An algorithm for the initial management of nasal trauma.

Hoffman JF.

FACIAL PLASTIC SURGERY  

2015;31:183-93

HEAD AND NECK

Risk factors for pharyngocutaneous fistula after laryngectomy
Reviewed by: Jonathan Hughes
Vol 24 No6
 

Pharyngocutaneous or salivary fistula is a feared complication following laryngectomy, causing significant morbidity, prolonged hospital inpatient stay / cost and mortality. Previous radiotherapy / chemoradiotherapy is a well recognised risk factor and leads many surgeons to recommend onlay pectoralis major flaps for such cases. This paper explores further risk factors through the systematic review of data from 63 studies. The results confirmed previous radiotherapy / chemoradiotherapy as significant risk factors. Further patients factors included: chronic obstructive pulmonary disease (COPD), previous haemoglobin <12.5g/dL and blood transfusion requirement. Tumour factors included: supraglottic origin of tumour, hypopharyngeal involvement and advanced primary tumours (T3 and T4). Surgical factors included: positive surgical margins, concurrent neck dissection with laryngectomy, irrespective of type of neck dissection (i.e. selective or radical), and the use of catgut for pharyngeal closure compared to Vicryl™. The commonly performed second layer closure was not found to be a significant factor in fistula formation. This paper informs the head and neck surgeon of further factors that can be addressed to reduce the risk of pharyngocutaneous fistula following laryngectomy. 

Reference

Pharyngocutaneous fistula after total laryngectomy: Systematic review of risk factors.

Dedivitis RA, Aires FT, Cernea CR, Brandão LG.

HEAD AND NECK

2015;37(11):1691-7

HEARING RESEARCH

Childhood speech processing in background noise
Reviewed by: Hannah Blanchford
Vol 24 No6
 

Normal childhood development of the auditory systems involves mapping sounds to meaning and the neural coding of speech. Children are often subjected to adverse listening environments such as high levels of background noise. This paper aimed to delineate the effects of background noise on the speech-evoked frequency following response (FFR), which provides a snapshot of auditory processing. They assessed the auditory-physiological responses to a consonant-vowel sound syllable [da] in 58 normally developing 3-5 year olds in two environments: quiet and background noise (6-talker babble). Results showed that responses were degraded in noise: they were smaller and slower. They were an average of 0.3ms slower in noise than in quiet. Responses to the vowel sound were greater than the consonant, across both noise and quiet environments. Responses in quiet were more stable on a trial-by-trial basis than those in noise. The degradations in noise were more pronounced for the consonant than the vowel, demonstrating particular vulnerability in processing these speech sounds in noise. This is consistent with other studies showing that the properties of consonants make them more susceptible to masking and thus more difficult than vowels to recognise in noisy environments. Before we are able to understand auditory processing disorders and their neurophysiological correlates in early childhood, it is necessary to develop an understanding of the neurophysiology of speech processing in normally developing pre-schoolers. This paper goes some way to provide an objective profile for auditory-neurophysiological speech processing in pre-school children, which may be useful when evaluating children for auditory processing difficulties. This cohort will be followed up and I am interested to see how these evoked potentials may relate to their future listening and literacy skills.  

Reference

Auditory-neurophysiological responses to speech during early childhood: Effects of background noise 

White-Schwoch T, Davies EC, Thompson EC, et al. 

HEARING RESEARCH

2015;328;34-47.

HEARING RESEARCH

Cochlear implants for tinnitus
Reviewed by: Hannah Blanchford
Vol 24 No6
 

This study from Belgium is the first to look at the long term reduction in tinnitus for a cohort of 23 patients with unilateral profound hearing loss and incapacitating tinnitus implanted with cochlear implants (CI). The authors were able to follow up patients between three and 10 years after implantation. Participants had either single-sided deafness (SSD), with normal contralateral hearing, or asymmetrical hearing loss (AHL), with mild to moderate contralateral hearing. Interestingly, 83% of the SSD group reported that reduction in their tinnitus was the primary benefit of the CI. Perception of tinnitus loudness was significantly reduced on the visual analogue scale (VAS) from 8/10 preoperatively to 4/10 a month after the first fitting and 3/10 at three months after first fitting. These scores then remained stable whether subjects were tested at three or 10 years post-implant. Similar results were found for the Tinnitus Questionnaire. At long term testing, the authors found no difference between VAS scores when the cochlear implants were switched off and the patients’ preoperative scores. In all but one participant, switching the cochlear implant on was the first thing done in the morning and switching it off was the last thing done at night, which surely highlights the significant benefit participants felt it had on their life. These long-term results provide evidence for a stable reduction in tinnitus in patients with unilateral hearing loss and incapacitating tinnitus. The authors stress the importance of appropriate selection of patients for CI. Their cohort had severe, stable tinnitus for at least two years and had already tried conventional tinnitus treatments.

Reference

Cochlear implantation as a long-term treatment for ipsilateral incapacitating tinnitus in subjects with unilateral hearing loss up to 10 years. 

Mertens G, De Bodt M, Van de Heyning P.

HEARING RESEARCH

2016;331:1-6

THE HEARING JOURNAL

Hearing intervention to prevent dementia
Reviewed by: Linnea Cheung
Vol 24 No6
 

People with hearing impairment have an increased risk of incident all-cause dementia proportional to the severity of loss compared to those with normal hearing. Treating hearing impairment may therefore serve to slow or prevent the onset of cognitive decline. This article highlights the areas of ongoing research into this interesting area. A recent pilot study has suggested a dose-response relationship between the severity of hearing loss and cognitive decline, with an accelerated decline in memory tasks when hearing loss was more severe.  The effects of cochlear implantation on neurocognitive performance in older adults has also been studied and have shown a significant improvement in cognitive test scoring after implantation, with reduction in frequency of self-reported depression. This preliminary data is encouraging.  Might there be a role for counselling patients of the potential benefit of sound amplification on reduction of cognitive decline, particularly in challenging hearing environments?  Furthermore, might there be a role for audiologists, in addition to audiologic assessment, to conduct a brief auditory-cognitive assessment by integrating a short cognitive screening test into their practice as additional baseline and outcome measures of treatment?

Reference

Preventing cognitive decline: hearing interventions promising.

Weinstein B.

THE HEARING JOURNAL

2015;68(9):22-6.

THE HEARING JOURNAL

Listening in noise to predict learning disability
Reviewed by: Linnea Cheung
Vol 24 No6
 

Noise disrupts the neural coding of consonants more than vowels. Listening in noise presents a challenge for everybody, but particularly to children whose language skills are underdeveloped. This team views background noise as a disruption to the necessary neural mechanisms for language development. By using electrophysiological evaluation and standardised tests, three metrics were found to be predictive of how well a child would perform in preliteracy tests at age three and four.  These metrics recorded in response to consonants included: the rapidity of response; consistency of the response across trials; and its harmonic representation. Furthermore, electrophysiology could correctly identify 75% of children with a learning disability and 90% of children with typical development. Electrophysiology, therefore, being a quick and objective test could be a marker for early literacy. Could this mean a future for introducing targeted listening-in-noise training to young children to enhance language development? 

Reference

Listening in the din: a factor in learning disabilities?

Kraus N, White-Schwoch T.

THE HEARING JOURNAL

2015;68(9):38-40.

RHINOLOGY

Time to endoscopic sinus surgery and outcomes
Reviewed by: Shabbir Akhtar
Vol 24 No 6
 

A well written prospective study, which demonstrates that patients who require endoscopic sinus surgery, should be operated on without long delay since this achieves better and more sustained outcomes. There were 1493 patients undergoing primary nasal surgery who had completed a SNOT-22 identified from the National Comparative Audit of Surgery for Nasal Polyposis and Chronic Rhinosinusitis. They were divided into three groups depending on how long their symptoms had been present for; up to a year, a year to five or more than five years. Postoperative SNOT-22 scores were also recorded over the following five years; of course the amount of data collected deteriorated with time. It was found that all patients reported a decrease in their SNOT-22 scores, however, even after correcting for patients with asthma, those in the early cohort demonstrated a significantly lower SNOT-22 both before and after surgery and also managed to maintain a low score over the five year follow up period. The prevalence of CRS is 11% and is a significant disease burden, those with symptoms should be treated promptly with medical management and those failures should receive early surgery, preferably within a year of onset of symptoms. This would seem to produce the best and most sustainable outcomes over this five year follow up period.

Reference

Does time to endoscopic sinus surgery impact outcomes in chronic rhinosinusitis? Prospective findings from the National Comparative Audit of Surgery for Nasal Polyposis and Chronic Rhinosinusitis.
Hopkins C, Rimmer J, Lund VJ.
RHINOLOGY
2015:53:10-17.

BRITISH JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY

Two for the price of one - multiple parotid neoplasms
Reviewed by: Adam Shakir
VOL 24 No 5
 

With advancing years come many benefits, but one drawback is the acquisition of parotid (or thyroid) neoplasms. Conventional teaching is that most are benign and slowly enlarge, and not infrequently are found bilaterally as in Warthin’s. Pleomorphic adenomas are also commonly encountered, but are usually solitary. This case series from Essex, describes three cases from 70 patients treated by a single surgeon. All three patients had a solitary parotid lump that was clinically apparent and brought them to the attention of maxillofacial surgeons. Further radiological investigation by MRI demonstrated additional lesions within the same parotid gland. Patients were successfully treated by extracapsular dissection or superficial parotidectomy, with no recurrence on follow-up declared. There is no definite aetiology given for these synchronous tumours, but the authors emphasise the importance of preoperative imaging; MRI and USS are favoured here. Do synchronous parotid tumours merit the use of superficial parotidectomy over extracapsular dissection? This author believes there is merit in being able to perform both.

Reference

Multiple, synchronous, unilateral parotid adenomas: a case series.
Andrews L, Shah N.
BRITISH JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY
2015;53:526–8.

AMERICAN JOURNAL OF OTOLARYNGOLOGY

Smaller gauge voice prosthesis is effective in secondary trans-oesophageal puncture
Reviewed by: Rohit Verma
VOL 24 No 5
 

Placement of voice prosthesis at the time of trachea-oesophageal puncture is well described using 20-French prostheses. There is debate about the optimal size of the prosthesis with work in the 1980s and 1990s supporting larger prostheses. The rationale was that larger size allowed greater airflow. However, as treatment of laryngeal malignancy has moved towards organ preservation protocols involving chemo-radiation, significant detrimental effects at the puncture site have manifested after salvage laryngectomy as widening fistula tracts. Therefore, there is a theoretical benefit in using a narrower gauge prosthesis initially, preserving the ability to upsize at a later date if required. This paper from Dr Deschler’s team at the Mass Eye & Ear Infirmary reports on 21 cases where a 16Fr transoesophageal voice prosthesis was placed using a secondary puncture technique (Blom-Singer tracheo-esophageal puncture kit) two out of three of the procedures were performed after salvage laryngectomy. Median time from laryngectomy to puncture was 5.1 months (range 1.6-178.6 months). In 100% of cases, the prosthesis was placed successfully. Voice fluency, as assessed by a speech and language pathologist was assessed and rated on a four point scale with the top two tiers being regarded as ‘fluent’ speech. Fluent speech was achieved in 85.7% with a median time to fluent speech of 18.5 days. Postoperative complications are comparable to larger prosthesis with a leak through the prosthesis reported in 14.3%. This paper shows, in a small cohort, that using a smaller gauge prosthesis gives good voice rehabilitation results and has low rates of complications attributable to the prosthesis itself.

Reference

Placement of a 16-French voice prosthesis at the time of secondary tracheoesophageal voice restoration.
Naunheim MR, Remenschneider AK, Bunting GW, Deschler DG.
AMERICAN JOURNAL OF OTOLARYNGOLOGY-HEAD AND NECK MEDICINE AND SURGERY
2015;36(4):509-12.

AMERICAN JOURNAL OF OTOLARYNGOLOGY

The theory of everything (tonsil)?
Reviewed by: Rohit Verma
VOL 24 No 5
 

Tonsil sepsis can manifest as acute tonsillitis, a peritonsillar abscess (PTA) or rarely as an intra-tonsillar (ITA) abscess. Whilst the management of these conditions is familiar to ENT surgeons from early in training, perhaps little attention has been paid to how these conditions develop and how previous episodes of tonsil infection may precipitate different manifestations with subsequent infections. The authors performed histological analysis of pathological specimens of PTA, acute tonsillitis and ITA. In cases of tonsillitis, the surface epithelium was eroded with invasion of neutrophils. In cases of PTA, there was neutrophil infiltration, tissue necrosis and abscess formation between the fibrous tonsillar capsule and the skeletal muscle of the pharyngeal constrictor muscles. In ITA, there was erosion of the epithelium as in tonsillitis but this time deep infiltration of neutrophils into the crypts resulting in a circumscribed abscess surrounded by normal parenchyma. The authors suggest that a PTA is more likely to occur than the rare ITA as lymphatic drainage within the tonsil parenchyma itself is rapid and drains to the lymphatic channels of the fibrous capsule. Therefore, after inflammatory swelling of the tonsils of previous PTA, alteration of lymphatic flow may allow adequate time for accumulation of virulent bacteria within the tonsillar parenchyma leading to ITA instead of the more common presentation of deep abscess between the capsule and pharyngeal muscles.

Reference

A unifying theory of tonsillitis, intratonsillar abscess and peritonsillar abscess.
Bair AB, Booth R, Baugh R.
AMERICAN JOURNAL OF OTOLARYNGOLOGY-HEAD AND NECK MEDICINE AND SURGERY
2015;36(4):517-20.

AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY

Combined sprays for allergic rhinitis maintenance
Reviewed by: Edward W Fisher
VOL 24 No 5
 

This meta-analysis looked at the reported efficacy for allergic rhinitis control of various topical sprays, particularly comparative studies. There were fewer ‘head to head’ studies than we would have hoped to exist. This review included intranasal anti-histamines, intranasal steroids and a combined spray (azelastine hydrochloride and fluticasone propionate). Twenty studies (four of which were on children) were included. The combination spray was well tolerated and superior in efficacy, with onset beginning 30 minutes after the spray. The combination spray appears to have an additive effect in patients with moderate to severe rhinitis, compared to the individual agents alone. Predictably, the order of efficacy (best to worst) was combined spray: topical steroid: topical anti-histamine. The point is made that compliance is a major factor and that a single agent is likely to be accepted better than multiple agents.

Reference

Intranasal spray medications for maintenance therapy of allergic rhinitis.
Berger WE, Meltzer EO.
AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY
2015;29(4):273-82.

AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY

Smell and mental health
Reviewed by: Edward W Fisher
VOL 24 No 5
 

This national survey from Korea asked questions about many aspects of health and one of these was about sense of smell. The prevalence of olfactory problems was 5% in the adult group surveyed, and other studies would suggest that this self-reported figure was an underestimate. What was more interesting was the apparent higher prevalence of suicidal ideation and depression in the group with self-reported smell problems compared to the self-reported ‘normosmic’ group. This is clearly a complex epidemiological problem and may not be as it seems at face value due to confounding factors and the nature of the study. Other factors that were related to olfactory problems included: social class (‘job, education’), alcohol intake (‘drinking habit’), waist circumference and rhinitis. Whether mental health affects reporting of smell problems is also a possible factor here.

Reference

Relationship between olfactory dysfunction and suicidal ideation: the Korea national health and nutrition examination survey.
Joo Y-H, Hwang S-H, Han K-d, Seo J-H, Kang J-M.
AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY
2015;29(4):268-72.

ANNALS OF THE ROYAL COLLEGE OF SURGEONS OF ENGLAND

Long-term outcomes after (adeno)tonsillectomy
Reviewed by: Thomas Jacques
VOL 24 No 5
 

Patient-reported outcome measures (PROMs) are used increasingly to fill an ‘evidence gap’ where healthcare rationing threatens particular treatments. Tonsillectomy is a long-established and effective treatment for recurrent tonsillitis and obstructive sleep apnoea (OSA) in children. The T-14 outcome measure examines disease-specific quality of life related to these two conditions. The authors present serial T-14 scores from a cohort of patients undergoing adenotonsillectomy or tonsillectomy. Scores were obtained preoperatively and at three, six, 12 and 24 months, with complete responses in 44 patients / parents. The results demonstrate a significant decrease in T-14 score from preoperative to three-month follow-up – from a mean score of 33.3/70 to a mean score of 3.4/70. Most importantly, these improvements in symptomatology and quality of life are sustained through to 24-month follow-up. The results do not take account of the natural history of paediatric OSA and frequent tonsillitis, which tends towards improvement over time for many patients. Nevertheless, it provides good evidence for rapid and prolonged improvement in quality of life after adenotonsillar surgery, in patients meeting the relevant diagnostic criteria (e.g. SIGN). This, and hopefully further controlled research, may help to safeguard against further assaults on the provision of valuable ENT surgical procedures.

Reference

A two-year follow-up observational study of the T-14 paediatric throat disorders outcome measure in tonsillectomy and adenotonsillectomy.
Konieczny KM, Biggs TC, Pringle MB.
ANNALS OF THE ROYAL COLLEGE OF SURGEONS OF ENGLAND
2015;97:382-5.

B-ENT

Postoperative pain in septoplasty
Reviewed by: Sunil Sharma
VOL 24 No 5
 

This is a prospective Turkish study that looked at factors affecting the postoperative pain response after septoplasty, a common ENT surgical procedure. Sixty patients were included in the study who underwent septoplasty. The authors looked at the influence of demographics and preoperative anxiety (measured using the Spielberger State-Trait Anxiety Index, a validated scoring system) on postoperative pain [measured using a Visual Analogue Scale (VAS) preoperatively and at intervals up to 24 hours postoperatively]. While the authors found no correlation between patients’ age and educational status and their postoperative pain levels, they did find a significant relationship between patients’ preoperative anxiety and their postoperative pain levels in the immediate and late periods. They also found that women were more likely to complain of more severe postoperative pain than men, in common with previous literature. The authors hypothesise that the physiological anxiety stress response can have an adverse effect on postoperative healing. This study is subject to some limitations, such as a small series of patients, presence of confounding factors, and lack of control group. However, the important message that this study does carry is that it is important to take a holistic view with our patients, and to recognise preoperative anxiety regarding their surgery and manage this as necessary, as well as including anxiety-reducing strategies in the postoperative period alongside standard analgesia.

Reference

Preoperative anxiety and postoperative pain in patients undergoing septoplasty.
Ocalan R, Akin C, Disli ZK, Kilinc T, Ozlugedik S.
B-ENT
2015;11:19-23.

B-ENT

T1 lip cancer and cervical lymph node metastases
Reviewed by: Sunil Sharma
VOL 24 No 5
 

The management of large lip squamous cell carcinoma (SCC) (T2, T3, T4 tumours) or those with nodal disease is well established. However the management of T1N0 tumours is controversial due to the assumed low risk of occult lymph node metastases. This study looked at the prevalence of metastatic lymphadenopathy via a multicentre retrospective analysis of 59 patients treated for T1 lip SCC over a 10 year period in France. Cervical lymph node metastases was found in 11.9% of the cases during follow-up (never at the time of diagnosis), and the mean time for appearance of lymph node metastases was at 13.3 +/- 7.9 months. These results would suggest that the incidence of occult lymph node metastases in T1N0 SCC patients is higher than previously thought, and would suggest that concurrent neck dissection at the time of initial resection of tumour may be recommended in appropriate cases. However, a good quality randomised control trial is required to look at the incidence of lymph node metastases in the T1NO SCC lip group and to determine the impact of this therapeutic procedure on survival.

Reference

Cervical lymph node metastases and T1 squamous cell carcinoma of the lips.
Mardion NB, Raucourt DD, Babin E, Rame JP, Dehesdin D, Choussy O.
B-ENT
2015;11:89-93.

BRITISH JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY

Righting the paralysed lip
Reviewed by: Adam Shakir
VOL 24 No 5
 

Many surgical procedures that otolaryngologists perform put the facial nerve at risk of injury, a complication that the surgeon and patient fear alike. Unfortunately, injuries to the nerve can and do happen despite adequate precautions, and facial paralysis may be permanent, with the functional and cosmetic penalties this entails. Injury to the marginal branch of the facial nerve denervates muscles resulting in rolling of the vermillion border cranially and elevation of that half of the lower lip rather than weakness of the orbicularis oris muscle. This paper describes a static repair to the lower lip margin and associated muscles. An appropriately marked out skin ellipse adjacent to, but not including, the vermillion border is excised. Additionally, the denervated lip depressors are mobilised inferiorly. Performing this under local anaesthetic enables intra-operative adjustments to suit the cosmetic outcome desired. The author states that existing oral function is preserved and appearances maintained on follow-up.

Reference

Symmetrical repair of a paralysed lower lip.
Hakim SG.
BRITISH JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY
2015;53:574–6.

CLINICAL OTOLARYNGOLOGY

Development of an ENT undergraduate curriculum
Reviewed by: Andrew Hall
VOL 24 No 5
 

With over a third of medical schools not including any clinical attachment in the subject, this is a laudable attempt to confront the deficiencies in undergraduate ENT teaching within the UK. The Delphi process is an established method of developing a validated curriculum and a two-round process was utilised here to discern a consensus of items to include in undergraduate training. If we acknowledge approximately 25% of consultations in primary care involve ENT- it is right for the specialty to press for recognition of this fact through recognition within medical school teaching. It is vital that ENT specialists engage in the process and assist medical schools as they develop the doctors of the future.

Reference

Development of an ENT undergraduate curriculum using a Delphi survey.
Lloyd S, Tan ZE, Taube MA, Doshi J.
CLINICAL OTOLARYNGOLOGY
2014;39(5):281-8.

CLINICAL OTOLARYNGOLOGY

Research ethics and otolaryngology
Reviewed by: Andrew Hall
VOL 24 No 5
 

The aim of this review was to assess the frequency of reporting of informed consent and regional ethical committee (REC) approval in all reports of trials published in the three major European otolaryngology journals in 2012 (including Clinical Otolaryngology itself!). In total 49.9% of the manuscripts reporting human subjects, human tissue or identifiable personal data research lacked a statement of REC approval and 42.9% lacked disclosure of informed consent. Articles that did not state REC approval were associated with additionally not stating informed consent (P < 0.05). Clearly it is imperative that in the present publishing climate adequate attention is given to correct procedure and protocol with the onus placed on the submitting authors to detail their involvement. It is pleasing to see that in publishing such an article themselves Clinical Otolaryngology recognise their responsibility in promoting this area.

Reference

The reporting of research ethics committee approval and informed consent in otolaryngology journals.
Murphy S, Nolan C, O’Rourke C, Fenton JE.
CLINICAL OTOLARYNGOLOGY
2015;40:36-40.

COCHLEAR IMPLANTS INTERNATIONAL

Another comparison of stapedial reflex thresholds and comfort levels in implantees
Reviewed by: Thomas Nikolopoulos
VOL 24 No 5
 

Many studies in the past have attempted to correlate electrical stapedius reflex threshold (eSRT) and comfort levels in implantees, mainly to assist fitting in young children or adults with difficulties in cooperation with audiologists. The present study assessed 11 adult implantees comparing eSRTs with comfort levels at two weeks and at one year post-fitting. The results revealed a pretty good correlation; Pearson correlation coefficients of 0.65 at two weeks and 0.60 at one year (both statistically significant). Finally, the authors claimed that they have calculated a predictive equation model with a clinically acceptable margin of error. However, the sample size is quite small with only 11 patients. In addition, a study of users’ preferences and performance under behavioural and predicted comfort levels would help to assess the margin of error. Finally, all these assessments concern individual channels and not a group of channels and the latter could make a difference.

Reference

Comparison of eSRTs and comfort levels in users of Digisonic SP cochlear implants.
Bergeron F, Hotton M.
COCHLEAR IMPLANTS INTERNATIONAL
2015;16(2):110-14.

COCHLEAR IMPLANTS INTERNATIONAL

‘FOX’ – a new software programme in cochlear implant fitting for audiologists
Reviewed by: Thomas Nikolopoulos
VOL 24 No 5
 

Taking into account the complex parameters involved in cochlear implant fitting, it appears that the procedure is becoming more and more difficult and variable across cochlear implant centres. For this reason, a software programme called FOX was designed attempting to facilitate and standardise the procedure. The authors compared FOX with the standard fitting procedure with regard to the fitting time and the efficiency in achieving improvements in speech perception.The subjects included 27 adult implantees in various cochlear implant centres across Europe. The results revealed that the fitting time using FOX was significantly reduced at 14 days but not afterwards. This controlled, randomised study has weaknesses including multicentre nature and no well-matched groups. However, it is a first attempt to facilitate and standardise the procedure and as such is more than welcome. Such software programmes may be proven very valuable in the future.

Reference

Assessment of ‘Fitting to Outcomes Expert’ FOX™ with new cochlear implant users in a multi-centre study.
Battmer RD, Borel S, Brendel M, et al.
COCHLEAR IMPLANTS INTERNATIONAL
2015;16(2): 100-109.

CURRENT OPINION IN OTOLARYNGOLOGY AND HEAD AND NECK SURGERY

Immunotherapy – could it be cheaper?
Reviewed by:
VOL 24 No 5
 

Immunotherapy is the only treatment for allergy to alter the disease course. Limited data exist on direct and indirect costs of subcutaneous (SCIT) and sublingual (SLIT) immunotherapy in America. This article assesses the cost effectiveness worldwide of the two immunotherapies. The risk of systemic allergic reactions to SLIT is low, although case reports of anaphylaxis exist. The first dose is given under specialist supervision, followed by home administration. Of note, in America multiple allergens are administered per SCIT course compared to Europe. Only one American study evaluated SLIT versus SCIT costs. SLIT was on average $500-1200 per year (for less than 10 allergens). Authors concluded SLIT was more affordable than SCIT when taking indirect costs into account. A Canadian study suggested the most cost effective option was Oralair (a type of SLIT given for six months per year for 2-3 years). It cost $2471 for the first year of treatment; $948 less expensive than year-round or SCIT administered seasonally. Grazax (another SLIT given for 12 months per year for three years) was also less expensive than year-round SCIT, but more expensive than seasonal SCIT. Findings were similar in a German study. A UK cost evaluation of SCIT (Alutard SQ) and SLIT (Grazax) was based on the assumption that clinical improvement achieved during three years of SCIT or SLIT is maintained for another three years after cessation. SLIT was estimated to require 13 clinic visits per year compared to 46 for SCIT. SLIT resulted in an overall cost reduction of £2869, compared to SCIT. In summary, the cost of immunotherapy in America is a complex topic. Few cost comparisons exist in the literature. The authors suggest that costs of SLIT may be more contained if the number of antigens administered per patient are more carefully selected.

Reference

Comparative costs of subcutaneous and sublingual immunotherapy.
French C, Seiberling K.
CURRENT OPINION IN OTOLARYNGOLOGY AND HEAD AND NECK SURGERY
2015;23(3):226-9.

CURRENT OPINION IN OTOLARYNGOLOGY AND HEAD AND NECK SURGERY

Tricky post-laryngectomy swallows
Reviewed by:
VOL 24 No 5
 

Despite improvements in chemoradiation therapy and the adoption of organ preservation for some head and neck cancers, total laryngectomy remains the treatment often providing best survival chances for advanced laryngeal cancer. This article reviews the causes of dysphagia post-laryngectomy and the use of evaluation tools. The authors describe the incidence of dysphagia between 50-72% following laryngectomy; often under-reported and resulting in psychosocial limitations. Assessment of swallow is most commonly associated with videofluoroscopy. Fibreoptic endoscopic evaluation of swallowing (FEES) identifies secretions and residue post swallow. It is useful in those who are not medically fit for videofluoroscopy, but direct visualisation of the oral and oesophageal stages of swallowing are not possible. A study of manometry, measuring bolus pressure and timing of the contractile wave during swallowing at anatomical points, such as upper or lower oesophageal sphincter, demonstrated impaired propulsive forces of the reconstructed pharynx after laryngectomy and suggested that biomechanical effects can be influenced by surgical techniques. Like videofluoroscopy, it involves radiation exposure and this technique is not readily available in small centres. Common causes of post-laryngectomy dysphagia are described including pseudodiverticulae, fistulae, strictures, reduced propulsion in the neopharynx, voice prosthesis leakage and reflux. Each of these problems results in dietary modifications and difficulty maintaining a balanced diet. In summary, the authors highlighted that a significant number of post-laryngectomy patients suffer with dysphagia. Its management is facilitated by comprehensive swallowing evaluation. Further research is required to illuminate dysphagia rehabilitation.

Reference

Swallowing after laryngectomy.
Coffey M, Tolley N.
CURRENT OPINION IN OTOLARYNGOLOGY AND HEAD AND NECK SURGERY
2015;23(3):202-7.

DYSPHAGIA

The right kit matters… How important is video recording in FEES?
Reviewed by: Roganie Govender
VOL 24 No 5
 

As a portable alternative to videofluoroscopy, fibreoptic endoscopic evaluation of swallowing (FEES) is often carried out at the patient’s bedside. The authors of this paper have chosen to examine the reliability of the penetration-aspiration ratings (Rosenbek scale) of FEES examinations when rated, having the full advantage of video recordings (frame by frame analysis and repeat viewings) compared with a single viewing of the examination on a 7.5 inch screen to simulate real time FEES examinations. Eighty exams (10 for each score on the PAS scale) as rated by ‘master’ raters, were presented in random sequences to four ENT clinicians experienced in FEES. They were required to determine the PAS score under the ‘without video’ scenario. This was repeated two weeks later. Six months later, the same ENTs were presented with the same examinations (re-randomised) but with access to the video recordings played as many times as necessary and / or using frame by frame features to rate the exam played on a standard 17-inch screen (with video scenario).  Repeat ratings in re-randomised sequence were once again done after a two-week interval. Inter-rater, intra-rater and concurrent validity were assessed for both evaluation methods using the PAS scale. The authors’ overall conclusion was that the detection of aspiration-penetration without video recording was not as reliable as with video recording. Concurrent validity as measured by comparison with a reference standard rated by ‘master’ raters was also better for the video method of evaluation. They also suggest that this benefit could be greater if the raters were less experienced than the clinicians who participated in this study. This is a useful paper to read, particularly if putting together a bid for FEES equipment. Do however bear in mind that video recording offers much more than the focus in this paper – including a permanent record for future comparison, biofeedback for the patient, visual and personalised education about swallow function for the patient and family and the opportunity to have multiple clinicians view and discuss findings.

Reference

Penetration–aspiration: is their detection in FEES reliable without video recording?
Hey C, Pluschinski P, Pajunk P, Almahameed A, Girth L, Sader R, Stover T, Zaretsky Y.
DYSPHAGIA
2015;30(4):418-22.

EUROPEAN ANNALS OF OTORHINOLARYNGOLOGY, HEAD AND NECK DISEASES

Aerosols and polypi
Reviewed by: Badr Eldin Mostafa
VOL 24 No 5
 

Infection in the operative cavities after endoscopic sinus surgery for sinonasal polyposis leads to recurrence of symptoms and mucopurulent discharge. The usual therapies include systemic antibiotics sometimes with steroids. The authors hypothesised that the use of a topical antimicrobial (tobramycin 150mg/3mL) as an aerosol could be more effective than isotonic saline administered by the same aerosol apparatus in eradicating infection and relief of symptoms. It was a prospective multicentric randomised study. It included 72 patients who were previously operated on at least three months prior to inclusion and having bacterial superinfection of the cavities. The commonest organism was Staph aureus. The patients received two daily treatments for seven days. At the end of the trial 46.88% of bacteria were eradicated in the trial group versus 17.39% in the saline group (p = 0.02). The authors conclude that this form of therapy is well tolerated and quite effective in such a group of patients. However the main flaw is that they did not compare with a third group receiving systemic antibiotics as routinely used in most cases. This would have shown whether this novel therapy is really effective or not.

Reference

Efficacy of tobramycin aerosol in nasal polyposis.
Bonfils P, Escabasse V, Coste A, et al.
EUROPEAN ANNALS OF OTORHINOLARYNGOLOGY, HEAD AND NECK DISEASES
2015;132(3):119–23.

HEAD AND NECK

Are organ-preserving treatment strategies for T3 laryngeal cancers reducing patient survival?
Reviewed by: Jonathan Hughes
VOL 24 No 5
 

This article presents the 10-year results of a single institution’s treatment of advanced laryngeal cancer. The institution established a protocol based on the Dutch Head and Neck Society consensus document on laryngeal cancer diagnostics and treatment published in 1991. This protocol consisted of organ-preserving radiotherapy for T3 disease, supplemented with chemotherapy for extensive neck disease, with total laryngectomy and adjuvant radiotherapy for T4 disease. The primary endpoint was overall survival (OS); there was no measurement of voice, swallowing or quality of life outcomes. One hundred-and-eighty-two patients were studied, 60 of which had total laryngectomy. The five-year OS showed no statistical difference between T3 and T4 cancers: 52% for T3 cancers and 48% for T4 cancers (p = 0.528). As the majority of T3 cancers were treated non-surgically and the majority of T4 cancers were treated with total laryngectomy and radiotherapy, the question should be asked if organ-preserving strategies for the treatment of T3 disease are adversely affecting patient survival. This question has been raised by other groups, who have noted decreased survival for patients with advanced laryngeal cancer in the United States at the same time as increasing use of organ-preserving treatment modalities over surgery.

Reference

T3-T4 laryngeal cancer in The Netherlands Cancer Institute; 10-year results of the consistent application of an organ-preserving/-sacrificing protocol.
Timmermans AJ, de Gooijer CJ, Hamming–Vrieze O, Hilgers FJM, van den Brekel MWM.
HEAD AND NECK
2015;37(10):1504-8.

HEARING RESEARCH

Role of potassium channel opener in salicylate induced tinnitus
Reviewed by: Faiz Tanweer
VOL 24 No 5
 

The exact mechanism in the origin of tinnitus is not known. Many pharmacological agents have been tried to to treat tinnitus without great success. Aspirin is a commonly used medicine in the elderly population to reduce the risk of stroke but one of its annoying side-effects is tinnitus. Authors of the present study have used this molecule to induce tinnitus in a rat models. Behavioural changes were noted along with changes in distortion product otoacoustic emission (DPOAE) and combined action potential (CAP) following the use of high dose salicylate. From previous studies it is known that sodium salicylate blocks the KCNQ4 channel in outer hair cells and outward potassium current in inner hair cells in cochlea. It is presumed that potassium channel dysfunction may be the underlying cause of peripheral auditory damage and tinnitus. The authors used potassium channel activators Maxipost and Retigabine to see the reversal of the above mentioned subjective and objective findings. Maxiprost and Retigabine both improved CAP amplitude and DPOAE. However this improvement was frequency dependent and is perhaps because of variable expression levels of potassium channel in different parts of rat cochleas. Retigabine improved CAP at low frequencies below 8kHz and hence is more clinically relevant. Maxiprost and Retigabine are the licensed medications originally developed for stroke and epilepsy respectively. On the basis of animal model experiments, the authors have suggested that these medications can reduce salicylate-induced tinnitus. I suppose a human trial in future could be commenced to see the therapeutic potential of these medications.

Reference

Potassium ion channel openers, Maxipost and Retigabine, protect against peripheral salicylate ototoxicity in rats.
Sheppard A M,  Chen G, Salvi R.
HEARING RESEARCH
2015;327:1–8.

INTERNATIONAL FORUM OF ALLERGY AND RHINOLOGY

Getting your nose dry: endoscopic vidian neurectomy – an old technique given new life
Reviewed by: Christos Georgalas
VOL 24 No 5
 

We are often faced with patients with intractable watery rhinorhea – patients with no demonstrable allergy, a diagnosis of NAR and no response to ipratropium or capsaicine. For such patients, vidian neurectomy has been devised – an old technique that had been discredited because of its high complications and poor efficacy. However, the use of endoscopes has given new life to this old technique – and the endoscopic version of it, as described by Kamel and Wormald, is increasingly gaining popularity. These authors from Canada have carried out one of the few prospective (but uncontrolled) studies of endoscopic vidian neurectomy, as performed on 11 patients and 22 sides. All patients underwent an opthalmological consultation before and after the operation (to asses for xerophthalmia, one of the most feared complications of the technique) while the PROM used was SNOT 22 and SSQ. The technique used was the pterygomaxilary approach, the one most commonly used (and my personal favourite). None of the patients suffered a dry eye after surgery, while the mean follow- up was a year and a half. SNOT 22 decreased from a very high 44 to an almost normal 10 after surgery. Overall, this study, despite its limitations, provides some of the best evidence for the efficacy and safety of endoscopic vidian neurectomy.

Reference

Endoscopic vidian neurectomy: a prospective case series.
Zhang H, Micomonaco DC, Dziegielewski PT, Sowerby LJ, Weis E, Wright ED.
INTERNATIONAL FORUM OF ALLERGY AND RHINOLOGY
2015;5(5):423-30.

INTERNATIONAL FORUM OF ALLERGY AND RHINOLOGY

Measuring is understanding: an unsupervised PROM clustering of CRS patients
Reviewed by: Christos Georgalas
VOL 24 No 5
 

It has been clear for quite some years, at least for anyone dealing daily with chronic rhinosinusitis (CRS) patients, that CRS is an ‘umbrella’ diagnosis. There are significant differences between patients, including different demographic data, different endoscopic and radiographic images, different disease burden and different responses to surgery and medications. The holy grail of modern rhinology has been to phenotype CRS patients, searching for its own “unifying theory of everything” that can explain these differences. The authors of this clever study have started the other way round. Instead of creating another difficult to prove theory, they looked closely at their data. They performed cluster analysis, a statistical method of defining groups within patients, using endoscopic, radiographic, age, gender and patient outcome data, without using any a priori classification model. The result was five clusters, each characterised by different objective signs of disease (endoscopy and CT scans) and different PROM measures. Cluster 5 was the smaller group but the one worst affected in terms of loss of productivity and quality of life, with half of its patients reporting depression, and the second worst objective measures of disease. On the other hand, cluster 2 had the oldest patients (mean age of 61 years), the biggest number of male patients, with the worst objective signs of disease but only intermediately depressed QOL. Overall an interesting read, food for thought and open to many interpretations. Unfortunately the authors were unable to collect any biomarker data – hopefully someone will follow up on this study and attempt to explore any underlying connections. Watch this space.

Reference

Identification of chronic rhinosinusitis phenotypes using cluster analysis.
Soler ZM, Madison Hyer J, Ramakrishnan V, Smith TL, Mace J, Rudmik L, Schlosser RJ.
INTERNATIONAL FORUM OF ALLERGY AND RHINOLOGY
2015;5(5):399-407.

INTERNATIONAL JOURNAL OF ORAL and MAXILLOFACIAL SURGERY

Intermediate risk factors SCC tongue
Reviewed by: Stuart Clark
VOL 24 No 5
 

This retrospective review from Japan assessed 89 patients who underwent surgery for squamous cell carcinoma of the tongue, specifically they reviewed the evidence of perineural and vascular invasion (27.0% and 23.6%). Their results suggest, not unsurprisingly, that perineural and vascular invasion are effective predictors of regional metastases. Furthermore, they concluded that perineural invasion may be a clinical predictor of survival. The five year survival of stage I and stage II disease with these factors was significantly lower than those without. They advocate elective neck dissection in clinical stage I and II cases when perineural or vascular invasion is found.

Reference

A clinicopathological study of perineural invasion and vascular invasion in oral tongue squamous cell carcinoma.
Matsushita Y, Yanamoto S, Takahashi H, Yamada S, Naruse T, Sakamoto Y, Ikeda H, Shiraishi T, Fujita S, Ikeda T, Asahina I, Umeda M.
INTERNATIONAL JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY
2015;44:543-8.

INTERNATIONAL JOURNAL OF ORAL and MAXILLOFACIAL SURGERY

No difference upper or lower lip
Reviewed by: Stuart Clark
VOL 24 No 5
 

This is a retrospective review from the Netherlands over a 20-year period to 2009 of squamous cell carcinoma (SCC) of the lip. In total, 979 cases of the lower lip were identified and 126 of the upper lip, with men being 2.6 times more often affected. The overall five year survival was 74%.  The 10 year survival for patients with upper lip SCC was 94% compared to 90% for the lower lip. There was no survival difference for those treated by surgery alone. They unexpectedly found that upper lip patients were more frequently treated by surgery and less often by radiotherapy than lower lip patients, acknowledging that both are reported to be fully effective.

Reference

No evidence for a survival difference between upper and lower lip squamous cell carcinoma.
Pietersma NS, de Bock GH, de Visscher JGAM, Roodenburg JLN, van Dijk BAC.  
INTERNATIONAL JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY
2015; 44:549-54.

INTERNATIONAL JOURNAL OF PEDIATRIC OTORHINOLARYNGOLOGY

Bone anchored implant stability predicted one week after implantation
Reviewed by: Patrick Spielmann
VOL 24 No 5
 

Bone conduction (BC) devices can now be implanted as a single stage procedure with minimal soft tissue thinning to reduce the complications in the surrounding skin. The question of optimal loading time has to my mind not been answered. Here the authors have followed 10 children for a year post implantation with regular monitoring of the implant stability quotient (ISQ). Radiofrequency analysis (RFA) of the implant was performed at one week, three, six and 12 months postoperatively. A score less than 30 at one week suggested poor osseointegration in two cases, these did indeed fail within the study period. As abutments lengthen to accommodate no / minimal soft tissue reduction techniques so the stability of the implant decreases. These conflicting issues must be balanced and using RFA to objectively assess implant stability and permit earlier loading or abandoning an implant that appears doomed to fail is attractive particularly in children. I shall be lobbying my managers for this measurement device...

Reference

Prospective analysis of stability testing for bone-anchored hearing implants in children after osseointegrating surgery without skin thinning.
Hultcrantz M, Lanis A.
INTERNATIONAL JOURNAL OF PEDIATRIC OTORHINOLARYNGOLOGY
2015;79:465-8.

INTERNATIONAL JOURNAL OF PEDIATRIC OTORHINOLARYNGOLOGY

How young is too young for tympanoplasty?
Reviewed by: Patrick Spielmann
VOL 24 No 5
 

This paper presents the largest series of pre-school age children undergoing tympanoplasty compared with older children. The authors have collected much prospective data on 259 children undergoing 284 surgeries so were able to perform multivariate analysis. The age groupings of two to four years, five to seven years and 8-13 years were analysed separately to look for predictors of success / failure. The very young children were shown to have a five -fold greater risk of re-perforation compared with the oldest age group even in the relatively short follow-up of (median) seven months. The authors argue that despite the improvement in quality of life and modest hearing gains, the risk of graft failure and need for revision surgery are too high so surgery should be delayed if at all possible.

Reference

The effect of age on paediatric tympanoplasty outcomes: A comparison of preschool and older children.
Duval M, Grimmer JF, Meier J, et al.
INTERNATIONAL JOURNAL OF PEDIATRIC OTORHINOLARYNGOLOGY
2015;79:336-41.

JAMA OTOLARYNGOLOGY HEAD AND NECK SURGERY

Medialisation laryngoplasty can relieve pain related to voice use
Reviewed by: Shabbir Akhtar
VOL 24 No 5
 

Odynophonia, or pain associated with voice use, is a relatively uncommon manifestation of glottal insufficiency related to vocal fold motion impairment (VFMI). Its incidence is approximately 15% in patients with vocal fold paresis. Medialisation laryngoplasty (ML) was popularised by Isshiki in 1974 and remains the gold standard for the long-term treatment of hoarseness related to glottal insufficiency. Medialisation laryngoplasty is also commonly performed for aspiration and dysphagia related to glottal insufficiency from vocal fold motion impairment. In this study authors speculated that patients with a chief complaint of odynophonia may achieve pain relief with medialisation laryngoplasty, even when the degree of vocal impairment is mild or nonexistent. A retrospective review of medical records of eight patients from two tertiary care laryngology centres who underwent medialisation laryngoplasty for the chief complaint of odynophonia was conducted. Pain with voice use was the chief complaint for all patients in the study, and relief of their pain was assessed by patient self-report following intervention. Preoperative Voice Handicap Index 10 and Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) scores were compared with postoperative scores. CAPE-V is an auditory-perceptual evaluation tool that uses a visual analogue scale from 0 to 100 to rate overall severity, roughness, breathiness, strain, pitch and loudness. CAPE-V assessments were performed by certified speech-language pathologists specialising in the evaluation of voice disorders. Eight patients underwent ML for the chief complaint of odynophonia over a two-year period. Mean follow-up time was 14.1 months. Dysphonia was not the primary complaint in any of the cases reviewed. Gore-Tex was used for the ML in six patients, and Silastic was used in the other two patients. All eight patients experienced relief of odynophonia following ML. The presence of pain or discomfort may be underappreciated by the clinician who is focused primarily on voice quality. Compensatory supraglottic hyperfunction is common in patients with glottal insufficiency, and the resulting muscle strain is presumed to be the predominant underlying cause of odynophonia in these patients. Authors have hypothesised that relief of odynophonia is a result of reduced muscle strain in most of these patients. The conclusions from this study should be made with caution, limited by a small number of patients and retrospective design.

Reference

Medialization laryngoplasty for odynophonia.
Kupfer RA, Merati AL, Sulica L.
JAMA OTOLARYNGOLOGY HEAD AND NECK SURGERY
2015;141(6):556-61.

JAMA OTOLARYNGOLOGY HEAD AND NECK SURGERY

Octreotide in the medical management of chyle fistula post neck dissection
Reviewed by: Shabbir Akhtar
VOL 24 No 5
 

Chyle leak, although rare (1% and 2.5%), is a well-documented complication following surgical dissection of the neck. Although the left side of the neck is the most common site, chyle fistulas have been reported in the right side of the neck as well because of the variability in the lymphatic system, with the possibility of a thoracic duct outlet on the right side. Prolongation of a chyle leak can lead to longer hospital stays, delayed healing and necrosis of skin flaps. In refractory cases, a return to the operating room is also required, causing a substantial increase in cost for the hospitalisation. Traditional treatments for a chyle leak of the neck involve diet modification, closed drainage and use of pressure dressings. Octreotide has been documented for the treatment of chylothorax as an effective means to resolve fistulas but its role to control chyle leak after neck dissection is controversial. Authors aimed to assess the effectiveness and safety of octreotide for prompt resolution of chyle leaks of the neck. A retrospective review of 12 patients who received octreotide for chylous fistula after neck dissection was performed at two tertiary care academic hospitals. Octreotide therapy was started in all patients after clinical detection of the chyle fistula. Dosing of octreotide ranged from 50 mcg subcutaneously twice daily to 150 mcg subcutaneously every six hours. The most common dosing in this study was 100 mcg subcutaneously every eight hours. The chyle fistula resolved without operative intervention in all of the patients, with decreased drain output beginning on the first day of octreotide therapy. The chyle fistula resolved after a mean of 5.5 (range two to 11) days. Complications were uncommon and octreotide therapy was well tolerated in all patients. Octreotide is synthetic analogue of somatostatin. It has many inhibitory functions on hormones, but its effects on closing chyle leaks derive from its ability to decrease absorption of triglycerides and inhibit splanchnic circulation and gastrointestinal motility. Octreotide’s advantage over somatostatin is that it does not require continuous intravenous infusion, but rather, use of subcutaneous injection can sustain long-lasting effects. However, given the small sample size, definitive conclusions and recommendations cannot be made to endorse routine use of octreotide in patients with chyle leak.

Reference

Use of octreotide for the management of chyle fistula following neck dissection.
Swanson MS, Hudson RL, Bhandari N, Sinha UK, Maceri DR, Kokot N.
JAMA OTOLARYNGOLOGY HEAD AND NECK SURGERY
2015;141(8):723-7.

JOURNAL OF CRANIOFACIAL SURGERY

Marginal gains
Reviewed by: Stuart Burrows
VOL 24 No 5
 

Many consider facial nerve monitoring compulsory in parotid surgery yet few do the same for the marginal mandibular nerve in a submandibular approach, even though the nerve is finer and more difficult to identify. Here a group map the nerve on the surface of the skin utilising transcutaneous stimulation, a technique commonly used by anaesthetists undertaking nerve blocks. The article reports that their transcutaneous mapping corresponds to the operative findings. They have taken 40 patients and preoperatively mapped the course of the marginal mandibular nerve then utilised intraoperative nerve monitoring to locate the nerve and compare its position to that mapped transcutaneously. They successfully mapped 39 out of 40 nerves. The literature reports marginal mandibular nerve injury rates of up to 17.5%. The technique described seems simple and potentially useful clinically. The variability of the marginal mandibular nerve proved a challenge and if mapping can reduce the rate of nerve injury in this cosmetically sensitive area this technique may be worth adopting.

Reference

Preoperative percutaneous nerve mapping of the mandibular marginal branch of the facial nerve.
Lin B, Lu X, Shan X, Zhang L, Cai Z.
THE JOURNAL OF CRANIOFACIAL SURGERY
2015;26:411–4.

JOURNAL OF CRANIOFACIAL SURGERY

Two for one forearm flaps
Reviewed by: Stuart Burrows
VOL 24 No 5
 

There are many and varied free flaps available for reconstructions. Here is a variant on the workhorse radial free forearm flap. The modification involves a longer, narrower flap that can be rotated back on itself to increase the flap width yet enable primary closure of the forearm defect. It relies on independent proximal and distal perforators to supply each of the paddles. The enabling of primary closure reduces the morbidity of the skin grafted forearm and the graft donor site. This paper reports 11 successful flaps undertaken over a six year period to fill oral cavity and tongue defects. All 11 were complication free with a minimum of three months’ follow-up. By limiting the width of the forearm defect to 3cm they were able to achieve primary closure in all cases. This new variation may overcome one of the major drawbacks of the radial forearm flap. Time will tell if this modification will prove popular with reconstructive surgeons.

Reference

Bipaddle radial forearm flap for head and neck reconstruction.
Zhang Y, Xi W, Lazzeri D, Zhou X, Li Z, Nicoli F, Zenn MR, Torresetti M, Grassetti L,  Spinelli G.
THE JOURNAL OF CRANIOFACIAL SURGERY
2015;26:350–3.

JOURNAL OF VOICE

The benefits of early voice therapy for unilateral vocal cord paralysis
Reviewed by: Christopher Burgess
VOL 24 No 5
 

This retrospective review of voice outcomes following a diagnosis of unilateral vocal fold paralysis divided patients into three groups according to the time of initiation of voice therapy following the onset of paralysis. The ‘early’ group started voice therapy within four weeks, the ‘intermediate’ group started therapy between four and eight weeks and the ‘delayed’ group started treatment over eight weeks after symptom onset. The early, intermediate and delayed groups comprised 78, 49 and 44 patients respectively with median ages of 57, 55 and 55.5 years. In all groups, the commonest aetiology was iatrogenic following partial or total thyroidectomy. Of the 171 patients, 106 (62%) recovered vocal fold motility. More patients in the early group recovered (65%) than in the intermediate (61%) and delayed (56%) groups. Among patients whose vocal cord paralysis persisted in spite of voice therapy, 93% of those in the early group and 95% of those in the intermediate group showed glottal compensation after treatment. By contrast only 26% of patients in the delayed group showed glottal compensation. Significant improvements in the mean values of Jitter and Shimmer were also noted in the early and intermediate groups following voice therapy but not in the delayed group. On the basis of these results, the authors recommend that voice therapy should ideally commence within four weeks after the onset of vocal cord paralysis to optimise functional outcomes, and certainly no later than two months after injury. Whilst a prospective, randomised trial might provide more robust evidence to support this assertion, it would certainly seem reasonable to prioritise patients with unilateral vocal cord paralysis for early initiation of voice therapy.

Reference

Results of early versus intermediate or delayed voice therapy in patients with unilateral vocal fold paralysis: our experience in 171 patients.
Mattioli F, Menichetti M, Bergamini G, Molteni G, Alberici MP, Luppi MP, Nizzoli F, Presutti L.
JOURNAL OF VOICE
2015;29(4):455-8.

NEUROSURGERY

Surgical anatomy for central auditory device implantation
Reviewed by: Gauri Mankekar
VOL 24 No 5
 

This cadaveric study by researchers in the USA and Japan examined the cerebellopontine angles with the aid of the surgical microscope and 45o endoscope via the retrosigmoid and translabyrinthine approach. Using fibre dissection technique, the ascending auditory pathways between the cochlear nuclei and inferior colliculi and above were examined. The authors report that both the translabyrinthine and retrosigmoid routes provide adequate exposure for concurrent removal of tumour and implantation of the auditory brain stem device at either the cochlear nuclei or inferior colliculus. They also found that if the cochlear nuclei are not functionally or structurally suitable for implantation, then the inferior colliculus is an alternative site for implantation due to its accessibility via both the approaches as well as due to its position in the auditory pathways. This study provides an excellent description of the anatomy and surgical approaches to the cochlear nucleus complex and the inferior colliculus. This surgical knowledge is very important for surgeons planning to place central auditory prostheses, which are becoming increasingly popular due to their improving results.

Reference

Auditory brainstem implantation: anatomy and approaches.
Komune N, Yagmurlu K, Matsuo S, Miki K, Abe H, Rhoton AL.
NEUROSURGERY    
2015;S11(2):306-21.

OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY – HEAD AND NECK SURGERY

Botulinum toxin and drooling – how much, how often and where?
Reviewed by: Suzanne Jervis
VOL 24 No 5
 

This was an incredibly useful article covering all aspects of the use of botulinum toxin as a treatment modality in sialorrhoea. The article starts by outlining why treating sialorrhoea is important and describes the non-pharmacological and pharmacological options, highlighting that a recent Cochrane review found no one treatment as being superior. There are two types of the toxin (A and B) that are used clinically in one of four different preparations within the USA, albeit off-licence from the FDA. These are BOTOX (aka OBTXA), Xeomin, Dysport (all type A) and botulinum toxin B – Myobloc (type B). However, (and of critical importance) each has an individual potency so a unit of one is not equivalent to another. The anatomy and physiology of saliva production is covered in impressive detail as is the literature review regarding the products and the dosing regimens, which vary wildly. The authors recognise a non-response rate to the treatment in about 10% and also a potential loss of response in the longer term, which may improve upon changing to an alternative toxin. The procedure is described in detail, with the preference of using lidocaine cream (e.g. EMLA) on the skin surface to avoid repeated general anaesthetics. The three approaches are covered – blind injection based on anatomical landmarks, USS guided and EMG guidance. The first two are aided with diagrams, photographs and USS images regarding needle placement. The authors remind the reader that serious complications such as dysphagia, choking and aspiration are likely to result in toxin diffusing into localised muscles, either by excessive doses or volumes. This was a highly useful article to anyone embarking upon this treatment modality in their practice and encourages them to use the USS technique as the method of choice due to its accuracy.

Reference

Botulinum toxin injection techniques for pediatric sialorrhea.
Daniel S.
OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY – HEAD AND NECK SURGERY
2015;26(1):42-9.

OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY – HEAD AND NECK SURGERY

Tongue tie – just a snip?
Reviewed by: Suzanne Jervis
VOL 24 No 5
 

This article regarding ankyloglossia raises an eyebrow; surely it’s just a snip isn’t it? Seemingly not. The authors describe two types of tongue tie – the first being posterior, with the frenulum being short and tight, the second being anterior, where it is abnormally attached to the ventral surface of the tongue anteriorly. The evidence regarding undertaking the procedure is not really discussed, which would have been helpful in clinical settings when discussing the options with parents. Recurrence from scarring is also mentioned but the incidence is omitted, leaving the reader wondering how much of a problem it really is. The straightforward frenulotomy (or -ectomy) is explained, with intraoperative photographs. They encourage blunt dissection once a cut has been made to avoid damaging the veins on either side of the frenulum and breaching the muscle. They then proceed to explain a horizontal to vertical frenuplasty, a Z-plasty (two flap technique) and a W-plasty (four flap technique). These are all based around plastic surgery techniques for releasing scar contractures. Diagrams are used to explain the various techniques. However, advice is lacking in which cases these techniques should be adopted (anterior or posterior – or doesn’t it matter?) It would seem that in children the frenuloplasties would be significantly more painful than a simple ‘snip’, and I wonder whether these techniques should only be reserved for repeat procedures for re-scarring. A useful paper but some more clinical information would have improved it.

Reference

Surgical treatment of ankyloglossia.
Baker AR, Carr MM.
OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY – HEAD AND NECK SURGERY
2015;26(1):28-32.

ORAL AND MAXILLOFACIAL SURGERY CLINICS OF NORTH AMERICA

Post-cancer prosthodontic reconstruction
Reviewed by: Deepak Chandrasekharan
VOL 24 No 5
 

A functional outcome after head and neck cancer resection is aimed at restoring speech and swallow. Dental reconstruction greatly facilitates this, particularly by enabling the patient to chew food. The authors reinforce the need for careful presurgical planning with treatment dependent on the level of edentulousness and the type of defect. Whilst jaw reconstruction with bone harvest and free flaps are commonplace, a toothless jaw is becoming an increasingly unacceptable endpoint. The utility of ilium or fibula twinned with osseointegrated implants is discussed in detail as well as roles for biologic reconstructions. Interestingly, the advent of cone beam CT with virtual surgery simulators and computer guided implantation has the potential for excellent outcomes. The authors also acknowledge the difficulty in reconstructing intra-oral skin. Taken together, the variety of treatment options for functional reconstruction (and decisions about biological vs prosthodontics) means there is a need for careful planning with an MDT approach and this is reiterated towards the end of the article.

Reference

Prosthodontic considerations in post cancer reconstructions.
Boonsiriphant P, Hirsch J, Greenberg A, Genden E.
ORAL AND MAXILLOFACIAL SURGERY CLINICS OF NORTH AMERICA
2015;27:255-63.

OTOLOGY AND NEUROTOLOGY

3D printed temporal bones for drilling are here
Reviewed by: Anand Kasbekar
VOL 24 No 5
 

It was only a matter of time before the 3D printer was used to help us with simulated temporal bone (TB) drilling. This group printed three paediatric TB models and evaluated their quality. They were found to be of ‘high quality’ with good anatomical detail. Various anatomical structures were printed in different colours. The model was based on the CT scan of a six month old infant which opens up the possibility of duplicating any bone you are about to drill the following day in theatre. Procedures such as a posterior tympanotomy and cochleostomy were apparently accurately perfomed. They did mention a lack of variation in the hardness between the cortical and cancellous bone. The plastic model is also softer than cadaveric bone. This is similar to using Pettigrew bones where there is a similar lack of differentiation. Compared to the Voxel-man TB drilling computer simulator, which is a large initial investment, I can see the 3D model being more cost efficient. It is difficult to judge such a model unless one has drilled the model themselves. The usefulness of the model will depend on the quality and capability of the 3D printer, the experts working it, and a lot of trial and error I suspect.  Some technical details are provided in the paper to help you replicate this. The cost of the 3D model isn’t really discussed which is interesting. Expect more reports from the use of 3D TB models in the near future.

Reference

3D printed pediatric temporal bone: a novel training model.
Longfield EA, Brickman TM, Jeyakumar A.
OTOLOGY AND NEUROTOLOGY
2015;36(5):793-95.

RHINOLOGY

Budesonide irrigation in polyposis
Reviewed by: Anand Kasbekar
VOL 24 No 5
 

It is very well known through many RCTs and now meta-analyses that saline-based irrigation is beneficial in patients after sinus surgery. It is also demonstrated that intranasal steroids are beneficial postoperatively but there is also a trend for steroid based irrigation, in particular with budesonide and this paper attempts to address whether this is more beneficial than saline alone. Fifty patients in North Carolina who had failed medial treatment for chronic rhinosinusitis with nasal polyposis were randomised to normal saline irrigation and normal saline with budeosnide irrigation post endoscopic sinus surgery. The patients of four different surgeons were recruited. Patients were assessed using various validated quality of life questionnaires on three occasions, 1-2 weeks, 3-8 weeks and 3-6 months post operatively. The study follows the CONSORT guidelines and appropriate statistical analysis was used. Results concluded that both irrigation types improved quality of life scores at all points on the pathway but crucially there was no significant difference between the two. Larger scale studies would be beneficial but currently there appears to be no benefit in adding a steroid to a nasal irrigation fluid postoperatively.

Reference

Post-operative budesonide irrigations for patients with polyposis: a blinded, randomized controlled trial.
Rawal RB, Deal AM, Ebert CS, Dhandha VH Jr, Mitchell CA, Hang AX, Gore MR, Senior BA, Zanation AM.
RHINOLOGY
2015;53(3):227-34.

RHINOLOGY

Hereditary haemorrhagic telangiectasia
Reviewed by:
VOL 24 No 5
 

This is a very nicely written overview of this difficult condition by two expert rhinologists with a tertiary practice. The genetic basis, pathophysiology, diagnosis, natural history and available management options are all discussed. Clearly there is a large spectrum of patients within this disorder in whom effective management can vary widely, particularly according to the availability of local resources. These patients should be managed in large specialist centres however, they do present locally to many different ENT surgeons as emergencies and all should be aware at least, of the dos and don’ts of urgent care as beautifully outlined in this paper. Avoid packing the nose if possible as this causes more trauma, use something absorbable such as Surgicell, Nasopore or even FloSeal. Do not apply silver nitrate as this causes full thickness mucosal damage. Further techniques are described to maintain these patients. Well worth a read and should stimulate some deeper thought on this interesting condition.

Reference

Hereditary haemorrhagic telangiectasia.
Rimmer J, Lund VJ.
RHINOLOGY
2015;53(3):195-203.

SLEEP AND BREATHING

Linking tooth extraction and snoring
Reviewed by: Vik Veer
VOL 24 No 5
 

One of the more contemporaneous theories about OSA is that extraction of teeth or other orthodontic treatment during the development of the facial skeleton leads to alteration of bony growth and therefore alteration of the final result. There is evidence for example that removing large numbers of teeth during childhood for crowding will lead to a reduced jaw size as an adult. Retrognathism is well known to contribute to OSA and snoring, hence this is the tenuous link that gave birth to this theory. This article attempts to collate the available evidence and present it in a coherent way. Unfortunately this was always going to be an uphill battle. There is little in the way of standardised regimes in orthodontic treatment as all management is individualised, more or less. Also there are changing trends in treatment, and so different generations have been subjected to an incalculable number of variations in management options. Also the lag time from childhood to adulthood and the ethical ramifications of these studies makes them rather unpalatable. The authors have made a good attempt at categorising these treatment modalities and assessing the results. The outcome measure they used was airway dimensions and a reduced upper airway size was taken to be a possible precursor for OSA. Sadly even with these criteria there was little consensus in the studies reviewed, and no meta-analysis was possible due to the heterogeneity of treatments offered. Inevitably this article concluded in a similar manner to most reviews; there isn’t enough data available to make concrete statements and more evidence is required in the form of high quality trials. The authors did suggest however that there was some evidence that extraction of the four premolars on each side lead to a significant reduction in airway size.

Reference

The effect of teeth extraction for orthodontic treatment on the upper airway: a systematic review.
Hu Z, Yin X, Liao J, Zhou C, Yang Z, Zou S.
SLEEP AND BREATHING
2015;19(2):441-51.

THE HEARING JOURNAL

Outcome measures for hearing loss
Reviewed by: Linnea Cheung
VOL 24 No 5
 

This short editorial explores some possible options in measurement of quality of care in audiology.  We traditionally tend to use clinician-related outcomes in place of patient-reported outcome measures and so we could miss a wealth of data on the impact of intervention on functional and psychosocial status and patient wellbeing.  Furthermore, process-related outcomes regarding individual personalisation of treatment and the way in which service is delivered could highlight whether we are taking a patient-centred approach to care. Outcomes usually used in auditory rehabilitation research are mostly based upon self-reported hearing aid use, adherence, satisfaction and speech recognition but we rarely utilise measures of process and patient-level outcomes as we tend to assume that communication and quality of life have improved if the issued hearing products are not returned. It is therefore suggested that recording outcome measures via validated questions on process and patient-level aspects can both provide evidence for treatment effects on patient function and help shape a patient-centred approach to care.

Reference

Outcome measurement in audiology: A call to action.
Weinstein B
THE HEARING JOURNAL
2015;68(7):24-6.

THE JOURNAL OF INTERNATIONAL ADVANCED OTOLOGY

N-acetylcysteine may have a role in the protection of cochlear hair cells
Reviewed by: Emma Stapleton
VOL 24 No 5
 

Gentamycin is an aminoglycoside antibiotic which is widely used throughout the world, despite its ototoxic potential. It therefore seems wise to continue the search for accessible otoprotective agents. The aim of this study was to clarify the potential protective role of N-acetylcysteine in gentamycin ototoxicity. An animal model (rat) was used, and a combination of gentamycin and / or N-acetylcysteine was administered intraperitoneally to 36 rats in three groups. The rats’ hearing levels were tested using ABR and OAE, following which the rat cochleas were examined histopathologically. The authors propose that N-acetylcysteine might block a cascade where reactive oxygen species result in apoptosis in the cochlea via its antioxidant effect, and their study clearly demonstrates a protective effect of N-acetylcysteine in preserving ABR and OAE thresholds; confirming histopathologically that evidence of cochlear hair cell apoptosis was considerably less in rats who received both gentamycin and N-acetylcysteine. This is an encouraging outcome which makes one wonder whether otoprotective agents in combination with topical antibiotic eardrops might be a useful development for the future.

Reference

N-acetylcysteine prevents gentamicin ototoxicity in a rat model.
Somdaş MA, Korkmaz F, Gülsen Gürgen S, Sagit M, Akçadağ A.
THE JOURNAL OF INTERNATIONAL ADVANCED OTOLOGY
2015;11(1):12-18.

THE JOURNAL OF INTERNATIONAL ADVANCED OTOLOGY

Nasal packing after septoplasty
Reviewed by: Emma Stapleton
VOL 24 No 5
 

This Turkish study aimed to investigate the effects of different types of nasal packings on middle ear pressure in patients undergoing septoplasty. The authors reference several articles that describe eustachian tube dysfunction, temporary ear fullness and mild pain due to the use of nasal packing after septoplasty. Sixty patients were randomised to have either merocel packs or intranasal silicone splints following septal surgery; middle ear pressure was measured using tympanometry. Interestingly, there was no control group; the use of a control group might have provided a useful comparison between packing and not packing after surgery. There is a current vogue for the use of dissolvable packs following nasal surgery, but these did not feature in the study. The study draws the conclusion that merocel packing placed in the nasal cavities after nasal surgery caused a higher decrease in the middle ear pressure compared with the silicone intranasal splint. The authors explain this by stating that merocel packs cause eustachian dysfunction due to a mechanical obstruction extending to the nasopharynx. They do not state which size of merocel pack was used, nor whether the packs were trimmed appropriately. The authors also conclude that cannulated silicone intranasal splints are better in terms of patient comfort after intranasal surgery. However, patient comfort was not addressed or measured as part of the current study.

Reference

Is middle ear pressure effected by nasal packings after septoplasty?
Şereflican M, Yurttaş V, Oral M, Yılmaz B, Dağlı M.
THE JOURNAL OF INTERNATIONAL ADVANCED OTOLOGY
2015;11(1):63-5.

THE JOURNAL OF LARYNGOLOGY AND OTOLOGY

Benefits of combined antiviral and corticosteroid therapy in Bell’s palsy and the role of decompression surgery
Reviewed by: Madhup Chaurasia
VOL 24 No 5
 

Early use of steroids has been established as standard management in Bell’s palsy but simultaneous use of antiviral agents has variable acceptance. This review article analyses statistically based evidence to settle the issue. High quality evidence from a 2009 Cochrane review did not show significant benefit from antiviral treatment compared to placebo and antivirals were less effective compared to corticosteroids. However, this does not refer to combination therapy. A number of shortcomings have been cited in this review. A series of prospective trials comparing combination therapy with steroids only has in general, shown much better results with the former. The authors have illustrated that leaving out studies with most ‘positive’ results and most ‘negative’ results, combination therapy is distinctly better, and they state that the full dose of antivirals, also to cover herpes simplex, should be used with corticosteroids. The issue of decompression surgery is addressed favourably with emphasis towards early intervention in patients with complete paralysis and in those with electro-physiological confirmation of poor recovery prospects. The surgery should include decompression medial to the geniculate ganglion. However, to avoid collateral damage of surgery, the operation should be done by only those few who are adequately skilled.

Reference

Antiviral agents convey added benefit over steroids alone in Bell’s palsy; decompression should be considered in patients who are not recovering.
De Ru JA, Brennan PA, Martens E.
THE JOURNAL OF LARYNGOLOGY AND OTOLOGY
2015;129:300-6.

THE JOURNAL OF LARYNGOLOGY AND OTOLOGY

Reasons for rejection of BAHA in patients with unilateral hearing loss
Reviewed by: Madhup Chaurasia
VOL 24 No 5
 

Ever since Tjellström first developed the procedure of BAHA implantation, the techniques have come a long way towards faster and more convenient surgical methods to offer better hearing for a wide variety of conditions. Unilateral hearing loss has now been established as one of the more recent indications for implanting BAHA. However, after successful trialling, less than 20% of this subgroup of hearing loss patients seem to accept BAHA. In this retrospective study of 90 patients, only 30.4% of suitable patients accepted BAHA. Other studies have shown even lesser acceptance. The acceptance is less than in patients with single and bilateral conductive and mixed hearing loss. In this study, the main reason for rejection amongst BAHA suitable patients was limited benefit perceived after trial (47.3%). About 33% of patients were anxious about surgery. Wireless CROS device was preferred by 23.6%, 21.8% of patients rejected BAHA for cosmetic reasons and 3.6% found headband more acceptable. The results are revealing and authors contend that clinicians should not rush to implant BAHA. It also opens up the question as to how significant is the loss of directional hearing and sound recognition due to unilateral hearing loss if it requires major surgery to overcome the problem, compared with disabling hearing due to bilateral conductive or mixed hearing loss where acceptance of BAHA seems to be better.

Reference

Bone-anchored hearing aids and unilateral sensorineural hearing loss: why do patients reject them?
Siau D, Dhillon B, Andrews R, Green KM.
THE JOURNAL OF LARYNGOLOGY AND OTOLOGY
2015;129:321-5.

THYROID RESEARCH

Amount of dietary iodine and thyroid cancer
Reviewed by: Adam Shakir
VOL 24 No 5
 

Two molecular scientists from Zurich wrote this paper as a systematic review, asking the question of whether dietary iodine intake is a risk factor for developing thyroid cancer later on life. They speculate that low iodine intake is a risk factor, and this was shown in animal models. The paper elegantly describes a theory of low iodine, high thyroid stimulating hormone and enlarged glands, with resultant increase in tumours and of follicular adenocarcinomas. Where this study comes unstuck is the analysis of human populations. Several confounding factors skew any long-term retrospective study between iodine intake and thyroid cancer. The authors rightly recognise the increasingly important role of early detection and surgery over time making analysis difficult. A weak link is shown between countries’ thyroid death rates and iodine intake in women. But they acknowledge that retrospectively assessing an individual lifetime intake of iodine is an inexact science. This paper aims to answer the question of iodine and thyroid cancer, but is so wide ranging it leaves many more questions unanswered.

Reference

Iodine intake as a risk factor for thyroid cancer: a comphrensive review of animal and human studies.
Zimmerman MB, Galetti V.
THYROID RESEARCH
2015;8:8.

AMERICAN JOURNAL OF OTOLARYNGOLOGY

Curettage adenoidectomy impairs eustachian tube function
Reviewed by: Rohit Verma
Vol 24 No 4
 

Adenoidectomy is a common procedure undertaken for obstructive sleep apnoea and nasal obstruction. Curettage is the most common technique but is associated with complications (mucosal trauma, bleeding) that may cause eustachian tube dysfunction (ETD). This study analysed changes in middle ear pressure in 64 children divided into two groups (group A <6 years old, group B >6 years old). These patients underwent adenoidectomy for adenoidal hypertrophy without otitis media with effusion. All adenoidectomies were done in the same centre using a standardised technique. Mean age was 91 months and all patients had Jerger type A tympanometry preoperatively. In the first 24 hours following adenoidectomy, decreases in middle ear pressures were seen in both ears. Three days after surgery, middle ear pressure started to increase in both ears. Middle ear pressures returned to preoperative values by the seventh postoperative day for both ears except in two patients. There were no statistically significant differences between right and left middle ear pressure preoperatively and on the first, third and seventh postoperative day. When groups A and B were evaluated separately, there were no statistically significant differences between right and left middle ear pressure preoperatively and on the first, third and seventh postoperative day in both groups. This study highlights that parents should be warned about the risk of ETD as a result of adenoidectomy, though this should be a temporary problem in most. Techniques that minimise local trauma or bleeding, such as microdebrider or endoscopically assisted laser adenoidectomy, may reduce the risk of ETD. Further comparative studies are advocated by the authors.

Reference

Evaluation of middle ear pressure in the early period after adenoidectomy in children with adenoid hypertrophy without otitis media with effusion.
Unlu I, Unlu EN, Kesici GG, Guclu E, Yaman H, Ilhan E, Ulucanlı S, Karadeniz D, Memis M.
AMERICAN JOURNAL OF OTOLARYNGOLOGY
2015;36(3):377-81.

AMERICAN JOURNAL OF OTOLARYNGOLOGY

Early ENT involvement can improve long-term quality of life after temporal bone fractures
Reviewed by: Rohit Verma
Vol 24 No 4
 

Sports injuries and road traffic accidents are common causes of head injuries, with 18-40% of skull base fractures involving the temporal bone. Often these patients have other more life threatening injuries so ENT intervention is delayed or absent. Facial palsy, deafness, imbalance, tinnitus and CSF leak are common sequelae and all can affect quality of life. This study looks at management of 39 cases involving 45 temporal bone fractures over an 11-month period. All patients presenting with immediate and total facial nerve palsy were managed with surgical exploration and decompression after imaging and EMG (mean 15 days). Vestibular symptoms were managed with high dose corticosteroids and vestibular rehab. SNHL and tinnitus were managed with high dose corticosteroids. Patients were followed up over 12 months. At initial assessment after injury, 28% patients had immediate facial palsy (HBIII-VI), 50% reported vestibular dysfunction and 85% had hearing dysfunction or impairment. Twenty-seven patients were reviewed after 12 months. Forty-four percent suffered with balance problems with 33% reporting it as disabling. Fifty-six percent had reduced hearing with 44% reporting disabling levels. Tinnitus was also reported in 56% with 44% reporting it as disabling. Fifteen percent had facial palsy after 12 months. Relationships were identified between the presence of initial facial palsy (>HBII) and long-term severe balance problems. Initial vestibular deficit was associated with long-term hypoacusis. This paper highlights the effects on quality of life of temporal bone fractures. Cochleo-vestibular sequelae can be disabling indicating the need for ongoing follow up with an ENT team as well as early involvement at the time of injury. The authors acknowledge that it is difficult to separate sequelae of cranial trauma from the symptom profile of temporal bone fractures.

Reference

Temporal bone fractures: sequelae and their impact on quality of life.
Montava M, Mancini J, Masson C, Collin M, Chaumoitre K, Lavieille J-P.
AMERICAN JOURNAL OF OTOLARYNGOLOGY
2015;36(3):364-70.

ANNALS OF OTOLOGY, RHINOLOGY AND LARYNGOLOGY

Benefit of prolonged voice rest following phonosurgery
Reviewed by: Laith Tapponi
Vol 24 No 4
 

The recommendation for voice rest following surgery is not agreed amongst surgeons, regarding either the type of voice rest (absolute or relative) or the optimal duration. In this ongoing study, 31 elective patients operated on for benign laryngeal lesions were randomised. They completed pre-and postoperative assessments, including perceptual voice quality (Grade, Roughness, Breathiness, Asthenia, Strain, Instability scale), Voice Handicap Index total score and voice analysis with both acoustic and aerodynamic measurements. Additional factors (smoking, vocal abuse, reflux and preoperative speech therapy) were also taken into account. 16 patients were randomised to follow five days voice rest and 15 patients were randomised to 10 days voice rest. The improvement in maximum phonation time with 10 days voice rest were significantly better. Collecting a larger patient sample will definitely permit us to draw safer conclusions.

Reference

The effect of voice rest on the outcome of phonosurgery for benign laryngeal lesions: preliminary results of a prospective randomized study.
Kiagiadaki D, Remacle M, Lawson G, Bachy V, Van der Vorst S.
ANNALS OF OTOLOGY, RHINOLOGY AND LARYNGOLOGY
2015;124(5):407-12.

ANNALS OF OTOLOGY, RHINOLOGY AND LARYNGOLOGY

Update on orbital complication of acute sinusitus
Reviewed by: Laith Tapponi
Vol 24 No 4
 

This study aims to illustrate the Graz experience. The study is retrospective, 53 patients with orbital complication of sinusitis were examined / confirmed by a University Hospital from 2000 to 2011. Thirty-seven underwent surgery, seven of which experienced a recurrence. The reason could be that the abscess expands and becomes less confined, which makes complete drainage more difficult and thus could lead to recurrence. They found that the recurrence rate increased with the delay to therapy. This study encourages ENT surgeons to follow the Graz concept, and combined or external approaches are still required in selected cases when the infection is located laterally and the abscess is not accessible by endoscopic surgery.

Reference

Transnasal endoscopic treatment of orbital complications of acute sinusitis: The Graz Concept.
Teinzer F, Stammberger H, Tomazic PV.
ANNALS OF OTOLOGY, RHINOLOGY AND LARYNGOLOGY
2015;124(5):368-73.

AUDIOLOGY AND NEUROTOLOGY

Short-term risk of falling after cochlear implantation
Reviewed by: Stuart Burrows
Vol 24 No 4
 

This paper examined the effect of cochlear implantation on balance function in 16 adult patients. The authors assessed balance pre- and (two weeks) post-operatively by timing how long each patient was able to stand on a foam pad with their eyes closed. Results ranged from 0 seconds (unable to stand) to a maximum of 30 seconds (considered to be normal function). All implantations were performed using ‘soft surgery’ techniques via the round window or antero-inferior cochleostomy. Post-operatively, balance function declined in nine patients, including four of the 10 patients with normal function pre-operatively. Each patient’s risk of falling was calculated using previously published data linking falls risk to the time achieved on the foam test. The average risk of falling increased by 1.6 times following surgery, though the increase was higher (2.1 times) in patients over 60 years of age. Although this paper has some methodological flaws: small numbers; multiple surgeons; a heterogenous group of patients; inclusion of bilateral as well as unilateral implantations; and no long-term follow-up it draws several important conclusions. Balance function is commonly reduced following cochlear implantation and may increase falls risk, particularly in older patients. This highlights the need for careful patient counselling and routine use of soft surgery techniques.

Reference

Short-term risk of falling after cochlear implantation.
Stevens MN, Baudhuin JE, Hullar TE.  
AUDIOLOGY AND NEUROTOLOGY
2014;19:370-7.

AUDIOLOGY AND NEUROTOLOGY

Vestibular functions of hereditary hearing loss patients with GJB2 mutations
Reviewed by: Stuart Burrows
Vol 24 No 4
 

Mutations of the GJB2 gene are a common cause of deafness, being found in 15-25% of cases of congenital deafness. Over 100 mutations are now recognised and may be associated with a hearing loss ranging from mild to profound. This paper describes the less-commonly reported effects of GJB2 mutations on the vestibular system. The study group consisted of 24 patients known to have biallelic GJB2 mutations, 23 underwent caloric testing and 36 ears of 21 patients underwent cervical VEMP testing (ears that had undergone cochlear implantation were excluded). A group of patients with normal-hearing ears were used as age-matched controls. Only two of 23 (8.7%) patients showed reduced caloric function, indicating largely normal lateral semicircular canal function in the GJB2 mutation group. In the VEMP test, 80% of the GJB2 mutations group (61% of ears) showed reduced function when compared to the controls, indicating reduced saccular function. Interestingly, no correlation was found between the hearing level and the vestibular function. No patients complained of balance disturbance, suggesting compensation in early life for the limited clinical manifestations of saccular dysfunction. This paper adds to the increasing knowledge base surrounding GJB2 mutations.

Reference

Vestibular functions of hereditary hearing loss patients with GJB2 mutations.
Tsukada K, Fukuoka H, Usami S.  
AUDIOLOGY AND NEUROTOLOGY
2015;20:147-52.

B-ENT

Hyperbaric oxygen for sudden onset sensorineural hearing loss
Reviewed by: Sunil Sharma
Vol 24 No 4
 

Idiopathic sudden onset sensorineural hearing loss (SSNHL) is a relatively common presentation to the ENT emergency department, and can have profound effects on patients’ lives. This retrospective study looked at 15 patients who were treated with hyperbaric oxygen after failure of steroid and vasodilator therapy. The hyperbaric oxygen was given with a mean delay of 24 days after the onset of SSNHL and involved 15 sessions. The results were compared with a control group of 30 patients who only received steroid and vasodilator treatment. Pure tone audiometry was performed prior to treatment and at three months post-treatment. The mean gain in the hyperbaric group was 12.1dB which was significantly better than that in the control group of 2.7dB, and was found to be better at the lower frequencies. Hyperbaric oxygen has been shown in previous studies to increase the partial pressure of oxygen in the inner ear fluids of the cochlea. This study tries to explain the apparent improvement in hearing at lower frequencies because the hair cells at the apical turn of the cochlea (representing the lower frequencies) are more sensitive to changes in the partial pressure of oxygen. The paper concludes that there is no exact time limitation for hyperbaric oxygen treatment, although the American Academy of Otolaryngology-Head and Neck Surgery recommend commencing treatment within three months of diagnosis. This paper highlights possible benefits of using salvage hyperbaric oxygen therapy for SSNHL (which carries few risks), but the relatively few hyperbaric oxygen centres in the UK may limit its widespread use.

Reference

Hyperbaric oxygen as salvage treatment for idiopathic sudden sensorineural hearing loss.
Psillas G, Ouzounidou S, Stefanidou S, Kotsiou M, Giaglis GD, Vital I, Tsalighopoulos M, Markou K.
B-ENT
2015;11:39-44.

B-ENT

Serum urea and epistaxis
Reviewed by: Sunil Sharma
Vol 24 No 4
 

This was a small retrospective review from Swansea looking at 278 patients who attended a teaching hospital Accident and Emergency department with a diagnosis of epistaxis. Only 119 of these patients had their serum urea measured. The investigators found that the mean serum urea level was significantly higher in those patients who were admitted than those patients who were discharged (even when those patients with elevated serum creatinine were excluded). There was however no significant difference in serum urea levels for those patients who did or didn’t undergo transfusion or surgical intervention. The reasoning for acute severe epistaxis causing elevated serum urea levels is due to increased ingestion of blood and possible pre-renal failure due to hypovolaemia. Elevated serum urea levels may be expected in patients with epistaxis and will not be a sole deciding factor in whether to admit or not. Nevertheless the message of this study is the potential use of serum urea in a scoring system for prognostic information regarding epistaxis severity, similar to that used for upper gastrointestinal bleeding.

Reference

The relationship between serum urea levels and outcome in acute epistaxis.
Fishpool SJC, Foley K, Bull S, Whittet H.
B-ENT
2015;11:25-9.

BRITISH JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY

A new free flap for the head and neck?
Reviewed by: Adam Shakir
Vol 24 No 4
 

Reconstruction of major defects in the head and neck is usually an area where maxillofacial or plastic surgery colleagues come to assist, with consideration of the size and function any repair has to fulfil. Whilst the radial forearm free flap (RFFF) is well known and tested, this group of surgeons from Sunderland, UK, discuss their experience with a comparable flap. They advocate the medial sural artery perforator flap (MSAPF), with a long pedicle if required and donor site primary closure as advantages over the RFFF. It also has the lack of bulk that is sometimes desired in a reconstruction. They speculate that its lack of popularity may be to do with concerns over poor perforating vessels, which was not the case in their series of six. Perhaps we will be hearing more of this free flap in oncology MDTs up and down the country in the near future.

Reference

Early experience with the medial sural artery perforator flap as an alternative to the radial forearm flap for reconstruction in the head and neck.
Nugent M, Endersby S, Kennedy M, Burns A.
BRITISH JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY
2015;53:461–463.

BRITISH JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY

Plunging new depths for the treatment of ranulas
Reviewed by: Adam Shakir
Vol 24 No 4
 

Within our scope of practice, we encounter a number of salivary gland pathologies, including the sublingual gland. Clinical signs are often subtle, and even with meticulous surgical management, morbidity can easily occur. Textbooks advocate excision of the gland as the definitive treatment. This series of 15 patients describes treatment with a suture technique performed as an outpatient under local anaesthesia, in a two-stage process. The authors state that they have modified a historical Chinese technique. During the first visit, the intra-oral ranula is needle aspirated, and the patient asked to re-attend 48 hours later. At the second visit, a silk suture is placed around the re-accumulated, but smaller, ranula. The intention is to strangulate the ranula and cause fibrosis of the feeding duct, preventing reaccumulation. In time, the silk suture extrudes and is swallowed. They describe two patients of the 15 who did not respond to this treatment and went on to formal gland removal.

Reference

Minimally invasive treatment of oral ranulae: adaption to an old technique.
Goodson A, Payne K, George K, McGurk M.
BRITISH JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY
2015;53:332-335.

CLINICAL OTOLARYNGOLOGY

Development of an ENT undergraduate curriculum
Reviewed by: Andy Hall
Vol 24 No 4
 

With over a third of medical schools not including any clinical attachment in the subject, this is a laudable attempt to confront the deficiencies in undergraduate ENT teaching within the UK. The Delphi process is an established method of developing a validated curriculum and a two-round process was utilised here to discern a consensus of items to include in undergraduate training. If we acknowledge approximately 25% of consultations in primary care involve ENT- it is right for the specialty to press for recognition of this fact through recognition within medical school teaching. It is vital that ENT specialists engage in the process and assist medical schools as they develop the doctors of the future.

Reference

Development of an ENT undergraduate curriculum using a Delphi survey.
Lloyd S, Tan ZE, Taube MA, Doshi J.
CLINICAL OTOLARYNGOLOGY
2014;39(5):281-8.

CLINICAL OTOLARYNGOLOGY

Head and neck cancer recurrence: a prospective analysis
Reviewed by: Andy Hall
Vol 24 No 4
 

The ‘cancer journey’ is synonymous for many individuals worldwide with frequent post-treatment hospital visits where the spectre of possible recurrence hangs over the consultation. This is a prospective analysis of 401 follow-up visits in Melbourne, Australia looking at follow-up in particular. In common with similar studies, patients seeking earlier review or reporting new symptoms have a higher rate of recurrence. Routine attendees without symptoms had a less than 1% incidence of recurrent disease, compared to 22% in those requesting an early appointment. Many hospitals lack the resources to provide urgent short notice review appointments on request, increased data such as this would suggest ‘ring fencing’ cancer patient drop in clinic slots could improve the overall patient pathway. The value of subjective reassurance through physical assessment cannot be under-estimated, yet rationalising or optimising follow-up is a key goal for head and neck surgeons involved in cancer care.

Reference

Head and neck cancer recurrence: a prospective analysis of 401 follow-up visits to an Australian cancer centre.
Stimpson P, Batt M, Vallance N.
CLINICAL OTOLARYNGOLOGY
2014;39(5):292-6.

CLINICAL OTOLARYNGOLOGY

Nursing care for ENT patients
Reviewed by: Andy Hall
Vol 24 No 4
 

Increasingly within the UK, issues related to bed availability can lead to ENT patients receiving care away from previously well-established specialist wards. This is a cause for concern in many institutions and the authors looked to assess this. They demonstrated nurses working on a dedicated ENT ward have an average higher score in a test of ENT related knowledge than nurses working on generic surgical wards. This difference was statistically significant and persists despite banding or training. Ensuring patient safety is a key priority in healthcare and evaluating ward competency is a valuable exercise. Certain aspects of nursing specialisation would appear self evident yet articles such as this allow departments to justify their position.

Reference

Nurses caring for ENT patients in a district general hospital without a dedicated ENT ward score significantly less in a test of knowledge than nurses caring for ENT patients in a dedicated ENT ward in a comparable district general hospital.
Foxton CR, Black D, Muhlschlegel J, Jardine A.
CLINICAL OTOLARYNGOLOGY
2014;39:334-7.

CLINICAL OTOLARYNGOLOGY

Post-operative debridement following FESS
Reviewed by: Andy Hall
Vol 24 No 4
 

Postoperative treatment pathways for patients following functional endoscopic sinus surgery (FESS) vary widely with the topic of debridement of the nasal cavity a subject of conjecture. This article is the result of two independent reviewers using the consort guidance for systematic reviews. Six randomised control trials were identified and included (Level of Evidence: 1B). Four studies compared debridement against no debridement with two assessing frequency of debridement. Cumulatively, 337 patients were included in the analysis with consistent use of visual analogue scores in all studies. There was no demonstrable difference in sino-nasal outcome test scores or objective endoscopic scores in long-term follow-up. Currently, there is no clear evidence for frequent postoperative debridement. Frustratingly, well-designed RCTs are required to establish benefit, optimal frequency, extent and timing of debridement post FESS.

Reference

Postoperative nasal debridement following functional endoscopic sinus surgery, a systematic review of the literature.
Green R, Banigo A, Hathorn I.
CLINICAL OTOLARYNGOLOGY
2015;40:2-8.

COCHLEAR IMPLANTS INTERNATIONAL

Differences in timbral cues’ perception between teenagers with cochlear implants and those with normal hearing
Reviewed by: Thomas Nikolopoulos
Vol 24 No 4
 

The authors aimed to assess timbral cues’ perception of teenagers with cochlear implants and compare it to the respective perception of normally hearing teenagers. Thirty-four teenagers were included in the study, nine Korean adolescents with cochlear implants and 25 adolescents with normal hearing. The procedure included four Western instruments and five traditional Korean instruments. It was not surprising that cochlear implantees recognised instruments significantly less often than the normally hearing teenagers as it is well known that one of the main shortcomings of most speech strategies is moderate music perception. However, no significant differences were found between the two groups with regard to timbre preferences. The authors also concluded that teenagers with implants show potential for detecting salient features in sound information, especially instrumental timbre. Although only a small number of implantees were involved in the study, it is more than evident that cochlear implant strategies should now focus on better music perception, especially in teenagers.

Reference

Can young adolescents with cochlear implants perceive different timbral cues?
Kim SJ, Cho YS, Kim EY, Yoo GE.
COCHLEAR IMPLANTS INTERNATIONAL
2015;16(2):61-8.

COCHLEAR IMPLANTS INTERNATIONAL

Do modern multiple microphones with beamforming facility really help implantees?
Reviewed by: Thomas Nikolopoulos
Vol 24 No 4
 

In this study the authors aimed to assess the benefit beamforming multiple microphones provide to implantees. Speech reception thresholds were assessed in different situations; fixed masking noise from eight loudspeakers around the subject at 0°, ±45°, ±90°, ±135° and 180° azimuth, or from five loudspeakers positioned at ±70°, ±135°, and 180° azimuth. In the third test setup, an additional roving noise was added to the six loudspeaker arrangement. The results revealed that beamforming multiple microphones made a difference and the most significant one was seen in the six speaker roving and fixed noise conditions. The authors concluded that in difficult and noisy environments, the new microphone beamforming facilities do help in speech perception. This is an interesting study encouraging further improvements in beamforming microphones in order to improve listening in noise and in various situations where implantees complain of poor listening perception. Of course, it remains to be seen if this benefit is significant in real life situations as perceived by the implantees themselves.

Reference

Speech reception threshold benefits in cochlear implant users with an adaptive beamformer in real life situations.
Geibler G, Arweiler I, Hehrmann Ph, Lenarz T, Hamacher V, Büchner A.
COCHLEAR IMPLANTS INTERNATIONAL
2015;16(2):69-76.

COCHLEAR IMPLANTS INTERNATIONAL

Is auditory frequency discrimination related to speech recognition in implantees?
Reviewed by: Thomas Nikolopoulos
Vol 24 No 4
 

Why do two identical implantees perform differently? This fundamental question has not yet been answered despite extensive research. The authors attempted to clarify the issue or at least approach it, by assessing the association between deficits in auditory frequency discrimination and speech recognition in deaf adults with cochlear implants. The study included 36 subjects, 20 adults with cochlear implants and 16 controls (normal-hearing adults). For research purposes the authors divided the implantees into two groups; proficient and non-proficient users (10 in each group). The comparison outcomes revealed that the normal-hearing controls outperformed the non-proficient implantees with regard to auditory frequency discrimination but they did not outperform the proficient implantees. Moreover, the statistical analysis found a significant relationship between speech recognition and frequency discrimination. This is very interesting, although the authors themselves admit that no causal link can be established from the present study. Moreover, closer inspection of the results reveals that the statistically significant association is true only for the lower frequency of 500 HZ.

Reference

Deficits in auditory frequency discrimination and speech recognition in cochlear implant users.
Turgeon C, Champoux F, Lepore F, Ellemberg D.
COCHLEAR IMPLANTS INTERNATIONAL
2015;16(2):88-94.

CURRENT OPINION IN OTOLARYNGOLOGY AND HEAD AND NECK SURGERY

Management of the neck in maxillary sinus carcinomas
Reviewed by: Anna Slovic
Vol 24 No 4
 

Primary malignant tumours of the sinonasal tract account for less than 10% of head and neck cancers, of which the maxilla is the second most common subsite and squamous cell carcinoma (SCC) is the most prevalent histological type. Maxillary SCCs commonly present with advanced disease (82% T3 or higher) but nodal metastasis is often low due to limited lymphatic drainage. Improvements have been seen in survival from maxillary SCC due to improved imaging, facilitating surgery and adjuvant therapies, leading to better local control. Thus treatment of the neck has become the focus and a topic of debate, evidenced by numerous reviews and a meta-analysis. This informative review from Memorial Sloan-Kettering (MSKCC) describes the role of elective treatment of the neck in maxillary SCC. Treatment failure overall occurs in 62% of all patients. Local recurrence is the most common site of treatment failure in any stage (44-68% incorporating MSKCC data), which is rarely amenable to salvage therapy. Most cervical relapse is accompanied by uncontrollable primary or distant relapse, explaining the poor survival of those with cervical relapse. Patients with cervical relapse alone can be salvaged in 50-70% of cases. Jatin Shah’s group does not recommend elective neck irradiation routinely in the clinically N0 neck. It is more important to achieve maximum local control with aggressive therapy of the primary tumour than elective neck treatment, which is only recommended by the group of patients with T3/4 primary maxillary sinus SCCs. Elective treatment of the neck in early-stage tumours is not recommended.

Reference

Management of the neck in maxillary sinus carcinomas
Dooley L, Shah J.
CURRENT OPINION IN OTOLARYNGOLOGY AND HEAD AND NECK SURGERY
2015;23(2):107-14.

CURRENT OPINION IN OTOLARYNGOLOGY AND HEAD AND NECK SURGERY

Transnasal oesophagoscopy in head and neck cancer: an update
Reviewed by: Anna Slovic
Vol 24 No 4
 

The role of transnasal oesophagoscopy (TNE) in the management of head and neck cancer patients is evolving. Until 1990, oesphagoscopy required specialist endoscopists, general anaesthesia or sedation. This review succinctly summarises updates in the evidence for TNE in: i) Screening and biopsying suspicious primary tumours, second primary tumours or other non-neoplastic disease (such as reflux or ulcers seen in 64% of patients with hypopharyngeal cancer). ii) Differentiating post-treatment changes from malignancy. iii) Performing office-based procedures such as oesophageal and tracheal stricture balloon dilatation, secondary TEP (minimising mucosal lacerations) and transnasal percutaneous endoscopic gastrostomy. TNE offers the otolaryngologist the opportunity to promptly manage head and neck patients unsedated in outpatient settings; improving safety by upwards of 60% in patients with several comorbidities and minimising lip or teeth trauma. Wang et al. reported a 97% completion rate compared to 79% for conventional transoral endoscopy (attributed to barriers such as tumour size, strictures and trismus). It is highlighted that conventional endoscopy was preferred to TNE by Dolan and Anderson in the initial work-up of unknown primary cancers and large tongue-base cancers, as is advantageous in tissue manipulation / palpation and tonsillectomy can be subsequently performed under anaesthetic. Su et al. demonstrated that routine TNE screening in those with existing head and neck tumours detected earlier second oesophageal primaries. TNE is a feasible alternative for screening for a second primary, differentiating post-treatment oesophageal changes from malignancy and performing several procedures. Increased utilisation and awareness of TNE may improve morbidity and survival in the head and neck patient.

Reference

Transnasal esophagoscopy in modern head and neck surgery.
Roof A, Amin M.
CURRENT OPINION IN OTOLARYNGOLOGY AND HEAD AND NECK SURGERY
2015;23(2):171-5.

INTERNATIONAL JOURNAL OF LANGUAGE AND COMMUNICATION DISORDERS

Gum as a thickening agent in dysphagia management
Reviewed by: Gauri Mankekar
Vol 24 No 4
 

Foods and fluids are commonly thickened with starch based thickeners in the management of dysphagia to prevent aspiration. Now gums are gaining popularity as thickeners as they are resistant to salivary amylase. This study compared the effect of human saliva on the consistency of drinks thickened with gum containing (GC) thickener with that of drinks thickened with four starch based (SB) thickeners. The researchers determined compression force and amount of thin liquid formed after 10 and 50 minutes of contact with human saliva with standardised amylase activity compared with a control inoculated with water. The results showed that GC thickeners contain their consistency better in contact with human saliva than SD thickeners. This, in turn, may improve swallowing safety for people with dysphagia.

Reference

Effect of human saliva on the consistency of thickened drinks for individuals.
Vallons KJR, Helmens HJ, Oudhuis AACM.
INTERNATIONAL JOURNAL OF LANGUAGE AND COMMUNICATION DISORDERS    
2015;50(2):165-75.

INTERNATIONAL JOURNAL OF LANGUAGE AND COMMUNICATION DISORDERS

Voice issues in transgender individuals
Reviewed by: Gauri Mankekar
Vol 24 No 4
 

Recently, former decathlete and TV personality, Bruce Jenner, admitted that he is transgender, thereby becoming the most famous and vocal advocate for transgender issues. Transgender refers to female to male or male to female identification. In either case, voice modification is a crucial part of the transgender transitioning including laryngeal shave. Transmasculine people, on the other hand, can be treated with testosterone which can lower the pitch and influence perception of voice gender. The current article is a comprehensive review evaluating data about transmasculine people’s vocal situations. It highlights the paucity of research so far conducted with transmasculine people and reports that although testosterone can lower pitch, it is unclear whether the extent of the pitch change is enough to result in a voice that is recognised by others as male. The author makes several recommendations for future research on this subject so that transmasculine people can be provided with reliable advice about the likelihood and nature of voice problems they may experience, and be offered treatment that is suitable to support them in their endeavour to be perceived as a member of the gender group to which they feel they belong.

Reference

Transmasculine people’s vocal situations: a critical review of gender related discourses and empirical data.
Azul D.
INTERNATIONAL JOURNAL OF LANGUAGE AND COMMUNICATION DISORDERS    
2015;50(1):31-47.

INTERNATIONAL JOURNAL OF LANGUAGE AND COMMUNICATION DISORDERS

Swahili speech development in pre-school children
Reviewed by: Gauri Mankekar
Vol 24 No 4
 

This study describes the speech development of 24 typically developing first language Swahili speaking children between the ages of three and five years 11 months in Dar es Salaam, Tanzania and  was motivated by the 2013 position paper drafted by the International Expert Panel on Multilingual Children’s Speech. Single word speech samples were obtained from each child using a set of culturally appropriate pictures designed to elicit all consonants and vowels of Swahili. Each child’s speech was audio recorded and phonetically transcribed using International Phonetic Alphabet (IPA) conventions. The results suggest a gradual acquisition of speech sounds and syllables between the ages of three and five years 11 months. All vowels and most of the consonants in Swahili are acquired by the age of three years of age. Complex and longer syllable structures were common amongst older children and mastered by five years 11 months. This study contributes preliminary normative data on speech development of Swahili speaking children by describing phonetic inventory, syllable structure inventory, phonological processes and PCC/PVC. It highlights the need for establishing assessments in Swahili considering the variation existing in speech acquisition across languages.

Reference

Swahili speech development: preliminary normative data from typically developing pre-school children in Tanzania.
Gangji N, Pascoe M, Smouse M.
INTERNATIONAL JOURNAL OF LANGUAGE AND COMMUNICATION DISORDERS    
2015;50(2):164-75.

JAMA OTOLARYNGOLOGY HEAD AND NECK SURGERY

Clinicopathological features of follicular variant of papillary thyroid carcinoma
Reviewed by: Shabbir Akhtar
Vol 24 No 4
 

The follicular variant (FV) of papillary thyroid carcinoma (PTC) is characterised by the presence of nuclear features of PTC together with a follicular growth pattern. It is currently reported to make up 11.8% to 53.3% of all PTC cases. It has a different genetic profile, with a lower prevalence of BRAF mutations and a higher incidence of RAS mutation, similar to follicular adenoma and follicular carcinoma. The purpose of the present study was to compare the clinicopathologic features of conventional papillary thyroid carcinoma and follicular variant of PTC and to see if major difference in prognosis is present. Conventional PTC was significantly more likely than FV PTC to have a malignant cytologic diagnosis. In contrast, FV PTC was significantly more likely to have false-negative benign preoperative cytologic findings. The mean size of the tumor in FV PTC was significantly greater than that of conventional PTC. There was a significant difference in incidence of microscopic extrathyroid extension (ETE). All cases of grossly invasive carcinoma occurred in the conventional PTC group. This study found some important differences in relation to preoperative cytologic findings, mean tumor size at diagnosis and incidence of ETE; but not in patient age or sex, incidence of tumour multicentricity or bilaterality, incidence of lymph nodes metastases, or prognostic grouping. Aspirates from cases of FV PTC are more likely to have had a false-negative (benign) cytologic result. This is an important issue because cases belonging to low-risk cytologic categories may be more likely to be recommended for nonsurgical follow-up, which may lead to increased risk of delayed diagnosis or failure to diagnose cases of FV PTC.

Reference

Follicular variant of papillary thyroid carcinoma: differences from conventional disease in cytologic findings and high-risk features.
Sheahan P, Mohamed M, Ryan C, Feeley L, Fitzgerald B, McCarthy J, Tuthill A, Murphy MS.
JAMA OTOLARYNGOL HEAD NECK SURG
2014;140(12):1117-23.

JAMA OTOLARYNGOLOGY HEAD AND NECK SURGERY

Depth of invasion of oral cancer should be incorporated in new AJCC staging system
Reviewed by: Shabbir Akhtar
Vol 24 No 4
 

Since 1977, when the first edition of the Manual for Staging of Cancer was published by the American Joint Committee on Cancer (AJCC), the primary tumour staging for oral squamous cell carcinoma (SCC) has remained unchanged. In the last four decades important prognostic factors in oral cancer have been identified. Depth of invasion (DOI) of the primary tumour is one independent predictor of recurrence and survival out of many others. Depth of invasion is already a feature in the AJCC staging of other cancers such as melanoma, cutaneous SCC and the uterine cervix. In this multicentre, retrospective study, author’s pooled data from 11 participating comprehensive cancer centres worldwide. Patients with histologically confirmed oral SCC undergoing surgical resection of the primary tumour and neck dissection with curative intent were candidates for inclusion. The final study population consisted of 3,149 patients. On multivariable analysis, DOI was significantly associated with disease-specific survival (P < 0.001), and provided complementary prognostic information to the AJCC T category. The authors propose a modification that incorporates DOI in future versions of the AJCC staging.

Reference

Primary tumor staging for oral cancer and a proposed modification incorporating depth of invasion: an international multicenter retrospective study.
The International Consortium for Outcome Research (ICOR) in Head and Neck Cancer: Ebrahimi A, Gil Z, Amit M, Yen TC, Liao CT, Chaturvedi P, Agarwal JP, Kowalski LP, Kreppel M, Cernea CR, Brandao J, Bachar G, Bolzoni Villaret A, Fliss D, Fridman E, Robbins KT, Shah JP, Patel SG, Clark JR.
JAMA OTOLARYNGOL HEAD NECK SURG
2014;140(12):1138-48.

JOURNAL OF INTERNATIONAL ADVANCED OTOLOGY

Speech audiometry tests in elderly patients with mild cognitive impairment
Reviewed by: Emma Stapleton
Vol 24 No 4
 

This paper caught my eye because, with our ageing population, mild cognitive impairment and dementia are a major, growing problem. We know that ageing causes a multitude of medical and social issues. So it seems wise to investigate the effects of this condition on hearing, and especially speech audiometry in noise, since we know that presbyacusis is associated with a decrease in speech perception, and the elderly do not live in sound-proofed booths. In this Italian study, 48 subjects were enrolled, and all underwent pure tone audiometry and speech audiometry in noise. Speech signals consisted of 20 meaningful sentences in the Italian language. The authors acknowledge the limitations of their study, and conclude that their study confirms the hypothesis that patients with mild cognitive impairment have an age-related dysfunction of central processing, which could be related to the process leading to dementia. They go on to propose speech audiometry in noise as a useful and easy to access tool to identify patients with mild cognitive impairment, on the basis that early identification of patients with mild cognitive impairment may allow an earlier clinical approach. And whilst this might seem a little far-fetched, I think there’s definitely potential for some valuable future work on this topic.

Reference

Speech audiometry tests in noise are impaired in older patients with mild cognitive impairment: A pilot study.
Aimoni C, Prosser S, Ciorba A, Menozzi L, Soavi C, Zuliani G.
JOURNAL OF INTERNATIONAL ADVANCED OTOLOGY
2014;10(2):228-33.

JOURNAL OF LARYNGOLOGY AND OTOLOGY

Adjuvant intratympanic steroid therapy in sudden sensorineural hearing loss
Reviewed by: Madhup K Chaurasia
Vol 24 No 4
 

Sudden sensorineural hearing loss (SNHL) means abrupt hearing loss by 30dB affecting three consecutive frequencies within 72 hours. This is treated by high tapering doses of systemic steroids, the role of which is controversial and fraught with possible complications in patients with diabetes and hypertension. The authors have elicited the role of intratympanic methylprednisolone in the treatment of SNHL as salvage treatment after the administration of high dose systemic steroids given for 7-10 days. Up to three intratympanic injections of methylprednisolone were given at weekly intervals. Remission in patients with non-functional hearing was defined as improvement to functional level (class A or B) and in patients with functional hearing, remission meant PTA reduction of 10dB or more and at least 20% improvement in speech discrimination score. Of the 128 patients, 57 had improved hearing after systemic steroids. From a total of 63 patients undergoing intratympanic treatment, 18 (28.6%) showed remission of hearing loss and 45 (71.4%) did not. Various characteristics of the ‘remission’ and the ‘non-remission’ groups were studied and it was noted that patients with vestibular symptoms and profound hearing loss had worse prognosis. Hearing improved more in the lower frequencies. The study is limited by lack of controls but opens avenues to more research such as comparison of intratympanic therapy with systemic therapy or both with no intratympanic therapy.

Reference

Intratympanic steroid injection as salvage treatment for sudden sensorineural hearing loss.
Belhassen S, Saliba  I.
JOURNAL OF LARYNGOLOGY AND OTOLOGY
2014;128:1044-9.

JOURNAL OF LARYNGOLOGY AND OTOLOGY

Endoscopic findings and prediction of outcome in unilateral vocal cord paralysis
Reviewed by: Madhup K Chaurasia
Vol 24 No 4
 

Unilateral vocal cord paralysis which is not due to irreversible causes such as malignancy, systemic disease or trauma varies considerably in terms of full recovery and restoration of voice. Usually electromyography is used to make possible predictions, but this facility is not universally available nor is the prognosis easy to determine. In this elaborate, well illustrated study, the authors have elicited details of vocal fold and arytenoid positions and vertical levels of affected fold in patients of unilateral vocal cord paralysis through repeated six week endoscopic observations for six months following detection of vocal fold paralysis. Individual muscle movements in the anterior and posterior parts of the vocal folds were assessed for adduction and abduction. Exact position of the vocal fold from median to lateral was noted, as was that of arytenoids – posteromedial, posterolateral and lateral. Compensatory movement of the normal cord was observed in the recovery phase. An interesting finding was that posterolateral tilt of the paralysed arytenoid had least or no chance of recovery. With these findings, it was also possible to predict the need for intervention, such as in cases where there is a lack of compensatory movement of the unaffected cord or vertical level incompatibility. Based on this study, supported by statistics, a useful algorithm has been presented demonstrating types of thyroplasty required in specific situations, or whether observation and voice therapy alone would do. This should provoke some interesting feedback.

Reference

Unilateral vocal fold paralysis: can laryngoscopy predict recovery? A prospective study.
Menon JKR, Nair RM, Priyanka S.
JOURNAL OF LARYNGOLOGY AND OTOLOGY
2014;128:1095-1104.

JOURNAL OF LARYNGOLOGY AND OTOLOGY

Hearing aids or grommets for children with OME?
Reviewed by: Madhup K Chaurasia
Vol 24 No 4
 

Otitis media with effusion is a highly prevalent condition in children and recurrence often occurs after surgical treatment with grommets. Repeated grommet insertion has its own problems of infection, perforation and scarring of the tympanic membranes, and continuity of providing amplification is not often achieved. As a result, a long-term debate rages over whether or not hearing aids should be preferred for these children. In this study the authors tested the validity of traditional concepts that children with hearing aids are often subjected to psychosocial impact. This was achieved by a questionnaire to parents comprising nine hearing aid related questions addressing negative associations, negative coping strategies and self esteem. Ninety-seven children participated in the study, 47 in the hearing aid group and 50 with grommets. The results were analysed statistically and showed no preference for negative ideas associated with hearing aids. The study has several limitations but it somewhat dissipates the traditional belief that hearing aids have a stigma attached, and there are options other than repeated insertion of grommets, with its attendant risks.

Reference

The psychosocial impact of hearing aids in children with otitis media with effusion.
Querishi A, Gabas G, Mallick A, Parker D.
JOURNAL OF LARYNGOLOGY AND OTOLOGY
2014;128:972-5.

JOURNAL OF LARYNGOLOGY AND OTOLOGY

Peritonsillar abscess - an indication for tonsillectomy?
Reviewed by: Madhup K Chaurasia
Vol 24 No 4
 

Extension of infection beyond the tonsil results in a peritonsillar abscess and is a frequent emergency presentation in otolaryngology. In many places one episode of peritonsillar abscess is not considered an indication for emergency or interval tonsillectomy and future episodes of tonsillitis and peritonsillar abscesses are therefore not prevented. In this study, the authors have assessed the recurrence rate of peritonsillar abscess in 121 patients, of which 18% had a history of recurrent tonsillitis, 1.7% had a history of diabetes and 4% a history of hypertension. The recurrence rate noted was 13.9 % in comparison to a 5-22% recurrence rate in the literature. Univariate analysis showed that recurrent tonsillitis was associated with recurrence of peritonsillar abscess. The authors performed CT scans on all cases of peritonsillar abscess and interestingly, multivariate analysis showed that spread of infection beyond the tonsillar capsule, lateral or inferior to the superior pharyngeal constrictor muscle as noted on the CT scans, was associated with recurrence of peritonsillar abscess. This particular feature of the study adds an important dimension to the management of peritonsillar abscess in terms of interval tonsillectomy.

Reference

Risk factors for recurrence of peritonsillar abscess.
Chung JH, Lee YC, Shin SY, Eun YG.
JOURNAL OF LARYNGOLOGY AND OTOLOGY
2014;128:1084-8.

JOURNAL OF PLASTIC, RECONSTRUCTIVE AND AESTHETIC SURGERY

A new flap for the perinasal region
Reviewed by: Sunil Kumar Bhatia
Vol 24 No 4
 

Perinasal defects are most commonly caused by tumour extirpation or trauma. There are a number of methods to reconstruct the defect, and the method chosen depends on the size of the defect and other patient considerations. When the defect is located in the central aspect of the face an aesthetic outcome with a single session surgery is preferred. When the defect is small local flaps are successful, however options are more limited for larger defects. The authors describe a flap pedicled on the superficial musculoaponeurotic system. This is useful for reconstruction of the nasal tip, supratip, lateral nasal margin and infraorbital area. They describe a series of 17 patients, 12 female and five male. The flap is designed on sound principles as the anatomy of the SMAS and the blood supply to the area is well discussed. Additional photographs outline the results. There are limitations in terms of size and scarring, so this flap is possibly best used in the elderly patient. This is a good flap to have in the facial surgeon’s armamentarium and is also a good flap for patients with previous surgery or trauma precluding using a forehead flap.

Reference

Propeller facial artery perforator flap as first reconstructive option for nasolabial and perinasal complex defects.
Ruiz-Moya A, Lagares-Borrego A, Infante-Cossio P.
JOURNAL OF PLASTIC, RECONSTRUCTIVE AND AESTHETIC SURGERY  
2015;68:457-63.

JOURNAL OF PLASTIC, RECONSTRUCTIVE AND AESTHETIC SURGERY

Nasal deformity following CPAP injury
Reviewed by: Sunil Kumar Bhatia
Vol 24 No 4
 

Nasal continuous positive airway pressure (nCPAP) is commonly used as a non-invasive alternative to endotracheal intubation and tracheotomy to provide respiratory support to very low birth weight (VLBW) (<1500 g) neonates. Nasal injury is a well recognised complication and figures quoted are as high as 13.2%-50%. This is a single institution, retrospective audit over 33 years. Eleven patients were identified who sustained nCPAP injury and were subsequently evaluated later in adolescent or adult years. The most common injuries recorded were involving the nasal soft triangle and columella. Secondary presenting deformities included obstruction, lack of projection and deviation of the nasal tip. All patients required corrective surgery and two required a minimum of two procedures. Most patients had tissue loss and necrosis and required staged repair with grafts strong enough to counter secondary scar contracture. This study confirms the most common site for nCPAP injury and the sequlae. It highlights the need for close monitoring and prevention in this subset of patients requiring CPAP. It also highlights the difficulties in achieving correction for deformities sustained in the growing phase. –

Reference

Late presenting nasal deformities after nasal continuous positive airway pressure injury: 33 year experience.
Li Y, Seulveda A, Buchanan EP.
JOURNAL OF PLASTIC, RECONSTRUCTIVE AND AESTHETIC SURGERY  
2015;68:339-43.

JOURNAL OF PLASTIC, RECONSTRUCTIVE AND AESTHETIC SURGERY

Semi dynamic reconstruction of the lower lip
Reviewed by: Sunil Kumar Bhatia
Vol 24 No 4
 

The main goal of reconstructive surgery for facial paralysis is the restoration of smiling and function of eye closure. The deformity of the lower lip in paralysis is ptosis of the corner of the mouth, eversion of the vermillion and the lip is pulled to the normal side. While these may not be noticeable at rest in children these are more marked in the elderly. Various dynamic approaches have been described for the paralysed lower lip; none are performed commonly due to the invasive nature, long recovery and unstable outcomes. The authors describe their innovative technique using modified bi-directional fascia grafting in nine patients treated between 2009 and 2011. The patients had this procedure alone or in combination, including one-stage free muscle transfer. Postoperatively patients were graded using a lower lip paralysis score and showed upgrading from poor to excellent. While this is a small cohort and it is difficult to objectively assess outcomes, this is a useful technique and in combination with other static / dynamic methods should be entertained. The technique is well described and the photographs show good results.

Reference

Bidirectional/double fascia grafting for simple and semi-dynamic reconstruction of the lower lip deformity in facial paralysis.
Watanbe Y, Sasaki R, Agawa K, Akizuki T.
JOURNAL OF PLASTIC, RECONSTRUCTIVE AND AESTHETIC SURGERY
2015;68:321-8.

JOURNAL OF THE AMERICAN ACADEMY OF AUDIOLOGY

Factors affecting hearing aid recommendations
Reviewed by: Cheka Spencer
Vol 24 No 4
 

There is a wide variety of hearing instruments available to the hearing impaired. Hearing care professionals are often confronted with making decisions on which to recommend based on audiometric and non-audiometric parameters (e.g. vision, manual dexterity and vanity). The factors which have been shown to influence professionals include certain psychological decision-making models such as the tendency to stick to the status quo and to ignore statistical evidence, as well as stereotypes of race, age and gender. This study investigated which parameters act as the primary influencers. The researchers identified a set of patient variables (and their respective levels) from 25 professionals from Germany, USA, France and Italy who were blinded to the scope of the study. These would be the basis of their recommendations. An experimental design was developed and 21 representative patient cases were generated. These were sent to 3500 randomly selected professionals from Germany, Italy, France and the USA. Seven-hundred-and-thirty-three patients responded with the majority from the USA.  The results of this study indicate that the recommended level of hearing instrument (HI) technology depends on: the patient’s activity level as perceived by the professional; the HI usage level (for experienced users) and; the patient’s age and speech discrimination score. This was an interesting study with applicability in a non clinical setting. Biases by professionals often have a self-fulfilling effect. This is also seen when a waiter believing a table will be a poor tipper is subsequently inattentive. The same is true with professionals who make judgements on the non-audiometric parameters of the patient. Conclusions to be drawn from this study are limited due to statistical significance not being universal, the 20% response rate increasing selection bias and the affiliations of the researchers (Oticon).

Reference

Case factors affecting hearing aid recommendations by hearing care professionals.
Gioia  C,  Ben-Akiva M,  Kirkegaard M, Jørgensen O,
Jensen K, Schum D.
JOURNAL OF THE AMERICAN ACADEMY OF AUDIOLOGY
2015;26(3):229-46.

JOURNAL OF VESTIBULAR RESEARCH

Vestibular migraine – the story so far and the work still to do
Reviewed by: Sunil Kumar Bhatia
Vol 24 No 4
 

This interesting discussion paper begins with an overview of the background to the development of vestibular migraine as a separate diagnostic category. It discusses in some depth the diagnostic uncertainties in the context of an entity without a biomarker and where an understanding of pathophysiology is incomplete. This paper provides a useful summary of ‘the story so far’ for vestibular migraine, including a table outlining the consensus criteria used in diagnosis. However, it goes further to reach to the decidedly fuzzy edges of the diagnosis, tackling the potentially knotty problem of comorbidity, highlighting the list of vestibular conditions that occur more frequently in those with migraine including BPPV, Menieres and motion sensitivity. This paper provides a helpful overview of vestibular migraine as currently understood but also rightly highlights the uncertainties inherent in the diagnosis. The calls for further research, validation and definition of this condition are timely given the danger that this is becoming the diagnosis of least resistance when more easily identified causes have been excluded.

Reference

Comorbidities in vestibular migraine.
Eggers SDZ, NEH BA Neff, NT Shepard NT, Staab JPO.
JOURNAL OF VESTIBULAR RESEARCH
2014;24:387-95.

NEUROSURGERY

Hearing preservation after Gamma knife in vestibular schwannomas
Reviewed by: Gauri Mankekar
Vol 24 No 4
 

This retrospective study reports the outcomes of hearing preservation up to three years after Gamma knife radiosurgery for Gardner-Robertson Class I (SDS>70% and PTA <30dB) patients with vestibular schwannomas. The authors report that patients with no subjective or objective hearing loss at diagnosis had better hearing outcomes at the end of a follow up period of 2.5 to three years after treatment. The authors conclude that radiosurgery offers the best chance of hearing preservation when carried out in vestibular schwannoma patients before they develop any subjective hearing loss. They recommend that the Gardner-Robertson classification should be modified to include class IA (patients with no subjective hearing loss and a pure tone average 15dB) and class IB (patients with subjective hearing loss and a pure tone average >15dB). The follow-up period in this study is too short and the study does not provide any data on long-term hearing preservation or tumour control, especially considering that the median age of patients in this series was 49 years.

Reference

Hearing preservation up to 3 years after Gamma knife radiosurgery for Gardner-Robertson Class I patients with vestibular schwannomas.
Mousavi SH, Kano H, Faraji AH, Gande A, Flickinger JC, Niranjan A, Monaco E III, Lunsford LD.
NEUROSURGERY    
2015;76:584–91.

NEUROSURGERY

Rare, aggressive pituitary adenomas
Reviewed by: Gauri Mankekar
Vol 24 No 4
 

This is a review article on published cases of the rare Crooke’s pituitary adenoma. These tumors are usually invasive and may be clinically aggressive; they may be endocrinologically silent or may produce adrenocorticotropic hormone causing Cushing’s disease. They often recur and have a low success of cure after reoperation and / or radiotherapy for recurrence. According to the authors, often there is lack of awareness amongst clinicians due to rarity of these tumours. This also makes it difficult to assess prognosis, treatment and clinical management. This article discusses the clinical and histopathological characteristics of these unusual neoplasms to improve awareness amongst physicians and neurosurgeons regarding their potential clinical aggressiveness. Current knowledge of ultrastructural and histological findings has made identification of these tumours more feasible. The authors recommend that patients diagnosed with these rare tumours should undergo strict clinical, radiological and biochemical follow-up over time as well as eventual multimodality treatment.

Reference

Crooke’s cell tumors of the pituitary.
Di Ieva A, Davidson JM, Syro LV, Rotondo F, Montoya JF, Horvath E, Cusimano  MD, Kovacs K.
NEUROSURGERY    
2015;76:616-22.

OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY

Approaching a ranula
Reviewed by: Suzanne Jervis
Vol 24 No 4
 

The March issue of Operative Techniques in Otolaryngology is the first of two concentrating on oral surgery within the paediatric setting. It sets the scene with a paper on the anatomy of the paediatric oral cavity and the associated surgical considerations. The next paper that catches the eye is regarding ranula excision – a good topic for the FRCS exam. The author guides the reader through the relevant sublingual gland anatomy and defines clearly the differences between simple and plunging ranulas. It then delineates the aetiology, being largely due to duct obstruction (mainly simple) or mucous extravasation leading to a pseudocyst (mainly plunging). The authors remind the reader that in 20% of plunging ranulas the intraoral component is absent – a good exam tip! Findings on clinical examination are explored and also imaging techniques (mainly MRI) that are used, especially in plunging ranulas. Usefully they remind the reader of a number of possible differentials. Treatment approaches are then discussed, including sclerotherapy as a non-surgical option with a reasonable risk of fever, pain and need for further injections. The main message with the approaches of marsupialisation, incision and drainage and cyst excision, is that unless the sublingual gland is removed during the same procedure, recurrence rates are high (> 50%). They then go onto describe, in a stepwise approach, the intra-oral and trans-cervical approaches used, the latter for the plunging ranulas considered too large or difficult for intra-oral removal. The trans-cervical approach is largely similar to that of a submandibular gland excision with the ranula tract often paralleling with the submandibular duct. These explanations are aided by helpful colour diagrams and a word or two at the end regarding complications to be wary of. The article is written in an easy-to-read style, with logical progression and useful additions of diagrams – a great revision article.

Reference

Ranula excision.
Abdul-Aziz D, Adil E.
OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY
2015;26(1):21-7.

OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY

Surgery for drooling
Reviewed by: Suzanne Jervis
Vol 24 No 4
 

This paper looks at the surgical options for sialorrhoea once the first two options of behavioural and physiotherapy interventions and pharmacotherapy have been exhausted. The social impact of sialorrhoea on patients and their families is significant and often lifelong therefore good, permanent outcomes are key. To avoid external incisions, four duct ligation techniques have been utilised with the aim of gland atrophy. Since the submandibular gland produces the largest amount of saliva (70%), as a bare minimum their ducts should be ligated, with the parotid ducts as optional, although these authors consider them required. They revise the anatomy in detail with regards to the ducts and their important structural neighbours to avoid damaging. The principle is the same for each duct in that the duct should be identified using a lacrimal probe and an incision placed proximally over the duct in the mucosa after infiltration with lignocaine and adrenaline. Blunt dissection is then used to identify and isolate the duct and this is then ligated in two areas and the ampulla diathermied. It helpfully concludes that the four published case series to date have reported low complication rates of less than 17% and these have included transient gland swelling, sialadenitis and ranula. Xerostomia and dental caries were not noted. This was a straightforward article with useful revision of the anatomy of the floor of the mouth (although a diagram in this regard would have been a useful addition). However, it would have been interesting to have included other surgical options such as duct relocation or gland excision to draw more informed decisions regarding which approach is more suitable on a case-by-case basis.

Reference

Four duct ligation.
Heffernan C, Adil E.
OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY
2015;26(1):39-41.

ORL

Is submandibular gland transfer effective in prevention of post irradiation xerostomia in head and neck cancer patients?
Reviewed by: Zi Wei Liu
Vol 24 No 4
 

Post irradiation xerostomia is a common side effect of irradiation to the head and neck region, with up to 90% of patients reporting some symptoms. Submandibular glands account for 70% of resting saliva production. Surgically transferring the submandibular gland to the submental region and shielding it during radiotherapy has been postulated to reduce post irradiation xerostomia. The authors of this systematic review summarise the evidence in this field. Seven studies with 369 participants were identified. There were two RCTs, two prospective cohort studies, two case series and one controlled clinical trial. Submandibular gland transfer +/- shielding was compared to no intervention. One study compared submandibular gland transfer + shielding to standard radiotherapy + pilocarpine. The authors conclude that salivary gland transfer is an effective method for preventing post irradiation xerostomia based on both objective (stimulated salivary flow) and subjective measures, and furthermore is more effective than pilocarpine. There is no difference in survival outcomes. Although the results are impressive, submandibular gland transfer should be taken in the context of an already intensive treatment schedule for head and neck cancer patients, and does involve an additional surgical procedure. It is not recommended if there is suspicion of regional lymph node involvement in level 1b. The authors do not comment on whether patients received IMRT or small field radiotherapy, which would cause less radiation-induced fibrosis in the salivary glands.

Reference

Submandibular gland transfer for the prevention of postradiation xerostomia in patients with head and neck cancer: a systematic review and meta-analysis.
Wu F, Weng S, Li C, Sun J, Li L, Gao Q.
ORL
2015;77(2):70-86.

OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA

Paediatric salivary gland tumours
Reviewed by: Charlie Giddings
Vol 24 No 4
 

This is a review article of a rare group of neoplasms that frequently present as painless preauricular mass in older children. There is a wide differential including first branchial arch abnormalities, inflammatory and granulomatous processes. Those masses that are painless, persistent and firm should be thoroughly investigated as out of all salivary gland lesions approximately 50% will be malignant. Of the benign epithelial tumours by far the commonest is pleomorphic adenoma, with occasional basal cell adenomas and Warthins being extremely rare. Haemangiomas and lymphangiomas also occur. Malignant epithelial tumours are rare but do occur in children and adolescents and in descending order incidence are mucoepidermoid (60%), acinic cell carcinoma (11%), adenocarcinoma (10%) and adenoid cystic carcimoma (9%). Fine needle aspiration may be helpful but is controversial and accuracy is quoted as 33%. The mainstay of management is surgery with total conservative parotidectomy for those who have high-grade tumours or aggressive potential. The presence of enlarged lymph nodes is not uncommon in children, which can be misleading at surgery and neck dissection is only warranted in those with proven metastatic disease. Histopathological findings dictate further management with radiotherapy considered for high-grade malignancies, perineural invasion, soft tissue extension and incomplete resection. The five-year overall survival rate for children with malignancies of major salivary glands is 95%, unlike 59% in adults.

Reference

Disorders and tumours of the salivary glands in children.
OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA
Lennon P, Silvera VM, Perez-Atayde A, Cunningham MJ, Rahbar R.
2015;48:153-73.

OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA

When ears go bad
Reviewed by: Charlie Giddings
Vol 24 No 4
 

Whilst rare, squamous cell carcinoma is the commonest primary malignancy of the temporal bone and is discussed in this review article. This tumour frequently presents with otalgia, ottorhoea and hearing loss; less commonly, with facial palsy or parotid mass. Investigations typically involve audiometry, biopsy, PET CT and MRI which allow bone invasion, perineural spread and metastatic disease to be identified. There is no accepted staging system for this disease but the Modified University of Pittsburgh Staging system is proposed here. Essentially, early disease (T1/T2) has either no, or limited bone erosion. Advanced disease (T3/T4) has full canal thickness erosion with limited soft tissue involvement, or tumour eroding into important local structures with extensive soft tissue involvement. The staging for the neck is the same as for mucosal SCC. The surgical resections are discussed including lateral, subtotal and total temporal bone resection. Parotidectomy and neck dissection is controversial but should be considered based on stage. Two papers are quoted supporting the need for clear margins at resection, those patients with clear margins have at least double the disease free survival at two years. Postoperative radiotherapy is offered to patients with T2, T3 and T4 disease which is likely to represent all cases.

Reference

Squamous cell carcinoma of the temporal bone.
Beyea JA, Moberly AC.
OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA
2015;48:281-92.

OTOLOGY AND NEUROTOLOGY

When should that child’s wet ear be operated on?
Reviewed by: Anand Kasbekar
Vol 24 No 4
 

The team from Birmingham have provided a meta-analysis to answer the question of when to perform a type 1 tympanoplasty on chronic paediatric perforations (under 18 year olds). Forty-five studies were included which resulted in 2609 cases. Closure rate at one year was assessed. They found a mean closure rate of 83.4% which is slightly lower than the previous meta-analysis in 1999 on the same topic. This is accounted for by more stringent and longer follow up criteria in the current meta-analysis, the authors state. Age is not a significant factor affecting closure rate as we are traditionally taught, although the numbers for analysis are small. Large perforations (over 50% size) had a slightly lower rate of closure (80% vs 86%). An underlay, inlay or onlay graft did not affect outcome.  They suggest that waiting till the contralateral ear OME has resolved before operating is best, and this seems very sensible although conclusive data on this seems to be lacking. There is an interesting discussion on the effect of concurrent adenoidectomy, eustachian tube function and contralateral OME in relation to the outcome of surgery, and future studies should focus on addressing these questions. I would recommend reading this article in full.

Reference

Tympanoplasty for chronic tympanic membrane perforation in children: systematic review and meta-analysis.
Hardman J, Muzaffar J, Nankivell P, Coulson C.
OTOLOGY AND NEUROTOLOGY
2015;36(5):796-804.

RHINOLOGY

Clonidine based vs Remifentanil based hypotensive anaesthesia in FESS
Reviewed by: Suki Ahluwalia
Vol 24 No 4
 

A study investigating the use of clonidine preoperatively in FESS surgery. A double blinded trial of 47 patients in Barcelona randomised into receiving clonidine (20 minutes preoperatively) versus Remifentanil (continuous infusion). Propofol and fentanyl were used for induction and then sevofluorane used for maintenance. This study had good randomisation, blindness of the operating assessing surgeon and external rhinologist assessor although low numbers. Bleeding was assessed using the Boezaart and Wormald scales and also a VAS every hour by both surgeons independently. Clonidine is an alpha 2 adrenergic agonist which acts via the CNS to induce peripheral arterial vasodilation and Remifentanil is an opioid which induces hypotension via histamine and nitrous oxide release. The results showed a significant decrease in bleeding scores for Clonidine based anaesthesia during the first two hours of the procedure. Ideally this would have been compared with total intravenous anaesthesia, the preferred choice for many FESS surgeons.

Reference

A randomized double blind clinical trial to compare surgical field bleeding during endoscopic sinus surgery with clonidine-based or remifentanil-based hypotensive anaesthesia.
Cardesín A, Pontes C, Rosell R, Escamilla Y, Marco J, Escobar MJ, Bernal-Sprekelsen M.
RHINOLOGY
2015;53(2):107-15.

RHINOLOGY

Coblation versus microdebrider submucosal inferior turbinoplasty
Reviewed by: Suki Ahluwalia
Vol 24 No 4
 

This prospective randomised study from Riyadh compares submucosal coblation and submucosal microdebrider inferior turbinate reduction. Seventy patients were recruited who had failed medical treatment and were undergoing isolated inferior turbinate surgery. Outcome measures included the Friedman score and VAS for various nasal symptoms over a six month period. It is not stated whether the assessor is the operating surgeon or not. Appropriate statistical techniques are used in the analysis and both techniques demonstrated a significant reduction in turbinate size and nasal symptoms, reproducible at six months and with minimum complications. The coblation group also had significantly less postoperative pain. Could this be a safe and effective office-based turbinate procedure for the future?

Reference

Inferior turbinate reduction; coblation versus microdebrider - a prospective, randomised study.
Hegazy H, El Badawey M, Behery A
RHINOLOGY
2014;52(4): 306-14.

AMERICAN JOURNAL OF OTOLARYNGOLOGY-HEAD AND NECK MEDICINE AND SURGERY

High dose betahistine as effective as, but slower acting compared to intratympanic dexamethasone in intractable Meniere’s disease
Reviewed by: Rohit Verma
Vol 24 No 3
 

The management of intractable Meniere’s disease poses a complex conundrum to otolaryngologists. The focus of treatment is decreasing the severity and frequency of vertigo and tinnitus whilst trying to preserve hearing. Betahistine has been used for many years in the treatment of Meniere’s disease often in combination with dietary modification and/or diuretics. In recent years, intratympanic (IT) dexamethasone has gained popularity although there is no current consensus on a protocol for IT administration. Betahistine at high doses (144mg/day) has also been demonstrated to be effective. In this randomised study, 66 patients received either IT dexamethasone and placebo tablet or IT saline and betahistine. Tinnitus Handicap Inventory (THI) and Dizziness Handicap Inventory (DHI) were evaluated for every patient in addition to audiolological assessment. The IT injections were given once a day for three days. IT dexamethasone (1ml of 4mg/ml) was administered using a 22 gauge needle with the patient supine and affected ear facing upward for 30 minutes. Betahistine was given at 48mg TDS. Patients were followed up over one year and frequency of vertigo symptoms assessed every three months with telephone calls to check compliance and side-effect profiles. In total 14/33 patients receiving IT dexamethasone reported complete control of symptoms and only one no control. High dose betahistine resulted in 12/33 reporting complete symptom control with no control in two patients. There were no significant differences between the groups in post treatment audiological assessments. Side-effects for betahistine did not cause any patient to leave the study. This study suggests that whilst there is a current trend for intratympanic dexamethasone to treat intractable Meniere’s disease, it may still be worth trialing higher doses of betahistine before IT dexamethasone. However, IT dexamthasone works within three days whilst betahistine took three months to take effect, supporting its use in disabling vertigo spells.

Reference

Intratympanic dexamethasone versus high dosage of betahistine in the treatment of intractable unilateral Meniere disease.
Albu S, Chirtes F, Trabalzini F, et al.
AMERICAN JOURNAL OF OTOLARYNGOLOGY-HEAD
AND NECK MEDICINE AND SURGERY
2015;36(2):205-9.

AMERICAN JOURNAL OF OTOLARYNGOLOGY

Beware of GPA as a cause of subglottic stenosis
Reviewed by: Rohit Verma
Vol 24 No 3
 

Up to 92% of patients with granulomatosis with polyangiitis (GPA) have concurrent ENT manifestations of the disease. Whilst we are familiar with sinonasal and middle ear presentations of GPA, subglottic stenosis (SGS) is another important and potentially life threatening manifestation. SGS is present in up to 23% of patients with GPA and occurs more commonly in younger patients. It can occur in isolation and be the presenting feature of GPA or can occur late. Stenosis is often limited to the subglottis / proximal trachea but it may also extend distally into the proximal bronchi or affect more proximally at the larynx or glottis. The course of SGS with GPA appears to run independently from the systemic disease. This study from a single centre identified 35 patients with both GPA and SGS. Diagnosis of GPA was made using either tissue biopsy, ANCA serology or a combination of both. In 31% SGS was the presenting manifestation of GPA. The remaining patients developed SGS at a median of 2.5 years from diagnosis. Thirty-four percent had multi-level airway involvement with 23% developing vocal cord paralysis, usually from fixation at the cricoarytenoid joint. All but one patient had concurrent head and neck manifestations of disease in addition to SGS. This paper highlights that GPA should be a differential diagnosis for any patient with SGS, without a clear history of airway trauma. The authors advise on the basis of their single centre study that patients with GPA and SGS should undergo bronchoscopy at the time of any airway intervention or trachea-bronchoscopy performed regularly in any tracheostomy dependent patient.

Reference

Multilevel airway stenosis in patients with granulomatosis with polyangiitis (Wegener’s).
Guardiani E, Sheikh Moghaddas H, Lesser J, Resta-Flarer F, Blitzer A, Bhora F, Lebovics R.
AMERICAN JOURNAL OF OTOLARYNGOLOGY
2015;36(3):361-3.

AUDIOLOGY NEUROTOLOGY

Long-term results of incus vibroplasty in patients with moderate-to-severe sensorineural hearing loss
Reviewed by: Stuart Burrows
Vol 24 No 3
 

The Vibrant Soundbridge (VSB) middle ear implant is now a well-accepted and widely utilised treatment option for patients with sensorineural hearing loss unable to use standard hearing aids.  However, as a relatively recent addition to the portfolio of implants available to the otologist, there are few reports to date of long-term safety and efficacy. In this paper, the authors report a retrospective review of 122 adult ears (104 patients) that underwent VSB for sensorineural hearing loss using an incus vibroplasty technique. Cases performed for mixed or conductive hearing loss, or using other techniques for conduction of sound (i.e. round window or coupler vibroplasty) were excluded. Examining the whole group, the initial postoperative testing showed an average surgically-induced air-bone gap (ABG) of -2.7dB, though the degree of ABG was different at each frequency and was not found to be statistically significant at the most clinically important 2-4KHz frequencies. This ABG remained stable over time. A minor reduction in high frequency bone conduction (BC) levels was also seen at the initial postoperative stage, but interestingly not at follow-up beyond a year.  No significant difference in the age-related deterioration of BC thresholds over time was found between the implanted and non-implanted ear in 82 patients, including a group of 16 patients with the longest follow up (mean 11.1 years, range 8.2-13.9 years). A significant improvement in word recognition scores was seen at all stages of follow-up. These results suggest that inner and middle ear function remain stable following VSB surgery.

Reference

Long-term results of incus vibroplasty.
Maier H, Hinze AL, Gerdes T, Busch S, Salcher R, Schwab B, Lenarz T.  
AUDIOLOGY NEUROTOLOGY
2015;20:136-46.

AUDIOLOGY NEUROTOLOGY

Three years later: report on the state of well-being of patients with chronic tinnitus who underwent modified tinnitus retraining therapy
Reviewed by: Stuart Burrows
Vol 24 No 3
 

This paper reports on 130 patients with tinnitus of at least three months duration who underwent ‘Modified Tinnitus Retraining Therapy’ (MTRT). MTRT combines psychological and physical therapies with standard tinnitus retraining therapy provided as a course of multi-disciplinary treatment, as individuals and in groups, over seven days. Patients then received ongoing follow-up every three months. Patients with clinical depression and suicide risk were excluded from the study and treated separately. Study patients underwent a series of audiological and psychometric tests (tinnitus, stress and depression questionnaires as well as a global well-being scale) pre-treatment, at the end of the seven-day course, and at three years. At the initial assessment following treatment, tinnitus annoyance, overall stress perception and depressive symptoms showed significant reductions, and quality of life improved. These effects remained at three years. As might be expected, the largest improvements occurred in patients with the worst pre-treatment scores, with gender and age having a variable effect for each of the outcome measures. Interestingly, the hearing level and duration of the tinnitus had little effect on the outcome of the treatment. Whilst it is impossible to be sure that the improvements seen relate directly to MTRT, (such intensive treatment is unlikely to be routinely available in the UK National Health Service), this study highlights the need for tinnitus treatment to systematically address background psychological and physical problems.

Reference

Long-term results of modified tinnitus retraining therapy.
Seydel C, Haupt H, Szczepek AJ, Hartmann A, Rose M, Mazurek B.
AUDIOLOGY NEUROTOLOGY
2015;20:26-38.

B-ENT

Radiofrequency for tonsillectomy
Reviewed by: Sunil Sharma
Vol 24 No 3
 

This Turkish study compared the use of radiofrequency (RF) tonsillectomy to the more traditional cold steel dissection (CD) technique. The authors enrolled 114 patients undergoing tonsillectomy for chronic tonsillitis and tonsil hypertrophy (causing upper airway obstruction) over a 4-month period. Each patient underwent RF tonsillectomy on one side and CD tonsillectomy for the other side. Both patients and the surgeons were blinded as to which method was used on which side. The RF system utilises an alternating RF current which has dual functions for cutting and coagulation. The device calibrates the power output by measuring the tissue impedance, and cuts out once tissue death is achieved. Interestingly, all patients were given a 10-day prophylactic antibiotic course post-operatively and only oral paracetamol as analgesia. There was no significant difference between the two groups in terms of the mean operation time, but there was significantly lower intraoperative bleeding in the RF group. Post-operative pain was measured using a VAS scale, and throughout the post-operative period, the mean pain score was higher in the RF group compared to the CD group. Return to a painless dietary regime took four days longer in the RF group. This study describes yet another technique that can be used for tonsillectomy, but whether there is any superiority of this method over cold steel is debatable, particularly in terms of post-operative pain.

Reference

Impedance-controlled radiofrequency vs. cold dissection tonsillectomy.
Ozkul MH, Bayram O, Balikci HH, et al.
B-ENT
2014;10:285-89.

CLINICAL OTOLARYNGOLOGY

Outpatient injection laryngoplasty
Reviewed by: Andy Hall
Vol 24 No 3
 

The benefits of a local anaesthetic centred laryngoplasty service in the outpatient environment may interest surgeons and hospital managers alike. This case series looked at patients over a two-year period undergoing local anaesthetic injection laryngoplasty in outpatients. Patient-rated (Voice Performance Questionnaire) and observer rated (GRBAS score) outcomes for 57 individuals were recorded. The patient rated Voice Performance Questionnaire score showed a median improvement from 42 to 21 (P < 0.0001). Observer assessment (GRBAS) also reflected positively. The clear description of the technique used in this series is of great benefit to those with an interest in laryngology. Comparison with general anaesthetic techniques was not a focus of this series yet the potential ability to achieve auditory feedback at the time of procedure is attractive. The technical challenges of local anaesthetic procedures should not be underestimated however.

Reference

Injection laryngoplasty in the outpatient clinic under local anaesthetic: a case series of sixty-eight patients.
Powell J, Carding P, Birdi R, Wilson JA.
CLINICAL OTOLARYNGOLOGY
2014;39:224-7.

CLINICAL OTOLARYNGOLOGY

Paediatric coblation intracapsular tonsillectomy
Reviewed by: Andy Hall
Vol 24 No 3
 

The ENT-UK tonsillectomy audit in 2005 created understandable caution in the promotion of Coblation techniques. This prospective study on 100 consecutive paediatric patients looked at outcomes following ‘cold’ radiofrequency ablation (Coblation) intracapsular tonsillectomy. This series shows the technique to be associated with rapid recovery, no postoperative bleeding (early or late) or any need for re-admission. The mean T14 (Paediatric throat disorders outcome tool) score for both objective and infective domains fell dramatically. This early data suggests that Coblation intracapsular tonsillectomy is likely to become an area of great interest to ENT surgeons who regularly perform tonsillectomy in children. This is surely an area where a randomised control trial would provide invaluable information if constructed correctly. In the mean time, large scale case series such as this are piquing interest in the technique.

Reference

Our experience. Coblation® intracapsular tonsillectomy (tonsillotomy) in children: a prospective study of 100 consecutive cases.
Hadjisymeou S, Modayil PC, Dean H, et al.
CLINICAL OTOLARYNGOLOGY
2014;39(5):301-7.

COCHLEAR IMPLANTS INTERNATIONAL

Cochlear implantation in immunosuppressed patients. Is it feasible?
Reviewed by: Thomas Nikolopoulos
Vol 24 No 3
 

The effectiveness of cochlear implantation has led to a relaxation of the candidate criteria. Patients who had been rejected in the past may now be accepted and their outcomes are encouraging. However, the acceptance of immunosuppressed patients as cochlear implant candidates is rather challenging as the risk of infection may put not only the device at risk (need for explantation) but also their lives due to a possible infection that may be difficult to control. The authors describe the first reported case of successful cochlear implantation in a patient who had previously undergone successful combined liver and kidney transplant. The authors describe the precautions that they had taken in order to minimise the risk and claim that they did not have any significant complications from surgery with a very good audiological outcome at three months. However larger studies are needed in order to assess the real risk of cochlear implantation in immunosuppressed patients.

Reference

Cochlear implantation in a patient with combined renal and liver transplantation.
Mahalingam S, Mathew R, Patel S, et al.
COCHLEAR IMPLANTS INTERNATIONAL
2014;15(6):333-6.

COCHLEAR IMPLANTS INTERNATIONAL

Neurosarcoidosis: another aetiologic factor for deafness and labyrinthitis ossificans
Reviewed by: Thomas Nikolopoulos
Vol 24 No 3
 

Very few studies describe deafness secondary to neurosarcoidosis as the latter is a rare inflammatory disorder of the nervous system usually associated with facial nerve and optic nerve disorders. This interesting case report describes a rare case of cochlear ossification as a result of neurosarcoidosis in a patient with bilateral profound sensorineural hearing loss. At the time of surgery, the cochleostomy revealed that the scala tympani was ossified and drilling did not achieve to identify a lumen. Therefore, the authors decided to proceed with a scala vestibuli insertion which was successful. Although the follow-up was rather short after the operation (four months), the outcome was encouraging. I fully agree with the authors that early imaging and monitoring of these patients is recommended and signs of cochlear obliteration should lead to timely assessment and possible surgery as an emergency.

Reference

Bilateral sensorineural hearing loss and labyrinthitis ossificans secondary to neurosarcoidosis.
Dhanjal H, Rainsbury J, Irving RM.
COCHLEAR IMPLANTS INTERNATIONAL
2014;15(6):337-40.

EUROPEAN REVIEW OF ENT

Military acoustic trauma: incidence and management
Reviewed by: Badr Eldin Mostafa
Vol 24 No 3
 

This is a retrospective study on the effects of acute acoustic trauma on the hearing thresholds of 225 military personnel. The main symptom after acute acoustic trauma due to firearm use was tinnitus. The authors consider it as the main indicator of acoustic trauma. The second symptom was hearing loss. It was commoner in the left ear with a mean loss of 33.98 dB HL at presentation. The main frequencies affected were 4 and 6 KHz. All patients were managed within 24 hours. They were hospitalised and received and IV infusion of methylprednisolone (1.5 mg/kg/day) in the morning and pentoxyfilline 300 mg twice daily. The majority were treated for five days with a maximum of 10 days. In more severe cases and those not responding within 48 hours hyperbaric oxygen therapy was added for two sessions. Audiograms were evaluated on admission, at discharge and one month later. The average audiometric gain was 13.85 dB HL at discharge and 18.28 dB HL on the later evaluation. In 40% of cases hearing loss was permanent especially if the initial loss was 40 dB or more. One of most recognised risk factors is non-compliance with the use of ear protectors. Most responders mentioned malpositions, falls and interference with their field performance by hampering auditory interaction with their environment and balance problems.

Reference

Acute acoustic trauma, a retrospective analysis about 225 military cases.
Bonfort G, Billot D, Trendel D, et al.
EUROPEAN REVIEW OF ENT
2014;135(1):25-31.

HEARING RESEARCH

Aided speech auditory brainstem response
Reviewed by: Faiz Tanweer
Vol 24 No 3
 

Auditory brainstem response (ABR) is commonly used for hearing screening and is considered as one of the important means of objective audiometry. Speech ABR is a relatively new concept and is regarded as a marker of speech encoding at the brainstem level. One of the potential uses of speech ABR is in selection and evaluation of hearing aid performance. Measurement of speech ABR can be associated with artefacts. Here authors have used wireless techniques to transmit the stimulus to the hearing aid to reduce artefacts caused by head movement. Data were recorded using a new 32 channel BrainAmp EEG system. It improved signal-to -–noise ratio and quality of speech ABR. A high quality speech ABR can provide precise spectro-temporal information on auditory processing. This research work is an improvement over previous studies using low frequency auditory steady state response (ASSR) and cortical evoked response audiometry (CERA). However, this study is based on the responses obtained from four healthy adult subjects only. Further study on a larger number of subjects is required, specifically in hearing impaired children, before the widespread use of technology. This technique can be valuable in difficult to evaluate patients who require hearing aids.

Reference

Speech auditory brainstem response through hearing aid stimulation.
Bellier L, Veuillet E, Vesson J F, Bouchet P, Caclin A, Thai-van H.
HEARING RESEARCH
2015;325:49-54.

INTERNATIONAL JOURNAL OF LANGUAGE AND COMMUNICATION DISORDERS

English language development in bilingual toddlers
Reviewed by: Gauri Mankekar
Vol 24 No 3
 

It is known that bilingual children have a smaller vocabulary in each of their two languages than monolingual children and also take a little longer to reach the same levels as monolinguals on various grammatical tasks. The authors of the article assessed 35 bilingual six year olds exposed to British English and an additional language and 36 British monolingual toddlers on the auditory component of the Preschool Language Scale, British Picture Vocabulary Scale and object naming measure. The results indicated that the proportion of exposure to English was the main predictor of the performance of bilingual toddlers and that typically developing toddlers who are bilingual in English and another language and who hear English 60% of the time or more, perform equivalently to their typically developing monolingual peers.

Reference

How much exposure to English is necessary for a bilingual toddler to perform like a monolingual peer in language tests?
Cattani A, Abbot-Smith K, Farag R, et al.
INTERNATIONAL JOURNAL OF LANGUAGE AND COMMUNICATION DISORDERS
2014;49(6)649-71.

INTERNATIONAL JOURNAL OF PEDIATRIC OTORHINOLARYNGOLOGY

How young is too young for tympanoplasty?
Reviewed by: Patrick Spielmann
Vol 24 No 3
 

This paper presents the largest series of pre-school age children undergoing tympanoplasty compared with older children. The authors have collected much prospective data on 259 children undergoing 284 surgeries so were able to perform multivariate analysis. The age groupings of two to four years, five to seven years and 8-13 years were analysed separately to look for predictors of success/failure. The very young children were shown to have a five -fold greater risk of re-perforation compared with the oldest age group even in the relatively short follow-up of (median) seven months. The authors argue that despite the improvement in quality of life and modest hearing gains, the risk of graft failure and need for revision surgery are too high so surgery should be delayed if at all possible.

Reference

The effect of age on paediatric tympanoplasty outcomes: A comparison of preschool and older children.
Duval M, Grimmer JF, Meier J, et al.
INTERNATIONAL JOURNAL OF PEDIATRIC OTORHINOLARYNGOLOGY
2015;79:336-41.

JOURNAL OF LARYNGOLOGY AND OTOLOGY

For how long is post-pinnaplasty head bandage really necessary?
Reviewed by: Madhup K Chaurasia
Vol 24 No 3
 

It is customary to put on a head bandage after pinnaplasty and the general consensus is that it should remain on for about a week to prevent haematoma and splint the reshaped pinna in place. In this review article, the authors identified 34 papers of which seven met their inclusion criteria. Only one was a randomised controlled trial (RCT), one ‘quasi’ RCT, three case series and one review article. In the RCT comprising 78 children, there was no statistically significant difference in the complication rates between children having the bandage for just 24 hours compared to those having it for a week. In the quasi RCT study, the complication rate was ten percent more in the non-bandaged group. The general observation from other studies was that putting a bandage on does not reduce complications. The authors note that discomfort, pain and need to replace the bandage within a week has not been considered as a complication. It would appear that it is not necessary to bandage after pinnaplasty for more than 24 hours considering prolonged bandaging can produce serious complications such as cartilage necrosis and pressure sores.

Reference

Should the duration of head bandaging be reduced after pinnaplasty? A systematic review.
McMurran AEL, Khan I, Mohammad S, et l.
JOURNAL OF LARYNGOLOGY AND OTOLOGY
2014;128:948-51.

JOURNAL OF THE AMERICAN ACADEMY OF AUDIOLOGY

Stimulation for tinnitus
Reviewed by: Cheka Spencer
Vol 24 No 3
 

Tinnitus is known to be inhibited by stimulation of the auditory system by stimuli such as acoustical, electrical and magnetic. Residual inhibition (RI) is when tinnitus is temporarily eliminated for a period of time lasting seconds, minutes, up to hours or even days in some people. There are various theories to explain tinnitus. Some studies hypothesise that it is a trade-off between a central gain increase and neural noise – which seeks to maintain neural homeostasis. This study sought to investigate tinnitus and RI mechanisms further; in particular alterations in auditory change detection and memory related to RI induced by electrical stimuli. This was done using a novel technique of brain mapping – mismatch negativity focusing on the fact that tinnitus is considered an alteration of neural activity. The study was well designed as a single-blind randomised controlled clinical trial with two groups: auditory electrical stimulation (AES) and placebo electrical stimulation. Thirteen of 28 participants with problem tinnitus (46.42%) indicated RI after receiving AES. All of the comparisons made in this study achieved statistical significance. One of the conclusions to be drawn is that RI induced by AES reflects the temporary reestablishment of auditory change detection in tinnitus sufferers. As tinnitus is not completely understood its treatment is also complicated. This study indicates that inducing RI could potentially provide long term relief. Further research is needed and mismatch negativity mapping is a promising tool.

Reference

Alterations in auditory change detection associated with tinnitus residual inhibition induced by auditory electrical stimulation.
Mahmoudian S,  Farhadi M,  Mohebbi M,  Alaeddini F,  Najafi-Koopaie M, Farahani ED, Mojallal H, Omrani  R, Daneshi A, Lenarz T.
JOURNAL OF THE AMERICAN ACADEMY OF AUDIOLOGY
2015;26(4):408-22.

JOURNAL OF VOICE

The laryngeal microdebrider – a useful adjunct in the surgical treatment of Reinke’s oedema?
Reviewed by: Christopher Burgess
Vol 24 No 3
 

The surgical treatment of Reinke’s oedema traditionally involves a cold steel incision placed in the lateral aspect of the vocal fold with aspiration of the characteristic gelatinous contents. In this paper, the authors compare voice outcomes in patients treated with either the carbon-dioxide laser (n = 10) or the laryngeal microdebrider (n = 16). Specifically, the carbon-dioxide laser was used in the first group for a lateral mucosal incision followed by aspiration of the vocal fold contents, whereas a cold-steel incision was used in the second group followed by microdebrider debulking of vocal fold contents and redundant mucosa. The laser settings were 1W, superpulse, continuous mode whilst the microdebrider was used in oscillation mode with a maximum speed of 800 rpm and low suction. The trial design was prospective and randomised, with the voice assessors blinded to treatment arm. Comparison of pre- and postoperative voice quality on the GRBAS scale showed consistent improvement in all parameters in both the laser and the microdebrider group, although the improvements in breathiness and strain parameters were not statistically significant in either group. Improvements in grade of hoarseness, roughness and asthenia were reported to be significantly greater after microdebrider surgery relative to laser surgery. Improvements in other acoustic voice parameters (fundamental frequency, jitter, shimmer, noise-to-harmonic ratio and maximal phonation time) were additionally significantly greater in the microdebrider group. It is debatable whether the carbon dioxide laser is an appropriate comparator to use in surgery for Reinke’s oedema. Nevertheless the use of the microdebrider to facilitate the surgical treatment of Reinke’s is conceptually appealing, and this paper would appear to confirm that good voice outcomes can be achieved.

Reference

Assessment of voice quality after carbon dioxide laser and microdebrider surgery for reinke edema.
Burduk PK, Wierzchowska M, Orzechowska M, Kaźmierczak W, Pawlak-Osińska K.
JOURNAL OF VOICE
2015;29(2):256-259.

NEUROSURGERY

Clival chordoma recurrence
Reviewed by: Showkat Mirza
Vol 24 No 3
 

Chordomas are generally slow growing and are histologically considered low grade tumours. Their high recurrence rate even after postoperative radiation renders them difficult to treat. This is particularly true for clival chordomas whose deep anatomic location and proximity to vital anatomic structures makes surgical resection challenging. This paper retrospectively reviews 50 patients over a 20 year period treated at the Centre for Minimally Invasive Skull Base Surgery in San Francisco. Thirty-four of the cases had a transphenoidal approach. Other approaches included trans-oral, craniotomy and staged approaches. Post-operative radiation included 19 cases of proton beam, seven with cyber knife, six with intensity modulated radiation therapy and 10 with external beam. At last follow-up 23 / 47 patients remained disease free or had stable residual tumour. As expected, gross tumour removal reduced chordoma recurrence. The lower third of the clivus frequently harboured residual or recurrent tumour despite staged approaches. Several investigators advocate proton beam radiation because its sharp dosimetry decline at the tumour edge minimises the radiation dose to which the surrounding normal structures are subjected. This paper found no benefit of proton based over photon based radiation, contradicting conventional presumptions.

Reference

Factors predicting recurrence after resection of clival chordoma using variable surgical approaches and radiation modalities.
Jahangiria A, Chin AT, Wagner JR, et al.
NEUROSURGERY
2015;76(2):179-86.

OTOLOGY AND NEUROTOLOGY

Damage to the cochlear nucleus with electrocautery to the cochlear nerve
Reviewed by: Anand Kasbekar
Vol 24 No 3
 

This study is of importance to neurotologists and neurosurgeons. It is unclear why patients with NF2 have poorer outcomes with an auditory brainstem implant compared to non-tumour patients. This effect is postulated to be due to damage to certain cells in the cochlear nucleus that are needed for sound modulation either by the tumour or the surgery to remove it. This study looked at the effect transecting the cochlear nerve has on the cochlear nucleus with and without electrocautery in anaesthetised adult gerbils. They effectively showed that electrocautery close to the root entry zone caused significant cochlear nucleus cell body injury. Transection of the cochlear nerve away from the root entry zone along with distal electrocautery did not show any histopathological damage to the cochlear nucleus when sectioned and looked at under a microscope. This encourages surgeons to debulk tumours and peel them medially before applying electrocautery. It is however not very clear how this accurately translates to humans and the exact distance one would need to keep from the brainstem before electrocautery can be safely applied.

Reference

Effect of cochlear nerve electrocautery on the adult cochlear nucleus.
Iseli CE, Merwin WH 3rd, Klatt-Cromwell C, et al.
OTOLOGY AND NEUROTOLOGY
2015;36(4):670-7.

RHINOLOGY

Quality of life after FESS or balloon sinuplasty
Reviewed by: Lakhbinder Pa
Vol 24 No 3
 

This randomised control trial compared the SNOT-22 questionnaires both pre-operatively and three months post-operatively in patients with chronic rhinosinusitis undergoing either FESS or balloon sinuplasty to the maxillary sinus. Forty two patients participated in the study, 21 in each treatment group. There was a subjective improvement in symptoms after surgery in both groups. An objective improvement in the quality of life was seen as a decrease in the total SNOT 22 score. Both balloon sinuplasty and FESS significantly improved all the parameters of the SNOT-22 questionnaire, with no significant difference being found between the two groups. Since no significant difference was found between traditional FESS and balloon sinuplasty in terms of improvement in SNOT-22 parameters, the authors suggest further studies on the cost-benefit of balloon sinuplasty due to its high material costs. It should be noted that this is a short-term study as follow-up with SNOT-22 was at three months post-op only.

Reference

Quality of life after endoscopic sinus surgery or balloon sinuplasty: a randomised clinical study.
Bizaki AJ, Taulu R, Numminen J, Rautiainen M.
RHINOLOGY
2014;52:300-5.

RHINOLOGY

Quality of life outcomes in paediatric endoscopic sinus surgery
Reviewed by: Lakhbinder Pa
Vol 24 No 3
 

This prospective cohort study evaluated chronic rhinosinusitis patients aged 5-18 years undergoing endoscopic sinus surgery in terms of quality of life. General and chronic rhinosinusitis surveys were completed by the parents and the child pre-ESS and at 30-90 days post-operatively. They found that general quality of life was improved pre-operatively and sinus symptoms improve significantly one to three months after sinus surgery. Parents reported statistically worse chronic rhinosinusitis symptom scores than the children.

Reference

Comprehensive quality of life outcomes for pediatric patients undergoing endoscopic sinus surgery.
Taylor RJ, Miller JD, Rose AS, et al.
RHINOLOGY
2014;52:327-33.

RHINOLOGY

Rhinosinusitis in secondary school children - Part 2: main project analysis of MSNOT-20 Young Persons Questionnaire (MSYPQ)
Reviewed by: Lakhbinder Pa
Vol 24 No 3
 

This study used the modified SNOT-20 in Young Persons Questionnaire (MSYPQ) to evaluate the prevalence and effects of rhinosinusitis in adolescent children (aged 11-16 years). This was performed in three large secondary schools in the UK with one group completing the MSYPQ and another the ARIA-based questions for comparison. This involved face to face interviews and postal surveys. 71% scored an abnormal value on the MSPYQ for at least one symptom, 32% of those assessed suffered from symptoms compatible with rhinitis and more than 20% suffered from the effects on quality of life. Cough was one of the significant symptoms (80%), followed by nasal discharge (75%) and malodourous breath (50%). The ARIA group showed that symptoms were intermittent in 44% and confirmed significant impairment of sleep and daily activities. The authors concluded that the MSYPQ demonstrates a high prevalence and impact on quality of life of rhinitis and rhinosinustis symptoms in adolescents, with levels comparable to results from an adult population. They also concluded that the MSYPQ rhinitis subgroup of questions was concordant with ARIA-based questions.

Reference

Rhinosinusitis in secondary school children – Part 2: main project analysis of MSNOT-20 young persons questionnaire (MSYPQ).
Sami AS, Scadding GK.
RHINOLOGY
2014;52(3):225-30.

THE HEARING JOURNAL

New aminoglycosides with reduced ototoxicity risk
Reviewed by: Linnea Cheung
Vol 24 No 3
 

Aminoglycoside antibiotics are widely used for infections affecting patients of all ages and at different sites, however they carry a risk of ototoxicity, nephrotoxicity and rarely peripheral neuropathy. Preventing ototoxicity is crucial to the maintenance of auditory function and quality of life in patients treated with aminoglycosides. This short article reviews the work on assessment of the cytotoxic properties of apramycin (an aminoglycoside used widely in veterinary medicine), paromomycin (used for protazoal parasitic infections) and sisomicin (a modified biosynthetic precursor of gentamicin) tested on in vitro animal models. Apramycin resulted in significant reduction in threshold shifts and cochlear hair cell loss when compared with gentamicin. Paromomycin and sisomicin both resulted in negligible losses of hair cells. Due to the particular properties of these agents, the article concludes that aminoglycosides that do not bind effectively to eukaryotic ribosomes, or those that are modified with a methysulfonyl group, result in reduced risk of hair cell death and hearing loss. The next steps for research are to evaluate the long-term effects of administration, and identify quantities for correct dosing in the presence of infection.

Reference

Novel aminoglycoside antibiotics show reduced ototoxicity risk.
Steyger P.
THE HEARING JOURNAL
2015;68(4):32-5.

THYROID RESEARCH

Ultrasound assessment of metastatic disease
Reviewed by: Adam Shakir
Vol 24 No 3
 

This Japanese study of 10 patients over 15 years, assesses the role of ultrasonography in assessing metastatic disease to the thyroid gland, specifically renal clear cell carcinoma (RCCC). Whilst uncommon, the authors state that there is a favourable prognosis when RCCC is confined to the thyroid gland and is amenable to surgery. They used five assessment markers when evaluating thyroid glands with ultrasonography, and found that RCCC formed one or two well demarcated lesions within the thyroid gland and was not diffusely involved. With two patients, postoperative histological analysis identified previously unknown RCCC arising from the kidney. Ultrasonography was used in conjunction with fine needle aspiration cytology (FNAC), with false negatives reported in four out of 10 patients. The authors recommended in their discussion for thyroglobulin levels to be analysed in FNAC washouts to help determine primary thyroid clear cell disease or disease arising elsewhere. Their conclusion was that preoperative assessment of these patients’ thyroid glands was useful and correlated well with postoperative histological analysis.

Reference

Metastatic carcinoma to the thyroid gland from renal cell carcinoma: role of ultrasonography in preoperative diagnosis.
Kobayashi K, Hirokawa M, Yabuta T et al.
THYROID RESEARCH
2015;8:4

AMERICAN JOURNAL OF OTOLARYNGOLOGY-HEAD AND NECK MEDICINE AND SURGERY

Chemo-radiation in elderly patients with head and neck cancers
Reviewed by: Rohit Verma
Vol 24 No 2
 

Chemo-radiotherapy is the standard of care for organ preservation in stage three and four oropharyngeal cancer, prospective data on patients over 65 has not been available as they are usually excluded from randomised trials. This paper reviews the experience of a single institution on 32 patients aged between 65 and 87 (median 74). Karnofsky Performance score was >70 for all patients and co-morbidities that were adequately controlled with medical therapy were included. These co-morbidities included diabetes, coronary arterial disease, hypertension and stroke. Radiotherapy was delivered at 68-70Gy. In total 29 patients received platinum based chemotherapy, three received cituximab / nimotuzimab. Mean overall treatment time was 49.4 days (44-65 days). Response was assessed six to eight weeks after treatment was completed using RECIST criteria with toxicities measured against National Cancer Institute common toxicity criteria. Ninety percent of patients completed the planned doses of radiotherapy and at least five cycles of chemotherapy. This is higher than in other studies quoted. One patient developed septicaemia during the treatment and did not complete treatment. For acute toxicity, 6% patients experienced grade three skin toxicity, with 14 experiencing grade three mucosal toxicity. Significant late toxicity (grade 3>) was only seen in six percent of patients. Tumour response in the 31 patients completing treatment was evaluated six to eight weeks after treatment. Complete response was seen in 29 (77%) patients with partial response in seven. In the cohort of partial response, all received salvage chemotherapy and are still alive. Loco-regional control at two years was 72%, with survival at two years of 89%, better than previous studies. The authors conclude that radical chemo-radiation is a valid treatment for option for organ preservation in well elderly patients, with special emphasis on nutritional support and oral hygiene. Further stage III trials are needed to draw definitive conclusions.

Reference

Chemoradiation in elderly patients with head and neck cancers: a single institution experience.
Kataria T, Gupta D, Kumar V, et al.
AMERICAN JOURNAL OF OTOLARYNGOLOGY-HEAD
AND NECK MEDICINE AND SURGERY
2015;36(2):117-21.

AMERICAN JOURNAL OF OTOLARYNGOLOGY-HEAD AND NECK MEDICINE AND SURGERY

Seeking medical attention with tonsillectomy complications depends on who you are. Lessons from the USA
Reviewed by: Rohit Verma
Vol 24 No 2
 

In the current UK model, NHS care is free at point of access so there are no perceived economic barriers to seeking attention with postoperative complications. This study from the US examines surgical and emergency room databases from across California, Iowa, Florida and New York for 2010-11 assessing revisits within 14 days of tonsillectomy in adults. Common presenting symptoms were pain, bleeding and fever / nausea / vomiting / dehydration (FVND). Associations with age, sex, race, median household income and co-morbidity scores were analysed. Ethnicity was identified as White, Black, Hispanic or Other. 17836 tonsillectomies were performed (63.7% female, median age 29.0). Revisit rates for bleeding was 5.1%, FVND was 1.5% and pain 2.8%. Female sex was associated with lower rates of revisit for bleeding but higher rates for pain than males. Similar disparities were seen for revisit rates for pain and FVND between ethnic groups. Lower household income was associated with higher rates of revisit for pain. Multivariate analysis of revisits for bleeding reveals that only female sex was associated with a decreased bleeding rate, the other demographic factors did not impact significantly. Female sex also increased odds for revisits with pain or FVND. Increasing household income decreased the likelihood of visits for pain. Black or Hispanic ethnicity increased likelihood for revisit with pain relative to white patients but did not alter rate for revisits for FNVD. By undertaking a multi-state, cross sectional analysis, this paper highlights that statistically significant disparities exist between groups in their experience of postoperative complications and their healthcare seeking behaviour. Postoperative recovery from tonsillectomy is often difficult for patients. Identification of populations at elevated risk of complications can help to reduce the disparity and relieve some of the associated costs of revisits to the healthcare economy and to the patient.

Reference

Healthcare disparities in revisits for complications after adult tonsillectomy.
Bhattacharyya N.
AMERICAN JOURNAL OF OTOLARYNGOLOGY-HEAD
AND NECK MEDICINE AND SURGERY
2015;36(2):249-53.

B-ENT

Cochlear implantation and inner ear malformations
Reviewed by: Sunil Sharma
Vol 24 No 2
 

In this study the authors attempted to compare the outcomes in children who underwent cochlear implantation (CI) with inner ear malformations to those that had normal inner ear anatomy. Sixty three children with prelingual deafness who underwent CI were included. Twelve of these patients had inner ear malformations including enlarged vestibular aqueduct, a common cavity, incomplete partition, and cochlear hypoplasia. Outcomes were measured at intervals up to two years post-surgery (pre-operatively, and at six, 12, and 24 months post-operatively) using the Categories of Auditory Performance (CAP) and Speech Intelligibility Rating (SIR) scores. In both groups the CAP and SIR scores increased with time after implantation, and there was no significant difference in the scores between the two groups at any of the four follow-up assessments. The authors compare the results to other studies, which have suggested limited improvement in patients with CI with inner ear abnormalities. These papers hypothesise that there are reduced spiral ganglion cell numbers in patients with inner ear malformations, and therefore CI is not as effective. The authors hypothesise that the reason for their seemingly good outcomes may be the fact that they have selected a group of children early in their development, as compared to some other studies. This paper demonstrates that CI in children with inner ear malformations can be of similar benefit to CI in children with normal inner ears if performed early enough in a child’s development.

Reference

Evaluation of cochlear implantation in children with inner ear malformations
Zhou H, Sun X, Chen Z, et al.
B-ENT
2014;10:265-9.

B-ENT

External auditory canal carcinoma
Reviewed by: Sunil Sharma
Vol 24 No 2
 

Although uncommon, primary malignant tumours of the external auditory canal (EAC) are associated with a poor prognosis as they often present late. In this study the authors evaluate the clinical and pathological factors associated with treatment and outcome of EAC carcinomas. They identified 23 patients over a 20-year period for inclusion, with a range of pathology from T1 to T4. Interestingly, in half of patients the main presenting complaint was otorrhoea, closely followed by otalgia. The majority of cases of EAC carcinoma were SCC (70%), followed by adenoid cystic carcinoma (22%), basal cell carcinoma (4%) and verrucous carcinoma (4%). The majority of patients underwent surgical treatment (83%), including total canal resection, lateral temporal bone resection, parotidectomy and supraomohyoidal neck dissection. Only one patient received postoperative chemoradiotherapy (CRT), whilst seven patients had postoperative radiotherapy (RT). The 5-year survival rate was 75.2% and 10-year survival was 60.2%. SCC patients had a significantly poorer prognosis compared to the other histological subtypes. As one might expect, those patients who had surgical treatment with post-operative CRT / RT had a significantly better prognosis than those patients who had unresectable disease. Although the numbers in this study are small, it highlights the importance of having a high index of suspicion of EAC carcinoma, as it presents with very non-specific symptoms. No patients in the study had cranial nerve palsies, and the presence of these suggests a very poor prognosis indeed. Perhaps the main conclusion to take away is that EAC carcinomas should be treated aggressively with complete resection and postoperative CRT.

Reference

Carcinoma of the external auditory canal: histological and treatment groups.
Hosokawa S, Mizuta K, Takahashi G, et al.
B-ENT
2014;10:259-64.

CLINICAL OTOLARYNGOLOGY

Botulinum toxin in ENT
Reviewed by: Andy Hall
Vol 24 No 2
 

This comprehensive review neatly summarises non-cosmetic uses of botulinum toxin within otorhinolaryngology, it is perhaps easy to forget the medical use of botulinum toxin has now been approved for the last thirty years. Its overall safety profile places it as an attractive minimally invasive treatment option in a wide range of conditions including voice disorders, facial scarring and dysphagia. The current evidence base for both injection sites and reported mean total doses are included, giving a practical overview to the treatments themselves. Spasmodic dysphonia is perhaps one of the areas where botulinum toxin use to inhibit laryngeal hyperkinesias has been well established. A key distinction is shown however between the abductor and adductor variants, with much higher rates of effectiveness demonstrated in the latter with duration of benefit between 6-15 weeks.

Reference

The use of botulinum toxin in otorhinolaryngology: an updated review.
Mandavia RO. Dessouky O. Dhar V, D’Souza A.
CLINICAL OTOLARYNGOLOGY
2014;39:203-9.

CLINICAL OTOLARYNGOLOGY

Unilateral vocal cord mobility impairment and laryngopulmonary physiology
Reviewed by: Andy Hall
Vol 24 No 2
 

The concept of iatrogenic recurrent laryngeal nerve injury following thyroid surgery is often considered with respect to voice change but its potential impact on airway physiology has thus far not been evaluated. A cross-sectional observational study reviewed 21 patients with unilateral vocal fold mobility impairment (UVFMI) against 53 control patients with no history of lung disease or laryngeal pathology. The authors identified a reproducible flow-volume loop pattern suggestive of selective inspiratory airway obstruction in UVFMI patients. The findings allow flow-volume loops to act as an objective measure of laryngeal abductor function. The authors recognise the potential value in confirming a diagnosis of recurrent laryngeal palsy or indeed measuring a change in airway physiology as an arbiter of success in vocal cord medialisation procedures. The hidden prevalence of UVFMI (and indeed better understanding of surgical complications) may perhaps be better understood through incorporation of this easily accessible physiological test, particularly where other surgical disciplines may not have access to post-operative laryngoscopy.

Reference

Impact of unilateral vocal fold mobility impairment on laryngopulmonary physiology.
Nouraei SA, Whitcroft K, Patel A, et al.
CLINICAL OTOLARYNGOLOGY
2014;39:209-15.

COCHLEAR IMPLANTS INTERNATIONAL

Does head trauma as aetiology of deafness affect the outcomes of cochlear implantation?
Reviewed by: Thomas Nikolopoulos
Vol 24 No 2
 

Head trauma associated with temporal bone fractures is a well known aetiological factor for deafness. The literature assessing the outcomes of cochlear implantation in such cases is rather limited. In this paper, the authors compared the performance of implantees with deafness secondary to head trauma, with controls who had another aetiology of deafness. The results of the study revealed that the performance of the group of cochlear implant adult users who have acquired hearing impairment after head trauma was globally lower than that of the group of hearing impairment with other aetiologies. Few comparisons were found statistically significant and this may be attributed to the small number of participants in the head trauma group (only 14). It seems that head trauma co-morbidities may affect the outcome and auditory rehabilitation may improve the outcome. However, better study design with more patients could clarify these rather theoretical views.

Reference

Auditory rehabilitation after cochlear implantation in adults with hearing impairment after head trauma.
Alves M, Martins JH, Moura JE, et al.
COCHLEAR IMPLANTS INTERNATIONAL
2014;15(6):312–7.

COCHLEAR IMPLANTS INTERNATIONAL

How do the rejected candidates for cochlear implantation feel?
Reviewed by: Thomas Nikolopoulos
Vol 24 No 2
 

This interesting study from the UK explored, using personal interviews, how rejected candidates for cochlear implantation feel and deal with the decision not to implant. The authors assessed 10 adult cochlear implant candidates who had undergone the evaluation process were found not eligible for implantation, mainly due to audiological reasons. Although most of their hearing was too good for implantation, as assessed by the audiologists, they themselves felt rather isolated both socially and emotionally. Moreover, they felt that their hearing loss affected their work. Finally, the participants’ general view was that speech discrimination testing and the other audiological measures in the assessment process do not reflect their everyday life and therefore were disappointed and felt that their expectations had not been met. It is clear that these views should be taken into account in a more patient orientated pathway.

Reference

The experiences of adults assessed for cochlear implantation who did not proceed.
Athalye S, Mulla I, Archbold S.
COCHLEAR IMPLANTS INTERNATIONAL
2014;15(6):301-11.

CURRENT OPINION IN OTOLARYNGOLOGY HEAD AND NECK SURGERY

Facial pain and headaches
Reviewed by: Susan A Douglas
Vol 24 No 2
 

This paper reviews the present knowledge and the recent publications on the cause, characteristics, course and treatment of chronic and recurring facial pain and headaches. Facial pain should be defined in terms of frequency, duration and severity, and also in terms of quality, site and accompanying factors such as photophobia, nausea or vomiting and exacerbation on physical exertion. Rating the intensity of the pain from zero (no pain) to 10 (unbearable pain) is helpful because higher pain levels are associated with facial migraine or cluster headache. Pain distribution is important because migraine, cluster headache and paroxysmal hemicrania are usually unilateral. Daily and constant pain is unlikely to be of rhinogenic origin. Although chronic facial pain has conventionally been considered to be due to sinusitis because of anatomical proximity, there is increasing evidence to support the contrary.
The key points are as follows:
I.     Facial pain is an uncommon symptom of chronic rhinosinusitis. Only 20% of patients with purulent sinusitis or nasal polyposis confirmed by nasal endoscopy actually complained of facial pain.
II.     A temporal correlation of episodes of facial pain with rhinogenic symptoms of nasal obstruction, rhinorrhoea and hyposmia, and the presence of endoscopic and CT scan evidence of sinusitis are important to consider the pain to be of rhinogenic origin.
III.     Chronic facial pain is most likely to be due to nonrhinogenic causes. Facial pain of nonrhinogenic origin is a diagnosis of exclusion. Chronic tension-type facial pain followed by facial migraine is the commonest type of nonrhinogenic facial pain in a community setting.
IV.    An eight week course of low-dose tricyclic antidepressants is a well tolerated and effective first line of treatment for chronic facial-tension-type pain and facial migraine. Addition of pindolol reduces analgesic consumption by reducing pain intensity.

Reference

Rhinogenic and nonrhinogenic headaches.
CURRENT OPINION IN OTOLARYNGOLOGY HEAD AND NECK SURGERY
Aguis AA, Sama A.
2015;23:15-20.

CURRENT OPINION IN OTOLARYNGOLOGY HEAD AND NECK SURGERY

Treatment algorithm for olfactory disorders
Reviewed by: Susan A Douglas
Vol 24 No 2
 

The purpose of this paper is to review the current evidence in diagnosing olfactory disorders and suggest an algorithmic approach to patients with relevant complaints. Age-associated olfactory loss is often multifactorial and requires a careful history and physical exam. A table demonstrating the common causes of olfactory disorders is given describing the aetiology under the headings - obstructive / conductive (septal deviation, nasal polyposis, sinonasal neoplasms), sensorineural (ageing, post infection, neurodegenerative) delineating anatomic obstruction and mixed (CRS, sinonasal surgery, medication). MRI is helpful for further evaluation of sinonasal tumors skull-base diseases, lesions with intracranial or facial soft-tissue extension, and confirmation of agenesis of the olfactory bulb as in Kallmann syndrome. Psychophysical tests have a role in screening patients at risk for Parkinson’s and Alzheimer’s disease, but there is lack of evidence regarding timing and patient selection. Olfactory training is suggested to be an emerging modality in patients with post-infection olfactory loss. Patients with CRS may require medical management and surgical treatment for alleviation of their symptoms.
The key points are as follows:
I.     All patients with impaired olfaction should undergo complete nasal endoscopy and psychophysical olfactory testing.
II.     At present, olfactory testing cannot be used as a guide for prognostication or to direct potential therapy.
III.     There is no unique characteristic that can be used to predict which CRS phenotype will have the greatest improvement in olfaction after endoscopic sinus surgery.
IV.    Olfactory training is a promising non-invasive treatment modality for improvement of post-infection hyposmia and anosmia.
V.    Safety counselling is an indispensable part of the treatment in patients with olfactory disorders.

Reference

An algorithmic approach to the evaluation and treatment of olfactory disorders.
Daramola OO, Becker SS.
CURRENT OPINION IN OTOLARYNGOLOGY HEAD AND NECK SURGERY
2015;23:8-14.

DYSPHAGIA

Prophylactic swallowing exercises in head and neck cancer
Reviewed by: Roganie Govender
Vol 24 No 2
 

Clinicians working in head and neck cancer will be familiar with the increased interest in prophylactic swallowing exercises to reduce the devastating impact of dysphagia experienced by patients undergoing radiation or chemo-radiation therapy. This study from Denmark is one of only a handful of RCTs designed to test the effectiveness of providing patients with exercises prior to the start of their treatment. The purpose is to maintain the function of the swallowing musculature and possibly delay or reduce long-term fibrotic changes, keeping patients eating by mouth for a longer period. The study did not show any significant benefit in the intervention group compared with the usual care control group on all of the multidimensional swallowing outcome measures at any of the multiple time points up until 11 months post radiotherapy. The primary outcome measure was the Swallowing Performance Status Scale (SPSS), but secondary measures included the EORTC, MBS, clinical measures (weight, mouth opening, tube feeding, DAHANCA dysphagia scale) and patient compliance. Findings were similar in both groups at the different time points with a similar change over time. Only 51% of patients were available at the final follow-up (dropout rate reported to be similar in both arms) with only 53% of patients reporting adherence to the exercise protocol at week five of radiotherapy and 33% at 11 months post. The authors provide a good discussion about their findings in relation to other studies as well as problems encountered in their own study. They also provide a very useful table in the supplementary information describing the current evidence for the effect of swallowing exercises on different endpoints. This paper has all the elements (methodological quality, challenges of conducting an RCT with this population, is there enough evidence yet to be “pushing” prophylactic exercises in clinical practice, lessons for future studies) for an interesting journal club discussion!

Reference

Prophylactic swallowing in head and neck cancer radiotherapy.
Mortensen HR, Jensen K, Aksglaede K, et al.
DYSPHAGIA
Published online 19 Feb 2015
DOI 10.1007/s00455-015-9600-y

EAR AND HEARING

Communication patterns during audiological rehabilitation history taking
Reviewed by: Vinaya Manchaiah
Vol 24 No 2
 

Nature of communication among patients, their communication partners and hearing healthcare professionals is an important part of audiological rehabilitation and can have some influence on the patient outcome. As history taking quite often forms the first instance of communication between patients and professionals it is an important stage in the development of relationship and in the success of subsequent shared decision making. This study was aimed at exploring the nature of verbal communication among patients, audiologists and companions during history taking and also the factors associated with communication dynamics. Video recording of 63 audiology consultations were made and the consultations were coded using the Roter Interaction Analysis System and divided into three consultation phases, which included: history, examination and counselling. Further, they analysed the history-taking phase in terms of opening structure, communication profiles of each speaker, and communication dynamics. Results suggest that on an average the history taking took about 9 minutes and a companion was present only in 27% of the consultations. The three areas of communication were: opening structure, information exchange and relationship building. Audiologists tend to control the history opening structure by using closed-ended questions in about 62% of the time. In addition, audiologists often interrupted patients. Generally, audiologists dominated the history taking session by asking 97% of the questions and asked primarily closed-ended questions including topics such as biomedical and psychosocial / life-style. Few emotionally focused utterances were observed from any speaker (less than 5% of utterances). These results provide an insight on what was overlooked from the previous literature highlighting that little involvement of patients during history taking in terms of evoking their own responses. These findings are important in implementing patient-centered audiological rehabilitation.

Reference

Communication patterns in audiologic rehabilitation history-taking: audiologists, patients, and their companions.
Grenness C, Hickson L, Laplante-Lévesque A, et al.
EAR AND HEARING
2015;36(2):191-204.

EUROPEAN REVIEW OF ENT

To monitor or not to monitor
Reviewed by: Badr Eldin Mostafa
Vol 24 No 2
 

This is a report on an e-mail based survey of 1249 otologic surgeons on their practice regarding facial nerve monitoring during ear surgery. The response rate was very low (6.6%). The majority of responders (92%) stated that they did not use facial nerve monitoring during stapes surgery, ossiculoplasty or myringoplasty. In cochlear implant surgery 78% monitored the facial nerve. As regards non-cholesteatomatous CSOM, the majority (68%) did not use the monitor. On the other hand, in primary surgery for cholesteatoma, 52% of the responders used the monitor. This proportion rose to 62% in revision cases. For the vast majority (97%) the choice to monitor was based on CT data especially if the lesion was diffuse, near the course of the facial nerve or if a bony dehiscence was suspected. One of the limiting factors for the availability and / or use of facial nerve monitors seems to be economic restraints including the initial and running costs in addition to poor coding for the procedure.

Reference

Facial nerve monitoring during middle ear surgery: results of a French survey.
Mazzaschi O, Juvanon J-M, Mondain M, et al.
EUROPEAN REVIEW OF ENT
2014;135(1):11-7.

EUROPEAN REVIEW OF ENT

Vestibular screening in occupational medicine
Reviewed by: Badr Eldin Mostafa
Vol 24 No 2
 

Occupational vestibular disorders carry a high medico legal and economic burden. The occupational medicine physician must rely on rapid, non-invasive, economical and reproducible screening tests. This article compares the simplified caloric test of Veits (CTV) with the skull vibration-induced nystagmus test (SVINT) in 87 workers. The end points were reproducibility, tolerance and duration of the examination. The mean duration of the CTV was 15 minutes whereas that of SVINT was one minute. In 69 subjects there were autonomic side-effects to CTV whereas SVINT was much better tolerated. The authors conclude that the SVINT should be included in the screening of subjects during occupational medical check-ups. It is a rapid, robust and reliable test as it is not influenced by compensation.

Reference

Benefit of skull vibration induced nystagmus test in occupational medicine.
Beatrice F, Karkas A, Bucolo S, et al.
EUROPEAN REVIEW OF ENT
2014;135(1):19-24.

HEAD AND NECK

Hyperbaric oxygen therapy and flap reconstruction: does it help?
Reviewed by: Sunil Kumar Bhatia
Vol 24 No 2
 

This is a multicentresite retrospective review from four clinics in the USA on patients who received radical debridement and free flap reconstruction for osteoradionecrosis (ORN) between 1 Jan 1995 and 30 June 2011. Patients were stratified divided based on having prior undergone prior hyperbaric oxygen (HBO) treatment or not. Eighty-nine patients received a free flap reconstruction, of these 39 had a history of HBO and 50 did not. A total of 56% with prior HBO developed complications compared with 50% without prior HBO therapy, there was no statistical difference. However there was a marginal significant increase in infections rate in patients with HBO therapy. Interestingly this group also had a lower incidence of diabetics. This is a first study that examines the association of prior HBO and postoperative complications. This data suggests that patients that have continued ORN with failed conservative therapy and HBO are at risk for postoperative infections. This may be a selection bias because these patients failed conservative and initial treatment of ORN. Also repeated debridement could account for repeated injury. The authors accept the limitations of this retrospective study and accept that causality cannot be determined by this. It is however a well written paper that brings together patients, with a fairly uncommon and difficult condition, from four large centres and is worth reading.

Reference

Comparison of complications in free flap reconstruction for osteoradionecrosis in patients with or without hyperbaric oxygen therapy.
Nolen D, Cannady SB, Wax MK, et al.
HEAD AND NECK
2014;36(11):1701-04.

INTERNATIONAL FORUM OF ALLERGY AND RHINOLOGY

Back to basics: nasendoscopy beats CT, again!
Reviewed by: Christos Georgalas
Vol 24 No 2
 

There are few otolaryngologists (or patients) who have not been confronted with a computed tomography scan referring to a deviated septum. In a very similar way to the accidental findings of sinus mucosal thickening, the clinician is left in a difficult position, trying to explain to the patient (and to the referring physician or neurologist) that the diagnosis of sinusitis is clinical and not radiological. This paper resolves, in a rather elegant way, the issue: septal deviation associated with significant nasal obstruction is a clinical diagnosis, based on thorough examination including endoscopy and clinical history. Blinded assessment of septal deviation on CT does not correlate with clinically important septal deviation, except in the area of bony septum (and then again, only poorly).

Reference

Radiographic evaluation of nasal septal deviation from computed tomography correlates poorly with physical exam findings.
Sedaghat AR, Kieff DA, Bergmark RW, et al.
INTERNATIONAL FORUM OF ALLERGY AND RHINOLOGY
2015;5(3):258-62.

INTERNATIONAL FORUM OF ALLERGY AND RHINOLOGY

Not so innocent, after all: a meta-analysis of the effects of intranasal corticosteroids on growth
Reviewed by: Christos Georgalas
Vol 24 No 2
 

The use of intranasal corticosteroids has revolutionised the management of allergic rhinitis and rhinosinusitis and there is now significant evidence of their safety. The problem with side-effects is that clinical studies are designed to demonstrate efficacy, but are underpowered to show evidence of side-effects. None of the studies pooled in this meta-analysis has shown a significant effect of intranasal corticosteroids on growth, however they all showed a consistent trend towards reduced growth velocity. This meta analysis pooling their results showing the effect to be real and consistent, albeit small, as measured by knemometry growth velocity, even after use as limited as for a few weeks. What is not clear is the long-term effect, and whether the children can later catch up. In any case, it is a study that certainly calls for exercising caution in their use and always use the lowest effective dose.

Reference

Topical intranasal corticosteroids and growth velocity in children: a meta-analysis.
Mener DJ, Shargorodsky J, Varadhan R, Lin SY.
INTERNATIONAL FORUM OF ALLERGY AND RHINOLOGY
2015;5(2):95-103.

INTERNATIONAL JOURNAL OF AUDIOLOGY

Hearing protection and hearing loss
Reviewed by: Rick Navaro
Vol 24 No 2
 

This study examined the interaction of hearing protection for noise reduction and hearing loss with speech recognition performance. Forty five subjects with four hearing loss profiles were fitted with two different level dependent hearing protectors (circumaural and inserts) in two different military noises. Each protector was tested under passive and electronic filtering. Passive protection resulted in the greatest reduction in speech recognition for the hearing impaired users but little effect for normal hearers. Circumaural devices resulted in better frontal speech recognition due to microphone placement but electronic filtering of noise resulted in better speech recognition for the hearing impaired subjects. This study has important implications in documenting that hearing impaired subjects will not understand speech as well in noisy environments but that electronic filtering helps to preserve speech recognition ability.

Reference

The interaction of hearing loss and level-dependent hearing protection on speech recognition in noise.
Giguere C, Laroche L, Vaillant V.
INTERNATIONAL JOURNAL OF AUDIOLOGY
2015;54:S9-S18.

INTERNATIONAL JOURNAL OF AUDIOLOGY

Hearing protectors and speech perception
Reviewed by: Rick Navaro
Vol 24 No 2
 

This study tested 31 subjects using hearing protectors by maintaining a constant intensity level for the speech signal while varying background noise levels. The goal was to use this test to detect speech perceptual abilities under different hearing protectors – passive vs. electronic filtering. The results showed that electronic filtering resulted in the best overall speech intelligibility. The study elucidated the various types of noise that may be encountered in workplace situations and discussed the implications of the different noises for differentiating between hearing protectors. There are many variables in trying to conduct such a study and deriving meaningful conclusions. One potential caveat is that most speakers will automatically elevate their vocal effort in noise (Lombard effect) to speak over the noise. This reduces some of the power of the study’s conclusion that the proposed test is a viable method for differentiating hearing protectors.

Reference

To measure the impact of hearing protectors on the perception of speech in noise.
Hiselisu P, Edvall N, Reimers E.
INTERNATIONAL JOURNAL OF AUDIOLOGY
2015:54:S3-S8.

INTERNATIONAL JOURNAL OF LANGUAGE AND COMMUNICATION DISORDERS

Relationship between ART and language development
Reviewed by: Gauri Mankekar
Vol 24 No 2
 

Assisted Reproduction Technology (ART) and especially more invasive techniques of ART may be associated with an increase in neurodevelopmental problems including language delay. Some studies have reported slightly worse perinatal outcomes of IVF babies compared to naturally conceived babies. The purpose of this study was to determine the language development in three to 10 year old children born following assisted oocyte activation (AOA). The authors assessed expressive and receptive language development of 20 children with a mean age of 5.4 years. They used the Clinical Evaluation of Language Fundamentals (CELF-IV-NL) for children older than five years and the Reynell Developmental Language Scale (RTOS) for children younger than or equal to five years. They found that the language development of singleton babies was significantly better than that of twins born following AOA. Further long-term follow-up studies in this population are needed to provide information on the language development of children born following ART /AOA.

Reference

Language development of children born following intracytoplasmic sperm injection (ICSI) combined with assisted oocyte activation (AOA).
D’haeseleer E, Meerschaut FV, Bettens K, et al.
INTERNATIONAL JOURNAL OF LANGUAGE AND COMMUNICATION DISORDERS
2014;49(6):702-9.

INTERNATIONAL JOURNAL OF LANGUAGE AND COMMUNICATION DISORDERS

Specific language impairment in bilingual vs monolingual children
Reviewed by: Gauri Mankekar
Vol 24 No 2
 

Research has focused mainly on the specific language impairment (SLI) in monolingual children. This article focuses attention on the SLI in bilingual children. The study was conducted with bilingual children from Luxembourg and monolingual children from Portugal who all had Portuguese as their first language. The bilingual group performed equally well compared with their peers on measures of visuospatial working memory but had lower scores than both control groups on tasks of verbal working memory. The authors’ results support the position that SLI is not a language specific disorder. In fact, bilingualism may represent a protective factor against some of the cognitive limitations associated with SLI in monolinguals.

Reference

Specific language impairment in language –minority children with low income families.
Pascale MJ, de Abreu E, Cruz-Santos A, Puglisi ML.
INTERNATIONAL JOURNAL OF LANGUAGE AND COMMUNICATION DISORDERS
2014;49(6):736-47.

INTERNATIONAL JOURNAL OF PEDIATRIC OTORHINOLARYNGOLOGY

Bone anchored hearing devices in very young children
Reviewed by: Patrick Spielman
Vol 24 No 2
 

This paper presents results of BC devices in very young children and helps inform an honest discussion of risks / benefit with prospective parents. The authors of this article from Starship Children’s Hospital, Auckland, New Zealand have a series of 24 children (26 ears) aged under five years who have had BAHA implantation. Most had two-stage surgery with a 3mm screw and skin thinning techniques, more recent patients had minimal or no soft tissue reduction surgery. Similarly three generations of implants were used as the series spans 11 years. A wide range of aetiologies were treated, typically isolated microtia. Benefit was assessed using a children’s version of the Glasgow Benefit Inventory with very high scores reported and a 75% response rate. Good hearing outcomes were also demonstrated with a Parents’ Evaluation of Aural perfomance of Children questionnaire. The authors have collected much detail on the complications encountered and present a comprehensive analysis: including a 42% return to theatre rate for skin problems, a 53% Holgers skin reaction grade three or worse and 10% implant loss. Despite these problems and the multiple repairs, only three children stopped using their implant suggesting significant benefit is gained and the audiologic benefits are clear. The benefit is clear but the complications may reinforce the argument for the use of semi-implantable or completely implantable devices for such children. It is a valuable addition to the BC device literature.

Reference

Experience of bone-anchored hearing aid implantation in children younger than five years of age.
Amonoo-Kuofi K, Kelly A, Neeff M, Brown CRS.
INTERNATIONAL JOURNAL OF PEDIATRIC OTORHINOLARYNGOLOGY
2015;79:474-80.

JOURNAL OF INTERNATIONAL ADVANCED OTOLOGY

Leptin has no role in idiopathic sudden sensorineural hearing loss
Reviewed by: Emma Stapleton
Vol 24 No 2
 

This paper from Turkey claims to be the first study dealing with the relationship between leptin and idiopathic sudden sensorineural hearing loss (ISSHL). I remember leptin being a fashionable topic in obesity research, when leptin deficiency was thought to be an aetiological factor in obesity. Who could forget those photos of obese, leptin-deficient white mice? So what is its relevance to hearing loss? Leptin is a proinflammatory cytokine secreted mainly from adipocytes, is responsible for the regulation of energy metabolism and raises the sensation of satiety by acting on the hypothalamus. It is a member of the IL-6 cytokine subgroup and its effects on body weight and energy metabolism are mediated by receptors in the central and peripheral nervous system. The authors explain that they were looking for a relationship between IL-6 cytokines and ISSHL in order to identify potential treatment options. Their results, from 33 patients with BMI <30 and ISSHL, indicated that serum leptin levels in the ISSHL patients were not different from un-matched controls.

Reference

Serum leptin levels in patients with idiopathic sudden sensorineural hearing loss.
Ural A, Alver A, Işık AÜ, İmamoğlu M.
JOURNAL OF INTERNATIONAL ADVANCED OTOLOGY
2014; 10(3): 201-4.

JOURNAL OF PLASTIC, RECONSTRUCTIVE AND AESTHETIC SURGERY

Surgical indications for infantile haemangiomas
Reviewed by: Sunil Kumar Bhatia
Vol 24 No 2
 

Infantile haemangiomas are embryonal tumours and represent the most common tumour of infancy, with an estimated incidence 4-5%. There is well-described natural history, usually becoming apparent in the first few weeks of life and proliferating rapidly in the first few weeks of life with 80% reaching their maximal size by five months of age. This is followed by involution without scarring. There is however a subset that have severe morbidities such as pain, bleeding, scarring and psychosocial issues. Currently treatment is medical with Propanolol and intervention with LASER or surgical excision. There is paucity of data reviewing the predictive risk factors associated with a need for surgery. This is a good retrospective review of a single surgeon’s series of 112 patients from 2004 to 2011. Of the 112 patients 97 underwent one procedure, 14 patients two, and one patient three procedures. This is a good look at the surgical demographics of this cohort but it is a selected group, and many lesions may not have been referred if intervention was not required. It is also a small series of an individual surgeon and the authors accept both these limitations. The majority were also treated prior to the widespread use of Propanolol. This paper suggests there will always be a role for the surgeon and this study may be used as a comparison with a series of patients undergoing treatment with oral Propranolol.

Reference

A retrospective study to classify surgical indications for infantile haemangiomas.
Lee AHY, Hardy KL, Goltsman D, et al.
JOURNAL OF PLASTIC, RECONSTRUCTIVE AND AESTHETIC SURGERY
2014;67:1215-21.

JOURNAL OF THE AMERICAN ACADEMY OF AUDIOLOGY

Noise’s effect on ageing memory
Reviewed by: Cheka Spencer
Vol 24 No 2
 

Working memory is used everyday by individuals of all ages. The authors of this study sought to compare the effect of background noise on the memory of either young adults or middle aged adults. They did this by recruiting 10 young adults aged 22-30 years old (mean of 25 yr) and 10 middle aged adults 46-60 years old (mean 55.1 yr). Each participant listened to lists composed of five pairs of words in quiet and in a 20-talker babble. When cued with one word they were required to write down the second word of that pair. As was hypothesised both groups did better at recalling the first and last items which is termed the primacy effect and the recency effect respectively. There was a significant main effect of age group [F(1,18) = 7.054, p = 0.016]. Interaction effects of background noise by age group [F(1,18) = 3.620, p = 0.073] was not statistically significant but the older age group did not perform as well in the presence of background noise. This was an interesting experiment whose results make sense and are biologically plausible. Long-term memory has been shown by various studies to deteriorate with age and it is no surprise that with the extra pressure of background noise performance in any age group would deteriorate. The clinical relevance of this paper is that the majority of our patients are middle aged adults who complain of difficulty understanding speech in noisy listening environments. Their audiological assessments are often normal in spite of this. This article suggests that this may be due to certain central processes including auditory processing which are not tested with our conventional techniques. Nonetheless a solution to this problem is difficult.

Reference

The effect of background babble on working memory in young and middle-aged adults.
Neidleman M, Wambacq I, Besing J, et al.
JOURNAL OF THE AMERICAN ACADEMY OF AUDIOLOGY
2015;26(3):220-228.

JOURNAL OF THE AMERICAN ACADEMY OF AUDIOLOGY

Treating benign positional paroxysmal vertigo
Reviewed by: Cheka Spencer
Vol 24 No 2
 

Benign positional paroxysmal vertigo (BPPV) is one of the most common causes of dizziness. Its treatment is the repositioning of displaced otoliths by the canalith repositioning manoeuvre (CRM). Post manoeuvre restrictions are commonly given to the patient. Their benefit has been widely debated as many people feel that these are unnecessary. This paper was a randomised controlled trial which sought to determine the efficacy of the epley manoeuvre, a hybrid manoeuvre called the Ganz manoeuvre (GRM) and post manoeuvre restrictions. Forty-five patients were randomised into three treatment groups matched for gender: CRM with post manoeuvre restrictions; GRM alone; and GRM with post manoeuvre restrictions. They had weekly interventions until their symptoms were objectively and subjectively resolved. This took on average two visits in the GRM with post manoeuvre restrictions, 1.7 in the GRM alone and 1.6 in the CRM group. There was no statistical significant difference between the three groups. This may suggest that the GRM is as effective as CRM and that post manoeuvre restrictions add no extra clinical benefit. This is in keeping with other published studies that negate the need for these restrictions. Patients find these difficult on their everyday lives while shopping or driving and this study suggests that they can be advised to return to normal activities. Furthermore, the fact that GRM was as effective as CRM is useful knowledge in the management of the many elderly patients with BPPV with neck problems, or those with a history of trauma, as there is no need for cervical hyperextension. Additionally, whilst the small sample size of this study is questionable, its positive results could be translated to routine ENT and audiology practice.

Reference

Effect of a hybrid maneuver in treating posterior canal benign paroxysmal positional vertigo.
Badawy W, El-Mawla E, Chedid A, Mustafa A.
JOURNAL OF THE AMERICAN ACADEMY OF AUDIOLOGY
2015;26(2):138-144.

JOURNAL OF VESTIBULAR RESEARCH

Selective otolith dysfunctions objectively verified
Reviewed by: Fiona Barker
Vol 24 No 2
 

Three cases of patients with acute onset vertigo are presented here. The presenting symptoms are described for each case along with the results of vestibular and audiologic examination. This paper focuses on the results of vHIT in the plane of the horizontal and vertical canals, cVEMPs and oVEMPs. The results of the tests make a good case for exploiting the ability of these tests to give information about the function of the whole vestibular system. These three patients all had abnormal VEMPs (cervical, ocular or both) but normal vHIT responses which the authors’ state shows selective otolith dysfunction. Call me old fashioned, which I’m sure many of you will (including the eminent authors of this paper), but I was left wondering what the caloric results looked like. None of the patients cited here had calorics. I completely accept that there are severe limitations to caloric testing, which are outlined in this paper, but in my own practice I see patients reasonably often who have normal vHIT results but an asymmetry on calorics that is consistent with their symptom profile or other assessment such as VEMPs. I am aware that factors other than horizontal canal function may influence a caloric result but, taking into account any of these as far as they can be known in an individual case, I would still consider a caloric asymmetry to be evidence of abnormal horizontal canal function, albeit at low frequency, especially when it is consistent with other findings. I would be more convinced of selective otolith dysfunction in these cases had caloric testing (where appropriate) also been normal in addition to vHIT. I support the argument for using the newer tests to explore vestibular function beyond the horizontal canal and these cases provide a good example of how this can yield additional information. I’m just not quite sure I am ready to abandon the older tests yet. It will also be interesting to see how this extra information regarding dysfunction supports management decisions and prognosis.

Reference

Selective otolith dysfunctions objectively verified.
L Manzari, HG MacDougall, AM Burgess, IS Curthoys.
JOURNAL OF VESTIBULAR RESEARCH
2014;24:365-73.

JOURNAL OF VOICE

Gardasil vaccination – an effective adjuvant therapy for RRP?
Reviewed by: Christopher Burgess
Vol 24 No 2
 

The clinical manifestations of recurrent respiratory papillomatosis (RRP) can vary hugely from individual to individual. Whilst some affected children will outgrow the disease, a subset of patients will experience frequent recurrences and require multiple surgical procedures over the course of their lifetime, even as frequently as once a month. Several adjuvant therapies have been trialled to improve the clinical course of severe RRP, but none have achieved universal acceptance. Cidofovir and bevacizumab (Avastin) are the most commonly used adjuvants in the USA. The restricted availability and expense of these treatments limit their clinical utility in the NHS however. Gardasil is a quadrivalent vaccine against HPV types 6, 11, 16 and 18. By combining viral capsid proteins with adjuvants such as aluminium, a much higher antibody titre is achieved after vaccination than with a natural infection. It has therefore been hypothesised that administration of this vaccine to patients with RRP could help to achieve clearance of the disease, or at least extend periods of remission. In this paper, a retrospective chart review was conducted for 20 patients (12 male, median age 43) with established RRP who received Gardasil vaccination in addition to standard care at the Medical University of South Carolina. Eight patients (40%) experienced complete remission following vaccination. In the remainder, a significant increase in inter-surgical interval from 4.9 to 8.0 months was observed (p = 0.006). The absence of a control group and the variability in the natural course of RRP mean that the change in disease course following vaccination cannot conclusively be attributed to the effects of the vaccination alone. Nevertheless the results are certainly encouraging and merit further research, especially given the comparatively low cost and excellent side-effect profile of Gardasil vaccination relative to other adjuvant treatments for RRP.

Reference

The use of the quadrivalent human papilloma virus vaccine (Gardasil) as adjuvant therapy in the treatment of recurrent respiratory papilloma.
Young DL, Moore MM, Halstead LA.
JOURNAL OF VOICE
2015;29(2):223-229.

LARYNGO-RHINO-OTOLOGIE

Inpatients versus Outpatient: septoplasty cost analysis in Germany
Reviewed by: Anna Slovick
Vol 24 No 2
 

Although the vast majority of septoplasties in the UK are performed as day surgery procedures, the authors of this article highlight the differences in healthcare in Germany. The authors calculated a yearly cost reduction of 180 million euros if the operation was performed as an outpatient procedure. There seems to be little incentive for German hospitals to move towards outpatient septoplasty due to current poor outpatient remuneration. The authors recommend an adjustment of the remuneration to encourage change in practice and overall cost savings.

Reference

Potenzialanalyse und Kostenbewertung bei der ambulanten Durchführung der Septumkorrektur.
Schuldt T, Ovari A, Olzowy B.
LARYNGO-RHINO-OTOL
2015;94:18-24.

LARYNGO-RHINO-OTOLOGIE

The Impact of sleep endoscopy for paediatric obstructive sleep-disordered breathing
Reviewed by: Anna Slovick
Vol 24 No 2
 

Paediatric obstructive sleep apnoea (OSA) is not always resolved or improved with adenotonsillectomy. Persistent or complex cases of paediatric OSA may be due to sites of obstruction in the airway other than the tonsils and adenoids. Investigation of paediatric obstructive sleep apnoea (OSA) by drug-induced sleep nasendoscopy (DISE) may be of help in determining the level of obstruction and planning targeted therapy, but evidence is weak. The authors performed a retrospective review of the medical records of children (n=25) who underwent polysomnography and DISE (05/2012-12/2013). After DISE, the initial management plan changed in five patients (20%). The authors suggest this is a promising technique to help guide OSA treatment, but suggest further studies are required to predict persistent OSA based on this tool.

Reference

Bedeutung der Schlafendosckopie bei obstruktiv-schlafbezogener Atmungsstörung im Kindes- und Jungenalter.
Quante M, Merkenschlager A, Kiess W, et al.
LARYNGO-RHINO-OTOL
2015;93:831-39.

NEUROSURGERY

Choosing Wisely
Reviewed by: Gauri Mankekar
Vol 24 No 2
 

This article focuses on the prickly topic of healthcare costs and specifically on reducing spending on neuroimaging for headaches. Epidemiological studies indicate that the prevalence of lifetime headaches is 93 to 99% and accounts for 1.5% of all primary care visits. The cost of neuroimaging for headaches and migraines between 2007 and 2010 in the United States was a whopping $1.2 billion! The Choosing Wisely initiative guidelines by the American College of Radiology and Consumer Reports focuses on reducing healthcare spending and suggests avoiding imaging for uncomplicated headaches. The authors of this article argue that these guidelines are inconsistent with the neurosurgeon’s experience of patients with brain tumours who frequently present with minimal symptoms or isolated headache syndromes. They recommend further research for the development of validated and tested clinical decision rules on the neuroimaging for headaches. This article highlights the problems dividing population-driven healthcare methods and individualised patient tailored medicine.

Reference

Choosing wisely: a neurological perspective on neuroimaging for headaches.
Hawasli AH, Chicoine MR, Dacey RG.
NEUROSURGERY
2015;76(1):1-6.

NEUROSURGERY

Comparing surgical freedom of four transsphenoidal approaches to the sella
Reviewed by: Gauri Mankekar
Vol 24 No 2
 

Four transspenoidal approaches to the sella were performed and studied by the authors on eight silicon-injected cadaveric heads. Surgical freedom, that is, the ability of the surgeon to move his or her hands in a fixed space, was determined with stereotactic image guidance using previously established techniques. The authors studied not only the ability to move at the target point but also at the ability to move when one is fixed on the target point with the instrument and one wants to move one’s hand at the point where one is holding the instrument. Their results show that the endoscopic bi-nostril approach had the greatest surgical freedom at the pituitary gland and ipsilateral and contralateral internal carotid arteries compared to the other three approaches – microscopic sublabial; endoscopic uni-nostril and microscopic endonasal approach. The axial angle of attack was greatest for the microscopic sublabial approach while endoscopic bi-nostril was superior to the other three approaches for the saggital angle of attack. For standardisation, the authors used only straight instruments and 00 endoscopes. Angled instruments may provide different and greater surgical freedom.

Reference

Evaluation of Surgical Freedom for Microscopic and Endoscopic Transsphenoidal Approaches to the Sella.
Elhadi AM, Hardesty DA, Zaidi HA, et al.
NEUROSURGERY
2015:11(S2):69-79.

NEUROSURGERY CLINICS OF NORTH AMERICA

Argh! Facial pain! What to do??
Reviewed by: Gentle Wong
Vol 24 No 2
 

We often come across patients with presentation of facial pain, but unless this is sinugenic in origin, our understanding and management of it can often be found wanting. Craniofacial pain is in fact highly complex and encompasses a wide range of causes including trigeminal neuralgia, and atypical facial pain (aka persistent idiopathic facial pain). Treatment with medications alone can often have suboptimal results. Tolerance, dependence and side-effects of these medications often provide patients with an impetus to steer towards the surgical options. This review aims to cover the surgical alternatives and discusses patient selection, risks, and benefits associated with each of these therapies. The interest in management of craniofacial pain has gained momentum in recent years within neurosurgical circle and is being explored at a rapid pace. As a specialty, it’s important for us to be able to appreciate that beyond amitriptyline, gabapentin and pregabalin, our neurosurgical colleagues might just have that extra trick in their sleeves in peripheral nerve stimulation (PNS), ganglion stimulation (e.g. sphenopalatine ganglion), microvascular decompression (for trigeminal neuralgia) and deep brain stimulation.

Reference

Surgical options for complex craniofacial pain.
Sharma M, Shaw A, Deogaonkar M.
NEUROSURGERY CLINICS OF NORTH AMERICA
2014;25(4):763-76.

OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY

Experience of the Sophono transcutaneous bone conduction system
Reviewed by: Suzanne Jervis
Vol 24 No 2
 

This article is a frank discussion of the authors’ experience implanting these devices. The principle of the device is surgical implantation of a bilobed magnet within a bony well in the cranium (similar position to BAHA). The implant is a magnet only and the external device transmits sound via its baseplate, vibrating the surrounding tissues to both ears. Due to the diminution of sound, the candidacy for the Sophono is less than the BAHA (up to 45dB vs. up to 65dB for BAHA.) The surgical technique for insertion is described with explanations for implant placement and therefore the incision considerations. There are certain areas where the authors admit to deviating from the surgical manual, which include advocating skin thickness of 1cm rather than the advised 4-6mm, for the reasons of reducing postoperative pain and improving wearability. Interestingly, they also describe their experience with placement of the external device. They found that placing these too soon required stronger magnets (to overcome the post-operative swelling) which then ultimately resulted in skin irritation and decreased wear. They therefore advocated external placement six weeks post op and a graduated period of wear to avoid these issues. Their complications were outlined, which were few and included a haematoma (resolved conservatively), an infection (resolved with antibiotics) and a paediatric case with limited skull thickness such that Alloderm was used to provide increased soft tissue thickness to prevent skin irritation post op. This article was a truly helpful and honest description of their experience, especially for those embarking on fitting these implants at the early stages. Of particular note was their list of ‘pearls’ – key points of tried and tested surgical usefulness for this technique!

Reference

Surgical implantation of the Sophono transcutaneous bone conduction system
Friedland DR, Runge CL, Kerschner JA.
OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY
2014:25(4);344-7.

ORL

Combined endoscopic and transcutaneous approach for removal of parotid stones
Reviewed by: Zi Wei Liu
Vol 24 No 2
 

The authors describe a small case series (n=8) of patients with obstructive symptoms from sialolithiasis of the parotid gland. A combined endoscopic and transcutaneous approach was used. The position of the stone in Stensen’s duct was identified by endoscopic transillumination. The stone was subsequently removed through either an incision made directly over the duct itself for distal stones, or a traditional S-shaped parotidectomy flap was raised and the duct dissected out from the parenchyma of the gland. Facial nerve monitoring was used as there is a theoretical risk of injury to the buccal branch of the facial nerve. The procedure was performed as a day case and 75% of patients were symptom free afterwards. Salivary fistulae have not been reported, although one case of post operative infection was noted. One patient went on to have a superficial parotidectomy for multiple stones. The authors recommend the combined approach for patients with large stones (>5-6mm), or where the stones are in an unfavourable position for endoscopic removal (e.g. hilum of the gland). This applies to 10-15% of parotid salivary stones. This approach is most useful for single large stones where lithotripsy or sialoendoscopy have failed. The patient can be spared a superficial parotidectomy and risk of injury to the facial nerve is minimal. The patient group that would benefit from the combined approach is well defined in this study. However, support from some one experienced in sialoendoscopy is essential and joint cases may not be feasible in all centres.

Reference

Retrospective analysis of a combined endoscopic and transcutaneous technique for the management of parotid salivary gland stones.
Numminen J, Sillanpää S, Virtanen J, et al.
ORL
2014;76:282-7.

OTOLARYNGOLOGY – HEAD AND NECK SURGERY

Evidence for balloon eustachian tuboplasty
Reviewed by: Thomas Jacques
Vol 24 No 2
 

Balloon eustachian tuboplasty is an emerging intervention aimed at the management of eustachian tube dysfunction (ETD) and its sequelae. The authors acknowledge that ETD is a common but frequently ill-defined problem, with no well-established direct treatment. They performed a systematic review of the evidence for balloon eustachian tuboplasty, finding that no randomised controlled or case-control studies exist in the current literature. Considerable heterogeneity in the nine included studies precluded the pooling of data for meta-analysis. Results suggested a tendency to improvement of subjective (ETDQ-7 questionnaire) and objective (e.g. tympanometry) measures. However, many patients underwent adjunctive interventions, introducing a high risk of bias. No severe adverse outcomes were reported. A safe and effective intervention for troublesome ETD is highly desirable, particularly because of the theoretical ‘upstream’ improvements in the pathogenesis of chronic middle ear disease. However at present, no high-quality evidence exists to support the use of eustachian tuboplasty. The lack of diagnostic criteria and reliable outcome measures mean that the indications for tuboplasty are currently unclear. Of course this does not mean that the technique has no value, but larger more rigorous trials are needed before widespread adoption. If proven successful, the technique could impact upon a significant number of otological conditions. Until then, informed consent should include a frank discussion of the current state of the evidence.

Reference

Balloon eustachian tuboplasty: a systematic review.
Randrup TS, Ovesen T.
OTOLARYNGOLOGY – HEAD AND NECK SURGERY
2015;152(3):383-92.

OTOLARYNGOLOGY – HEAD AND NECK SURGERY

Local dexamethasone infiltration in tonsillectomy
Reviewed by: Thomas Jacques
Vol 24 No 2
 

Intravenous dexamethasone is routinely given during tonsillectomy for its effects on postoperative pain and nausea. This Chinese randomised study divided 240 children undergoing tonsillectomy into three groups, receiving either no steroid, intravenous dexamethasone, or the same amount of dexamethasone infiltrated into the upper, middle and lower poles of the tonsils. The same volume of saline was infiltrated into the tonsils in the first two groups as a control, and to maintain surgeon blinding. The authors found that postoperative pain scores were significantly affected by the technique used: the highest pain scores in the non-steroid group, significantly lower in the IV steroid group, and significantly lower again in the local infiltration group. These children also had lower opiate (fentanyl) requirements postoperatively. However, postoperative nausea and vomiting was lower in the IV group than the local group, presumably due to lower systemic absorption. Readmission rates for vomiting or pain control were not affected. Local infiltration of steroid is not common UK practice, although local anaesthetic infiltration is used in some centres. This well-conducted study demonstrates a useful adjunctive measure in tonsillectomy symptom control. The authors intended, but were unable to, perform blood assays of steroid concentration in the study participants. Presumably, a future study including these measurements might lead to development of a dual IV+local steroid protocol, with appropriate safe dosing, thus improving postoperative pain whilst eliminating the need for compromise of nausea prevention.

Reference

Comparison of local and intravenous dexamethasone for postoperative pain and recovery after tonsillectomy.
Gao W, Zhang QR, Jiang L, Geng JY.
OTOLARYNGOLOGY – HEAD AND NECK SURGERY
2015;152(3):530-5.

OTOLOGY AND NEUROTOLOGY

Consider PCR testing in culture negative necrotising otitis externa
Reviewed by: Anand Kasbekar
Vol 24 No 2
 

Necrotising otitis externa (NOE) often does not yield identification of a causative organism to treat although in 90% of cases it is a member of the pseudomonas species. The incidence of fungal NOE is not to be forgotten and this group from Israel looked at cases of refractory NOE who had been initially treated with ciprofloxacin and did not respond. In a six year period, 19 patients were diagnosed with NOE of which five had negative microbiology cultures for causative organisms. Patients were taken to theatre and deep biopsies for histology and culture were obtained. PCR analysis testing was undertaken for a range of bacteria and fungi. All five cases had likely causative fungi isolated on PCR although sensitivities were not possible as fungi and bacterial cultures were negative.
Empirical antifungal treatment (directed by local microbiology knowledge), was started while anti-bacterials were halted. All patients clinically and radiologically improved and were discharged home on average after 39 days. Systemic treatment was for a total of eight weeks. Gallium scan, blood tests and clinical follow-up proved complete cure. Had it not been for the PCR tests, continued treatment with anti-pseudomonals would have continued with further deterioration. Other methods of diagnosing fungal infection were not used and often required skilled personnel. PCR testing is expensive but can test for several fungi in a short space of time without expert mycologists. Your hospital laboratory may be able to perform this PCR with the kit they already have for your next case of refractory NOE.

Reference

Clinical utility of a polymerase chain reaction assay in culture-negative necrotizing otitis externa.
Gruber M, Roitman A, Doweck I, et al.
OTOLOGY AND NEUROTOLOGY
2015;36(4):733-6.

OTOLOGY AND NEUROTOLOGY

The effect on taste buds due to severing of the chorda tympani nerve
Reviewed by: Anand Kasbekar
Vol 24 No 2
 

The long-term histological effect on taste buds following cutting of the chorda tympani in humans is not clear. Confocal laser scanning allows in-vivo examination of the same group of taste buds and is aiding our understanding of why patients recover from their taste disturbance. This clever group of surgeons and scientists from Japan looked at seven patients’ taste buds before and after the chorda was cut during tympanoplasty. Electrogustometry was used to assess gustatory function and showed no response within one month after surgery. All taste buds were calculated to disappear by 50 days after surgery. The first step is the disappearance of the taste pores followed by atrophy of the taste buds. Their next study is looking at regeneration of taste buds which starts at about three months after surgery and is likely to vary between individuals. It would be nice to know if there is any preoperative measurement that would enable us to tell how severely affected an individual will become after chorda sacrifice and how long it will last.

Reference

Degeneration process of fungiform taste buds after severing the human chorda tympani nerve - observation by confocal laser scanning microscopy.
Saito T, Ito T, Ito Y, et al.
OTOLOGY AND NEUROTOLOGY
2015;36(3):539-44.

OTOLOGY AND NEUROTOLOGY

When should we decompress the facial nerve in Bell’s Palsy?
Reviewed by: Anand Kasbekar
Vol 24 No 2
 

It has been over three decades since Fisch popularised facial nerve (FN) decompression for Bell’s Palsy. Studies further exploring this have been few since, partly due to the major complications that can occur following this type of surgery. The current study looked at a retrospective cohort of 14 Bell’s patients with grade six HB FN palsy that are known to have poorer FN prognosis. Surgical criteria included greater than 90% degeneration on ENoG testing and no voluntary EMG potentials. This would normally mean at best a 50% chance of recovery to HB one or two. Previous studies have shown the meatal foramen and the labyrinthine segment to be the narrowest segment of the bony canal and it is these parts of the facial nerve that were decompressed via the middle fossa approach. High dose steroids were given as routine and surgery carried out within 14 days of onset. Results were impressive with no major complications and match other studies. Three patients experienced gustatory hyperlacrimation. Ten patients (71%) regained good FN function (HB one or two) within a year, the remaining to HB three. Patients over 60 years of age did worse, when compared to decompression over 14 days, results were significantly better when surgery was undertaken within 14 days (only 20% return to HB1/2 if surgery over 14 days). ENoG needs to be undertaken within two weeks to be predictive and also enable early surgery. There was no change in hearing pre and post surgery. This is a convincing argument for early investigation and intervention and I wonder how many skull base surgeons would be keen to adopt this protocol?

Reference

Facial nerve outcomes after middle fossa decompression for Bell’s Palsy.
Cannon RB, Gurgel RK, Warren FM, Shelton C.
OTOLOGY AND NEUROTOLOGY
2015;36(3):513-18.

RHINOLOGY

Four (more) ways to reduce turbinates
Reviewed by: Jo Rimmer
Vol 24 No 2
 

Setting aside the issue of when/if to reduce inferior turbinates, the issue of how to reduce turbinates is a never-ending story. This edition of rhinology carries two articles looking at this subject, both prospective randomised trials comparing two different methods – four (more) ways to skin a turbinate. Hegazy et al compared coblation in 40 patients with the microdebrider in 30, over a six month follow-up period. Kisser et al compared laser diode and radiofrequency treatment in 26 patients, randomising each patient to receive laser on one side of the nose and radiofrequency on the other; follow-up was three months. Nasal symptoms, as rated by visual analogue scores (VAS), improved significantly following surgery in all patients, with no difference between the treatments in each study. Postoperative pain was significantly worse in the microdebrider group (compared to coblation) and the radiofrequency side (compared to the laser side). There was no significant difference in complications between the treatment modalities in each study, although bleeding occurred in 77% of turbinates treated with radiofrequency (compared to none with the laser). Kisser et al also compared objective measures including acoustic rhinometry and rhinomanometry, and found no difference between treatments (or, indeed, before and after treatment). Interestingly, although radiofrequency was more painful than laser, 50% of patients would have radiofrequency treatment repeated compared to only 23% for the laser; 19% would have both again and 8% neither. So all four treatment modalities resulted in a significant improvement in subjective nasal symptoms, with no difference between them in each study. The search for the most effective method of turbinate reduction continues...

Reference

Inferior turbinate reduction; coblation versus microdebrider – a prospective, randomised study.
Hegazy HM, El Badawey MR, Behery A.
RHINOLOGY
2014;52(4):306-14.
Diode laser versus radiofrequency treatment of the inferior turbinate – a randomized clinical trial.
Kisser U, Stelter K, Gurkov R, et al.
RHINOLOGY
2014;52(4):424-30.

RHINOLOGY

The association of frontal recess anatomy and mucosal disease on the presence of chronic frontal sinusitis: a computed tomographic analysis
Reviewed by: Lakhbinder Pabla
Vol 24 No 2
 

Ostial obstruction is a primary pathophysiological mechanism contributing to sinusitis, which can be caused by anatomical variations, mucosal inflammation or both. This retrospective case series aimed to identify anatomical factors and inflammatory areas relating to chronic frontal sinusitis on nasal / paranasal CT scans. 240 sides of CT scans in adult patients with chronic rhinosinusitis underwent logistic regression analysis to compare distribution of various frontal recess cells and surrounding inflammatory conditions in patients with and without sinusitis. Opacification of the frontal recess and sinus lateralis was found to be associated with a significantly increased risk of frontal sinusitis and developing blockage of drainage pathways – evidence that mucosal inflammation in these two areas is an important factor in leading to chronic frontal sinusitis. They also showed that the presence of septal deviation and suprabulbar cells tended to correlate with a higher frequency of frontal sinusitis, although there was no significant association between these anatomical factors and the presence of frontal sinusitis. The patients with frontal sinusitis also had shorter AP diameters of the frontal ostium and frontal recess in comparison to those without frontal sinusitis. These findings highlight the potential role of anatomy of the frontal sinus drainage pathways to the development of chronic frontal changes.

Reference

The association of the frontal recess anatomy and mucosal disease on the presence of chronic frontal sinusitis: a computed tomographic analysis.
Lai WS, Yang PL, Lee CH, et al.
RHINOLOGY
2014;52(3):208-14.

SAUDI JOURNAL OTO-RHINO-LARYNGOLOGY & HEAD & NECK SURGERY

Sulcus vocalis in patients attending voice clinics: A retrospective study
Reviewed by: B Viswanatha
Vol 24 No 2
 

Sulcus vocalis was first described by Giacomini. This includes a variety of anatomic indentations of the vocal fold, ranging from shallow longitudinal furrows to deep vocal cord pits.
This retrospective study was conducted at King Saud University between 2006 and 2011.There were 105 patients in this study. The aim of the study was to identify the prevalence of sulcus vocalis among voice patients at King Saud University, and to describe the different voice presentations of this disorder along with exploring different treatment modalities offered.
Inclusion criteria were the diagnosis of true vocal fold sulcus. Exclusion criteria were:
1.    Patients associated with other associated vocal fold lesions.
2.    Patients with incomplete medical charts.
The results of this study show that the prevalence of sulcus vocalis in this study group was 3.8%. Family history of sulcus vocalis was reported in 9.5% of patients. Thirty one percent of the study group had true vocal fold augmentation. There was significant post operative improvement in these patients. However the difference between the pre-and post operative gap sizes did not reach a significant level. Author is of the opinion that the sulcus vocalis is not rare in Saudi population and suggests further genetic studies in this population.

Reference

Prevalence of sulcus vocalis in patients visiting outpatient voice clinics at King Saud University.
Malki KH.
SAUDI JOURNAL OTO-RHINO-LARYNGOLOGY & HEAD & NECK SURGERY
2014;16(1):24-30.

SEMINARS IN HEARING

Hearing aid standards and test systems
Reviewed by: Vinaya Manchaiah
Vol 24 No 2
 

Hearing aids are the most used management / rehabilitation option for people with hearing loss. Generally, hearing instrument manufacturers perform the hearing aid performance measurements and provide its specification in terms of functionality. However, it is also common for government agencies or hearing aid dispensing professionals to perform such measurements at least in a sample of the hearing aids they purchase. In addition, hearing aid dispensers also perform such measurements routinely to test hearing aid functioning and to troubleshoot any problems. There are various documents that provide standards and good practice guidelines for such measurements. These standards are aimed at ensuring robust measurements techniques are used based on evidence and also the measurements are performed uniformly across practices. American National Standards Institute (ANSI) and International Electrotechnical Commission (IEC) are the two organisations that provide most of the standards in this area. This article provides an overview of various acoustic and electromagnetic compatibility parameters and describes several test systems available.

Reference

Hearing aid-related standards and test systems.
Ravn G, Preves D.
SEMINARS IN HEARING
2015;36(1):29-48.

SLEEP & BREATHING

Diagnosis and treatment of snoring in adults – S2k Guideline of the German Society of Otorhinolaryngology, Head and Neck Surgery
Reviewed by: Vik Veer
Vol 24 No 2
 

This article summarises the work done by the German Society of Otorhinolaryngology, who have developed guidelines for the management of snoring. ‘S2k’ is German nomenclature for a consensus based guideline, which (for those of you interested in such things), is one step above an informal consensus (S1), and two steps below a full evidence validated review (S3).  For a ‘S2k’ review, this is a remarkably comprehensive account of the present evidence related to snoring surgery. Evidence for each step in the patient journey is provided from presentation to aftercare. A reasonable algorithm protocol is outlined for ‘Diagnostic measures’ and a separate one for ‘Therapeutic principles’. A good section on history taking and minimal standards for examination of snoring patients is provided. In addition the evidence for the more peripheral, esoteric aspects of snoring management is presented, such as acoustic analysis, rhinoresistometry, nasal dilators etc. Predictably the level of evidence for much of this protocol is rather lower than what one would like when judged against modern levels of scrutiny, but as a current state of the evidence, it is an impressive work. My impression however of the level of enthusiasm for some of the measures in the protocol was slightly too high. It felt too positive in the description of some of these measures, when really little evidence was presented. This may be due to a heightened cultural acceptance of snoring management in Germany, or perhaps secondary to the translation process from German to English. I would have liked a little more information about questionnaires used in snoring patients, but the brevity of this section may again be due to the lack of evidence for a more detailed account. The algorithms do seem to make a good attempt at avoiding sending everyone off for full polysomnography, but some of steps aren’t clearly defined. For example the step before PSG is ‘objective diagnostic measures’, but the evidence presented suggests that there aren’t any. The article seems to leave this to the discretion of the reader. Developing a protocol for snoring management was never going to be easy, particularly as we still don’t even have the basics such as a working definition! But I would recommend this article to anyone considering setting up a snoring practice / clinic, as it does provide a reasonable protocol and an overview of the state of our understanding (or lack of it) with regards snoring management.

Reference

Diagnosis and treatment of snoring in adults – S2k Guideline of the German Society of Otorhinolaryngology, Head and Neck Surgery.
Stuck B, Dreher A, Heiser C, et al.
SLEEP & BREATHING
2015;19:135-48.

THE HEARING JOURNAL

A future for unilateral deafness
Reviewed by: Linnea Cheung
Vol 24 No 2
 

Every year, we see several patients struggling with irreversible unilateral hearing loss that is non-responsive to sound amplification. This article emphasises that clinicians should not underestimate the functional and psychological impairment single-sided deafness can have on an individual, even though patients themselves may find it difficult to describe this impact, particularly when the hearing loss is mild. Usually the complaint is of poor discrimination of sounds in the presence of background noise, for instance, at a social gathering, but the problem can be more dangerous in situations where audio-spatial discrimination is required, such as when crossing a busy road. There are several devices available including various CROS-aids and bone-anchored hearing aids that may be useful in these patients, but this article highlights that some evidence shows cochlear implantation may also play a beneficial role. It is however too early to tell which patients exactly may benefit and clearly further studies are required to evaluate this potential, but for the meantime, cochlear implantation is not recommended by United States or British guidance authorities. Paediatric patients pose a further challenge since the brain’s ability to adapt is enhanced by early identification and intervention of unilateral deafness, and therefore further work is required in order to evaluate when and what intervention is appropriate in the management of this problem particularly in babies and infants. In general there has been an improvement in awareness of this condition but for now there is no perfect solution without further research. We should no longer be settling for just “one good ear”. We should strive to seek out more accurate evaluation studies for assessment of sound localisation and hearing ability and research further into the comparative efficacy of the devices currently available so that we are best able to inform and manage our patients for the future.

Reference

Single-sided deafness: causes, and solution, take many forms.
Weaver J.
THE HEARING JOURNAL
2015:68(3):20-4.

THYROID RESEARCH JOURNAL

Follicle stimulating hormone receptors; an aid for the pathologist?
Reviewed by: Adam Shakir
Vol 24 No 2
 

It is well known that Follicle Stimulating Hormone receptors (FSHRs) are found in extra-gonadal tumours such as those within thyroid tissue. This Polish study analysed 44 thyroid resection specimens to look for the presence of these receptors. No mention is made for the indications for surgery or pre-operative investigation results. Eight specimens were formally reported as benign (follicular adenomas) and the rest a mix of undifferentiated, papillary and follicular carcinomas. Specimens were analysed using an antibody immunostaining technique and evaluated using a subjective scoring system based on microscopic appearance and quantity of staining seen. FSHRs were not seen in normal thyroid tissue and also in the majority of follicular adenomas (six of eight). The majority of follicular and papillary carcinomas (28 of 32) and all four undifferentiated carcinomas displayed strong staining. The authors speculate that such laboratory testing may be a useful aid for pathologists with specimens that are difficult to interpret, particularly in differentiating follicular adenomas from follicular adenocarcinomas. The authors also rightly state that conclusions would be best derived from a bigger study.

Reference

Expression of follicle stimulating hormone receptors (FSHR) in thyroid tumours – a marker of malignancy?
Pawlikowski M, Fuss-Chmielewska J, Jaranowska M, et al.
THYROID RESEARCH
2015;8:1.

TRENDS IN HEARING

Hearing loss in the young and self-esteem
Reviewed by: Ameera Abdelrahim
Vol 24 No 2
 

How can those involved in the care of children with hearing loss identify those at risk of low self-esteem? This study provides some guidance. Overall differences from hearing peers in terms of communication skills, physical appearance and social maturity place this group at risk. The authors of the study explore the effect of generic and specific factors on self-esteem in children and adolescents with hearing loss. Fifty children with cochlear implants (38) or hearing aids (12) were assessed using interview questionnaires that included validated questionnaires on communication skills, social engagement, temperament and self esteem. The age range of the children was eight to 18 years (mean 12.88, SD=2.32) with an almost equal ratio M:F. Mean age for fitting of the device was 3.43 years (SD=2.28. Age 8m - 9yrs). Interestingly the findings in the study were that this particular group rated their self-esteem slightly but significantly more positively than typically developing children. Temperament and behaviour characteristics were the only factors that correlated with self esteem appraisal. Greater affiliation and attention had a positive effect whilst depressive mood had a negative effect. The authors highlight early implantation and device use as a factor that would potentially explain the positive result. A proportion of participants with cochlear implants were chosen from a cochlear implant summer camp which in itself would provide a positive environment and would include children who are well supported overall. The recommendation for professionals working with children with hearing loss is that they should pay attention not only to communication performance but also quality of life. A full assessment of factors affecting self-esteem would identify those at greater risk of lower self-esteem. This in turn would allow for earlier referrals to the required services and for appropriate support mechanisms to be accessed.

Reference

Self-esteem in children and adolescents with hearing loss.
Warner-Czyz A, Loy B, Evans C, et al.
TRENDS IN HEARING
2015;19:1–12.

AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY

Outcomes in rhinosinusitis
Reviewed by: Edward W Fisher
Vol 24 No 1
 

This review goes through the various different ways of assessing outcomes and describes the pros, cons and limitations of each. The different methods are described in the context of guidelines in diagnosis and management and compared with other conditions such as rheumatological conditions. This is a useful and compact update which is authoritative and includes discussion of: symptoms, examination, endoscopy, imaging, correlation symptoms-CT-endoscopy, olfaction, cultures, allergy tests, nasal airflow and the difficulties in putting it all together for the purpose of trials or clinical outcomes analysis. There are as many questions as answers but this is a useful summary of the current position.

Reference

Measuring outcomes in rhinosinusitis.
Benninger MS, Hopkins C, Tantilipikorn P.
AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY
2014:28(3):249-54.

AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY

Sarcoidosis and the nose
Reviewed by: Edward W Fisher
Vol 24 No 1
 

This retrospective case note review from Mount Sinai in New York looked at just 14 patients with sarcoidosis. Individual ENT units in the UK are likely to see relatively few of these patients, unless there is a major tertiary referral in the particular unit, so it is still interesting to view the experience of a group of patients of this size. The authors suggest a classification of the patients into four groups: atrophic / hypertrophic / destructive / nasal enlargement. This seems to me to be useful, as it reminds us of the wide variety of manifestations of sarcoidosis in the nose, with more than one pattern of behaviour. The authors emphasise that the vast majority of cases will be managed medically with relatively few requiring surgery.

Reference

Sinonasal sarcoidosis: a new system of classification acting as a guide to diagnosis and treatment.
Lawson W, Jiang N, Cheng J.
AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY
2014:28(4):317-22.

ANNALS OF THE ROYAL COLLEGE OF SURGEONS OF ENGLAND

Patient-reported outcome measures in septorhinoplasty
Reviewed by: Thomas Jacques
Vol 24 No 1
 

Patient-reported outcome measures (PROMs) are used increasingly in surgical research to quantify the efficacy of surgical interventions. This can help to fill an ‘evidence gap’ where healthcare rationing threatens particular treatments. Procedures aimed at improving quality of life, especially with a cosmetic element such as septorhinoplasty, are termed ‘procedures of limited clinical efficacy’ by many UK commissioning groups. The authors used the validated Rhinoplasty Outcomes Evaluation (ROE) questionnaire to assess patient satisfaction in 100 patients. The satisfaction score overall was 73.3%. In supplemental questions, 75% of patients were happy with the result of the procedure, and 83% would be happy to undergo the procedure again based on the final outcome. The ROE tool would ideally be used longitudinally to compare preoperative and postoperative scores, which was not performed in this study. Nevertheless the study provides good evidence of efficacy from a patient-centred perspective, an essential indicator in quality of life surgery. However, patient satisfaction alone may not necessarily be deemed sufficient justification for NHS funding for partly cosmetic interventions.

Reference

Patient reported outcome measures in septorhinoplasty surgery.
Biggs TC, Fraser LR, Ward MJ, et al.
ANNALS OF THE ROYAL COLLEGE OF SURGEONS OF ENGLAND
2015;97:63-5.

AUDIOLOGY NEUROTOLOGY

Aural fullness in Ménière’s disease
Reviewed by: Stephen James Broomfield
Vol 24 No 1
 

This survey of the Finnish Ménière’s Association aimed to examine the severity and consequences of aural fullness, the least reported cardinal symptom of Ménière’s disease. An initial pilot survey informed a second, restructured survey, giving a total of 726 respondents (response rate 53%). The survey included tools for measuring symptom severity, general quality of life and ability to cope. Overall, aural fullness was commoner in females and occurred in 493 (68%) at the time of the survey. Tinnitus and hyperacusis were strongly associated with aural fullness, which was described as moderate or severe by 30% and as a ‘major complaint’ by 4.4%. Severity of anxiety, low ability to cope and mood diseases were connected with more severe aural fullness, which was associated with reduced quality of life and social isolation. Relaxation was found to be the only statistically significant method for alleviating aural fullness. Whilst there are some methodological flaws in this study, it highlights the potential impact of aural fullness for patients with Ménière’s disease.

Reference

Aural fullness in Ménière’s disease.
Levo H, Kentala E, Rasku J, Pyykko I.
AUDIOLOGY NEUROTOLOGY
2014:19;395-99.

AUDIOLOGY NEUROTOLOGY

Clinical evaluation of an image-guided cochlear implant programming strategy
Reviewed by: Stephen James Broomfield
Vol 24 No 1
 

This study ingeniously combines two current areas of active research in cochlear implantation (CI), the first is the use of imaging to assess intra-cochlear electrode position. The second, is the optimisation of a programming strategy to prevent current spread between active electrodes resulting in loss of speech discrimination. In this study, pre- and postoperative CT imaging was used to assess the position of the implanted electrodes relative to the cochlear modiolus and spiral ganglion. Using the principle that electrodes will maximally stimulate the closest population of spiral ganglion cells, the authors predicted which frequencies each electrode would stimulate. Current spread was then reduced by switching off electrodes whose predicted regions of stimulation significantly overlapped (when two electrodes were found to stimulate the same frequency regions of the spiral ganglion, one of the electrodes was deactivated). This strategy was applied to 22 bilateral and 46 unilateral CI recipients with an average of 2.9 years of CI use and previously thought to have a stable and optimal CI map. Employing the programming strategy as described led to significantly improved speech recognition, spectral resolution and subjective hearing quality. As new imaging and programming techniques develop, it is likely that future research will increasingly examine techniques that allow for personalised programming strategies rather than a ‘one-size-fits-all’ approach.

Reference

Image-guided cochlear implantation programming.
Noble JH, Gifford RH, Hedley-Williams AJ, et al.
AUDIOLOGY NEUROTOLOGY
2014:19;400-11.

B-ENT

Cochlear implantation in Ménière’s disease
Reviewed by: Sunil Sharma
 

This was a Belgian retrospective study of seven patients with Ménière’s disease who underwent cochlear implantation. All patients had bilateral severe to profound hearing loss and all met AAO-HNS criteria for Ménière’s disease. Follow-up for patients ranged from six months to two years. In terms of hearing outcomes there was a statistically significant improvement in hearing post cochlear implantation and in speech recognition. The mean improvement in speech recognition in noise is reported as 47%. In terms of vestibular outcomes, the authors report that four out of the seven patients had no vertigo symptoms post-implantation, but of these four patients only one patient had vertigo symptoms pre-implantation. Indeed, one patient actually had new onset of vertigo post-implantation. The authors also used the Nijmegen Cochlear Implant Questionnaire (NCIQ) to measure quality of life in cochlear implantation patients (using six domains). The mean NCIQ score was 48.3% post-implantation, which is considered satisfactory, but it is not clear how far after implantation these scores were obtained. This is lower than NCIQ scores reported in other patients after implantation, and the authors postulate this may be due to the general negative effect that Ménière’s disease has on overall quality of life. Although there is proven improvement in hearing and quality of life post-cochlear implantation in Ménière’s disease, there does not seem to be any clear improvement in vertigo symptoms.

Reference

Is cochlear implantation an effective treatment for Ménière’s disease?
Vermeire K, Van Yper L, De Vel E, Dhooge I.
B-ENT
2014;10:93-8.

BMC EAR, NOSE AND THROAT DISORDERS

Cochlear Implantation in SSD?
Reviewed by: Gauri Mankekar
Vol 24 No 1
 

Contra lateral routing of signals (CROS) using hearing aids and bone conduction devices has been the conventionally accepted modality for the treatment of single sided hearing impairment. The CROS hearing aid has been found to improve speech understanding in noise, when the signal-to-noise ratio is more favourable at the impaired ear than the non-impaired ear. However, the indiscriminate routing of signals to a single ear has practical detrimental effects when interfering sounds are located on the side of the impaired ear. Recently several reports have suggested that cochlear implantation in single sided hearing impairment can restore access to the binaural cues which underpin the ability to localise sounds and segregate speech from other interfering sounds. The current article reports on a prospective trial which has started recruiting and is designed to assess the efficacy of cochlear implantation, compared to a CROS hearing aid in restoring binaural hearing in adults with acquired single-sided deafness. The patients will be assessed at baseline and after receiving a CROS hearing aid. A cochlear implant will be provided to those patients who do not receive sufficient benefit from the hearing aid. The outcome of this trial promises to be interesting and may provide an answer to whether cochlear implantation will replace CROS devices as the standard of care in single sided hearing impairment.

Reference

Comparison of the benefits of cochlear implantation versus contra-lateral routing of signal hearing aids in adult patients with single-sided deafness: study protocol for a prospective within-subject longitudinal trial.
Kitterick PT, O’Donoghue GM, Edmondson-Jones M, et al.
BMC EAR, NOSE AND THROAT DISORDERS
2014:14:7.

BMC EAR, NOSE AND THROAT DISORDERS

Incidental findings in paranasal sinus Magnetic Resonance Imaging (MRI) studies
Reviewed by: Gauri Mankekar
Vol 24 No 1
 

Incidental findings in the paranasal sinuses of mucosal thickening and polyps in MRI studies may  cause concerns for clinicians and patients. The authors studied MRIs of 982 participants with a mean age of 58.5 years who randomly and independent of their medical history underwent MRI of the head as part of a large public health survey in Norway. Incidental opacifications were found in 66% of the participants, mucosal thickenings in 49% and this most common in the maxillary antra (29%). Other opacifications occurred in the anterior ethmoid (23%), posterior ethmoid (21%), frontal sinus (9%), and sphenoid (8%). Polyps and retention cysts were also found mainly in the maxillary sinuses in 32%. Fluid was observed in 6% of the MRIs. Mucosal thickening was observed more frequently in men than in women. The authors conclude that knowledge of these incidental findings is important as it can influence clinical practice.  Overzealous radiological reporting may also cause anxiety for patients.

Reference

Incidental findings in MRI of the paranasal sinuses in adults: a population-based study (HUNT MRI).
Hansen AG, Helvik AS, Nordgård S, et al.
BMC EAR NOSE AND THROAT DISORDERS    
2014;14:13.

CURRENT OPINION IN OTOLARYNGOLOGY & HEAD AND NECK SURGERY

Current management of facial fractures in the preadolescent
Reviewed by: Susan A Douglas
Vol 24 No 1
 

This article reviews the trends in management of preadolescent facial fractures – a challenging population due to the need to consider growth, dynamic changes in dentition, and evolving fracture patterns. In summary, conservative management is preferred in all fractures in preadolescents whenever possible with the exception of significantly displaced fractures wherein the risks associated with open reduction and internal fixation outweigh the poor outcomes associated with inadequately aligned facial fractures. When necessary, brief periods of intermaxillary fixation are acceptable in the preadolescent. However, because of the primary or mixed dentition in this age group, alternatives to traditional tooth-anchored intermaxillary fixation may be required. Occasionally, a combination of techniques is useful. Consideration should be given to resorbable plating systems given the high growth potential of the facial skeleton in this age group and the need for metallic hardware removal. The article discusses the management of various facial fractures according to the anatomical location. This includes orbital and frontal skull base fractures, zygomatic and mid face fractures, mandibular fractures and nasal fractures. For nasal fractures, the authors recommend closed reduction but in the 7 to 12 year old group, recommend a ‘watch and wait’ philosophy for minimally displaced fractures. This is because of the need for general anaesthetic, the potential for further disruption of growth of the facial bones and the low likelihood of addressing septal deviation. They recommend formal septorhinoplasty after the age of 16 if necessary. As preadolescent fractures occur in a period of growth and evolving dentition in the facial skeleton, it is mandatory for the treating surgeon to have a thorough knowledge of standard and alternative treatment options to optimally manage these patients. This is a well written article with some useful images, which describes the current management of facial fractures in the preadolescent.

Reference

Current management of facial fractures in the preadolescent.
Alhumsi TR, Gilardino MS.
CURRENT OPINION IN OTOLARYNGOLOGY & HEAD AND NECK SURGERY
2014;22(4):336-41.

EUROPEAN REVIEW OF ENT

Facial reanimation
Reviewed by: Badr Eldin Mostafa
Vol 24 No 1
 

Non-conservative surgery in the parotid region results in a devastating complete facial paralysis (as with other causes of persistent facial palsy). Lengthening temporalis myoplasty is one of the available rehabilitating techniques. This is a series of 15 patients who had this procedure after a radical parotidectomy. Ninety-three percent had a good result at rest and 66.6% good result for smile. The authors recommend this type of surgery immediately after extirpation as it does not compromise the oncological field and improves the patient’s quality of life. It can be associated with additional measures to rehabilitate the upper face as well such as lengthening of the levator palpebris superioris or the implantation of a gold weight.

Reference

Lengthening temporalis myoplasty for facial palsy reanimation after parotid surgery.
Foirest C, Gatignol P, Bernat I, et al.
EUROPEAN REVIEW OF ENT
2013;134:259-65.

HEAD & FACE MEDICINE

Facial landmark localisation by curvature maps and profile analysis
Reviewed by: Bilal Gani Taib
Vol 24 No 1
 

The detection of three dimensional (3D) landmarks by scanning surfaces is a well established method in medical science. Anatomical landmarks are visually or palpably detectable and act as reference points for clinical measurements. When measuring these landmarks with a sliding calliper no 3D image is created. This shortcoming can be overcome with surface laser scanners or parallel white light projections. The measurements of 15 residents were performed with the FastSCAN™ laser-scanning system and their curvature maps were calculated. The Koenderink shape index maps identified several landmarks from which seven commonly used distances were calculated and compared to manual measurements by way of Lin’s concordance correlation coefficient. The study measured the intercanthal distance, mouth length, nasal width, outer eye corners distance, soft tissue nasion to subnasal point distance, subnasal point to mento labial point distance and the distance between subnasal point and soft tissue pogonion. In general, measurements obtained from the scanned faces were very similar to manual measurements based on the physical face with only a few major discrepancies, this may be due inadequate image quality exacerbated by head movement during the scanning process. This preliminary study is a first step towards an automatic and objective localisation method of the anatomical landmarks and pertaining distances in clinical facial analysis.

Reference

Facial Landmark localisation by curvature maps and profile analysis.
Carsten Lippold, Xiang Liu, Kim Wangdo, et al.
HEAD & FACE MEDICINE
2014;10:54.

HEAD AND NECK

Proliferative Verrucous Leukoplakia; which one is this one?
Reviewed by: Sunil Kumar Bhatia
Vol 24 No 1
 

Oral leukoplakia has the potential for malignant change and it may frequently require histological analysis and a period of regular clinical observation. The majority of oral leukoplakia remains constant but there is a subset that progress to carcinoma. The authors discuss Proliferative Verrucous Leukoplakia (PVL) that is unique in that it is progressive variant. It is suggested that identifying this form is by repetitive clinical and histological observation. The difficulty in early diagnosis is mainly due to the overlapping clinical and pathologic features with conventional leukoplakia with dysplasia. PVL is rare but aggressive and can present in any of its four clinical progressives states: early focal; geographic expansion; verrucous appearance; and malignant change. It also has no risk factors identified. This is a good paper that discusses the problem of oral leukoplakia and devotes a section to the differential diagnosis of leukoplakia that includes lichen planus.

Reference

Proliferative verrucous leukoplakia: recognition and differentiation from conventional leukoplakia and mimics.
Gillenwater AM, Vigneswaran N, Fatani H, et al
HEAD AND NECK
2014;36(11):1662-7.

HEAD AND NECK

The stigma of HPV in oral cancer
Reviewed by: Sunil Kumar Bhatia
Vol 24 No 1
 

The increase of oropharyngeal carcinoma (OPC) in the developed world seems to be largely caused by infection with the human papillomavirus (HPV). HPV is a group of 150 DNA viruses that are common and most people will be infected at some point. While less than 1% of infections cause cancer, it may account for 5% of all cancers and may be the second most significant human carcinogen after tobacco. HPV status is relevant as HPV-positive OPC has significantly better outcomes and lower regional failures, independent of the treatment methods. While knowledge of the HPV status should not affect the routine clinical management it is required to inform discussions about prognosis and trial eligibility. This excellent article summarises the key messages about HPV in OPC, which are that it is common and affects most people at some time in their lives, is transmitted by normal sexual activity and not a marker of promiscuity or abnormal sexual practices. Infection does not imply recent infidelity. This editorial is a well written informative and summative and a must read for all involved in head and neck cancer.

Reference

Sexual health in oral oncology: breaking the news to patients with human papillomavirus-positive oropharyngeal cancer.
Evans M, Powell NG.
HEAD AND NECK
2014;36(11):1529-33.

INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY

Cadaveric variation of nasolacrimal duct lateral nasal wall landmarks
Reviewed by: Laith Tapponi
Vol 24 No 1
 

Twenty mid-sagittal head sections of 10 fresh frozen cadavers were studied after removal of the nasal septum. This study showed that the most anterior projection of the middle turbinate head was noted to be anterior to the nasolacrimal duct in 70% of specimens. In positional relationship, the maxillary line was posterior to the nasolacrimal duct in 55%, whereas the bulla ethmoidalis and the free edge of uncinate process were uniformly posterior to the nasolacrimal duct in all the specimens. This study provides useful anatomic and positional relationships between the nasolacrimal duct and the major lateral wall landmarks. Although the maxillary line and the head of the middle turbinate are often considered useful guides to the position of the ipsilateral nasolacrimal duct, their spatial relationship to the duct is not consistent. These landmarks, therefore, cannot be solely relied upon during surgery to avoid injury to the nasolacrimal duct.

Reference

Anatomic relationship of nasolacrimal duct and major lateral wall landmarks: cadaveric study with surgical implications.
Ali MJ, Nayak JV, Vaezeafshar R, et al.
INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY
2014;4(8):684-8.

INTERNATIONAL JOURNAL OF AUDIOLOGY

Frequency Compression – is there a benefit?
Reviewed by: Richard Navarro
Vol 24 No 1
 

The goal of this study was to investigate whether frequency compression (FC) hearing aids provide more benefit than conventional hearing aids. Twelve experienced hearing aid users 65-84 years of age with moderate to severe high frequency hearing loss wore the same hearing aid for six weeks in two conditions- FC enabled and FC disabled. Data from speech recognition in quiet and noise and two questionnaires was gathered. The authors reported that FC results were significantly higher in all of the administered speech tests and high frequency phoneme perception improved over time with the FC; however, subjective perception of benefit from the questionnaires failed to show a significant change. This is an important study as many individuals have high frequency hearing loss with consequent difficulty understanding speech. This study, however, has multiple deficiencies that limited the applicability of the data. The small sample size is further complicated by the heterogeneity of hearing loss in the subjects. There was no mention of the ear coupler-earmold configuration and no testing to explore for cochlear dead regions. With this sample population, cognitive ability was another variable that was not tested. This report was interesting but presented too many methodological errors to be of benefit in addressing the real question regarding superior benefit from FC.

Reference

Benefit from, and acclimatisation to, frequency compression hearing aids in experienced adult hearing-aid users.
Ellis RJ, Munro KJ.
INTERNATIONAL JOURNAL OF AUDIOLOGY
2015;54:37-47

INTERNATIONAL JOURNAL OF AUDIOLOGY

Promotion of trust with adult hearing impairment in hearing healthcare
Reviewed by: Richard Navarro
Vol 24 No 1
 

The goal of this study was to assess how trust is promoted among adult hearing impaired patients seeking hearing healthcare. Previous interview transcript data collected from 29 adults across hearing health care centres in four countries was re-analysed thematically in an attempt to determine how adult subjects sought and pursued hearing healthcare services. A major conclusion of the study was that trust evolves over time from practising good communication, encouraging shared decision making in hearing aid sales, and providing a professional clinic setting. This is an important question as many consumers have developed a sense of mistrust or confusion regarding hearing aid sales due to many factors. This study is a good read for those planning a marketing plan or improving their clinical service. Unfortunately the sample size from each country was too small to draw specific conclusions or to do a comparative study across the sample countries. Some data was collected from facilities where the consumer did not pay for the hearing aids as hearing aids were provided at no charge. The lack of homogeneity across the population sample and the clinical / sales environment makes meaningful conclusions tenuous. The authors’ conclusions support common sense but the data analysis provides little new insight.

Reference

Perceptions of adults with hearing impairment regarding the promotion of trust in hearing healthcare service delivery.
Preminger JE, Oxenball M, Barnett MB, et al.
INTERNATIONAL JOURNAL OF AUDIOLOGY
2015;54:20-28.

JOURNAL OF INTERNATIONAL ADVANCED OTOLOGY

Full Vs tapered dose of oral prednisolone for sudden sensorineural hearing loss
Reviewed by: Emma Stapleton
Vol 24 No 1
 

I was drawn in by the title of this article, in the expectation that it might be a randomised controlled trial, but it was not. Sudden sensorineural hearing loss is an uncommon condition, which has a potentially disastrous outcome, so any new evidence could be valuable. The paper concludes that “Prescription of a tapering dose of prednisolone is highly recommended as routine management for patients with sudden sensorineural hearing loss. Compared with full-dose treatment, it has equivalent efficacy while reducing the risk of severe side-effects.” The study appears to suggest that there was no significant difference in outcome between the two groups (27 subjects in each) and that one patient in the full dose group developed acute closed-angle glaucoma. This is an interesting observation but it isn’t a sufficiently large or robust study to draw such a confident conclusion. Patients were not randomised to each of the treatment groups, but allocated ‘based on the specialist’s clinical experience’ and this was a retrospective study. There was no control group. The full dose group received seven days of 1mg/kg followed by seven days of a 1/3 dose, whilst the tapered dose group received three days of 1mg/kg, four days of 2/3 dose and seven days of 1/3 dose, so there was not a great deal of difference in dosing regimen between the two treatment groups. It was interesting to note that, in contrast to our practice in the UK, patients presenting to this department with sudden sensorineural hearing loss all underwent both ABR and MRI in order to exclude intracranial pathology, and that they all spent at least seven days as an inpatient. But overall, I don’t think we can learn a great deal about the treatment of sudden sensorineural hearing loss from this article.

Reference

The efficacy of varied oral steroid doses on the treatment of sudden sensorineural hearing loss.
Liu CL, Ho KY, Wang LF, et al.
JOURNAL OF INTERNATIONAL ADVANCED OTOLOGY
2014;10(2):113-7.

JOURNAL OF INTERNATIONAL ADVANCED OTOLOGY

The effect of sleep deprivation on auditory processing
Reviewed by: Emma Stapleton
Vol 24 No 1
 

This article caught my eye for personal and professional reasons. As a full time ENT trainee working 24-hour on-calls, I also have young children who have never slept through the night and don’t respect weekends or days off. My FRCS revision took place between midnight and 3am over a recent twelve-month period. Sleep deprivation is my normal state of existence, and I’m sure I’m not alone. But back to the paper… This study from India aimed to observe the effects of 24 hours of sleep deprivation on temporal processing and frequency resolution in 16 healthy adults. Local ethical approval was acquired, and a number of tests were carried out on the subjects. A paired T-test was used to demonstrate statistical significance of the results of all tests between the two conditions, with p<0.005. The authors acknowledge that the reduced scores may be due to the effects of sleep deprivation on working memory, arousal, attention, concentration etc, and recommend that clinicians should take proper care in diagnosing a patient if sleep deprivation is a factor. This was a very small but neat study, which could lead onto some interesting further research. In the meantime though, I’ll keep in mind that sleep deprivation – my patients’ and mine – can have a serious effect on cognitive function. Goodnight

Reference

The effect of acute sleep deprivation on temporal processing and frequency resolution in normal healthy adults.
Arora A, Bhat JS, Raj D, et al.
JOURNAL OF INTERNATIONAL ADVANCED OTOLOGY
2014;10(2):134-7.

JOURNAL OF LARYNGOLOGY & OTOLOGY

Association of sinonasal symptoms with ear disease
Reviewed by: Madhup K Chaurasia
Vol 24 No 1
 

The study explores the possible association of sinonasal symptoms with ear disease. The subjects were patients with ear problems which were categorised as group A – patients with external ear problems (15%), group B1 – patients with middle ear mucosal disease, (30%), B2 – patients with squamous disease and group C – patients with inner ear disease. Assessment of sinonasal symptoms was via the Dundee Rhinogram. The mean sinonasal symptom scores for groups A, B1,B2 and C were 0.8, 5.94, 0.72 and 1.65 respectively. The association between middle ear mucosal disease and sinonasal symptoms was statistically significant. Some previous studies have shown association between septal deviation, nasal polyposis and eustachean tube dysfunction. One interesting aspect of this study was lack of association between squamous middle ear disease and sinonasal symptoms and it is believed that the link with acquired cholesteatoma may be indirect. The study has its limitations and only sinonasal symptomatology is considered.

Reference

Sinonasal symptoms in adults with ear disease.
Yin B-S, Miah MS, Hussain SSM.
THE JOURNAL OF LARYNGOLOGY & OTOLOGY
2014;128(5):438-41.

JOURNAL OF LARYNGOLOGY & OTOLOGY

Chronic facial pain: types and long-term treatment
Reviewed by: Madhup K Chaurasia
Vol 24 No 1
 

This publication discusses the details and differences between chronic tension type headache and migraine and followed a cohort of 240 patients over 36 months. The authors applied strict criteria to distinguish between chronic tension headache and migraine, these essentially being that in the former, the pain lasted for hours not days, the pain was bilateral and photophobia, nausea and vomiting were much less prevalent than in migraine. It was noted that patients suffering from facial pain had no difference in BMI but were better educated and in more professional occupations. Strict inclusion and exclusion criteria were applied. Patients who had past sinus surgery, baro-trauma, trauma, TMJ dysfunction, were pregnant, had a history of drug usage for depression or use of solvents and alcohol were excluded. Patients with positive sinus CT findings were also excluded. In the three-year follow-up, it was observed that 45.5% of patients with chronic tension headache who received regular amitriptyline for eight weeks reported resolution (less than one episode per month) whereas only 23% of those with migraine, treated with 10mg amitriptyline or propanolol, achieved the same. Patients on regular medication did better than ones taking NSAID for chronic tension headache and triptans for migraine as and when required. Interestingly, pain was reported as bilateral in 48% of patients with migraine, in contrast to the general belief that it is unilateral. The incidence of rhinitis, positive skin tests, cigarette smoke and exposure to systemic illnesses was similar in patients with mid-facial pain and migraine in comparison with the general Maltese population; this is in contrast to a previous Norwegian study. This is an elaborate study that highlights symptomatology and presentation of facial pain common to otolaryngology clinics.

Reference

Prospective three-year follow-up of a cohort study of 240 patients with chronic facial pain.
Agius AM, Jones NS, Muscat R.
THE JOURNAL OF LARYNGOLOGY & OTOLOGY
2014;128(6):518-26.

JOURNAL OF MEDICAL CASE REPORTS

Head and neck myxofibrosarcoma: a case report and review of the literature
Reviewed by: Bilal Gani Taib
Vol 24 No 1
 

Myxofibrosarcoma is the most common soft tissue sarcoma that occurs in late adult life, peaking in the seventh decade, and it is mainly encountered in the lower extremities. Cases within the head and neck region are extremely rare and to date only 19 cases have been described so far. The case report described here is of 35-year-old caucasian man who presented with a complaint of facial asymmetry for a mass in his right midcheek area, which had increased in size over four months. An intraoral examination revealed an expansion of his upper right gums and the vestibular portion and his teeth were movable with the presence of a widespread periodontitis. Computed tomography revealed a hyperdense mass 83mm x55mm in the pterygopalantine fossa. An open biopsy sample was obtained and this was consistent with a myxofibrosarcoma. A total right maxillectomy was performed using a Weber-Ferguson approach preserving the orbital floor. The tumour was detached and the excised portion was reconstructed with a free rectus abdominis myocutaneous flap. Postoperative radiotherapy was given to the area. The authors having reviewed the literature recommend a complete tumour resection with adequate resection margins, followed by adjuvant radiotherapy with possible re-excision of recurrent lesions. Aggressive follow-up is required to monitor any possibility of metastases.

Reference

Head and neck myxofibrosarcoma: a case report and review of the literature.
Dell G, Orabona A, Laconetta G, et al.
JOURNAL OF MEDICAL CASE REPORTS
2014;8:468.

JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY

Multiple free flaps for head and neck cancer
Reviewed by: Sunil Kumar Bhatia
Vol 24 No 1
 

Most patients with advanced head and neck cancers now undergo microvascular free flap reconstruction. This is mainly as flaps facilitate complete tumour and margin removal by providing reliable wound coverage and better restoration of form and function. However despite this, loco regional recurrence remains the dominant form of treatment failure. Furthermore these patients are at risk for developing a second primary malignancy 55-30% and complications of multimodality treatment include osteoradionecrosis, strictures and fistulae. The optimal treatment for these might involve further microvascular free flap reconstruction. There is understandable hesitation in performing sequential head and neck free flaps, mainly for fear of lack of suitable vessels and other post operative complications. In this retrospective study the authors analysed patients that underwent one or more sequential flap reconstructions between 2000 and 2012. A total of 278 flaps were performed on 117 patients and 23 patients had two or three simultaneous flaps, one patient a total of five free flaps. This is an impressive series including a wide variety of flaps, receipt vessels and veins. Complications for subsequent free flaps 22.2-43.1% are reported and were not significantly different from those of primary flap surgery. Also survival and good function was demonstrated. The authors demonstrate that in selected patient cohort with the possibility of good long-term quality life it is worth considering sequential flap reconstruction. This is an impressive series of flaps for reconstruction in a difficult set of patients and gives the surgeon confidence to think about sequential free flaps.

Reference

Success of sequential free flaps in head and neck reconstruction.
Hanasono MM, Corbitt CA, Yu P, Skoracki J.
JOURNAL OF PLASTIC, RECONSTRUCTIVE AND AESTHETIC SURGERY
2014;67:1186-93.

JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY

Postauricular advancement flap for partial helix defect repair
Reviewed by: Sunil Kumar Bhatia
Vol 24 No 1
 

Ear defects can be the result of trauma, burns or ablative surgery. The three dimensional structure of the pinna presents a difficult reconstructive challenge as successful ear reconstruction requires both similar tissue cover and a supporting framework. Partial ear reconstruction can be achieved with a number of options and the postauricular advancement flap is a well-recognised technique to repair this defect. The authors present a novel method for helix repair with the use of the postauricular advancement flap and free ipsilateral conchal cartilage graft. The authors report on 10 cases, between May 2010 and October 2012, of unilateral partial ear defects repaired with this technique. A random pattern postauricular flap was raised and ipsilateral conchal cartilage harvested. Vaseline impregnated gauze was used to shape the neo-scapha and helix, and free cartilage and flap reconstructed the ear. This is a useful technique to be aware of, it is an elegant solution to quite a difficult reconstructive issue but it does require a secondary procedure. Advantages include single donor site, reduced trauma surgical simplicity and good colour match of the flap.

Reference

Partial helix defect repair by use of postauricular advancement flap combined with ipsilateral conchal cartilage graft.
Hu J, Zhang Q, Zhang Y, et al.
JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY
2014;67(8):1045-9.

JOURNAL OF VESTIBULAR RESEARCH

Alcohol and the vestibulo-ocular reflex (VOR)
Reviewed by: Fiona Barker
Vol 24 No 1
 

I was drawn to this paper initially for slightly unscientific reasons but in fact it proved a worthwhile read. It describes the effect of alcohol consumption on the VOR of eight healthy subjects as measured using video head impulse testing and the dynamic visual acuity test. It nicely measures what those of us fond of the odd glass of wine already know: that things get blurry after one too many glasses. However it also shows how relatively subtle changes in the VOR can be measured using these tests. This has implications for those who might want to use them to track compensation or treatment effect. In addition it also implies that these tests might have a higher association or correlation with subjective report of symptoms than our existing test battery has been shown to have.

Reference

Ethanol consumption impairs vestibulo-ocular reflex function measured by the video head impulse test and dynamic visual acuity.
Rotha TN, Weberb KP, Wettsteina VG, et al.
JOURNAL OF VESTIBULAR RESEARCH
2014;24(4):289-95.

JOURNAL OF VESTIBULAR RESEARCH

Visual vertigo and optokinetic response
Reviewed by: Fiona Barker
Vol 24 No 1
 

This study measured differences in optokinetic responses (sitting, standing, with and without a static visual target) in three groups of people: those classified as having unilateral vestibular loss (n=10), unilateral loss with visual vertigo (n=8) and a control group (n=10). In the abstract the authors have highlighted the differences between the visual vertigo group and the control group and used this to argue that visual dependency should be considered in vestibular rehabilitation. While I concur with this broad conclusion, further reading of the paper reveals little difference between the two groups with vestibular loss. They both differ from the control group on some of the test measures. It is therefore less clear what this paper is saying about visual vertigo as a separate ‘special case’ in addition to unilateral vestibular loss. The way the results are reported in the abstract represents potential reporting bias on the part of the authors and not a dispassionate presentation of the test findings. The title perhaps conveys the content more accurately than the abstract.

Reference

The influence of visual vertigo and vestibulopathy on oculomotor responses.
Zura O, Dickstein R, Dannenbaum E, et al.
JOURNAL OF VESTIBULAR RESEARCH
2014;24(4):305-11.

NEUROSURGERY

Long-term outcomes after endoscopic pituitary macroadenomas resection
Reviewed by: Ms Gauri Mankekar
Vol 24 No 1
 

In this retrospective study the authors attempted to find out long-term outcomes after pituitary macroadenoma resection via the endonasal endoscopic transsphenoidal route. Eighty of the 162 patients operated on met the study criteria of clinical and radiological follow-up for at least five years after resection. Seven patients who had grossly complete resection were found to have recurrences with a mean time to recurrence of 53 months. The authors found that patients with Knosp grade 0-2 tumours and tumour volumes <10 cm3 were significantly more likely to have received a grossly complete resection compared to patients with Knosp grade 3 to 4 tumours or tumours with volumes >10 cm3. Of the 23 patients who had sub-total resection, 11 progressed radiographically and three were found to have symptomatic progression. Recurrent or residual tumours were treated with either repeat surgery or gamma knife radiosurgery. The authors found that the rates of grossly complete resection, incidence of new hypopituitarism, and postoperative complications were similar to those in published literature on endoscopic and microscopic pituitary adenoma resection. The article however does not provide the author’s outcome results following microscopic versus endonasal endoscopic resection.

Reference

Long-term results of endonasal endoscopic transsphenoidal resection of nonfunctioning pituitary macroadenomas.
Dallapiazza RF, Grober Y, Starke RM, et al.
NEUROSURGERY
2015:76:42-53.

NEUROSURGERY

Outcomes after facial nerve preservation surgery for large vestibular schwannomas
Reviewed by: Gauri Mankekar
Vol 24 No 1
 

Large vestibular schwannomas (Koos grade three or four) are traditionally treated by surgical resection. Gross total resection of such large tumours often results in facial nerve dysfunction. Hence facial nerve preservation surgery was introduced in which maximal surgical resection is attempted with a potential residual tumour capsule or nodules left behind in an effort to maintain facial nerve function. The authors of this paper retrospectively studied the outcomes of this technique in 52 patients. Their findings support facial nerve preservation surgery as the new standard for acoustic neuroma treatment. They suggest that maximising resection with close postoperative radiographic follow-up enables early identification of tumours that will progress to radiosurgical treatment. This sequential approach can lead to combined optimal facial nerve function and effective tumour control rates. Facial nerve preservation surgery seems to definitely reduce the morbidity following vestibular schwannoma resection.

Reference

Facial nerve preservation surgery for koos grade 3 and 4 vestibular schwannomas.
Anaizi AN, Gantwerker EA, Pensak ML, Theodosopoulos PV.
NEUROSURGERY    
2014:75:671–7.

OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY

Cochlear implantation techniques
Reviewed by: Suzanne Jervis
Vol 24 No 1
 

This issue concentrates on the advancement in techniques within the field of implant otology starting with cochlear implantation. Here it is sub-divided into indications, candidacy (including full pre-operative testing and investigations), surgical technique and outcomes for both adults and children. The surgical section is further divided into the relevant surgical steps one progresses through. Of particular note, the authors explain the positioning of the ideal incision and the considerations with regard to avoiding post-operative wound complications. The merits of cochleostomy and insertion via the round window are discussed in detail but the extended round window technique is also described as a third option for electrode access. The article clearly has a central theme with regard to hearing preservation and the techniques adopted to optimise this. In particular, ‘soft surgery’ principles to minimise trauma and prevent contamination into the cochlear to preserve residual hearing are explained. The speed of electrode insertion with relevance to hearing preservation was also discussed. Issues regarding securing the device (especially in children where bony wells are less feasible) and the various techniques used were described. Complications that have been encountered in drilling the well down to the dura (CSF leaks and subdural haematomas) have been identified within the literature such that this technique is no longer favoured. Finally, the need for Pneumococcal vaccinations is emphasised to prevent meningitis in implant patients. These topics were all supported by current available evidence, which in the most part pertained to case series and cohorts rather than randomised trials. They also drew on their own experience at the Johns Hopkins School of Medicine, Baltimore. The reader is therefore reminded that the techniques described are based on personal preference with at best level IIb supporting evidence in some situations. However, a useful overview of the differing options in insertion techniques.

Reference

Techniques in cochlear implantation.
Weinreich HM, Francis HW, Niparko JK, Chien WW.
OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY
2014:25(4);312-320.

OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA

A higher aspiration for fine needles
Reviewed by: Charlie Giddings
Vol 24 No 1
 

Fine needle aspiration biopsy (FNAB) has aided in the diagnosis and management of thyroid nodules for decades. Now a rapid evolution is hoped to benefit an increasing cohort of patients with small nodules and non-diagnostic investigations. This review discusses the well-documented limitations of FNAB and the diagnostic utility of testing for somatic mutations and rearrangements found in thyroid cancer. Fine needle aspiration (FNA) with molecular alteration testing has high specificity and positive predictive value. FNA with gene expression has high sensitivity and negative predictive value and hopes to reduce the number of diagnostic thyroid lobectomies. Patients whose results are either follicular lesion of unknown significance or atypia of unknown significance may be the biggest beneficiaries as they frequently undergo diagnostic lobectomy that may be unnecessary, with associated healthcare costs and morbidity. Several mutations within the mitogen-activated protein kinase pathway have been documented in the development of papillary thyroid carcinoma, including RAS and BRAFV600E mutations and RET/PTC rearrangements. In follicular thyroid carcinoma and follicular adenoma, genetic mutations in the PI3K-AKT pathway are common. Well-differentiated thyroid cancer exhibits indolent behaviour but occasionally may behave in a very aggressive fashion. Prognostication using biomarkers may be a useful tool to guide the extent of initial surgery as BRAFV600E has been identified as an independent risk factor for the recurrence of papillary thyroid cancer and also death.

Reference

Clinical application of molecular testing of fine-needle aspiration specimens in thyroid nodules.
Yip L, Ferris RL.
OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA
2014;47(4):557-71.

OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA

Childhood bony facial tumours
Reviewed by: Charlie Giddings
Vol 24 No 1
 

This review article covering maxillary and mandibular tumours is from an edition of the Clinics covering paediatric head and neck masses from frequently encountered congenital malformations to the rarities. There is a wide differential diagnosis for childhood mandibular or maxillary masses and many have non-specific radiological findings making open biopsy essential. The conditions covered in this chapter are divided into odontogenic causes and non-odontogenic. Fibrous dysplasia (FD) is caused by a sporadic mutation in the GNAS1 gene on chromosome 20, causing replacement of normal bone with fibrous connective tissue with a slow clinical progression. FD is not a neoplastic disease, is characterised by ground glass appearances on CT and is divided into monosteotic, the majority of cases, and polyosteotic. Polyosetotic disease involves two or more bones and in combination with café au lait spots and endocrinopathies suggests McCune-Albright syndrome. Treatment is symptom driven, and also depends on sites involved and maturity of the skeleton. Bone pain may be aided with bisphosphonates and for those who require treatment, it is usually surgical. A comprehensive review article of lesions arising in the facial skeleton from simple cysts to histiocytosis.

Reference

Pediatric maxillary and mandibular tumours.
Trosman SJ, Krakovitz PR.
OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA
2015;48:101-19.

OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA

Thyroid nodules in children
Reviewed by: Charlie Giddings
Vol 24 No 1
 

Whilst 5% of nodules in adults may harbour malignancy it is reported in this review that about a quarter of nodules may do so in children. Malignancies in this group are almost always well-differentiated subtypes of papillary, follicular and medullary carcinoma. Radiation has been implicated with the risk increasing with increasing exposure, and the well-established genetics of multiple endocrine neoplasia (MEN) is described. Aside from MEN there is an increased risk in other syndromes including Cowden, Gardner, Peutz-Jeghrs and familial adenomatous polyposis, most of which are autosomal dominant. All solid thyroid nodules greater than 1cm in size should undergo a needle aspiration for cytology, smaller nodules only in the presence of other suspicious features. Once identified, nodules should undergo surveillance if a conservative course is followed. A useful algorithm for nodules in the paediatric population is presented along with unusual presentations either ectopic or in congenital cysts. A helpful description of methodology to monitor the recurrent laryngeal nerves is also described, in particular alternatives given the smallest endotracheal tube with monitoring electrodes is likely too big for almost all children. It should be noted in this review that quoted articles include ages up to 21.

Reference

Pediatric thyroid nodules and malignancy.
Jatana KR, Zimmerman D.
OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA
2015;48:47-58.

OTOLOGY & NEUROTOLOGY

BAHA loading two weeks after implant insertion
Reviewed by: Anand Kasbekar
Vol 24 No 1
 

The time thought necessary for sufficient osseointegration to occur  to enable use of a BAHA has reduced from months to a few weeks. This paper further reduces this timescale to two weeks in patients with healthy bone and soft tissue (excluding diabetes, radiotherapy etc). The implant tested was a Cochlear BIA300 with a 4mm implant and 9mm abutment. Forty-nine patients (mean age 61 years), were randomised to either dermatome and soft tissue reduction technique, or the newer linear incision with no soft tissue reduction. The implant stability quotient (ISQ) was measured every few days up to a month and then at various points up to one year. The results revealed no difference in ISQ between the surgical methods of implantation. Early loading of the implant at two weeks did not lead to any implant losses or any significant change in ISQ. It is important to note that this study only provides safety data on the particular implant used on patients with healthy bone.

Reference

Successful loading of a bone-anchored hearing implant at two weeks after surgery: randomised trial of two surgical methods and detailed stability measurements.
Høgsbro M, Agger A, Johansen LV.
OTOLOGY AND NEUROTOLOGY
2015;36(2):e51-7.

OTOLOGY & NEUROTOLOGY

Canal wall down with obliteration of cavity for paediatric cholesteatoma
Reviewed by: Anand Kasbekar
Vol 24 No 1
 

The authors present evidence that canal wall down (CWD) surgery with primary obliteration is an effective way to treat paediatric cholesteatoma. Fifty-eight ears were operated on and follow-up was for five years on average. Residual cholesteatoma rate was 9.9% with no recurrences. Otorrhoea rate at one year was 0%. Reoperation risk was 17% at five years which included reasons such as hearing improvement (ossiculoplasty), planned second look and abnormality on the post-op CT scan at one year.
The points to note are that firstly all children routinely require a CT scan post-op if they are compliant. This does not feel right, in view of the not so insignificant added risk of second malignancy in children exposed to CT scans. Perhaps this will change as the author’s institution has started diffusion weighted MR imaging. When performing this surgery, one has to be sure (as can be), that all cholesteatoma has been removed and all mastoid air cells are exenterated. The cavity is obliterated using cartilage plates and hydroxyapatite granules or glass-ceramic crystals. Follow-up for longer than 10 years may find extrusion of the exogenous material, although at the present time it is an attractive material to use. Good hearing results are also presented. Overall, the technique achieves with good probability the goal of leaving a trouble free, water-proof ear in children with often aggressive cholesteatoma and significantly reduces the need for automatic second-look surgery as in canal wall up surgery.

Reference

Paediatric cholesteatoma surgery using a single-staged canal wall down approach: results of a 5-year longitudinal study.
Trinidade A, Skingsley A, Yung MW.
OTOLOGY AND NEUROTOLOGY
2015;36(1):82-5.

OTOLOGY & NEUROTOLOGY

Nasal decongestants don’t improve Eustachian tube function
Reviewed by: Anand Kasbekar
Vol 24 No 1
 

Prescribing nasal steroids and decongestants. It’s something most of us do routinely, in an effort to reduce chronic middle ear effusion in an adult by trying to improve eustachian tube (ET) patency. This study used clever devices (tube manometry and the pressure equalization test) to measure opening pressures of the ET before and after (15 mins) instillation of xylometazoline (Otrivine). Adult subjects had intact ear drums (44 ears), non-infected perforated ear drums (43 ears) and six patients had upper airway infection. Decongestant was also instilled into the ear in some patients with perforated ear drums in an effort to get the medication into the ET. Overall, nasal decongestants did not improve ET patency and in some cases even led to reduced ET ventilation! If we think about it, how should solution in the nose work its way up the ET against the beating cilia. The environment of the nasal mucosa and the ET is also different and the vasoconstriction effect of the nasal mucosa will be much more than on the ET mucosa. Measurements made much longer than 15 mins after nasal decongestant instillation in other studies have not shown a beneficial effect either. This study was not geared towards proving any effect on patients with acute otitis media related to an upper airway infection which is a future area of research.

Reference

Can nasal decongestants improve eustachian tube function?
Ovari A, Buhr A, Warkentin M, et al.
OTOLOGY AND NEUROTOLOGY
2015;36(1):65-9.

OTOLOGY & NEUROTOLOGY

Revision stapedectomy with bone cement works well!
Reviewed by: Anand Kasbekar
Vol 24 No 1
 

Revision stapes surgery is notoriously difficult and results are worse than in primary surgery. This group in Utah have described the use of hydroxyapatite bone cement to stabilise the nitinol prosthesis they use in revision surgery due to incus necrosis related failure. It is worth a read for stapes surgeons as the word limit here is too short to describe the technique in full, and in stapes surgery, it’s all in the detail! There is also a video attached on-line. The results: 27 patients with average follow-up of only seven months. Postoperative closure of the air-bone gap to within 10dB was established in 78%, and closure within 20dB was achieved in 96%. These are excellent results by any standards and better than previous reports on revision stapes surgery. Their excellent results may be due to the rest of their technique rather than the bone cement use and it would have been so useful to have had a comparison group.

Reference

Revision stapedectomy with bone cement: are results comparable to those of standard techniques?
Hudson SK, Gurgel RK, Shelton C.
OTOLOGY & NEUROTOLOGY
2014;35(9):1501-3.

OTOLOGY & NEUROTOLOGY

Vascular loops found on MRI IAM for tinnitus
Reviewed by: Anand Kasbekar
Vol 24 No 1
 

This group from the Netherlands looks at the finding of vascular loops found on MRI IAMs requested for tinnitus. It is a common finding for all who request such imaging. This work adds to the body of evidence that such vascular loops should be regarded as an incidental finding. It occurred in 23% of patients scanned (321 patients). There was a 41% rate of abnormalities on MRI, which were not the cause of tinnitus. This is a familiar situation I face on a regular basis and deciding what requires further evaluation and what can be left alone safely without causing undue anxiety to the patient. Interestingly, their protocol scans for bilateral tinnitus (51% of patients), which in a cash strapped NHS is difficult to justify. Not unsurprisingly, unilateral tinnitus had a significantly higher chance of finding pathology that may account for the tinnitus (p=0.044). Two acoustic neuromas were found (1.7%) and both cases had hearing loss in addition. A discussion regarding whether unilateral tinnitus on its own merits an MRI is presented. It depends on your point of view but in my opinion it does not, and further clinical / audiometric signs are usually present. Rarely would I expect to find significant pathology (e.g. a large acoustic neuroma) warranting treatment, with symptoms of unilateral tinnitus, symmetrical hearing and no other clinical signs. Definitely worth a read and discussing with your radiology department to come up with your own guidelines for MRI IAM requests.

Reference

Diagnostic yield of a routine magnetic resonance imaging in tinnitus and clinical relevance of the anterior inferior cerebellar artery loops.
Hoekstra CE, Prijs VF, van Zanten GA.
OTOLOGY AND NEUROTOLOGY
2015;36(2):359-65.

SAUDI JOURNAL OF OTO-RHINO-LARYNGOLOGY HEAD & NECK SURGEY

Role of fine needle aspiration cytology in the management of thyroid neoplasm
Reviewed by: B Viswanatha
Vol 24 No 1
 

Fine needle aspiration cytology (FNAC) is a useful procedure in the assessment of thyroid swellings. This retrospective study was done at King Abdul-Aziz University hospital, King Saud University, Riyadh. The objectives of this study were: to determine the cytological pattern of thyroid lesions; to determine the diagnostic accuracy of FNAC of thyroid lesions; to compare the results with data published in literature; and to stress on the importance of using standardised cytological reporting system for thyroid FNAC. This retrospective study period was from January 2010 to December 2012. During this period 81 patients with thyroid lesions underwent FNAC. Results of the FNAC were grouped according to Bethesda system for reporting thyroid cytopathology. The results were as follows:
I)     1.2% patient’s results were not satisfactory
II)    59% patients had benign lumps
III)   14.8% patients had follicular lesion of undetermined significance
IV)    7.4% patients had follicular neoplasm
V)     2.4% patients had results suspicious for malignancy
VI)    14.8% patients had malignancy.
In this study FNAC findings, in relation to histopathological diagnosis, showed accuracy rate of 95% with a sensitivity rate of 80% and specificity of 100%. Authors state that the implementation of a standardised cytological reporting system with defined diagnostic categories will result in improved understanding of FNAC results and this will help in the management of thyroid neoplasm.

Reference

Thyroid gland fine needle aspiration cytology, a retrospective review in a tertiary hospital.
Al-Jabar I, Al-Aahmari M, Al-Qahtani K.
SAUDI JOURNAL OF OTO-RHINO-LARYNGOLOGY HEAD & NECK SURGEY
2014:16(1):11-14.

THE HEARING JOURNAL

Audiology in palliative care
Reviewed by: Linnea Cheung
Vol 24 No 1
 

The goal of palliation is to provide services that are centred on understanding the salient needs for the patient, maintaining quality of life and addressing any functional and supportive needs of the patient and those caring for them. The audiologist plays an important role in raising awareness of hearing impairment, teaching others to recognise behaviours indicative of hearing impairment, and outlining effective strategies and techniques by which to improve communication. Shifting focus to the promotion of good communication can help enhance shared decision making, thus enhancing patient autonomy, dignity and quality of life. Good communication certainly has an important role in all forms of decision making with regards to healthcare, but perhaps its role in the palliative setting has been previously overlooked. Expanding the palliative multidisciplinary team by involving of audiologists certainly seems like a wise idea, but as with many changes in healthcare, would inevitably require additional resources in both hospital and community settings.

Reference

Palliative care: defining the role of the audiologist.
Weinstein B.
THE HEARING JOURNAL
2015;68(1):23-4.

THE HEARING JOURNAL

Auditory brainstem response patterns are neural signatures
Reviewed by: Linnea Cheung
Vol 24 No 1
 

Through examples, this article describes how particular aspects of auditory brainstem responses can portray certain kinds of language or communication impairments – a characteristic pattern or ‘neural signature’. A reduction in processing of the fundamental frequency is seen commonly in dyslexia, impaired pitch tracking ability is seen in the context of autistic spectrum disorder and pervasive delays across all measures are observed in older subjects with an otherwise clinically normal audiogram. In addition, there are neural signatures that are characteristic for those subjects with hearing expertise, such as musicians and bilingual language speakers who have enhanced response consistency and earlier peak timing. An individual’s neural signature takes into account lifetime experiences therefore, such variation in auditory brainstem responses as mentioned above may be superimposed upon each other giving a unique picture for that individual, for example, a dyslexic bilingual subject. Whilst neural signatures may enhance the broad interpretation of auditory brainstem responses as recognisable patterns, ultimately, detailed analyses will still rely on interpretation of pure threshold values.

Reference

Identifying neural signatures of auditory function.
Kraus N, Anderson S.
THE HEARING JOURNAL
2015;68(1):38-40.

THE HEARING JOURNAL

Earplugs fit for purpose
Reviewed by: Linnea Cheung
Vol 24 No 1
 

The aim of occupational audiology is to prevent hearing loss caused by occupational sound exposure which can exacerbate the long-term effects of central presbyacusis as employees age. To provide the best noise protection over time, research suggests that best practice should be to attempt to limit sounds at the eardrum to 75-80dBA. Attenuation of sound by 10-15dB through earplugs should be sufficient to achieve this. Practical fit testing and counselling is required in order to obtain optimum hearing protection because although earplug manufacturers give noise reduction ratings for their products, this does not correlate the actual protection delivered when in use. The other benefit of proper fit testing is that it can be used to identify unusual configurations of ear canal anatomy which may result in incompatibility with certain earplugs. Low tone attenuation of >20dB must also be tested for separately to detect slit leak venting, as well as interaural performance difference. Three quarters of the earplug length should fit snugly and deeply into the ear canal with a deep seal, without significant slit leak and should not move outwards with temporomandibular joint movement, nor be able to be removed easily. Sound protection must be optimised for each individual employee as best possible in order to prevent hearing loss and to promote better lifelong hearing for all.

Reference

Fit for hearing protection with earplug testing.
Colucci D.
THE HEARING JOURNAL
2014;67(12):40

AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY

The stubborn polyp cases are ‘different’
Reviewed by: Edward W Fisher
Vol 23 No 6
 

The widely different behaviour of nasal polyp disease between patients is a major feature of rhinology practice and makes counselling of patients difficult when approaching their first operative intervention. Setting aside aspirin sensitivity (Samter’s triad), which is known to be indicative of a patient being in the ‘stubborn’ group of recalcitrant polyps, are there any other indicators? This study looked specifically at the immune mediators and immune profile in 21 cases of ‘first’ polypectomy and 15 cases where previous surgery had been undertaken. They found that some mediators or antibodies were higher in the recurrent polyp group. These included: specific IgE to Staph. Aureus enterotoxin, Eosinophil Cationic Protein (ECP) and interleukin 5 (IL-5) were raised in this group. This indicated a predominant Th2 type of inflammation in the recurrent polyp group. Another study in this issue of the journal showed that tissue eosinophilia and high levels of eosinophilic mucin was associated with recurrence. While this might help us to counsel patients, since medical therapy is likely to be tailored to the individual patient, I am not sure that knowing this helps us in management at this stage.

Reference

Differences in initial immunoprofiles between recurrent and nonrecurrent chronic rhinosinusitis with nasal polyps.
Van Zele T, Holtappels G, Gevaert P, Bachert C.
AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY
2014:28(3):192-8.

AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY

Waiting for smell to recover after post-viral hyposmia
Reviewed by: Edward W Fisher
Vol 23 No 6
 

The patient with post-viral anosmia will always want to know how long they must wait to reach a plateau. This study from South Korea of a comparatively small group (20 controls and 63 patients) tells us that favourable prognostic indicators were female sex and long follow-up. This was a retrospective case note study, which detracts somewhat from the conclusions, although many patients had threshold testing and the setting was a dedicated smell and taste clinic. Over 80% showed some recovery (subjectively) after a year. The occasions where a scientific article makes me laugh out loud (for good rather than bad reasons) are few and far between, but when this occurs it is a pleasant change from the weeping that is often the appropriate emotional response. On this occasion, the authors had a theory as to why female gender was a favourable prognostic factor (and the theory could be true, from what we know about the human capacity for olfactory training and regeneration): ‘most female participants in our study were housewives and continuous olfactory stimulation during cooking might have accelerated regeneration of olfactory neurons.’ I would not be brave enough to advocate support for this theory at the British Rhinological Society meeting (even if I think it is correct)!

Reference

Prognosis of postviral olfactory loss: follow-up for longer than one year.
Lee DY, Lee WH, Wee JH, Kim J-W.
AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY
2014;28(5):419-22.

ANNALS OF THE ROYAL COLLEGE OF SURGEONS OF ENGLAND

Variability in the management of differentiated thyroid cancer (DTC)
Reviewed by: Thomas Jacques
Vol 23 No 6
 

his retrospective study analyses for the first time the management planning of thyroid surgeons across the specialties. A questionnaire was sent to members of ENT-UK, the British Association of Endocrine and Thyroid Surgeons, Association of Surgeons of Great Britain and Ireland, and the Association of Breast Surgery. Six clinical vignettes were given, describing DTC patients with differing levels of risk, with several options in terms of subsequent management. The available options were denoted either risk-stratified (RS) or non-risk-stratified (NRS) choices, as determined by expert consensus based on current evidence. NRS choices indicated under- or over-treatment of the patient. Data regarding the experience and practice of the surgeons was also collected. The study revealed considerable variability in practice, particularly in patients of intermediate risk (e.g. older patients with incidental, low-risk disease). The authors attribute this in part to a lack of consensus at guideline level. ENT surgeons had a tendency to perform more aggressive nodal dissection; this was conjectured to be due to the influence of their experience of squamous head and neck tumours. However, in common with specialised endocrine surgeons, they exhibited more RS preference overall when compared with other surgeons. Surgeons who perform a higher volume of thyroidectomies (>25/year), those who participated in an MDT, and those in the early and middle years of their consultant careers, were more likely to make appropriate RS choices. This is in keeping with previously-published literature. Overall the study provides useful insight into concerning levels of variation in the management of DTC, and makes a case for more concentrated, multi-disciplinary thyroid surgery practice.

Reference

A cross-specialty survey to assess the application of risk stratified surgery for differentiated thyroid cancer in the UK.
Craig WL, Ramsay CR, Fielding S, Krukowski ZH.
ANNALS OF THE ROYAL COLLEGE OF SURGEONS OF ENGLAND
2014;96(6):466-74.

Auris Nasus Larynx

What’s the risk of regrowth with partial (intracapsular) tonsillectomy
Reviewed by: Ravi Thevasagayam
Vol 23 No 6
 

Partial (intracapsular) tonsillectomy is enjoying somewhat of a revival offering the potential for less postoperative pain and bleeding whilst relieving the obstructive element. The authors look at 303 patients, 82 of whom had partial tonsillectomy using coblation. They measured pre and post immunoglobulin levels in both groups and found no significant levels pre and post surgery or between the two groups. Partial tonsillectomy appeared to be quicker and most interestingly there were no postoperative bleeds in this group. Five patients in the partial group had tonsillar regrowth (6.1%) of which two went on to total tonsillectomy. All five had tonsillitis following the partial tonsillectomy. This small study seems to support data emerging that partial intracapsular tonsillectomy effectively deals with obstructive symptoms while potentially offering dramatic reductions in postoperative haemorrhage. The down side remains the potential for regrowth, tonsillitis and further surgery. More developments to follow I’m sure!

Reference

Long term outcome of tonsillar regrowth after partial tonsillectomy in children with obstructive sleep apnea.
Zhang Q, Li D, Wang H.
AURIS NASUS LARYNX
2014:41(3):299-302.

B-ENT

Deep neck infections
Reviewed by: Sunil Sharma
Vol 23 No 6
 

This study from Shanghai is a retrospective review of 142 patients presenting to an ENT hospital with deep neck infections (DNIs). The findings of the study are comparable to many of the previous studies, however the authors found tonsillitis and foreign bodies to be the most common cause for DNIs, as opposed to dental infections. This may well be due to the fact that this study took place in a specialist ENT hospital with no oral and maxillofacial surgery cover. The most common causative organism was found to be streptococci, which is comparable to the literature. The literature reports Klebsiella pneumonia as the most common causative organism in diabetic patients but the authors here describe that out of 30 patients with diabetes only one patient grew K. pneumoniae. The most common subsite for infections was the parapharyngeal space which is probably due to the high rate of tonsillitis patients in this study. There is a significantly lower rate of prophylactic tracheostomy for these patients that the authors postulate may be due to their use of intravenous steroids routinely in patients with pharyngeal infections. The authors have discussed the limitations in this study including the small numbers, retrospective data collection and the follow-up by telephone. The most important message that the authors make is regarding the significant possibility (46%) of underlying congenital lesions, such as a branchial cyst, in patients who have recurrent infections and the importance of thorough imaging in this subset.

Reference

Deep neck infections: a retrospective study of 142 patients.
Jin L, Zhang T.
B-ENT
2014;10:127-32.

B-ENT

ENT emergencies
Reviewed by: Sunil Sharma
Vol 23 No 6
 

This Belgian paper reports the epidemiology of 1296 patients attending the emergency department with ENT problems over a five-year period. As expected the most common presentation was epistaxis, but interestingly vertigo seemed to be the second most common presentation to the emergency department during most years. This is in contrast to many British hospitals where vertigo would more commonly present to the outpatient clinic. Indeed the authors don’t seem to give a clear reason for this high proportion of vertigo patients. They hypothesise the reason for a high rate of epistaxis is due to the perception that epistaxis is a severe ENT problem requiring urgent attention by an ENT specialist. The authors compare their results to a similar German paper, which has a higher rate of less urgent problems such as earplugs, etc. They hypothesise this may be because in the Belgian institute they have daily clinic slots available for (semi-) urgent cases compared to the German paper where there are longer waiting lists for outpatients, so patients are more likely to attend the emergency department rather than wait for an outpatient appointment. The authors also report a low rate of re-attendance and of admission (8%) compared to the literature. The low admission rate may be due to patients with nasal packs not being routinely admitted, which is at odds with UK practice. This paper gives an interesting insight into the epidemiology of ENT emergencies in Belgium across a large patient group, and highlights some important differences in service arrangements compared to the UK.

Reference

Epidemiology of ENT emergencies.
Lammens F, Lemkens N, Laureyns G, et al.
B-ENT
2014;10:87-92

BMC EAR, NOSE AND THROAT DISORDERS

Laryngopharyngeal reflux (LPR) in posterior laryngitis
Reviewed by: Gauri Mankekar
Vol 23 No 6
 

The authors of this study investigated the prevalence of acid reflux in the proximal oesophagus and functional gastrointestinal symptoms in patients with posterior laryngitis. They analysed plasma motilin as well as health-related quality of life (HRQOL) questionnaires before and after treatment in 46 patients. Oesophago-gastro-duodenoscopy, 24-h pH monitoring, Plasma motilin analysis and a 36-item short-form questionnaire were completed at inclusion and at follow-up 43±14 months later. Forty percent of patients showed distal acid reflux while 34% showed proximal acid reflux. Only 17% of the 94% patients who received acid reducing treatment showed relief of symptoms. Patients with reflux symptoms had lower plasma motilin levels compared to patients without reflux symptoms. The study concluded that only a minority of patients with posterior laryngitis had LPR and were cured by acid-reducing therapy. However, abnormal plasma motilin levels and functional gastrointestinal symptoms were found in patients with posterior laryngitis and the impaired HRQOL improves over time.

Reference

Posterior laryngitis: a disease with different aetiologies affecting health-related quality of life: a prospective case-control study.
Pendleton H, Ahlner-Elmqvist M, Olsson R, et al.
BMC EAR, NOSE AND THROAT DISORDERS
2013:13:11.

EUROPEAN REVIEW OF ENT

Day care or admission for aesthetic nasal surgery?
Reviewed by: Badr Eldin Mostafa
Vol 23 No 6
 

Day-care surgery is gaining in popularity throughout the surgical specialities due to economical constraints and patient convenience. However this is not without risk and a careful procedure by procedure evaluation should be performed to prove the suitability of this type of surgery for day surgery. The authors studied 424 patients admitted for septoplasty and / or septorhinoplasty and reviewed various pre- and postoperative variables to evaluate the risk / benefit ratio for daycare aesthetic nasal surgery. Between 17 and 40% of patients were eligible for day surgery especially those living <1 hour from the point of care. Given proper selection criteria, it is possible to offer patients undergoing aesthetic nasal surgery the option of a day care hospitalisation with all its benefits and without any additional risks.

Reference

Feasibility study of septoplasties and septorhinoplasties in ambulatory surgery.
Lechot A, De Gabory L.
EUROPEAN REVIEW OF ENT
2013;134:191-7.

EUROPEAN REVIEW OF ENT

The septum, outside!
Reviewed by: Badr E Mostafa
Vol 23 No 6
 

Extracorporeal sculpturing of the septum during septorhinoplasty (SRP) is a well-established technique. However, the extent of manipulations of the septum varies amongst authors. In a series of 630 patients undergoing SRP, the authors used a complex extracorporeal septal three dimensional structural composite graft in 63 patients. This technique allows a more precise fashioning of the graft and insertion under vision with proper positioning. The authors used 11 criteria to evaluate their results with a (rather short) mean follow-up period of 19 weeks. They had an 85% improvement in the dorsal axis, an 82% improvement in the tip projection and nasolabial angle. However they noted a 71% reduced stability and broadening in 28% of cases.

Reference

Post-operative evaluation of 63 cases of rhinoseptoplasty by nasal frameworks.
Hardy C, Goga D, Disant F.
EUROPEAN REVIEW OF ENT
2013;134:175-8.

INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY

Comparing patient and surgeon concerns in sinus surgery
Reviewed by: Laith Tapponi
Vol 23 No 6
 

This prospective observational study had a total of 180 patients undergoing endoscopic sinus surgery for chronic rhinosinusitis with or without polyposis. Data was analysed using descriptive statistics and analysis of variance. Subjects felt the greatest level of concern regarding potential need for revision surgery as well as the wait time for surgery. Patients were least concerned about psychological factors. No differences with respect to age or gender were identified. Patients’ areas of greatest concern may not align with those perceived by surgeons. This study provides insight into patient concerns prior to undergoing elective sinus surgery and emphasises the importance of the patient-centred approach to care. Patient-centred care is recognised as being fundamental to successful medical practice.

Reference

Preoperative concerns of patients undergoing endoscopic sinus surgery.
Yeung JC, Brandt MG, Franklin JH, et al.
INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY
2014;4(8):658-62.

INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY

The effect of cocaine or adrenaline dressing during endoscopic sinus surgery
Reviewed by: Laith Tapponi
Vol 23 No 6
 

A randomised controlled study of 37 patients took place that underwent endoscopic sinus surgery for chronic rhinosinusitis and received adrenaline or cocaine-soaked patties. The study showed no difference in the mean surgical field scores between adrenaline and cocaine sides. Adequate surgical field visualisation is among the most important factors in preventing complications in functional endoscopic sinus surgery, but this study was small and limited.

Reference

Topical cocaine vs adrenaline in endoscopic sinus surgery: a blinded randomized controlled study.
Valdes CJ, Bogado M, Rammal A, et al.
INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY
2014;4(8):646-50.

INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY

What are the best minimal surgical techniques used for concha bullosa?
Reviewed by: Laith Tapponi
Vol 23 No 6
 

This prospective endoscopic and radiologic evaluation studied 42 patients who underwent concha bullosa surgery, amounting to a total of 55 conchae surgeries. The patients were allocated consecutively to either of the two groups. The presurgical and one year postsurgical endoscopic nasal cavity images and computed tomography (CT) scans of all patients were recorded. Preoperative and postoperative measurements were compared using a paired t-test and student t-test. Crushing with intrinsic stripping is an effective and easy technique, when compared to crushing alone, and provides significantly more decrease in middle concha volumes as demonstrated both by the CT and by endoscopic evaluations.

Reference

A comparison of the long-term results of crushing and crushing with intrinsic stripping techniques in concha bullosa surgery.
Eren SB, Kocak I, Dogan R, et al.
INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY
2014;4(9):753-8.

INTERNATIONAL JOURNAL OF AUDIOLOGY

Diet quality, noise, and hearing
Reviewed by: Richard Navarro
Vol 23 No 6
 

This is an important article for all audiologists to better understand the relationship between dietary habits and hearing loss. It reports poor dietary habits plus noise exposure may lead to increased high frequency hearing loss. The literature review lays the groundwork for understanding that the ear is a part of a complex mechanism (the body) and should, therefore, not be viewed in isolation. The implication of this understanding is that audiologists must consider all aspects of the body, particularly metabolism, in trying to decipher causes, prevention, and treatment of hearing loss, tinnitus, and dizziness. The authors retrospectively reviewed data from the National Health and Nutrition Examination Survey, 1999-2002, using the Healthy Eating Index, correlated this data with low and high frequency tonal thresholds after controlling for age, sex, race / ethnicity, education, diabetes, hypertension, and smoking. From the population of 10,000 subjects, 2176 were included in the study. Significant differences were found between dietary habits and high frequency hearing loss. The major limitation of the study was that it was a cross sectional analysis; however, the size of the data pool is sufficient for useful conclusions. The conclusions are not entirely supported by histological evidence presented by Schuknecht that posited a flat audiogram as representative of a metabolic hearing loss. The literature review did not include research from the early 1980s that demonstrated audiometric improvements from nutritional supplementation for Meniere’s patients. Regardless of the weaknesses in the article, it should invite the audiologist to be proactive in learning how the ear is impacted by dietary habits so that more effective prevention and treatment options are developed. Effective hearing conservation is more than noise reduction or ear plugs and should include the entire spectrum of hearing health.

Reference

Associations between dietary quality, noise, and hearing: Date from the National Health and Nutrition Examination survey, 1999-2002.
Spankovich C, Le Prell CG.
INTERNATIONAL JOURNAL OF AUDIOLOGY
2014;Early Online: Posted online on June 30, 2014:1-14.

JAMA OTOLARYNGOLOGY – HEAD & NECK SURGERY

Patients with advanced oral cavity carcinoma are not candidates for the ‘organ preservation’ approach
Reviewed by: Shabbir Akhtar
Vol 23 No 6
 

The authors of this study, from the University of Michigan, evaluated the role of induction chemotherapy for patients with stages III and IV resectable oral squamous cell carcinoma. Nineteen patients were initially enrolled in the induction chemotherapy cohort. Patients with clinical or radiographic evidence of bone involvement were excluded. Patients with a response of at least 50% underwent concurrent chemoradiotherapy; those with a response of less than 50% underwent surgical treatment and postoperative radiotherapy. A comparison was made with cohort of patients treated with primary surgery. No difference was noted in age, sex, pretreatment AJCC stage, T and N classifications, smoking status, alcohol consumption, or tumour subsite between induction chemotherapy and surgical cohorts. Median follow-up was 9.4 years in the induction chemotherapy group and 7.1 years in the surgical cohort. The overall survival at five years was 32% in the induction chemotherapy group and 65% in the surgical group. The disease-specific survival was 46% in the induction chemotherapy group and 75% in the surgical group. The locoregional control was 26% in the induction chemotherapy group and 72% in the surgical cohort. Multivariable analysis demonstrated significantly better overall and disease-specific survival and locoregional control outcomes (P = .03, P = .001, and P < .001, respectively) in the surgical cohort. These findings support surgery as the principal treatment for oral squamous cell carcinoma.

Reference

Efficacy of induction selection chemotherapy vs primary surgery for patients with advanced oral cavity carcinoma.
Chinn SB, Spector ME, Bellile EL, et al.
JAMA OTOLARYNGOLOGY - HEAD & NECK SURGERY
2014;140(2):134-42.

JOURNAL OF LARYNGOLOGY & OTOLOGY

Anatomic guidelines to endolymphatic sac in transmastoid approach – a cadaveric study
Reviewed by: Madhup K Chaurasia
Vol 23 No 6
 

This study involved cadaveric dissection using transmastoid approach in cadaveric embalmed five half heads and posterior fossa approach in fourteen. The sac was identified by electron microscopy. The relatively consistent measurements were the relationship of the operculum to the internal auditory meatus (10mm) and the width of the operculum varied only slightly more. Marked variations were noted in the distance from superior petrosal sinus to the operculum (6-14mm), width of the sac (7-16mm), length of sac borders- lateral (5-15mm), medial (4-17mm) and the distance from the operculum to the sigmoid sinus – lateral (7-17mm), medial (8-15mm). In eight cases the endolymphatic sac extended beyond the medial margin of the sigmoid sinus. No appreciable lumen was identified in two. The most consistent finding was dural thickening in the region of the endolymphatic sac. Results are compared with previous studies and appear largely similar. Emphasis is laid on adequate removal of bone from superior petrosal sinus to the jugular bulb and from a point medial to the posterior semicircular canal to the sigmoid sinus, remembering that the sac can extend a bit further and decompression of this sinus may be required. A previously described method of measuring from the short process of the incus to the lower limit of the posterior semicircular canal in transmastoid approach is considered unreliable as it pertains to the intradural part of the sac where it is most variable.

Reference

Endolymphatic sac surgical anatomy and transmastoid decompression of the sac for the management of Ménière’s disease.
Locke RR, Shaw-Dunn J, O’Reilly BF.
THE JOURNAL OF LARYNGOLOGY & OTOLOGY
2014;128(6):488-93.

JOURNAL OF LARYNGOLOGY & OTOLOGY

Possibility of noise induced hearing loss during middle ear suction for secretory otitis media
Reviewed by: Madhup K Chaurasia
Vol 23 No 6
 

Emission of high intensity sound is dangerous to the cochlea and can result in noise induced hearing loss (NIHL). Removal of middle ear fluid is common in everyday practice and the possibility of inducing NIHL is seldom considered and not much is known about immission levels. In this study the authors measured sound intensity levels delivered to the ear in the use of suction to remove middle ear fluid. The subjects of the study were children of age six months to six years and sound intensity was measured with a microphone probe attached to the suction tip. The maximum peak intensity ranged from 84 to 157 dB SPL. Half the number of ears were exposed to greater than 140 dB of which 80% were exposed for more than 0.2msec. This is above pain threshold and considered detrimental in terms of NIHL. Higher intensities and duration of suction were recorded for evacuation of mucoid fluid. Suction of serous fluid and empty middle ear caused much less noise exposure in terms of duration and intensity. Interesting literature is discussed examining a direct correlation between the contributions of calibre of the suction tube and lack of finger closure. Most studies recorded lower intensities which can be attributed to less efficient technology in the past and possibly less awareness of this phenomenon. One study demonstrated temporary threshold shift of 15dB or greater. This however, has not been measured in this study but the authors are aware of its significance. This interesting study should be further explored and perhaps mentioned in any consent.

Reference

Measurement of sound intensity during suction of middle-ear fluid following myringotomy.
Wang, JC, Allen SJ, Rodriguez AI, et al.
THE JOURNAL OF LARYNGOLOGY & OTOLOGY
2014;128(7):604-11.

JOURNAL OF LARYNGOLOGY & OTOLOGY

Use of tranexamic acid in ENT surgery
Reviewed by: Madhup K Chaurasia
Vol 23 No 6
 

Postoperative bleeding in otolaryngologic procedures causes delayed discharge, requires re-admission and adds considerably to the cost of patient care. Whether the anti-fibrinolytic activity of tranexamic acid should be used routinely to prevent haemorrhagic complications after ENT operations is speculation but the author has given several examples of this practice being prevalent in other specialities and describes a number of studies supporting its role in reducing blood loss without causing thromboembolic complications. Tranexamic acid has been used in cleft palate and cardiac surgery, knee replacements, management of trauma patients and post-partum haemorrhage. Transfusion of blood has several risks in itself and this may be avoided with use of tranexamic acid. Use of tranexamic acid in tonsillectomy has been shown to reduce operative and immediate postoperative blood loss thus facilitating same day discharge but it does not prevent secondary haemorrhage. Irrigation of the nasopharynx with tranexamic acid after adenoidectomy reduced blood loss in one study. In a randomised controlled trial a single intravenous injection of tranexamic acid proved more effective than anterior nasal packing and similar encouraging results have been seen in functional endoscopic sinus surgery. The cost effectiveness of using tranexamic acid has been suggested by estimating savings achieved by avoiding post tonsillectomy haemorrhage. The author believes that in tonsillectomy haemorrhage, expenditure could be reduced from £8 million to £0.23 million. Side-effects of tranexamic acid are discussed, mainly thromoembolic phenomenon and gastrointestinal upsets, but the incidence of these is low.

Reference

Tranexamic acid – a useful drug in ENT surgery?
Robb PJ.
THE JOURNAL OF LARYNGOLOGY & OTOLOGY
2014;128(7):574-9.

JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY

Lipofilling for scar improvement
Reviewed by: Sunil Kumar Bhatia
Vol 23 No 6
 

Since Coleman et al. in 1991 reported on lipofilling, numerous applications have been reported; these include but are not limited to contour restoration, lip augmentation, and wrinkle therapy. There has also been some one off reported improvements in scars following autologous lipofilling. This paper is a prospective clinical evaluation of 26 patients with 35 scars on the face treated with autologous lipofilling between 2008 and 2012. The most common cause of the scars was trauma and surgical excision of nevus and acne. Scars caused by resection of malignant tumours were excluded. Standardised preoperative and postoperative assessments were used to assess success, patient and observer scar (POSAS), photographs and laser Doppler spectrometry of oxygen saturation (to assess the micro circulation). Postoperatively patients were followed up at one, three, six, and 12 months. Scar quality was improved in all cases with a high patient satisfaction. There was also an increase in the postoperative haemoglobin levels in the scar area. While this is a limited number of cases and the authors concede further studies are necessary this is a valuable method to add to facial surgeons’ armamentarium. Any technique to improve facial scars is always welcome in the facial surgeon’s practice.

Reference

Improvement of facial scar appearance and microcirculation by autologous lipofilling.
Pallua N, Baroncini A, Alharbi Z, Stromps JP.
JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY
2014;67(8):1033-7.

JOURNAL OF VESTIBULAR RESEARCH

Vitamin C, a possible remedy for seasickness?
Reviewed by: Victor Y Osei-Lah
Vol 23 No 6
 

The internet is full of devices and medicines vying for superiority over which one is the best for preventing seasickness. This study was based on the following observations: elevated histamine levels trigger seasickness; blockade on histidine decarboxylase prevents seasickness while elevating vitamin C levels in animal models; low concentration of vitamin C are seen in mastocytosis and nausea reduces after taking vitamin C. The aim of the double-blind placebo-controlled cross-over study was to investigate whether vitamin C suppresses nausea in people exposed to motion at sea. The authors recruited 70 volunteers aged between 19 years and 60 years, divided into two groups. They were exposed to one-metre waves in an inflatable raft in an indoor pool for 20 minutes on two separate days. Group VP received 2g of oral vitamin C one hour before exposure on day one and placebo before exposure on day two. The reverse was done in the other Group PV. Blood levels for histamine, diamine oxidase (DAO, degrades histamine), tryptase and vitamin C were determined one hour before exposure and immediately after the 20 minute exposure. Participants rated their symptoms on 10-point visual analogue scale (VAS) immediately after leaving the raft and at a 30-minute intervals for three hours. Twenty-two, 42 and six subjects reported slight, moderate and strong sensitivity to seasickness respectively. However, seven subjects (two females, five males) had no symptoms on either day. In both groups, the majority of subjects felt better and had fewer symptoms on the days they took vitamin C. In females, vitamin C was significantly associated with less symptoms than placebo. Twenty-three subjects left the raft before the 20 minute test duration but even so, those on vitamin C stayed significantly longer than those on the placebo. Histamine levels increased during exposure but DAO levels increased following intake of vitamin C. On the whole, vitamin C suppressed symptoms of seasickness but the effect was more pronounced for females than in males except in men younger than 27 years. The authors concluded that in women and in men under 27 years of age, vitamin C could effectively suppress seasickness while emphasising the quick onset of action and absence of significant side-effects in comparison to other motion sickness medication.

Reference

Impact of oral vitamin C on histamine levels and seasickness.
Jarisch R, Weyer D, Ehlert E, et al.
JOURNAL OF VESTIBULAR RESEARCH
2014;24(4):281-8.

NEUROSURGERY

Stereotactic radiosurgery for pituitary adenomas
Reviewed by: Showkat Mirza
Vol 23 No 6
 

Residual and recurrent functioning pituitary adenomas can be difficult to delineate on postoperative MRI scans, making them difficult targets for stereotactic radio surgery. In such cases radiation delivery to the entire sellar has been utilised as a radio surgical equivalent of a total hypophysectomy. This paper evaluated the outcomes of 64 patients over about 20 years who underwent stereotactic radiosurgery to the whole sellar region. The median endocrine follow-up was 41 months. Sixty-nine per cent of patients with acromegaly, 71% of patients with Cushing’s disease and 50% of patients with a prolactinoma achieved endocrine remission. One patient developed a new visual field deficit, two patients had an oculomotor nerve palsy and one developed an abducens nerve palsy. A new onset hypopituitarism developed in 43.5% of patients. Therefore whole sellar stereotactic radio surgery for image negative or venous sinus invasive adenomas following failed resection, can offer reasonable rates of endocrine remission with hypopituatrism being the most common complication.

Reference

Whole-sellar stereotactic radiosurgery for functioning pituitary adenomas.
Lee CC, Cheng CJ, Yen CP, et al.
NEUROSURGERY
2014;75(3):227-37.

NEUROSURGERY CLINICS OF NORTH AMERICA

Preoperative tumour embolisation
Reviewed by: Gentle Wong
Vol 23 No 6
 

This review article analyses the role of preoperative endovascular tumour embolisation in the treatment of a variety of hypervascular head and neck lesions including juvenile nasal angiofibroma, glomus tumour, carotid body tumours, and meningioma. Although the concept of tumour embolisation dates back several decades, this article provides a refreshing reminder and updates us with current improvements in catheter design, enhanced angiographic imaging capabilities, as well as novel embolic agents; all of these making endovascular intervention safer and easier. Despite its advances, the pertinent question to ask is not whether embolisation is feasible, but whether it is necessary. It is important to understand tumour hypervascularlity alone is not a good reason to subject the patient to the added risk of embolisation, especially if the tumour is small, and the major blood supply to the tumour is readily accessible early at surgery. On the other hand, if embolisation may decrease total operative time (and anaesthetic risk to the patient), or deal with surgically inaccessible arterial feeders, and improve visualisation at surgery thus facilitating tumour resection, then the appeal becomes apparent. In conclusion, as technology advances and more studies are conducted, embolisation will evolve to further complement (or substitute in some cases!) surgery.

Reference

Preoperative tumour embolisation.
Ashour R, Aziz-Sultan A.
NEUROSURGERY CLINICS OF NORTH AMERICA
2014;25(3):607-17.

ORL

Effects of nasal sprays on ciliary function
Reviewed by: Zi Wei Liu
Vol 23 No 6
 

What do topical nasal sprays do to the nasal mucosa in the long term? This study reports the effect of corticosteroids, antihistamines and common preservatives in nasal sprays, benzalkonium chloride (BKC) and potassium sorbate (PS), on an in-vitro model of human nasal mucosa. Fluticasone and azelastine were both shown to cause a remarkable rapid and irreversible decrease in ciliary beating frequency when applied undiluted or at 50% concentration. BKC, a common preservative in nasal steroid sprays including fluticasone proprionate and azelastine hydrochloride, induced ciliary stasis at half the concentration found in commercial preparations. Budesonide and potassium sorbate both had reversible or minor effects on ciliary motility. The long-term effect of topical nasal preparations on mucosa is controversial, and the results of this study must be interpreted with caution. There is little evidence to support the idea that fluticasone or azelastine have irreversible ciliotoxic effects from clinical observation, and indeed the authors of the study state that although their findings are in line with several other cell culture studies, these adverse effects cannot be replicated in vivo. This is likely to be due to the dilutional effect of nasal secretions and protective mechanisms which are not present in the in vitro model. Until further studies are done in vivo, this remains a cautionary tale that laboratory findings do not translate easily in complex biological systems.

Reference

The effect of topical corticosteroids, topical antihistamines, and preservatives on human ciliary beat frequency.
Jiao J, Meng N, Zhang L.
ORL
2014;76(3):127-36.

OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA

Thyroid cancer: to dissect the neck or not?
Reviewed by: Charlie Giddings
Vol 23 No 6
 

This is a good review of the much-debated management of the neck in thyroid cancer. It discusses oncological goals that must be achieved whilst maintaining voice, swallowing and parathyroid function. A clear description is made of the common nodal basins involved in metastatic disease, their boundaries and frequency of involvement. Therapeutic neck dissection for differentiated thyroid cancer is widely supported by the literature. The evidence for prophylactic neck dissection is less clear with a small but significant reduction in locoregional recurrence reported in some series. It is summarised that prophylactic dissection of level VI should be considered in tumours greater than 4cm in size or for those with extrathyroidal extension. Non-infiltrative types of follicular-variant of papillary thyroid cancer may however be an exception, with lower rates of reported nodal disease. Judicious dissection of level VI is also supported by the recently published British Thyroid Association guidelines that estimate approximately 20-30 patients would have to undergo prophylactic level VI dissection to convey benefit to one individual. Surgical technique is described and in particular the anatomical differences between the left and right sides along with optimum technique for the preservation of the parathyroid glands. Postoperative management of calcium is addressed, importantly the need to empirically start replacement with level VI dissection.

Reference

Management of the neck in thyroid cancer.
OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA
Schoppy DW, Holsinger FC.
2014;47(4):545-56.

OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA

Thyroid nodule update
Reviewed by: Charlie Giddings
Vol 23 No 6
 

This excellent article summarises the current diagnostic difficulties with an endocrine gland that frequently produces nodules, some of which may harbour malignancy. At 50 years of age and over there is about a 50% chance of having a nodule; at 90 years it is almost a certainty. Clinically insignificant thyroid cancers discovered incidentally at autopsy have been estimated to occur in up to 36%, and with better diagnostic imaging they are found easily. A good diagnostic algorithm is presented for the evaluation of a thyroid nodule with an up to date detailed risk factors assessment that might stimulate further investigation. Large one-off radiation exposure occurring after 20 years of age has not been proven to increase thyroid malignancy incidence. However radiation in childhood, even from CT and PET imaging, should be enquired about in any taken history. The commonest useful characteristics on ultrasound for the detection of malignancy are still microcalcifications, size greater than 2cms and entirely solid composition. Molecular markers are explored in more detail in another paper that is reviewed below. When considering intervention, attention is rightly drawn to the competing risk of death from other co-morbidities, given that the 20-year survival for papillary cancer (tumours of any size confined to the gland) is 99%.

Reference

Evidence-based evaluation of the thyroid nodule.
OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA
Davies L, Randolph G.
2014;47(4):461-74.

OTOLOGY & NEUROTOLOGY

Cochlear implants in Ménière’s disease
Reviewed by: Anand Kasbekar
Vol 23 No 6
 

This retrospective review firstly reminds us that a cochlear implant (CI) is possible with Ménière’s disease (MD) and provides a good account of what can be expected with a CI in patients with MD. Twenty MD patients who underwent cochlear implantation were matched (as well as could be expected) with controls having had similar types of CI. The results demonstrated equivalent hearing performance at one year post implant. Tinnitus was significantly reduced in MD patients. Unfortunately, ongoing dizziness in the MD group affected the overall quality of life (QoL) outcome (SF-36 questionnaire), but was nonetheless significantly improved from preoperatively. We are reminded that vertigo is the most disabling of symptoms for most of our otology patients. Control patients had a greater QoL outcome. MD patients must be warned of the risk of oscillopsia if the ear with the only remaining vestibular function is to be implanted; however it is very infrequent and should not be a contraindication state the authors. This is debatable in my view.

Reference

Cochlear implantation in patients with advanced Ménière’s disease.
Mick P, Amoodi H, Arnoldner C, et al.
OTOLOGY & NEUROTOLOGY
2014;35(7):1172-8.

OTOLOGY & NEUROTOLOGY

Endolymphatic sac surgery for Ménière’s disease
Reviewed by: Anand Kasbekar
Vol 23 No 6
 

This is a very useful meta-analysis for those that perform surgery for Ménière’s disease. It specifically looked at differences in various forms of endolymphatic sac surgery (ESS). A total of 36 papers were included. The results: ESS controls vertigo in the short-term (>1 year) in 75% of cases who haven’t had trial of intratympanic treatment. Long-term control drops to 63% (6.5 years follow-up). There is no difference between sac decompression (removing bone over the sac) and mastoid shunting (also inserting silastic into the sac to allow drainage), procedures for vertigo, however there is probable 6dB worsening of hearing with shunting procedures rather than just decompression. Interestingly, in shunting procedures, there is a greater chance of maintaining hearing if no silastic is used. The recommendation is to open the sac and not to leave in silastic as a stent. It is postulated that silastic causes an immunological reaction within the sac.

Reference

Endolymphatic sac surgery for Ménière’s disease: a systematic review and meta-analysisreconstruction in cholesteatoma surgery.
Sood AJ, Lambert PR, Nguyen SA, Meyer TA.
OTOLOGY & NEUROTOLOGY
2014;35(6):1033-45.

RHINOLOGY

Nasal peak inspiratory flow (NPIF) as a diagnostic tool for differentiating decongestable from structural nasal obstruction
Reviewed by: Lakhbinder Pabla
Vol 23 No 6
 

Identification of the cause of nasal obstruction is critical before surgical intervention such as septoplasty. This study assesses changes in nasal peak inspiratory flow (NPIF) as a tool for discriminating decongestable versus structural obstruction. A cross-sectional study of 52 patients (24 with decongestable, 28 with structural obstruction) undergoing nasal airflow assessment was performed. Rhinomanometry, nasal obstruction visual analogue score (VAS) and NPIF were performed pre- and post-decongestion. Population groups were defined with decongestable or structural obstruction by relative post-decongestion changes in airways resistance and symptoms. Pre- and post-decongestion NPIF were similar between groups. Absolute and percentage NPIF changes were larger with decongestable versus structural obstruction. Sensitivity and specificity for predicting decongestable obstruction were 75.0% and 60.7% for NPIF increase >20L/min; 75.0% and 64.3% for NPIF increase >20%. The respective positive predictive values were 62.1% and 64.3%. The study concluded that the NPIF increase after decongestion is larger with decongestable than structural obstruction but NPIF alone cannot discriminate the two conditions and does not replace more formal assessment.

Reference

Nasal peak inspiratory flow (NPIF) as a diagnostic tool for differentiating decongestable from structural nasal obstruction.
Chin D, Marcells G, Malek J, et al.
RHINOLOGY
2014;52(2):116-21.

SLEEP AND BREATHING

Postoperative complications in OSA patients
Reviewed by: Vik Veer
Vol 23 No 6
 

This well researched meta-analysis describes the various complications obstructive sleep apnoea (OSA) patients may acquire after surgery. These American reviewers found that OSA patients after non-upper airway operations, were more like to suffer (compared to non-OSA patients), from the following complications: respiratory complications were significantly more likely to occur in OSA patients (overall OR=2.77 – 95%CI 1.73–4.43). Specifically hypoxemia and the need for prolonged oxygen therapy postoperatively; cardiac complications including dysrhythmias, abnormal heart rate, myocardial infarction and ischemia, hypotension, and congestive heart failure had a OR=1.76 (95%CI 1.16–2.67); neurological complications including delirium, agitation, confusion, and excessive drowsiness had an OR=2.65 (95%CI 1.43–4.92); and the risk of an unplanned ITU admission was OR=2.97 (95%CI 1.90–4.64). The discussion concludes that patients at high risk of OSA need to be screened before undergoing an operation. This will hopefully reduce these stormy postoperative spells, and result in better outcomes for patients, and less sleepless nights for surgeons. Now all we need is a good screening tool! Currently all we have is clinical vigilance with preoperative polysomnography.

Reference

Post-operative outcomes in adult obstructive sleep apnea patients undergoing non-upper airway surgery: a systematic review and meta-analysis.
Gaddam S, Gunukula SK, Mador MJ.
SLEEP & BREATHING
2014;18(3):615-33.

THE HEARING JOURNAL

Earplug use in clubbers
Reviewed by: Linnea Cheung
Vol 23 No 6
 

Past studies show that there is a low frequency of use of earplugs at music events. In this research article produced by the National Acoustic Laboratories, Australia, a group of 51 regular attendees at music events were recruited and given music earplugs. An initial survey clarified their exposure regularity to music venues, and presence of any pre-existing hearing problems. They were followed up by surveys after four and 16 weeks of issue via e-mail, to explore their experiences of comfort, music enjoyment, ease of communication and overall attitude towards their use. Only 37 subjects completed all three surveys for comparative results. There was significant increase in reported comfort, ease of insertion and music enjoyment over time. The overall attitude towards the effect of earplugs on communication was unchanged at around half of all participants. Over 80% retained a positive attitude towards their use to prevent noise induced hearing loss at such events after the second survey. A small proportion of patients found difficulty with insertion, and an unsatisfactory level of music enjoyment from use. This study only evaluated the use of one particular type of earplug marketed specifically for exposure to loud music. It would be interesting to see parallel results using types of earplug for comparison. Clearly to achieve benefit from earplugs in the presence of loud music requires a positive attitude, perseverance, and a period of trial and error of the different products available by the user.

Reference

Clubbers’ attitude toward earplugs: better with use.
Nielsen LB, Beach E, Gilliver M.
THE HEARING JOURNAL
2014;67(4):6-11.

TRENDS IN HEARING

Controlling tinnitus
Reviewed by: Ameera Abdelrahim
Vol 23 No 6
 

The absence of sufficient evidence for the use of integrated sound generators for the management of tinnitus led the authors to conduct a randomised blind clinical trial in which they compared the use of a conventional hearing aid with a hearing device that contained an integrated sound generator. The study included 49 novice patients with mild to moderate bilateral symmetrical sensorineural hearing loss, at least six months of tinnitus and a Tinnitus Handicap Inventory (THI) > 20. The sound generator setting was started at the minimum setting and increased until the patient reported relief from their tinnitus. The minimum recommended treatment was use of the device for at least eight hours per day and the evaluation was conducted at three months. Both groups received counselling. The evaluator was blinded to the device provided. Measures included psychoacoustic measures of tinnitus, numeric scale and the THI. In total 47 patients completed the study. Both groups showed an improvement in symptoms when comparing the pre- and post-intervention scores. Of patients in the combined fitting group 62.5% had a reduction of 20 points or more in the THI. In the amplification group this rose to 78%. However, there was no statistical significance between outcomes for the two groups and levels of discomfort reduced for both from moderate to mild. Therefore this small study does not provide evidence for superiority of the combined device and finds both devices to be equally effective.

Reference

The influence of sound generator associated with conventional amplification for tinnitus control: randomized blind clinical trial.
Santos G, Bento R, Medeiros I, et al.
TRENDS IN HEARING
2014;18:1-9.

AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY

Passive smoking and rhinosinusitis
Reviewed by: Edward W Fisher
Vol 23 No 4
 

One would expect that subjects exposed to more passive smoke would have a significantly increased level of rhinosinusitis. This study looked at a reasonable number of sinusitis and control subjects (404 and 165) using hair nicotine as an assessment of the amount of exposure to cigarette smoke. Surprisingly, the nicotine levels were similar in the two groups and had not changed over time (one would perhaps expect the sinusitis group to actively avoid smoke after diagnosis). The prevalence of evidence of passive smoke exposure was higher in children, and had not reduced overall in the subjects over time despite many public health measures intended to reduce it. While this does not pretend to be a definitive study, the result is surprising and suggests to me that passive smoking is not a major aetiological factor in the pathophysiology of rhinosinusitis.

Reference

Passive smoke exposure in chronic rhinosinusitis as assessed by hair nicotine.
Wentzel JL, Mulligan JK, Soler ZM, et al.
AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY
2014:28(4):297-301.

ANNALS OF THE ROYAL COLLEGE OF SURGEONS OF ENGLAND

Primary ossicular chain reconstruction in open-cavity mastoidectomy
Reviewed by: Thomas Jacques
Vol 23 No 4
 

The authors performed a retrospective analysis of 21 patients who had undergone primary reconstruction of the ossicular chain during canal-wall-down mastoidectomy. The ossiculoplasty technique used consisted of removal of the malleus head and division of tensor tympani, and rotation of the malleus remnant to lie on the stapes superstructure. The procedure was deemed to have failed in three of 21 cases due to presumed non-adherence of the stapes to the malleus neck. Subgroup analysis of the 18 successful procedures showed a mean post-operative air-bone gap of 15dBHL, 19dBHL, 8dBHL and 26dBHL at 0.5, 1, 2 and 4 kHz respectively. The patients’ pre- and post-operative sensorineural thresholds were not reported, so the practical benefit of the good conductive results cannot be ascertained; however no patients suffered a ‘dead ear’. The conductive gap outcomes compared favourably with modified radical mastoidectomy alone, although no direct comparisons were drawn by the authors with other patients undergoing other forms of reconstruction. They note that further work to compare the quality-of-life outcomes of such a reconstruction with other techniques would be useful. Patients had no recurrence of cholesteatoma during the follow-up period. The paper presents a suitable technique for single-stage ossicular chain reconstruction in canal-wall-down surgery, albeit in selected cases, as the procedure relies upon the presence of an intact stapes.

Reference

Hearing outcomes following primary malleostapedial rotation ossiculoplasty in patients undergoing modified radical mastoidectomy.
Kanegaonkar RG, Whittaker M, Najuko-Mafemera A.
ANNALS OF THE ROYAL COLLEGE OF SURGEONS OF ENGLAND
2014;96(6):458-61.

Auris Nasus Larynx

A new septoplasty technique
Reviewed by: Ravi Thevasagayam
Vol 23 No 4
 

This article describes a novel septoplasty technique to correct a cartilaginous deflection. Although it took a while to understand it as the operative photographs were not very helpful it is an interesting concept. The author excises an inferior strip and performs a posterior chondrotomy. Then a slit is made in the quadrilateral cartilage anterior to the posterior chondrotomy. A small cartilaginous or bony strut (or ‘wedge’) is created and placed to run from the vomer to the slit via the convex side. This acts as a lever to pull the deflected septum to the midline. Whilst it's difficult to appreciate without the aid of the diagram in the article the concept seems very interesting. The paper describes a series of 17 consecutive patients and demonstrates both subjective and some objective measures of improvement although the acoustic rhinometry data is incomplete. My main concern would be thickening of the septum at the level of the strut, which the author concedes does happen but as this is well behind the nasal valve area this doesn't seem to be problematic. Limited numbers and data but an interesting concept and potentially a worthwhile addition to the array of techniques to try and correct the difficult cartilaginous septal deformity.

Reference

A novel wedge technique to correct the curved deviation of the cartilaginous nasal septum.
Ji-Eun L, Hahn JJ, Munyoung C, Hong RJ.
AURIS NASUS LARYNX
2014:41(2):190-94.

Auris Nasus Larynx

Risk factors for post tonsillectomy bleeds
Reviewed by: Ravi Thevasagayam
Vol 23 No 4
 

This paper reviews post-tonsillectomy bleeding in 692 patients and attempts to tease out risk factors. The overall bleed rate of 11.6% seems very high. The return to theatre rate was 2.6%. The paper identifies male patients and adult patients as risk factors. It also suggests that junior surgeons have increased bleed rates. The paper is most remarkable because patients at this institute remain inpatients for eight days and have their tonsillar fossae examined every day and hence the high bleed rate includes any blood staining during the prolonged inpatient stay. It is interesting that more than 10% of post-tonsillectomy patients have some degree of bleeding that is probably not seen in an environment where patients are discharged as day cases or overnight stays. The paper is most fascinating because it highlights the spectacular variations in worldwide practice with patients being admitted for over a week post-tonsillectomy.

Reference

Risk factors for post tonsillectomy hemorrhage.
Ryo Ikoma Sayake Sakane, et al.
AURIS NASUS LARYNX
2014:41(4):376-9.

B-ENT

Management of necrotising otitis externa
Reviewed by: Sunil Sharma
Vol 23 No 5
 

Although uncommon, necrotising (previously malignant) otitis externa (nOE) can be very aggressive, particularly if not managed appropriately. In this study the authors perform a retrospective review of 25 patients admitted with nOE over a four year period at a tertiary referral centre. They have also described a treatment algorithm for the management of nOE, having identified a lack of consistency in management within their department. Only 92% of patients had CT scanning, so two patients had no form of imaging. Almost 60% of cases were associated with pseudomonas aeruginosa, and the authors postulate that the increased use of quinolones in managing otitis externa has led to the increased finding of nOE associated with other bacterial strains. The issue of whether to biopsy these patients is a controversial one, and in this paper just over half of patients had a biopsy of granulation tissue. In 28% of cases, the biopsy sample aided the isolation of the causative organism in cases where canal swabs were negative, thus the authors recommend biopsy in resistant cases. In cases of resistant disease repeat CT was also suggested. However no mention is made of MRI scanning, which is suggested in other departments for evaluation of the extent of soft tissue involvement. In line with most UK departments, the authors’ department organises for patients to have extended course of intravenous antibiotics in the community, but the authors recognise that this can be fraught with difficulties in terms of organisation. This paper provides a useful initial management protocol for nOE but some departments may have existing protocols agreed with their local microbiology service.

Reference

Lessons learnt from the diagnosis and antimicrobial management of necrotising (malignant) otitis externa: our experience in a tertiary referral centre.
Williams SP, Curnow TL, Almeyda R.
B-ENT
2014;10:99-104.

BMC EAR, NOSE AND THROAT DISORDERS

Treatment of olfactory dysfunction
Reviewed by: Gauri Mankekar
Vol 23 No 4
 

The sense of smell is crucial to our being able to relish food and experience our environment. Olfactory dysfunction has been trivialised or ignored previously, but the negative consequences of the loss of sense of smell are being increasingly highlighted. For this study, the authors reviewed the experiences of a thousand patients with olfactory dysfunction. The patients answered 43 questions on the consequences of their problem. Although the patients did not experience any practical problems such as those associated with visual or auditory impairments, they did report their olfactory dysfunction as a debilitating condition. Loss of smell induced social isolation and motivational anhedonia having a severe detrimental effect on the quality of life of these individuals. The authors conclude that although educating the patients, the public, and medical professionals about disorders of olfaction would improve the quality of life for affected patients by reducing their practical and social problems, research into an effective treatment alone will provide the best solution to consequences of olfactory dysfunction.

Reference

Hidden consequences of olfactory dysfunction – a patient report series.
Keller A, Malaspina D.
BMC EAR, NOSE AND THROAT DISORDERS
2013:13:8.

CLINICAL OTOLARYNGOLOGY

Assessment in ENT: Intra-operative videos
Reviewed by: Andy Hall
Vol 23 No 5
 

An article examining the reliability and validity of remote scoring; a video assessment of myringotomy and grommet insertion. The primary outcome measures were to determine construct validity (differentiating between different grades of surgeons) and reliability of video scoring. Unfortunately, the study was underpowered with 10 procedures in each group (core trainee / specialist registrar and consultant) and therefore could not discern a statistical significance for construct validity on this occasion. The methodology shows promise and shouldn’t detract from further developments. There was a strong correlation between scores by the blinded raters and quite rightly this allows assessor bias to be avoided in the assessment. In the present climate it would appear video assessment is likely to become a useful adjunct for both the trainee and trainer.

Reference

A validation study on the use of intra-operative video recording as an objective assessment tool for core ENT surgery.
Bowles PF, Harries M, Young P, et al.
CLINICAL OTOLARYNGOLOGY
2014;39(2):102-7.

CLINICAL OTOLARYNGOLOGY

Emerging antimicrobial resistance in ENT outpatients
Reviewed by: Andy Hall
Vol 23 No 5
 

Given the recent statement from the UK Prime Minister on this issue, it would appear timely to assess the ‘time bomb’ of antibiotic resistance in otology. Comparison of ear swabs over twelve months from 2007 and 2012 demonstrates an increasing level of resistance: 6.5% gentamycin resistance amongst staphylococcus in 2012 (in comparison to 0% in 2007) while a similar increase in resistant pseudomonas was also demonstrated. The authors sensibly question the use of antibiotic alternatives (such as aluminium hydroxide) as an alternative. Given that it has been twenty-five years since the last ‘new’ topical antibiotic for the ear, it is wise we work closely with microbiology colleagues to ensure adequate treatment of the discharging ear.

Reference

An analysis of emerging antimicrobial resistance in an ENT outpatient department: a comparison of three hundred and forty-nine swabs taken in 2007 with five hundred and seventy-four swabs in 2012.
Prowse SJ, Marsh P, Raine CH.
CLINICAL OTOLARYNGOLOGY
2014;39(1)63-66.

CLINICAL OTOLARYNGOLOGY

Transnasal oesophagoscopy: prospective cohort review
Reviewed by: Andy Hall
Vol 23 No 5
 

This paper looked at 257 patients undergoing the procedure in a tertiary otolaryngology department. In light of the morbidity of upper GI endoscopy associated with the sedation required, the safety profile of transnasal oesophagoscopy is a clear advantage. This cohort demonstrated a 97% success rate with poor view preventing diagnosis in only 1% of cases. Most common indications were unexplained throat symptoms and dysphagia. Following transnasal oesophagoscopy 56% patients had no detectable abnormality, allowing discharge to primary care or referring specialty. Positive findings were most commonly of GI pathology including hiatus hernia, Barretts oesophagus and dysmotility. This procedure appears likely to significantly evolve patient care over the coming years and appears in trained hands a safe and diagnostically sensitive tool.

Reference

Transnasal oesophagoscopy: diagnostic and management outcomes in a prospective cohort of 257 consecutive cases and practice implications.
Abou-Nader L, Wilson JA, Paleri V.
CLINICAL OTOLARYNGOLOGY
2014;39(2):108-13.

CURRENT OPINION IN OTOLARYNGOLOGY & HEAD AND NECK SURGERY

Fungal rhinosinusitis
Reviewed by: Susan A Douglas
Vol 23 No 5
 

Allergic fungal rhinosinusitis (AFRS) has been defined by the following characteristics: presence of nasal discharge, nasal obstruction, decreased sense of smell or facial pressure for 12 weeks, mucin within the sinus cavity containing fungal hyphae and degranulating eosinophils, endoscopic evidence of nasal polyps within the sinus cavity, computed tomography (CT) or MRI findings consistent with chronic impaction of eosinophilic mucin within diseased sinuses, evidence of fungal-specific IgE by skin prick or serum IgE testing, and no evidence of invasive fungal disease. Fungal culture is variably sensitive, therefore the histologic appearance of fungal elements within eosinophilic mucin remains the more reliable indicator of AFRS. This is a well written review of the pathophysiology of allergic fungal rhinosinusitis (AFRS), which is not fully understood and is in constant evolution. Although initial theories favoured an immunoglobulin E-mediated immune response to fungal antigens as having a primary role in the immunopathologic process of AFRS, the purpose of this review was to highlight recent studies that suggest a more complex, epithelial cell-driven immune response being central to the pathophysiology. Recent studies demonstrate a central role of cytokines derived from respiratory epithelial cells, including interleukin (IL)-25, IL-33, and thymic stromal lymphopoietin, in the orchestration of both innate and adaptive T helper 2 (Th2) immune responses that are important components of the immunopathology of chronic rhinosinusitis with nasal polyposis and AFRS. In addition, the robust Th2 adaptive response may be mediated by both fungal antigens and Staphylococcus aureus superantigens. Given the evolving understanding of AFRS pathophysiology, management continues to focus on minimising the burden of the inflammatory trigger(s) and suppressing the inflammatory cascade. This is primarily accomplished through surgery and corticosteroid therapy. Immunotherapy, antimicrobial therapy and other immunomodulatory medications may help mediate the disease process as well.

Reference

Current understanding of allergic fungal rhinosinusitis and treatment implications.
Plonk DP, Luong A.
CURRENT OPINION IN OTOLARYNGOLOGY & HEAD AND NECK SURGERY
2014;22(3):221-6.

CURRENT OPINION IN OTOLARYNGOLOGY & HEAD AND NECK SURGERY

Tracheostomy safety project
Reviewed by: Susan A Douglas
Vol 23 No 5
 

Tracheostomy care is evolving, with the majority of procedures now performed percutaneously to facilitate weaning from mechanical ventilation in the critically ill. Traditional surgical indications remain, but surgical tracheostomies are increasingly performed in more complex patients. This brings unique challenges for the multidisciplinary team (MDT) in which speech and language therapists (SLTs) have a key role. Comprehensive tracheostomy care is a truly multidisciplinary process, and the roles of medical, nursing and allied health staff in safely managing and rehabilitating all patients with tracheostomies has been reinforced in the UK by the National Tracheostomy Safety Project (NTSP). Reviews of tracheostomy-related critical incidents have identified recurrent themes associated with adverse outcomes for this high-risk population. The vast majority of adverse incidents occur more than one week after initial tracheostomy tube insertion and many of these events are due to factors that are amenable to prospective system improvement strategies. Recent research has highlighted the impact of tracheostomy on communication and swallowing, along with the contribution of SLTs to the MDT, prompting new guidance for SLTs. The UK NTSP has developed educational and practical resources that have been shown to improve care. Similar approaches from around the world led to the newly formed Global Tracheostomy Collaborative. SLT-specific expertise in assessing and managing communication and swallowing needs is a vital part of this process.

Reference

The UK National Tracheostomy Safety Project and the role of speech and language therapists.
McGratha BA, Wallace S.
CURRENT OPINION IN OTOLARYNGOLOGY & HEAD AND NECK SURGERY
2014;22(3):181-7.

EUROPEAN ARCHIVES OF OTO-RHINO-LARYNGOLOGY

Swallowing outcomes following partial laryngectomy: objective assessment and pre-operative predictive factors
Reviewed by: George Garas
Vol 23 No 5
 

Partial laryngectomy constitutes one of the treatments for early stage glottic carcinoma (i.e. T1N0 and T2N0) in specialised centres. Over the years, several partial laryngectomy and reconstruction techniques have been described in the literature. The choice of technique depends on disease location and extension, as well as the individual surgeon’s preference. The most widely practised operations are vertical partial laryngectomy and horizontal supracricoid laryngectomy. Partial frontolateral laryngectomy with epiglottic reconstruction (PFLER) has been shown to produce functional and oncological results analogous to supracricoid partial laryngectomy (cricohyoidoepiglottopexy) for T1b and T2 glottic carcinomas. The purpose of this study was to evaluate swallowing following PFLER using reproducible and objective tests and also identify preoperative factors that could influence swallowing outcomes. Twenty four patients that underwent PFLER in the period 2008-2012 were retrospectively evaluated. Locoregional control was achieved in all cases, but one after a median follow-up of 16.7 months. Swallowing was evaluated within 15 days (early score) and at two months (late score) post-operatively. In this series, 83% of patients had achieved at least partial oral feeding at time of hospital discharge (mean 18 days, range 10-39 days) and 87.5% achieved exclusive oral feeding at two months postoperatively. An objective swallowing assessment by videofluoroscopy showed that 50% had a good or excellent early score, 4.2% had an average early score and 41.8% had a poor early score. Regarding late scores, 63% were classified as good or excellent, 29% were classified as ‘middle result’ because their time to recover was longer (i.e. between one and two months postoperatively), and only two patients had a poor late score. Finally, only one patient was partially fed by gastrostomy (180 days after surgery). All patients tolerated decannulation and none experienced chronic pulmonary problems. With regards to pre-operative factors, T stage was the only factor shown to influence early swallowing outcomes (but not late outcomes), probably a direct result of the extent of surgical resection. The study’s main limitation relates to the small number of patients (n=24). This knowledge may prove of particular significance to head and neck surgeons when selecting and consenting patients for partial laryngeal surgery.

Reference

Analysis of swallowing after partial frontolateral laryngectomy with epiglottic reconstruction for glottic cancer.
Fakhry N, Michel J, Giorgi R, et al.
EUROPEAN ARCHIVES OF OTO-RHINO-LARYNGOLOGY
2014;271(7):2013-20.

EUROPEAN ARCHIVES OF OTO-RHINO-LARYNGOLOGY

The anatomy and actual number of branches of the sphenopalatine artery: surgical implications
Reviewed by: George Garas
Vol 23 No 5
 

Endoscopic sphenopalatine artery ligation or cauterisation is nowadays the main treatment for epistaxis unresponsive to medical therapy. However, on review of the literature, there appears to be confusion relating to the anatomical nomenclature of the sphenopalatine artery branches and more importantly to their actual number. Many authors have described numerous branches (up to 10) arising from the sphenopalatine foramen but this is rarely the case in clinical practice. The idea of this study was to use a mixed cohort of live epistaxis patients and cadavers to investigate the actual number of branches at the level of the sphenopalatine foramen, the incidence of an accessory foramen and finally describe their surgical outcomes with sphenopalatine artery ligation. Of the 107 nasal cavities that the authors explored (combined live epistaxis and cadaveric cohorts), the sphenopalatine artery consisted of a single branch in 68 cases (63%), divided into two branches in 34 cases (32%) and three branches in five cases (5%). No more than three branches were identified. The presence of an accessory foramen was observed in 7% of cases. In each of these cases only one branch was found to traverse the accessory foramen. Their reported success rate with sphenopalatine artery ligation was 88% (15/17). Following analysis of the two failed cases, the authors found that this was due to one case where the vascular clip had been displaced following application and another where the bleeding point did not arise from a branch of the sphenopalatine artery, but from the anterior ethmoidal artery instead. This study provides useful information that has significant implications in clinical practice: 1. In most cases there will be one or two branches arising from the sphenopalatine foramen. 2. Coagulation is probably more effective than clipping as the vascular clips may not sit properly on the vessel and as a result become displaced leading to re-bleeding. 3. During endoscopic dissection it is advisable that the surgeon extends the subperiosteal flap inferiorly due to the possibility of discovering an accessory foramen through which one additional branch traverses.

Reference

Anatomical and surgical study of the sphenopalatine artery branches.
Gras-Cabrerizo JR, Ademá-Alcover JM, Gras-Albert JR, et al.
EUROPEAN ARCHIVES OF OTO-RHINO-LARYNGOLOGY
2014;271(7):1947-51.

EUROPEAN REVIEW OF ENT

CIs and the elderly
Reviewed by: Badr Eldin Mostafa
Vol 23 No 5
 

Although cochlear implantation (CI) is thought to be a predominantly paediatric procedure, more and more adults are candidates for cochlear implants. This retrospective study was performed on 80 adults aged above 50 who were implanted for at least nine months. Results showed an improved speech perception and quality of life throughout all studied age groups. It is well recognised that CI surgery is a low risk surgery and can be safely offered to adults of all age groups. Hearing rehabilitation is important and allows adults to regain an active role and to avoid social isolation and depression especially in the older patient.

Reference

Cochlear implantation in older patients: outcomes and comparisons.
Rafferty A, Tapper L, Strachan D, Raine C.
EUROPEAN REVIEW OF ENT
2013:134(3):119-24.

EUROPEAN REVIEW OF ENT

The unknown primary again
Reviewed by: Badr Eldin Mostafa
Vol 23 No 5
 

In this retrospective study of 35 patients, the authors followed a systematic protocol for the detection and management of malignant cervical lymph nodes without an apparent primary lesion. Although their one, three and five year survival results are consistent with the international literature, the study has some flaws. They did not submit their patients to a PET-scan, although it is in the recommendations of the French ENT society, they did not biopsy the nasopharynx (only a tonsillar biopsy in 25 cases), and a fine needle aspiration cytology was only performed in 19 cases whereas all cases underwent a preliminary open biopsy and frozen section examination during the presumptive definitive surgery. Although it confirms the dire prognosis of this cohort of patients, the group was rather heterogeneous as were the treatment protocols.

Reference

Treatment of head and neck squamous cell carcinoma of an unknown primary (HNCCUP): oncologic analysis of 35 cases.
Berta E, Atallah I, Quesada JL, et al.
EUROPEAN REVIEW OF ENT
2013;134(3):131-8.

FACIAL PLASTIC SURGERY

Freestyle facial artery perforator flaps for nasal reconstruction
Reviewed by: Sunil Kumar Bhatia
Vol 23 No 5
 

This is an update from the authors that originally described the freestyle facial artery perforator flap for one stage nasal reconstruction in 2009. They now update with their 10-year experience of freestyle facial artery perforator flaps, accumulating a series of 21 patients (out of 86 nasal alar reconstructions) since 2004. Only one flap had minor congestion leading to flap tip necrosis. There is a good overview of the technique with an insight into its evolution and discussion of the relevant anatomy. Crucially they describe planning methodology and contraindications with the technique illustrated clearly with excellent photographs. They conclude that near total alar subunit or lateral alar defects are well served with this freestyle facial artery perforator flap reconstruction. This is good read for all surgeons interested in nasal reconstruction.

Reference

Reconstruction of nasal alar defects with freestyle facial artery perforator flaps.
D’Arpa S, Pirrello R, Toia F, et al.
FACIAL PLASTIC SURGERY
2014;30(3)277-86.

FACIAL PLASTIC SURGERY

One stage nasal reconstruction with local flaps
Reviewed by: Sunil Kumar Bhatia
Vol 23 No 5
 

This is an excellent and authoritative review of an often difficult and controversial (as there are so many options or so few) clinical subject. Better education and earlier diagnosis of skin tumours allows defects with limited size and depth to present in clinical practice; achieving good reconstruction, however, is often challenging. The authors have put together an excellent article with schematic diagrams and case studies accompanied by photographs. The main themes are the supratip area, dorsum and side wall subunits, and their experience with local rotation or advancement flaps. It is obvious that the authors have a wealth of experience and the article discusses the planning, selection and use of local flaps. This is an excellent review for nasal tip / lateral wall cutaneous reconstruction and is worth reading as both a technical review and reminder of the options.

Reference

One stage nasal soft tissue reconstruction with local flaps.
Helml G, von Gregory HF, Amr A, et al.
FACIAL PLASTIC SURGERY
2014;30(3):260-7.

FACIAL PLASTIC SURGERY CLINICS OF NORTH AMERICA

May 2014 issue: Neck Rejuvenation
Reviewed by: Mrinal Supriya
Vol 23 No 5
 

The May issue of this popular facial plastic journal is dedicated to detailed discussion of surgical and non-surgical procedures for rejuvenation of the neck. Following descriptions of relevant neck and face anatomy, techniques are discussed for neck and face rejuvenation. In addition to commonly employed interventions such as botulinum toxin, chemical peels, dermabrasion and carbon dioxide laser, relatively uncommon means such as intensity focused ultrasound, plasma skin regeneration and micropulsed 1444-nm Nd:YAG interstitial fibre laser are mentioned in detail. Adjunctive procedures including implants and treatment of the ptotic submandibular gland has been given in a separate chapter. Equally useful are the chapters dedicated to careful and detailed description of various surgical procedures used for neck and face lifts such as classical superficial musculoaponeurotic system (SMAS), extended SMAS approach, deep plane lifts and vertical neck lifts. The final chapter is dedicated to discussion of complications and sequel of surgical procedures. There are exceptional pre- and post-procedure photographs, which are given in ample number throughout the journal. This edition is essential for any budding facial cosmetic surgeon as well as a useful one for the veterans.

Reference

FACIAL PLASTIC SURGERY CLINICS OF NORTH AMERICA
Edited: Thomas JR, Hamilton MM, Beaty MM.
2014;22(2):161-336.

INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY

The impact of rhino-sinusitis treatment on olfaction
Reviewed by: Laith Tapponi
Vol 23 No 5
 

This study included 28 adults prospectively enrolled between March 2011 and May 2013 into a non-randomised, multi-institutional cohort. Adults electing endoscopic sinus surgery experienced gains in olfaction comparable to adults electing continued medical management. The evidence in this study comparing the impact of medical and surgical management of chronic rhinosinusitis on olfactory function is limited. Further study with larger sample size and more sensitive measures of olfaction are needed to determine differences between treatment groups.

Reference

Comparative effectiveness of medical and surgical therapy on olfaction in chronic rhino sinusitis: a prospective, multi-institutional study.
DeConde AS, Mace JC, Alt JA, et al.
INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY
2014;4(9):725-33.

INTERNATIONAL JOURNAL OF LANGUAGE & COMMUNICATION DISORDERS

Ideal terminology for unexplained paediatric language problems
Reviewed by: Gauri Mankekar
Vol 23 No 5
 

This paper aims to open a discussion about the different labels being used to refer to children’s unexplained language impairments. A wide range of terminology has been applied creating confusion, impeding progress of research and access to appropriate services. For example, the terms ‘dyslexia’, ‘attention deficit hyperactivity disorder’ and ‘autistic spectrum disorder’ are used for difficulties with reading, attention or social cognition respectively. But there is no definitive label for children with unexplained language problems. In DSM-5, the term ‘language disorder’ is problematic as it identifies too wide a range of conditions on an internet search. The author of this paper suggests retaining ‘specific language impairment’ with the understanding that ‘specific’ means ‘idiopathic’ rather than implying there are no other problems beyond language. The author has also suggested several other diagnostic terms and their advantages and disadvantages for evaluation.

Reference

Ten questions about terminology for children with unexplained language problems.
Bishop DVM.
INTERNATIONAL JOURNAL OF LANGUAGE & COMMUNICATION DISORDERS
2014;49(4):381-415.

INTERNATIONAL JOURNAL OF PEDIATRIC OTORHINOLARYNGOLOGY

Cochlear implants with an absent or hypoplastic cochlear nerve?
Reviewed by: Patrick Spielmann
Vol 23 No 5
 

The cornerstone of successful cochlear implantation has been the presence of a population of cochlear nerve endings which are able to mount a neural response to electrical stimulation. The authors of this paper present their experience of five children with absent or hypoplastic cochlear nerves who received cochlear implants. All children used their implants daily and had some improvement in perception of sound but only one achieved intelligible speech, in common with other similar series. There were no pre-operative imaging or auditory factors that predicted good performance. It appears that a small number of children with apparent cochlear nerve dysplasia may benefit from cochlear implantation, but it is currently impossible to predict which. Further, more sophisticated imaging or physiological tests will probably tell us in the future.

Reference

Cochlear implantation in children with cochlear nerve deficiency.
Vincenti V, Ormitti F, Ventura E, et al.
INTERNATIONAL JOURNAL OF PEDIATRIC
OTORHINOLARYNGOLOGY
2014;78(6):912-17.

INTERNATIONAL JOURNAL OF PEDIATRIC OTORHINOLARYNGOLOGY

Do we need to intervene after complications of acute sinusitis in children?
Reviewed by: Patrick Spielmann
Vol 23 No 5
 

Complications of acute sinusitis in children are not uncommon and some are managed surgically. The authors of this paper reviewed their experience of subsequent chronic rhinosinusitis (CRS). Nine of 86 patients required surgery in the 12 months after their initial presentation for symptoms and signs of CRS. There was no difference between the initially surgically or medically managed groups but they were young (mean and median age <5 years). The authors, not unreasonably, suggest reviewing patients up to 12 months following an orbital or intracranial complication of sinusitis as a significant percentage (10% here) may require further intervention.

Reference

Do you need to operate following recovery from complications of pediatric acute sinusitis?
Patel RG, Daramola OO, Linn D, et al.
INTERNATIONAL JOURNAL OF PEDIATRIC
OTORHINOLARYNGOLOGY
2014;78(6):923-5.

INTERNATIONAL JOURNAL OF PEDIATRIC OTORHINOLARYNGOLOGY

Friendly bacteria in the ear nose and throat to combat the bad…
Reviewed by: Patrick Spielmann
Vol 23 No 5
 

The author presents a thorough review of bacterial interference and the studies that have been conducted in common ENT conditions. The simple concept is that a strong population of normal flora will interfere with colonisation and subsequent infection by pathogenic strains. By replacing or preserving this flora, the recurrence of infections can be reduced: alpha haemolytic streptococci have been successfully inoculated into the naso / oropharynx of children to reduce the recurrence of with Group A beta haemolytic streptococcal tonsillitis. Several randomised double-blind, placebo-controlled trials are presented to support this as an effective therapy. The role of selecting antibiotics to preserve normal flora (such as first or second generation cephalosporins) is presented, again with compelling evidence that a change in antibiotic prescribing away from penicillin might be a good thing. Bacterial interference appears to provide us with a new way to reduce the swelling tide of antibiotic resistance and is clearly worthy of further study.

Reference

The effects of antimicrobials and exposure to smoking on bacterial interference in the upper respiratory tract of children
Brook I.
INTERNATIONAL JOURNAL OF PEDIATRIC
OTORHINOLARYNGOLOGY
2014;78(2):179-85.  

JAMA OTOLARYNGOLOGY – HEAD & NECK SURGERY

Extent of central neck dissection in the patients with thyroid carcinoma
Reviewed by: Shabbir Akhtar
Vol 23 No 5
 

The first level of lymphatic spread in well-differentiated thyroid carcinoma is to the central compartment of the neck, namely, the paratracheal, prelaryngeal and pretracheal lymph nodes. Central neck dissection may carry an increased morbidity, namely, hypoparathyroidism and recurrent laryngeal nerve injury. The limits of central neck dissection are bordered by the hyoid bone superiorly, the suprasternal notch inferiorly (including the upper mediastinal lymph nodes), the common carotid artery laterally, and the trachea medially. Central nerve dissection refers to removal of the unilateral or bilateral paratracheal regions. The upper part of central neck lies between hyoid bone superiorly and cricoid cartilage inferiorly. The hypothesis of authors was that the upper part of central neck is devoid of lymphatic structures and need not be dissected as part of a routine central neck dissection. A total of 31 paratracheal neck dissections were performed. The surgical specimens were divided into upper and lower paratracheal regions, corresponding to the level of the cricoid. A median of 8 nodes were retrieved (range, 2-21). All metastatic lymph nodes were detected in the lower paratracheal region, and similarly all lymphatic structures were also located in the lower central neck dissection specimen. The upper specimens were devoid of lymphatic tissue or cancer-bearing lymph nodes and consisted of fibrofatty connective tissue only. This series challenges the need to dissect this area routinely as a part of central neck dissection for patients with well-differentiated thyroid cancer.

Reference

The upper limits of central neck dissection.
Holostenco V, Khafif A.
JAMA OTOLARYNGOLOGY – HEAD & NECK SURGERY
2014;140(8):731-5.

JOURNAL OF CRANIO-MAXILLO-FACIAL SURGERY

An analysis of 60 treated cystic lesions in children
Reviewed by: Sunil Kumar Bhatia
Vol 23 No 5
 

This is a retrospective single-centre study of 60 consecutive cases in children. Children aged four months to 14-years-old underwent intervention under general anaesthetic from 2000 to 2012. As one might expect, most of these cysts were mucoceles and ranulas. Of this group, 49 patients had an intraoral approach and 11 required an external. There is a good discussion of each of the common cysts, namely mucoceles, ranulas, plunging ranulas, dermoid and epidermoid cysts, cystic hygromas, branchial cleft cysts and thyroglossal cysts. The paper is worth reading just to get an overview of the incidence and treatment of the commonest types of these lesions. There are good photographs and some illustrations. It is also good to get a perspective on these fairly common and some uncommon lesions that may present unexpectedly.

Reference

Surgical treatment of oral and facial soft tissue cystic lesions in children. A retrospective analysis of 60 consecutive cases with literature review.
Kolomvos N, Theologie-Lygidakis N, Tzerbos F, et al.
JOURNAL OF CRANIO-MAXILLO-FACIAL SURGERY
2014;42(5):392-6.

JOURNAL OF CRANIO-MAXILLO-FACIAL SURGERY

Free flap reconstruction in stage three bisphosphonate-related osteonecrosis
Reviewed by: Sunil Kumar Bhatia
Vol 23 No 5
 

There is no widely accepted gold standard for the treatment of bisphosphonate-related osteonecrosis of the jaw (BRONJ). Early BRONJ is managed conservatively but there is controversy regarding the treatment of the later stages. Stage three is defined as exposed bone with pain and or infection, in the presence of at least one of the following: pathological fracture, extra-oral fistula or osteolysis extending to the inferior border. The authors present a systematic review of the literature and discuss their own series. Twenty-seven papers were analysed and eight papers fulfilled the inclusion criteria of academic publications, clinically and histologically confirmed diagnosis, reconstruction with vascularised free osseous transfer and minimum follow-up of 12 months. This paper goes some way to promoting free flap vascular transfer and suggests good results. It is a small dataset, and by the authors’ own admission, additional studies from larger case series or case controlled series are necessary.

Reference

Outcomes of osseous free flap reconstruction in stage III bisphosphonate-related osteonecrosis of the jaws: Systematic review and a new case series.
Vercruysse H,Backer T, Mommaerts MY.
JOURNAL OF CRANIO-MAXILLO-FACIAL SURGERY
2014;42(5):377-86.

JOURNAL OF CRANIOFACIAL SURGERY

A conservative approach to treat ameloblastoma
Reviewed by: Sunil Kumar Bhatia
Vol 23 No 5
 

Ameloblastoma is an odontogenic tumour that is benign but locally aggressive and is associated with local recurrence. They are rare, accounting for 1% of oral tumours, and occur almost exclusively in the jaws. It is more common in the mandible and occurs most frequently at the angle. It has traditionally been treated aggressively with wide local excision, marginal or sectional resections. The authors discuss the management of this lesion using a 19-year-old female patient as an example. This patient presented with a large cyst that on orthopantomogram (OPG) appeared radiolucent, centred around the third molar and ascending ramus of the mandible. Initial treatment with decompression and daily irrigation was followed by a further enucleation procedure and application of Carnoy’s solution. Three years post-operatively the patient is well with no recurrence. This does confirm that a less radical approach in the treatment is possible at least for some types of unicystic ameloblastomas. This is a well written and succinct paper quite pertinent for surgeons that operate in the maxillofacial region.

Reference

Conservative approach: using decompression procedure for management of a large unicystic ameloblastoma of the mandible.
Xavier SP, Mello-Filho FV, Rodrigues WC, et al.
JOURNAL OF CRANIOFACIAL SURGERY
2014;25(3)1012-1014.

JOURNAL OF CRANIOFACIAL SURGERY

Reconstruction after parotid surgery
Reviewed by: Sunil Kumar Bhatia
Vol 23 No 5
 

This is a retrospective study from Naples, Italy. The authors compare patients with benign parotid disease that were reconstructed with three different techniques. In total 224 patients between February 2002 and March 2009 were included; these patients had either formal superficial parotidectomy or extra capsular dissection and were reconstructed by superficial musculoaponeurotic system (SMAS) flap, sternocleidomastoid (SCM) muscle flap or a temporoparietal fascia (TPF) flap. The surgical approach was a modified facelift and only patients with pleomorphic adenoma or Warthin tumours were included. The authors conclude all three reconstructive techniques drastically reduce post-parotidectomy Frey’s syndrome. There is some discussion of the raising of the three flaps but it is limited. They advise the SMAS flap to reconstruct in middle aged patients, the SCM in patients with recurring neoplastic disease and the TPF flap in other patients. It would be interesting to check a similar number of patients with no reconstruction and compare their outcomes, especially quality of life. Similarly it would be interesting to gather data on the numbers of surgeons that perform immediate reconstruction and if it is indicated.

Reference

Reconstructive techniques of the parotid region.
Orabona GD, Salzano G, Petrocelli M, et al.
JOURNAL OF CRANIOFACIAL SURGERY
2014;25(3)998-1002.

JOURNAL OF LARYNGOLOGY & OTOLOGY

Application of paper patching in patulous eustachian tube
Reviewed by: Madhup K Chaurasia
Vol 23 No 5
 

The condition of patulous eustachian tube, as opposed to dysfunctional eustachian tube, is less frequently diagnosed. Symptoms related to this, such as autophony, aural fullness, ‘being under water’, ‘hearing their own breathing’, and hearing sensitivity (varying in either direction) can occur in other conditions such as eustachian tube dysfunction and canal dehiscence. In this interesting study, the authors diagnosed this problem on the basis of symptoms and tried paper patching to see if this resolved symptoms instantly or in the long term. Twenty-one patients were selected and paper patching was done under the microscope, with rectangular pieces of cigarette paper applied to the superior part of the tympanic membrane. Observations were made from a casual query after the procedure as to whether or not the symptoms disappeared. In 76.2% of patients the symptoms disappeared immediately. In some cases the symptoms disappeared only partly and therefore more paper patches were applied. In the long term the symptoms reappeared in half the number of ‘cured’ patients and this was because the paper patches were dislodged. Some patients experienced slight discomfort but there were no adverse effects. The authors explain the improvement on the basis that a lax tympanic membrane, which can be a feature of a patulous eustachian tube, allows a higher admittance for lower frequencies; stiffening by paper patching reduces this and relieves the symptoms. The presence of retraction pockets tensing up the tympanic membrane or a cholesteatoma may circumvent this phenomenon. High admittance of lower and mid-frequencies is related to the upper and lower parts of the tympanic membrane respectively. Other studies in literature have been described, one of which used clay to stiffen the tympanic membrane. The method described by the authors is simple, non-invasive and can be conveniently undertaken in a clinic setting and therefore, if successful, conforms to cost effectiveness.

Reference

Paper patching of the tympanic membrane as a symptomatic treatment for a patulous eustachian tube syndrome.
Boedts M.
THE JOURNAL OF LARYNGOLOGY & OTOLOGY
2014;128(3):228-35.

JOURNAL OF LARYNGOLOGY & OTOLOGY

Factors affecting the occurrence of salivary fistula after total laryngectomy
Reviewed by: Madhup K Chaurasia
Vol 23 No 5
 

It is generally believed that patients should be fed by nasogastric tube for 7-10 days after undergoing total laryngectomy or laryngopharyngectomy to avoid the occurrence of post-operative salivary fistula. This study challenges this belief and looks into various factors that cause occurrence of salivary fistula, predominantly the timing of resumption of oral feeding. Eighty-nine patients were divided into an ‘early feeding’ group in which oral feeding started 24 hours after surgery and a ‘late feeding’ group in which oral feeding began seven days later. The exact protocols for feeding were observed in the two groups in terms of starting with clear fluids and going on to semi-solids. Various other factors possibly causing the occurrence of post-operative salivary fistula were also assessed. Variables such as gender, pre-operative tracheotomy, presence of chronic co-morbidities, pre- and post-operative haemoglobin levels, nutritional status, tumour location (glottic, supraglottic, transglottic or hypopharyngeal), primary tumour surgery type, duration of surgery and size of the remnant pharynx did not exhibit any statistically significant difference in the development of salivary fistula. The same was the case with the type of neck dissection carried out, jugular vein ligation and blood transfusion requirement. It is interesting that the nutritional status of patients was also insignificant in determining the occurrence of salivary fistula. The only variable which was associated with the development of post-operative salivary fistula was the histopatholgical cancer involvement of the surgical margins. This did not matter if it was carcinoma in situ but the tumour invasion of the surgical margin significantly affected the development of salivary fistula. The results of this study are in agreement with earlier studies quoted from the literature that did not demonstrate that early feeding increases the risk of salivary fistula. The authors contend that early feeding does not add any risks to this complication. Early feeding is therefore recommended as it restores normal physiology, is possibly more hygienic and is, after all, no different from ingesting saliva. It would also encourage early discharge and therefore reduce the cost of the treatment.

Reference

Does early oral feeding increase the likelihood of salivary fistula after total laryngectomy?
Sousa AA, Porcaro-Salles JM, Soares JMA, et al.
THE JOURNAL OF LARYNGOLOGY & OTOLOGY
2014;128(4):372-8.

JOURNAL OF LARYNGOLOGY & OTOLOGY

Lower respiratory involvement in allergic rhinitis and chronic sinusitis
Reviewed by: Madhup K Chaurasia
Vol 23 No 5
 

The recent ARIA (Allergic Rhinitis and its Impact on Asthma) project has generated interest in simultaneous involvement of the lower respiratory airway in cases of chronic rhinosinusitis and allergic rhinitis. This study takes into account the extent of pulmonary function involvement in these patients. Relevant indicators of pulmonary function were assessed in 203 patients with chronic rhinosinusitis who were scheduled to undergo FESS because of failed medical treatment. These were divided into two groups, with and without nasal polyps. Another 89 patients with allergic rhinitis participated in this study. In all these patients there was no obvious or diagnosed lower respiratory involvement such as asthma or chronic obstructive pulmonary disease (COPD). Prior to FESS an extensive range of pulmonary function tests were performed along with rhinomanometry, and the radiographic severity of chronic sinusitis was assessed by the Lund-Mackay CT staging system. IgE levels were measured along with inflammatory mediators and exhaled nitric oxide concentration. The results showed that pulmonary function was significantly affected in chronic rhinosinusitis patients compared with normal controls but the presence or absence of polyps did not matter. Pulmonary function parameters did not seem impaired in patients with allergic rhinitis as compared with controls, and the same was the case regarding nasal obstruction between patients with chronic rhinosinusitis and controls. In patients with chronic rhinusinusitis, variations in CT scores according to the Lund-Mackay scoring system and IgE levels did not relate to the presence of nasal polyps. However, a higher level of IL-5 significantly correlated with reduced pulmonary function. The authors claim that this study has shown for the first time that patients with chronic sinusitis have latent obstruction of the small airways, as detected by pulmonary airflow testing, even though these patients may not be diagnosed as having obstructive lung function changes and tend to be asymptomatic. It has been suggested that cytokines and chemokines present in the post-nasal discharge are important factors causing asthma and COPD. The study is well controlled and subjected to statistical analysis. It adds an important dimension to the concept of ARIA.

Reference

Pulmonary function in patients with chronic rhinosinusitis and allergic rhinitis.
Kariya S, Okano M, Oto T, et al.
THE JOURNAL OF LARYNGOLOGY AND OTOLOGY
2014;128(3):255-62.

JOURNAL OF LARYNGOLOGY & OTOLOGY

Supplementing intranasal cortical steroids with montelukast: does it help
Reviewed by: Madhup K Chaurasia
Vol 23 No 5
 

Intranasal steroids are widely used in the treatment of allergic rhinitis. Whether or not the addition of montelukast helps was assessed in this study. This was a single centre prospective randomised double-blind placebo-controlled trial of two groups of patients, one receiving intranasal steroids with a placebo and the other intranasal steroids with montelukast. Symptom scores and quality of life questionnaires were obtained in the first visit when the treatment was started. All patients had moderate to severe allergic rhinitis and therefore sleep disturbance was also taken into account. Identical recordings were taken at four and eight weeks after starting the treatment. Patient compliance was studied and results were subjected to statistical analysis. At the end of one month the mean scores for daytime nasal and nocturnal symptoms, but not daytime eye symptoms, were significantly lower in the montelukast group compared to the placebo group. All symptom scores improved significantly at two months, but the improvement was significantly greater in the montelukast group. The quality of life score was improved in the montelukast group and the difference compared with the placebo group was statistically significant. A record was also made of breakthrough symptoms and requirement of loratidine; this was much lower in the montelukast group. The authors are aware that this study is limited due to lack of objective measures such as rhinomanometry. The results of this study quite convincingly suggest that addition of montelukast in patients with moderate to severe allergic rhinitis is helpful in reducing symptoms and improving quality of life. The study is well structured and suggests a simple method to improve the management of allergic rhinitis.

Reference

Quality of life assessment in patients with moderate to severe allergic rhinitis treated with montelukast and/or intranasal steroids: a randomised, double-blind, placebo-controlled study
Goh BS, Ismail MIM, Husain S.
THE JOURNAL OF LARYNGOLOGY & OTOLOGY
2014;128(3):242-248.

JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY

Coupler microvascular anastomoses: how good?
Reviewed by: Sunil Kumar Bhatia
Vol 23 No 5
 

This paper is written by a group of reconstructive surgeons and a school of computing. The study used computational fluid dynamics to model blood flow through idealised sutured and coupled vessels, to investigate if differing anastomotic techniques affect intravascular blood flow. A computer-aided three-dimensional interactive application (CATIA), computer-aided design (CAD) and a microvascular anastomotic coupling (MAC) device were employed to obtain results of simulated anastomoses. They demonstrated how the flow patterns in the two different anastomoses vary to produce different physical properties at the anastomotic site. Based purely on the simulated data gathered, it appears clot formation may be more likely using the sutured technique. It would suggest the coupled anastomosis has less thrombogenic potential.

Reference

Blood flow through sutured and coupled microvascular anastomoses: A comparative computational study.
Wain RAJ, Whitty JPM , Dalal MD, et al.
Journal of Plastic, Reconstructive & Aesthetic surgery
2014;67(7)951-59.

JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY

Harvesting the flexor hallucis longus: what is the increased morbidity?
Reviewed by: Sunil Kumar Bhatia
Vol 23 No 5
 

The free fibula flap is now widely used in clinical applications for microvascular reconstruction and occasionally, to add bulk, the flexor hallucis longus (FHL) muscle is harvested along with the fibula. The post-operative morbidity is usually described as mild and temporary, however a reduction of hallux flexion is expected when muscle is harvested. This retrospective study assessed 32 patients, all of whom had undergone mandibular reconstruction with a free fibula flap between 1995 and 2009. All patients were assessed by a blinded observer using an average of three measurements of the range of motion of the metatarsophalangeal joint, the interphalangeal joint and the combined strength of the hallux flexors. It was found that the donor leg had a significant decrease in strength of hallux flexion independent of FHL muscle harvest. It is suggested that following the harvest of the fibula and its peroneal vessels, the muscle is possibly left devascularised and denervated. While the morbidity is small, it appears that no benefit is conveyed by FHL preservation.

Reference

The effect of flexor hallucis longus harvest on hallux function: A retrospective cross-sectional cohort study.
Van den Heuvel SCM, van der Veen FJC, Winters HAH.
JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY
2014;67:986-91.

JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY

Nasolabial flap to reconstruct periorbital defects
Reviewed by: Sunil Kumar Bhatia
Vol 23 No 5
 

The authors present a series of 25, mainly geriatric patients that had ablative surgery with complex defects in the paranasal and orbital regions. The paranasal and periorbital regions are extremely important for facial aesthetics and quality of life. The authors describe a contralateral cranial based nasolabial flap for complex full thickness defects. The advantages of the flap are a thin and pliable flap, good aesthetic matching, minimal donor site morbidity, reliability and resilience of the flap and single stage closure of the defect. There are very good colour photographs that show the various stages. The surgical technique is very sparingly described and will require further reading prior to attempting this flap. In older patients this would be a very useful alternative to free flap reconstruction.

Reference

The cranially based contralateral nasolabial flap for reconstruction of paranasal and periorbital surgical defects.
Kerem H, Bali U, Sönmez E, et al.
JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY
2014;67(5):655-61.

JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY

The many uses of human amnion
Reviewed by: Sunil Kumar Bhatia
Vol 23 No 5
 

Human amnion has historically been the focus of much myth and superstition. To be born with the ‘caul’ intact was considered lucky and the caul was often manufactured into clothing. In 1910 foetal membranes were first used in skin transplantation and since then have been used with great success in almost all sites of the body by most surgical specialties. The authors have written an excellent paper discussing the various uses. They initially outline the anatomy and physiology and go on to discuss the mechanism of its therapeutic effects. This tissue provides an incredible versatile, economical and widely available substrate and is easy to store. This paper is definitely worth reading to appreciate this amazing material and its applications.

Reference

The clinician applications of human amnion in plastic surgery.
Fairbairn NG, Randolph MA, Redmond RW
Journal of Plastic, Reconstructive & Aesthetic surgery
2014;67(5):662-75.

JOURNAL OF VESTIBULAR RESEARCH

Be sober to stay on your feet
Reviewed by: Victor Y Osei-Lah
Vol 23 No 4
 

Readers would either have had a personal experience or observed the inelegant gait of the inebriated. Re-aligning the body during postural perturbations involves changes in head position, shoulders, and hip, knee and ankle joints. The main hypothesis of this study was that alcohol intoxication would cause misalignment of the head and other body segments in upright stance. A secondary aim was to investigate whether alcohol intoxication affects the ability for the body to adapt and maintain accurate body alignment during balance perturbations. Twenty-five adult subjects with no neurological / neuro-otological disease were recruited. The subjects consumed an unspecified amount of 70% ethanol diluted in elderflower juice. The balance tests required subjects to stand on a platform in quiet stance without perturbations and in upright posture with perturbations using calf muscle vibration, with eyes open and eyes closed. To measure the changes in posture in the antero-posterior and lateral directions, sensors were attached to five areas: head, shoulder, hip, knee and ankle. The tests were performed once a week for three weeks at three blood alcohol levels (BAC): 0.00%, 0.06% and 0.10%. In the absence of alcohol intoxication (BAC 0.00%), head position was more anterior when the eyes were closed. This head position increased further when perturbations were introduced; the position of the knee in quiet stance became more posterior, that is rigid, at higher BAC, made worse by both perturbations and eye closure. There was a significantly greater lateral displacement of the head, and antero-posterior displacement of the shoulders at high BACs. The displacements were worse during perturbations. An interesting finding was that the rigid alignment of the body when intoxicated was worse when the eyes were open than when closed, indicating that visual stabilisation is inadequate in compensating for alcohol-induced ataxia. Vertical alignment of the head was affected by alcohol intoxication most likely due to impairment in the perception of true vertical. The authors conclude that the changes in body alignment and the poor compensatory mechanisms probably contribute to the risk of falling in the inebriated.

Reference

Acute alcohol intoxication impairs segmental body alignment in upright standing.
Hafstrom A, Patel M, Modig F, et al.
JOURNAL OF VESTIBULAR RESEARCH
2014;24(4):297-304.

JOURNAL OF VESTIBULAR RESEARCH

Is auditory neuropathy spectrum disorder a disorder of the whole eighth cranial nerve?
Reviewed by: Victor Y Osei-Lah
Vol 23 No 5
 

Auditory neuropathy spectrum disorder (ANSD) is now well recognised in audiological circles. Vestibular nerve function has not been extensively studied in ANSD. The authors used cervical vestibular evoked myogenic potential (cVEMP) and caloric tests to assess the integrity of the inferior and superior vestibular nerves respectively in 26 ANSD subjects. There were 16 females and 10 males with ages ranging between 13 years and 42 years (mean 21.8 years). Vestibular complaints were reported by 15 subjects (57.6%) although I would not consider blackouts and loss of consciousness, vestibular in origin. A control group of 26 subjects were recruited. The results in the ANSD group were as follows: in 96.15% subjects (50 ears), cVEMPs were absent. In a further one ear, the amplitude was abnormal. Normal cVEMP was elicited in one ear. Caloric results were classified as hypoactive (86.53%), hyperactive (5.76%) or normal (7.69%). When the cVEMP and caloric abnormalities were combined, bilateral vestibular hypofunction was identified in 76.92%. Asymmetric dysfunction was seen in five subjects (19.23%) whereas in four subjects (15.38%), hypofunction was unilateral. Vestibular dysfunction did not correlate with the pattern and degree of hearing loss. This is an excellent study overall, that shows further evidence that ANSD is more than an ‘auditory’ nerve abnormality and vestibular function tests should perhaps be done in all such patients. The formula used by the authors to determine caloric abnormality was unconventional and it would have been interesting to know if the aetiology of the ANSD had any bearing on the type of caloric abnormality. Should ANSD, with its many synonyms, be renamed? That is a discussion for another time.

Reference

Cervical vestibular evoked myogenic potentials and caloric test results in individuals with auditory neuropathy spectrum disorders.
Sujeet KS, Niraj KS, Animesh B, et al.
JOURNAL OF VESTIBULAR RESEARCH
2014;24(4):313-23.

LARYNGOSCOPE

Paediatric pain control post-tonsillectomy
Reviewed by: Mark Puvanendran
Vol 23 No 5
 

The use of codeine in the paediatric population is widely debated since the American Food and Drug Administration (FDA) published warnings regarding overdose and death following the usage of codeine. Codeine is metabolised by the polymorphic cytochrome PY4502D6 (CYP2D6) in the liver. The variations of CYP2D6 lead to four phenotypes for the metabolism of codeine; ultra-rapid, extensive, intermediate and poor metabolisers. The paper highlights the frequencies of these phenotypes in Caucasians, Asians and Africans. The authors consist of a paediatric otolaryngologist, anaesthetist, paediatrician and pharmacist. Their literature review search strategy is not clearly described, the levels of evidence of the studies is summarised at the end but this information is not provided for individual study. The use of paracetamol, ibuprofen and dexamethasone are briefly discussed. Guidelines from the American Academy of Otolaryngology- Head and Neck Surgeons in 2011 are described. This is an important subject and clear guidelines derived from a solid evidence base are required. This paper is a nice summary of the problem but fails to provide adequate guidance on the next step in analgesia following paracetamol and ibuprofen. The consensus statement of the Royal Colleges of Anaesthetics, Paediatrics and Child Health and two groups of pharmacists in the UK provide additional guidance.

Reference

What Is the best non-codeine postadenotonsillectomy pain management for children?
Yellon RF, Kenna MA, Cladis FP, et al.
LARYNGOSCOPE
2014;124(8):1737-8.

NEUROSURGERY

Malignant craniopharyngiomas
Reviewed by: Showkat Mirza
Vol 23 No 5
 

Craniopharyngiomas are successfully managed with surgery and / or adjuvant chemoradiotherapy. The transnasal endoscopic route has become increasingly utilised in the management of these challenging tumours. This paper reviews 23 cases from the literature of the rarely reported malignant transformation. Histologically the most common tumour type was a squamous cell carcinoma. Twenty-two percent of the cases were diagnosed as malignant craniopharyngioma at first biopsy. Of the rest the median time from initial benign diagnosis to malignant transformation was 8.5 years (range 3-55 years). The median overall survival after malignant transformation was six months. Malignant craniopharyngiomas are therefore rare and associated with a poor prognosis. Malignant transformation tends to occur years after the initial benign craniopharyngioma diagnosis and is associated with multiple benign craniopharyngioma recurrences. Their analysis shows that contrary to wide spread belief there seems to be a poor colouration between radiotherapy and subsequent malignant transformation.

Reference

Malignant transformation in craniopharyngioma.
Sofela AA, Hettig ES, Curran O, Bassi S.
NEUROSURGERY
2014;75(3):306-14.

NEUROSURGERY CLINICS OF NORTH AMERICA

Endovascular management of cavernous and paraclinoid aneurysms
Reviewed by: Gentle Wong
Vol 23 No 5
 

This review discusses management of aneurysms arising from the internal carotid artery from the entrance into the cavernous sinus until just before the take off of the posterior communicating artery. Whilst paraclinoid aneurysms do not tend to have ENT presentations, cavernous ones may rarely present with epistaxis, and retro-orbital pain. Focusing on cavernous aneurysms, treatment depends upon whether they are ruptured / unruptured, and if they are symptomatic or not. Endovascular management is preferred over open surgical intervention because of the latter’s high morbidity and mortality. For unruptured, asymptomatic aneurysms (i.e. detected incidentally), treatment is not recommended if <13mm; and for those >13mm, the decision is made on a case-by-case basis. For the unruptured, symptomatic, and ruptured aneurysms, generally coil embolisation is well tolerated. Flow diversion is a newer technology and complements coiling well with higher occlusion rates

Reference

Endovascular management of cavernous and paraclinoid aneurysms.
Brown B, Hanel RA.
NEUROSURGERY CLINICS OF NORTH AMERICA
2014;25(3):415-24.

ORAL AND MAXILLOFACIAL SURGERY CLINICS OF NORTH AMERICA

Resection margins in head and neck surgery
Reviewed by: Deepak Chandrasekharan
Vol 23 No 5
 

Although an increasing proportion of head and neck malignancies are treated with non-surgical modalities, when surgery is undertaken an incomplete clearance results in significantly worse prognosis. However, the intraoperative assessment of an adequate margin is difficult. The personal practice of the authors in this review is to attempt margins of 1cm or greater of visible mucosa and 1cm of palpable deep margins. The review goes on to comprehensively explore the various factors influencing adherence to, or deviation from, this decision and the success of resection. As well as covering concepts such as anatomical and histological margins, it discusses the importance of meeting with the histopathologist to review the specimen, particularly in fragmented and poorly oriented tumours as is the case with minimally invasive approaches. Specimen tissue shrinkage may also affect margin analysis, and whilst electrosurgical instruments reduce shrinkage as compared with a steel scalpel (possibly due to thermal injury to tissues) the latter is associated with less tissue distortion of the margin which may affect subsequent analysis. Finally the review discusses the potential future role of molecular analysis of margins. The techniques of epigenetic analysis of tumour markers such as p16 and DAPK as well as using optical techniques of autofluorescence or topical fluorescent agents with high resolution micro-endoscopes may one day help intraoperative delineation of the dysplastic margin at a molecular level. Overall this is a useful and engaging review with appeal to both the generalist and specialist in head and neck surgery.

Reference

Pitfalls in determining head and neck surgical margins.
Weinstock Y, Alava I, Dierks E.
ORAL AND MAXILLOFACIAL SURGERY CLINICS OF NORTH AMERICA
2014;26(2):151-62.

ORL

Hyoid bone interposition graft in treatment of laryngotracheal stenosis
Reviewed by: Zi Wei Liu
Vol 23 No 5
 

Laryngotracheal stenosis remains a challenging condition to manage, with treatment options plagued by either high rates of recurrence or excessive morbidity. The authors describe two cases of adult laryngotracheal stenosis treated by a hyoid interposition composite graft. A two-step procedure is described in this study. The first patient had tracheal stenosis at rings 3-4 secondary to prolonged intubation, and the second had laryngeal stenosis due to lymphangiomatosis. In both cases an anterior split is performed through either the trachea or the larynx, and a mucosa lined 'trough' created. As a second stage procedure, the central portion of the hyoid bone is mobilised with thyrohyoid muscles on either side acting as pedicles, and reflected downwards into the trough. A covering tracheostomy is sited inferiorly and the patient is decannulated at a later date. The two patients had two- and ten-year follow-ups with satisfactory airway and swallow. Compared to primary laryngotracheal resection with end-to-end anastomosis, this procedure has the disadvantage of being a two-stage procedure. However, injury to the recurrent laryngeal nerves remains a notable risk in primary resection, and this technique may be a useful option depending on patient and surgeon preference.

Reference

Composite hyoid bone graft interposition for the treatment of laryngotracheal stenosis.
Mizokami D, Araki K, Tomifuji M, et al.
ORL
2014;76(3):147-52.

OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA

In the future there will be robots
Reviewed by: Charlie Giddings
Vol 23 No 5
 

This edition of review articles encompasses the emerging techniques of robotic surgery, written by international experts from centres that are increasing their repertoire of procedures. The treatment of oropharyngeal cancer is challenging irrespective of modality, as oncological and functional outcomes have great impact on quality of life. This article focuses on transoral robotic resections of oropharyngeal cancers for which acceptable oncological outcomes have been reported. The rationale behind this technique is to improve functional outcomes, avoid the morbidity of traditional open approaches, reduce length of stay, decrease tracheostomy and gastrostomy tube rates and de-escalate or obviate the need for chemoradiotherapy. Disease must be surgically resectable with negative margins and the technique is therefore most appropriate to small tumours. The procedures are described in detail, from setting up the equipment to the surgical procedures, and include many useful tips likely gained by personal experience. There is an accompanying set of four videos demonstrating the procedure from the initial incision to the dissection of the pharyngeal musculature. This is an excellent guide for robotic lateral oropharyngectomy for which robust outcome data is awaited.

Reference

Robotic approaches to the pharynx: tonsil cancer.
Brickman D, Gross ND.
OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA
2014;47(3):359-72.

OTOLOGY & NEUROTOLOGY

Mastoid obliteration for canal wall down surgery
Reviewed by: Anand Kasbekar
Vol 23 No 5
 

Surgery for acquired cholesteatoma is varied amongst surgeons with some only performing combined approach tympanoplasty. The change in lifestyle for patients with canal wall down surgery is significant and hence this group in Japan looked at 118 adult patients with acquired cholesteatoma who underwent canal wall down tympanomastoidectomy with reconstruction of the cavity and ear canal wall. They did this for cholesteatoma that only went up to the mastoid antrum and not into the cavity. The cavity was filled with autologous bone dust / pate (less chance of extrusion as autologous), fibrin glue and a bone pate plate to recreate the canal wall without gaps. The attic was also obliterated and no cartilage was used. The attic reconstruction is vital to stop re-retraction! Hearing results were not provided. Follow-up was at one and five years with a CT scan and otoscopy. There was a 2.5% postoperative otorrhoea. Ninety-six percent had an almost normal looking ear at five years. No residual / recurrent cholesteatoma was observed in the obliterated cavity (but there was none to begin with). Residual cholesteatoma in the tympanic cavity however was seen in 8% and is fairly low compared to other published series. This I believe was with a CT scan as details are not provided and is something we wouldn’t routinely perform without symptoms or signs. Overall, I like their technique of mastoid reconstruction, but it usually takes 10 years or longer to tell whether the reconstruction will hold. Using autologous bone for their ossiculoplasty and reconstruction is ideal in my view and likely to last. This paper however highlights the importance of trying to keep the canal wall or reconstruct it whenever one can to allow patients a normal quality of life and prevent those smelly discharging cavities

Reference

Long-term follow-up results of canal wall down tympanoplasty with mastoid obliteration using the bone pate plate for canal wall reconstruction in cholesteatoma surgery.
Yamamoto Y, Takahashi K, Morita Y, et al.
OTOLOGY & NEUROTOLOGY
2014;35(6):961-5.

RHINOLOGY

Importance of nasal septal cartilage perichondrium for septum strength mechanics: a cadaveric study
Reviewed by: Lakhbinder Pabla (Bal)
Vol 23 No 5
 

This experimental cadaver study aimed to investigate the biomechanical qualities of the perichondrium and cartilage, and to determine the strength of the septal cartilage against bending forces. The nasal septal cartilages of 14 fresh cadavers (eight hours post-mortem) without nasal septal deviation or any history of nasal trauma were excised. Each one was cut into two strips: one with the perichondrium (group A) and one without the perichondrium (group B). A three-point bending test was performed on the strips. The deflection of group A strips was larger than the deflection of group B. Flexural strength was also larger in group A compared to group B strips. The average modulus of elasticity was 122% higher in group A compared to group B and all conducted tests revealed statistically significant differences between the groups. This study objectively shows that the perichondrium provides the cartilage with a 25% bending strength and highlights the importance of the perichondrium, particularly its role in supporting the cartilage. However, the study is limited by the small sample size included. It is also important to remember that the septal cartilage does not exist in isolation but is fixed by the surrounding bone, cartilages and other soft tissues. Therefore, it may not be appropriate to extrapolate from small pieces of individual cartilage to real-life physiological and pathological situations.

Reference

Importance of nasal septal cartilage perichondrium for septum strength mechanics: a cadaveric study.
Tekke NS, Alkan Z, Yigit O, et al.
RHINOLOGY
2014;52(2):167-71.

SEMINARS IN SPEECH AND LANGUAGE

Postconcussion syndrome: weighing up the options on balance
Reviewed by: Roganie Govender
Vol 23 No 5
 

Balance problems, dizziness, headaches, nausea, vomiting and sensitivity to light and sound, are a few of the symptoms which may be associated with post concussion syndrome (PCS), concussion symptoms which persist longer than 21 days. This article presents a physical therapy perspective on managing dizziness experienced by athletes with PCS. It provides an overview of conditions that may contribute to dizziness: this may include benign paroxysmal positional vertigo (BPPV), poor gaze stabilisation, visual motion sensitivity, postural instability and cervicogenic dizziness. Goals of physical therapy targeted at the identified cause are explained. This article is set within the context of a journal edition devoted to raising awareness of concussion or mild traumatic brain injury (mTBI) particularly as it relates to the variety of sporting activities (both amateur and professional) that may put an individual at risk for concussion. A useful read for any practitioner involved in differential diagnosis of balance disorders.

Reference

Management of athletes with postconcussion syndrome.
Diaz DS.
SEMINARS IN SPEECH AND LANGUAGE
2014; 35:204-10.

SLEEP AND BREATHING

European position paper on drug induced sedation endoscopy (DISE)
Reviewed by: Vik Veer
Vol 23 No 5
 

DISE is a controversial topic but a practice that is largely accepted in the UK. There has been much variation about the technique, and how to interpret the results. For this reason, a collection of European DISE bigwigs aimed for consensus of opinion with a position paper. In summary this group decided that standard practice for DISE should include: avoidance of local anaesthesia, or decongestants or indeed any drugs at all that may influence the examination of the upper airway; assess supine, with and without gentle jaw thrust to simulate a mandibular advancement splint; sedation may be induced by propofol, midazolam or a combination. The advantages and disadvantages, and differing infusion techniques of each are appraised in the paper. Although not implicitly stated, a combination of the two seems to be favoured; and depending on the drugs used for sedation, two or more cycles of airway collapse need to be allowed before beginning the examination. The major stumbling block was on how to describe what is found. Seven common classification systems were examined, and no consensus was found indicating that they are probably all flawed. There is a long way to go before we have a standardised DISE technique, and this is mainly because of lack of research in the field. The exponential growth in DISE related research in recent years should help this European group reach a more satisfactory conclusion next time they meet.

Reference

European position paper on drug-induced sedation endoscopy (DISE).
De Vito A, Carrasco Llatas M, Vanni A, et al.
SLEEP AND BREATHING
2014;18(3):453-65.

THE HEARING JOURNAL

Treatments for hyperacusis
Reviewed by: Linnea Cheung
Vol 23 No 5
 

Centred on a patient’s experience, this article provides a brief summary of the condition of hyperacusis as an introduction to the treatments that are currently available. It is enhanced by the fact that the individual mentioned is a musician by profession, whose journey of diagnosis and treatment had a significant impact on his quality of life. The article categorises hyperacusis into four different subtypes based upon the patient's emotional response to sound. References are made to research conducted within the last decade highlighting the overall prevalence of the condition and the potential role of increased tensor tympani muscle activity causing pain in response to sound. Various different forms of sound therapy are available for hyperacusis, such as continuous low level broadband noise, successive approximation of high level broadband noise with or without partial masking. The featured case found benefit from a ‘pink noise program’ using open air headphones where sound presentation was incrementally adjusted in a successive approximation fashion. The article reiterates the need for further studies in this condition to improve understanding, which in turn would hope to better the diagnostic pathways and highlight an aim for targeted therapy for affected cases.

Reference

Help for hyperacusis: treatments turn down discomfort.
Lindsey H.
THE HEARING JOURNAL
2014;67(8):22-8.

THE JOURNAL OF INTERNATIONAL ADVANCED OTOLOGY

Pomegranate juice as an otoprotective agent
Reviewed by: Emma Stapleton
Vol 23 No 5
 

Chemotherapeutic agents such as cisplatin, given alongside irradiation, offer a survival advantage in head and neck cancer. Some patients often complain bitterly about side-effects of their treatment, one of which is ototoxicity. In this paper, the authors propose the use of freshly squeezed pomegranate juice, allegedly known for its antioxidant properties, to prevent free-radical mediated damage to cochlear hair cells. The study used 56 albino rats, which were randomised to sham treatments, or various combinations of cisplatin, radiotherapy, and fresh pomegranate juice. Changes in hearing were measured using DPOAEs, and histopathological examination of the cochleas. The results appear to indicate that fresh pomegranate juice has the potential to eliminate damage to cochlear hair cells resulting from irradiation, cisplatin, and combined use of cisplatin and irradiation. These were small animal groups, and the study does not take into account more modern techniques that can reduce the dose delivered to radiation sensitive tissue. Nevertheless, in the current oncological environment, newer treatments are constantly being sought in order to cure cancer with minimal side-effects, and there is a vogue for ‘natural’ treatment options. If a freshly squeezed fruit juice has genuine potential for reducing the ototoxic effects of cancer treatment, this certainly seems to be a topic worth pursuing in human subjects. What’s the worst that could happen?

Reference

Does short term usage of fresh pomegranate juice (FPJ) protect cochlear hair cells after cisplatin-based chemo-irradiation?
Akdağ M, Daşdağ S, Alabalık U, et al.
THE JOURNAL OF INTERNATIONAL ADVANCED OTOLOGY
2014;10(2):128-33.

TRENDS IN HEARING

Viral induced hearing loss
Reviewed by: Ameera Abdelrahim
Vol 23 No 5
 

Viruses are a common cause of hearing loss both in children and adults. This article provides a good review of the viral causes of hearing loss and can be regarded as an essential read. The authors divide the viruses into three categories: those causing congenital hearing loss (cytomegalovirus, rubella and lymphocytic choriomeningitis virus); those causing both acquired and congenital hearing loss (human immunodeficiency virus and herpes simplex virus types 1 and 2); and lastly those causing acquired hearing loss (measles, varicella zoster virus, mumps and West Nile virus). Prevention and management are discussed for each of these. Sensorineural hearing loss is the commonest outcome and treatments discussed range from primary prevention by vaccination, antiviral therapy to treat the acute phase and reduce associated complications, and hearing aids or cochlear implants to treat the subsequent hearing loss. They highlight conductive hearing loss secondary to recurrent bacterial infections of the middle and outer ear in immuno-compromised individuals as a virus related hearing loss. Furthermore they advocate recommending vaccination against common viruses to patients and parents to protect against the risk of these devastating complications.

Reference

Viral causes of hearing loss: a review for hearing health professionals.
Cohen B, Durstenfeld A, Roehm P.
TRENDS IN HEARING
2014;18:1-17.

WORLD JOURNAL OF SURGICAL ONCOLOGY

CT and intraoperative nerve monitoring to identify non-recurrent laryngeal nerve during thyroid surgery
Reviewed by: Jonathan Hughes
Vol 23 No 5
 

A non-recurrent laryngeal nerve (NRLN) is a rare (incidence 0.3% to 1.3%) anatomical variant that results in a higher rate of vocal cord palsy following thyroid surgery. This team from China examined the utility of preoperative CT and intraoperative nerve monitoring in identifying these at risk patients. NRLN is associated with abnormalities of the aortic arch and brachiocephalic / subclavian arteries which are detectable by CT. Nine NRLN were detected on imaging out of 1574 patients undergoing thyroid surgery. Seven of these were identified preoperatively and two following a retrospective scan analysis. Intraoperative nerve testing required exposure of the vagus nerve at a proximal and distal level (inferior thyroid pole). A positive electromyography signal at the proximal vagus and negative signal at the distal vagus was diagnostic for NRLN; with positive signals at both levels suggestive of RLN. All nine NRLN were identified using nerve monitoring. This paper suggests that CT and intraoperative nerve monitoring may have a place in patients undergoing thyroid surgery. However the morbidity of the radiation exposure of CT and the additional dissection required when exposing the vagus nerve at two levels to identify a very rare anatomical variant makes it questionable whether this should be routine practice for all patients. There are also health economic factors to consider, as most patients currently will only have an ultrasound scan prior to thyroid surgery.

Reference

Increased prediction of right nonrecurrent laryngeal nerve in thyroid surgery using preoperative computed tomography with intraoperative neuromonitoring identification.
Gao E-L, Zou X, Zhou Y-H, et al.
WORLD JOURNAL OF SURGICAL ONCOLOGY
2014;12:262.

ACTA OTOLARYNGOLOGICA

Head injury and prolonged bed rest, but not inner ear disease, predict poorer outcome after Epley manoeuvre in posterior semicircular canal benign paroxysmal positional vertgo (P-BPPV)
Reviewed by: Victoria Possamai
September/October 2014 (Vol 23 No 4)
 

This Japanese study included 197 patients with P-BPPV treated over a two and a half year period. The vast majority had idiopathic BPPV (n=157). The remaining 40 had secondary BPPV, eight following head trauma, 14 due to prolonged bed rest and 18 related to inner ear disease, including sudden sensorineural deafness, Ménière’s disease and vestibular neuritis. A single Epley manoeuvre was performed by the same therapist in all patients, and patients were followed up weekly with repeat Epley manoeuvre to assess response. Comparing response at seven days, there was 73% resolution in the idiopathic group, 56% in the inner ear group (no significant difference), 25% in the head trauma group and 36% in the bed rest group (both statistically significant). The study then assessed resolution over the longer term with helpful Kaplan Meier curves to demonstrate that again there was no significant difference in resolution rates between the idiopathic and inner ear groups at one and three months post Epley manoeuvre, but significantly lower rates of resolution at these intervals in the head trauma and bed rest groups. In all groups the majority of patients had resolution by three months. This was poorest in the head trauma group with 25% of patients still unresolved, whereas for the three other groups this was less than 10%. One must bear in mind the small numbers of patients in each of the secondary BPPV groups when considering the strength of the conclusions, however this study certainly adds weight to the notion that idiopathic P-BPPV has a better outcome than that secondary to a separate pathology. The authors hypothesise regarding the possible mechanism of deposition of otoconial debris to explain their observations.

Reference

Risk factors for poor outcome of a single Epley maneuver and residual positional vertigo in patients with benign paroxysmal positional vertigo.
Sato G, Sekine K, Matsuda K, Tadeka N.
ACTA OTOLARYNGOLOGICA
2013;133(11):1124-27.

ALLERGY

Is there a cause-and-effect relationship between allergic rhinitis and chronic rhinosinusitis?
Reviewed by: Evangelia Tsakiropoulou
September/October 2014 (Vol 23 No 4)
 

This review examines the possible causative relationship between allergic rhinitis (AR) and chronic rhinosinusitis (CRS) that has long been proposed. Many observational and experimental studies exist, however no clear and definitive connection has been established. This is mainly due to great diversity in study methodology. For this reason, the authors applied the revised Bradford-Hill guidelines to relevant studies, aiming to answer the question “is AR a predisposing factor for CRS?”. Despite the ‘unified airway’ concept, multiple pathophysiologic mechanisms seem to be involved that are not common in both clinical entities. This review identifies that there is a lack of consistency in the terms used to define AR and CRS, which undermines the strength of the association. The authors conclude that no clear and definitive causal relationship can be established, especially in children. It is also suggested that any CRS patient with uncontrolled symptoms should be evaluated for underlying allergies. The authors appropriately reinforce this principle, also supported by the Joint Task Force on Practice Parameters (JTFPP) document, Clinical Practice Guideline: Adult Sinusitis (CPG:AS), The British Society for Allergy & Clinical Immunology (BSACI) and European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS) guidelines.

Reference

Is chronic rhinosinusitis related to allergic rhinitis in adults and children? Applying epidemiological guidelines for causation.
Georgalas C, Vlastos I, Picavet V, et al.
ALLERGY
2014;69(7):828-33.

AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY

Evidence and nasal polyp treatments
Reviewed by: Edward W Fisher
September/October 2014 (Vol 23 No 4)
 

The change in the routine management of nasal polyps in the past 2-3 decades has been fascinating and this review from Charleston covers the topics of systemic treatment, local treatment, perioperative treatment and immunotherapy and touches on the lower airway effects. Few would disagree with the statement ‘aggressive medical and surgical treatment of CRSwNPs (chronic rhinosinusitis with nasal polyps) improves asthma outcomes’, but it deserves repetition. Otolaryngologists would be particularly interested in topical steroid delivery methods such as bioresorbable materials and we are reminded that ‘topical antibiotic use for CRSwNPs is not currently supported by evidence. We are informed that ‘macrolides and doxycycline have anti-inflammatory effects and macrolides also have mucolytic and anti-biofilm properties. Thus it is difficult to attribute any benefit solely to antimicrobial characteristics.’ This is an article for all rhinologists to read. I would be surprised if something here is not new to a reader.

Reference

Evidence-based treatment of chronic rhinosinusitis with nasal polyps.
Schlosser RJ, Soler ZM.
AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY
2013;27(6):461-66.

AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY

Improving smell outcomes after sinus surgery: impregnated dressings?
Reviewed by: Edward W Fisher
September/October 2014 (Vol 23 No 4)
 

There is much we can do to improve the airway of patients with chronic sinus disease, especially those with polyps. However, the olfactory outcomes are usually disappointing and patients miss this important sensory modality, which has an effect on their quality of life. These authors report a study in which a gelatin dressing was placed high in the nose, as close as possible to the olfactory epithelium, at the conclusion of sinus surgery. The gelatin had been impregnated with triamcinolone. The 60 patients were divided into two groups, one of which did not receive the triamcinolone. The outcome for smell was good in the treated group, but follow-up was only 8 weeks. While this is gratifying, it is the long-term effect that is demoralising for this group of patients and I would be surprised if this short-term gain was translated into a superior long-term gain.

Reference

The effect of an absorbable gelatin dressing impregnated with triamcinolone within the olfactory cleft on polypoid
rhinosinusitis smell disorders.
Bardaranfar MH, Ranjbar Z, Dadgarnia MH, et al.
AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY
2013;28(2):172-75.

AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY

What do we put in our nasal douches? Anything?
Reviewed by: Edward W Fisher
September/October 2014 (Vol 23 No 4)
 

The rise of the popularity of saline nasal douches, with several commercial preparations available, may be a rediscovery of an age-old tradition, but it has been shown to benefit patients. The question then arises as to whether this can be improved by adding in various medications, especially in recalcitrant cases of chronic rhinosinusitis (CRS) in patients who perhaps have had several operations. This paper pulls together information on anti-infective additives (rather than corticosteroid or anti-inflammatory additives), which include topical antibiotics (e.g. mupirocin, gentamicin, tobramycin), topical antifungals and ‘additives’ which include surfactants, xylitol, manuka honey and N-Chlorotaurine (an antiseptic). The overall message is that such additives are not part of the routine management of standard CRS patients, but should be reserved for recalcitrant cases, but that research is weak on most of these categories (apart from antibiotics). The evidence on antifungals is particularly weak and these are not recommended. Clearly, there is a long way to go before we have enough evidence to recommend use of these categories of additives to douches with a good evidence base, except for antibiotics and, even in those cases, there are many unanswered questions (dose, risk-benefit balance, outcomes, case selection, etc).

Reference

Topical anti-infective sinonasal irrigations: update and
literature review.
Lee JT, Chiu AG.
AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY
2013;28(1):29-38.

ANNALS OF THE ROYAL COLLEGE OF SURGEONS OF ENGLAND

Consequences of tonsillectomy rationing?
Reviewed by: Thomas Jacques
September/October 2014 (Vol 23 No 4)
 

This article examines Hospital Episode Statistics and Office for National Statistics data to investigate the change in rates of tonsillectomy and admissions for tonsillitis and its complications, over a 20-year period. Between 1991 and 2011, 44% fewer tonsillectomies were performed. This was accompanied by a 310% increase in admissions for tonsillitis. Admissions for retropharyngeal and parapharyngeal abscesses rose by 39% between 1996 and 2011. The trends were most pronounced in paediatric patients. It was identified that ‘Procedures of Limited Clinical Effectiveness’ guidance varies regionally by clinical commissioning group (CCG), with some adhering to Scottish Intercollegiate Guidelines Network (SIGN) guidelines, and others being more stringent. The authors rightly state that these data cannot imply causation, and are subject to some limitations in terms of accuracy. However it is likely that they represent sobering evidence of the erroneous economic and clinical logic behind surgical rationing. Whilst the authors caution that a return to historical rates of tonsillectomy is not desirable, they conclude that deliberate disregard of the evidence for the efficacy of tonsillectomy, in the pursuit of monetary savings alone, may be endangering patients.

Reference

The rising rate of admissions for tonsillitis and neck space abscesses in England, 1991-2011.
Lau AS, Upile NS, Wilkie MD, et al.
ANNALS OF THE ROYAL COLLEGE OF SURGEONS OF ENGLAND
2014;96(4):307-10.

ANNALS OF THE ROYAL COLLEGE OF SURGEONS OF ENGLAND

Trends in parathyroidectomy
Reviewed by: Thomas Jacques
September/October 2014 (Vol 23 No 4)
 

he authors retrospectively analysed Hospital Episode Statistics data for parathyroidectomy between 2000 and 2010. Overall, parathyroidectomy rates nearly doubled from 3.3/100,000 population in 2000 to 5.8/100,000 in 2010, with particularly significant increases in elderly patients. The authors attribute this rise to the development of standardised endocrinological guidelines indicating surgery in asymptomatic hypercalcaemia, and an increasing life expectancy. Improvements in pre-operative localisation have also led to an increase in minimally-invasive parathyroidectomy, allowing shorter anaesthetic times, or even surgery under local anaesthesia. The data may not apply to surgery for secondary or tertiary hyperparathyroidism (HPT), but the authors point out that the most recent British Association of Endocrine and Thyroid Surgeons (BAETS) audit shows that around 90% of surgery is performed for primary HPT. The authors’ conclusions do rely on inference, but the reasoning is very plausible and an interesting insight. They reflect that the changes mirror a more general trend, whereby improvements in diagnostic and surgical technology tend to expand the indications for surgical procedures.

Reference

A decade of change in the uptake of parathyroidectomy in England and Wales.
Evans LM, Owens D, Scott-Coombes DM, Stechman MJ.
ANNALS OF THE ROYAL COLLEGE OF SURGEONS OF ENGLAND
2014;96(5):339-42.

BMC EAR, NOSE AND THROAT DISORDERS

3D ultrasonography for evaluation of muscles following facial palsy
Reviewed by: Gauri Mankekar
September/October 2014 (Vol 23 No 4)
 

Reconstructive surgery for facial nerve palsies is not recommended beyond two to three years after a degenerative facial nerve lesion. Since the time course of muscle atrophy is variable, this timeline is a rough guideline. The only assessment method currently used is needle electromyography (EMG). This paper describes a fast, non-invasive, and reliable method to evaluate the condition of the facial muscles and the degree of atrophy. The authors used a 3D ultrasonographic (US) acquisition system driven by a motorised linear mover combined with conventional US probe to acquire 3D data sets of several facial muscles on both sides of the face in a healthy subject and in seven patients with different types of unilateral degenerative facial nerve lesions. The US results were correlated to the duration of palsy and the EMG results. The facial muscles on the side of the paralysis, with the exception of the frontal muscle, were much smaller than on the healthy side in patients with severe facial nerve injuries. This new 3D ultrasonographic tool seems to be a promising innovation for the quantitative evaluation of facial muscles in patients considering reconstructive surgery or conservative treatment.

Reference

3D-Ultrasonography for evaluation of facial muscles in patients with chronic facial palsy or defective healing: a pilot study.
Volk GF, Pohlmann M, Finkensieper M, et al.
BMC EAR, NOSE AND THROAT DISORDERS
2014;14(4):2-8.

BMC NEUROLOGY

Head and neck radiation and the brain
Reviewed by: Badr Eldin Mostafa
September/October 2014 (Vol 23 No 4)
 

An increasing number of patients with head and neck squamous cell carcinoma and other lesions are treated with high dose radiotherapy. An increase in survival rates is being reported along with a younger patient demographic. The long-term effects of treatment on the carotid arteries and hence cerebral function are not well recognised. The authors followed 103 patients undergoing head and neck irradiation for a variety of lesions for more than five years. Baseline protocol (before radiotherapy) included screening for cerebrovascular risk factors and intima media thickness measurement of carotid arteries by ultrasonography. Follow-up assessment after radiotherapy included screening for cerebrovascular risk factors, cerebrovascular events, neurological examination with gait and balance tests, extensive neuropsychological examination, self-reported questionnaires, ultrasonography of the carotid arteries with measurement of intima media thickness and elastography, magnetic resonance imaging of the brain and magnetic resonance angiography of the carotid arteries. The final results are not yet published but the mere amount of data is likely to improve our understanding of the causes and consequences of long-term cerebral and vascular changes after radiotherapy of the neck. These data will be helpful to develop a protocol for accurate diagnosis and aid preventive strategies to avoid long-term neurological complications in patients undergoing radiotherapy treatment

Reference

Long term cerebral and vascular complications after irradiation of the neck in head and neck cancer patients: a prospective cohort study: study rationale and protocol.
Wilbers J, Kappelle AC, Kessels PCR, et al.
BMC NEUROLOGY
2014;14:132.

BRITISH JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY

Is it time for cone-beam CTs to replace the traditional orthopantomogram in the primary diagnosis of temporomandibular joint disorders?
Reviewed by: Sampath Chandra Prasad
September/October 2014 (Vol 23 No 4)
 

Cone-beam CT requires a lower dose of radiation compared to the multidetector CT and provides much more detailed information in 3D about the bony structures of the temporomandibular joint (TMJ) when compared to the traditional orthopantomogram (OPG). In this article the authors assess the value of cone-beam computed tomographic (CT) images in the primary diagnosis and management of 128 outpatients with disorders of the temporomandibular joint (TMJ). After clinical examination, an assessment of the cone-beam CT images was made and the oral and maxillofacial surgeon was allowed to revise the provisional primary diagnosis and management. The degree of certainty was rated by the clinician before and after the cone-beam CT had been assessed. The primary diagnosis was changed in 32 patients (25%), additional diagnostic procedures were changed in 57 (45%), and the treatment was changed in 15 (12%). In 4/15, the treatment was changed to a (minimally) invasive procedure. A total of 74 patients (58%) had their diagnosis and management changed after the cone-beam CT had been assessed. Changes in diagnosis and management were clinically relevant in 9/32 and 9/61 patients, respectively. The clinician’s certainty about the primary diagnosis increased after the cone-beam CT had been assessed in 57 patients. Logistic regression analysis showed that the odds in favour of changes in primary diagnosis and management increased when limited mandibular function was a primary symptom, the patient was taking medication for pain, and the articular eminence could not be assessed on OPG. Assessment of cone-beam CT led to changes in primary diagnosis and management in more than half the patients with disorders of the TMJ.

Reference

Value of cone-beam computed tomography in the process of diagnosis and management of disorders of the temporomandibular joint.
de Boer EW, Dijkstra PU, Stegenga B, et al.
BRITISH JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY
2014;52(3):241-6.

BRITISH JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY

Role of copper ions in drinking water in the pathogenesis of oral submucous fibrosis: the missing link in the aetiopathology?
Reviewed by: Sampath Chandra Prasad
September/October 2014 (Vol 23 No 4)
 

Often a breakthrough link in the understanding of the aetiopathogenesis of a hitherto common pathology that has been evading the medical community may not come from the hi-tech labs of the developed world, but from the intelligent investigations from a modest laboratory of a developing nation. Researchers from a far-flung district in Southern India have investigated the concentration of copper ions in drinking water and attempted to determine whether copper has a role in the pathogenesis of oral submucous fibrosis (OSMF). They studied 50 patients with clinically and histologically diagnosed OSMF from the Yadgir district of Karnataka in India. Fifty healthy people, matched for age and sex, were used as controls. In both groups concentrations of copper ions in serum, saliva, and home drinking water were measured using atomic absorption spectroscopy and intelligent nephelometry technology. Serum ceruloplasmin concentrations were also estimated in both groups. The studies showed that the mean (SD) concentration of copper in the home drinking water of patients with OSMF was significantly higher (764.3 (445.9)μmol/L) than in the controls (305.7 (318.5)μmol/L) (P<0.001). Patients with OSMF also had a significantly higher copper concentration in serum and saliva, and serum ceruloplasmin than controls (P<0.001). The authors claim that, for the first time, a positive association between copper concentrations in home drinking water and OSMF has been established. It raises the possibility that increased copper in drinking water contributes to the development of OSMF, and adds to that ingested when areca nut is chewed.

Reference

Evaluation of possible role of copper ions in drinking water in the pathogenesis of oral submucous fibrosis: a pilot study.
Arakeri G, Patil SG, Ramesh DN, et al.
BRITISH JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY
2014;52(1):24-28.

CLINICAL OTOLARYNGOLOGY

Balloon dilatation of the eustachian tube: An evidence based review
Reviewed by: Andy Hall
September/October 2014 (Vol 23 No 4)
 

Eustachian tube dysfunction has long provoked debate among otolaryngologists with wide-spread variation in management. Establishing a safe and effective surgical technique to bring about resolution would be of benefit to those affected, with an estimated incidence of 0.9% in the UK. This well-constructed article takes a pragmatic approach to evaluating the current evidence through a case series review of cartilaginous dilatation. Pre- and post-operative parameters of tympanometry, otoscopy findings, valsalva and subjective symptoms were used focusing on short term (<6 months) and long term (>6 months). The literature demonstrates balloon dilatation performed on 375 eustachian tubes from 235 patients with clear short-term benefits across the aforementioned outcome measures. A complication rate of 3% was observed, yet these were deemed minor and short-lived. Indeed, in the absence of bony dilatation the practice of a routine pre-operative CT scan is questioned by the authors. The stage appears set for the eventual evolution of its use in mainstream practice, although the authors sensibly emphasise the importance of formalised training and meticulous review of outcomes.

Reference

Balloon dilatation of the Eustachian tube: an evidence based review of case series for those considering its use.
Miller BJ, Elhassan HA.
CLINICAL OTOLARYNGOLOGY
2013;38(6):525-32.

CLINICAL OTOLARYNGOLOGY

Clinical coding: variability and error in otolaryngology
Reviewed by: Andy Hall
September/October 2014 (Vol 23 No 4)
 

The ever topical spectre of coding in otolaryngology is comprehensively evaluated in this article. It attempts to debunk the mystique of current coding practices and the challenge of health informatics in the modern NHS. A total of 3131 randomly selected otolaryngology patients initially coded in the standard manner were evaluated by a clinician-auditor multi-disciplinary team. This was substantially larger than the sample size used to audit coding accuracy in the entire NHS by the audit commission! Overall this led to a 13% rate of change in both the primary procedure and underlying diagnosis. Coding data informs resource allocation and has an influence on clinical prioritisation within the NHS. Attempts to decrease variability and drive excellence in coding should remain a priority for clinicians as well as managers yet achieving this continues to present difficulties.

Reference

An audit of the nature and impact of clinical coding subjectivity variability and error in otolaryngology.
Nouraei S, Hudovsky A, Virk J, et al.
CLINICAL OTOLARYNGOLOGY
2013;38(6):512-24.

CLINICAL OTOLARYNGOLOGY

Cost effectiveness and vestibular schwannoma surgery
Reviewed by: Andy Hall
September/October 2014 (Vol 23 No 4)
 

This is the first cost effectiveness modelling study looking at the three main treatment options for small to medium sized vestibular schwannomas. This study uses the widely accepted cost per quality adjusted life year (QALY) outcome measure to evaluate three hypothetical cohorts of adult patients receiving conservative, radiosurgery or surgical treatment. The model used finds initial conservative management to be the most cost effective treatment strategy available for small to medium sized vestibular schwannomas (extrameatal diameter less than 2cm). Slow growth allows two-thirds of these to never require aggressive treatment. Overall this strategy appears to offer more QALYs at a lower cost, yet overall quality of life data in this patient population continues to need evaluation.

Reference

Conservative management, surgery and radiosurgery for treatment of vestibular schwannomas: a model-based approach to cost-effectiveness.
Gait C, Frew EJ, Martin TPC, et al.
CLINICAL OTOLARYNGOLOGY
2014;39(1):22-31.

CLINICAL OTOLARYNGOLOGY

Management of metastatic neck disease
Reviewed by: Andy Hall
September/October 2014 (Vol 23 No 4)
 

This article publishes the findings of a recent expert-led evidence based management symposium in the UK with recommendations according to the SIGN level of evidence and grading. The article neatly summarises the key points, and its clarity despite the complexity of the topic should be recognised. Naturally any topic such as this will continue to involve areas in need of further research and discussion; one key point, however, is in the need for international agreement on the most appropriate neck dissection classification system. Consistency in terminology is vital in areas such as this. This article is a must for oncological surgeons looking for a neat review of the current understanding of the topic; anyone with examinations around the corner would also be wise to review.

Reference

Management of metastatic neck disease – summary of the 11th Evidence Based Management Day.
O'Hara J, Simo R, McQueen A, et al.
CLINICAL OTOLARYNGOLOGY
2014;39(1):3-5.

CLINICAL OTOLARYNGOLOGY

National analysis of outcome of head and neck cancer surgery
Reviewed by: Andy Hall
September/October 2014 (Vol 23 No 4)
 

Patient outcomes continue to become ever more visible in the NHS with ongoing drives to demonstrate transparency in our delivery of healthcare. This article reviews unit-level data publication using Hospital Episode Statistics data in all units undertaking head and neck cancer surgery in England. This includes 10,589 patients who underwent major head and neck cancer surgery between 2006 and 2011. Interestingly the authors used an in-hospital mortality measure in contrast to the commonly accepted 30-day mortality used elsewhere. Data such as an overall in-hospital mortality rate of 3.05% and myocardial infarction rate of 4% is provided. The important issue of variability between units is explored and the demonstration of distinction between units performing ‘intermediate’ numbers of major surgeries (16-25 a year) as opposed to high volumes is not unexpected given work in other areas (cardiothoracics and vascular). Summarising this paper is no mean feat owing to the breadth of issues discussed and illustrated; I urge you to read and consider for yourself how the future of head and neck cancer care is likely to develop and be monitored.

Reference

A national analysis of the outcome of major head and neck cancer surgery: implications for surgeon-level data publication.
Nouraei S, Middleton SE, Hudovsky A, et al.
CLINICAL OTOLARYNGOLOGY
2013;38(6):502-11.

CLINICAL OTOLARYNGOLOGY

Sham controlled trial: BPPV
Reviewed by: Andy Hall
September/October 2014 (Vol 23 No 4)
 

I was drawn to this study and it proved an enlightening read; it also is a good example of where recommendations of a Cochrane review for long-term evidence of benefit have been acted upon! The study looked at the efficiency of the Epley manoeuvre as a long-term therapeutic procedure for posterior canal benign paroxysmal positional vertigo (BPPV). A randomised, double blind sham-controlled trial involving two groups of 22 patients ensued. Following identification of BPPV, participants were treated with either an Epley or sham procedure and followed up for a year post treatment. Outcome measures of both conversion of a positive Dix Hallpike test to a negative Dix Hallpike test and Dizziness Handicap Inventory were used. Treatment success was found in 91% of patients after 12 months of follow-up in the Epley group as opposed to 46% in the sham group.

Reference

A randomised sham-controlled trial to assess the long-term effect of the Epley manoeuvre for treatment of posterior canal benign paroxysmal positional vertigo.
Bruintjes TD, Companjen J, van der Zaag-Loonen HJ, van Benthem PP.
CLINICAL OTOLARYNGOLOGY
2014;39(1):39-44.

COCHLEAR IMPLANTS INTERNATIONAL

Cochlear implantation in elderly candidates and effect on quality of life
Reviewed by: Thomas Nikolopoulos
September/October 2014 (Vol 23 No 4)
 

The authors aimed to assess the improvement in quality of life (QoL) of cochlear implant patients over 60 and its relation to audiometric benefits. An observational retrospective study was conducted on 26 individuals older than 60. The outcome was compared to the respective outcome in 10 implanted patients aged between 40 and 60. A full postoperative audiological evaluation was completed and the Glasgow Benefit Inventory test was used to assess QoL. The patients in both groups had similar preoperative speech recognition levels. Preoperative audiometric thresholds were significantly worse in patients from 40 to 60 years of age, although they scored better in speech recognition after implantation. Patients experienced significant improvement in their QoL in all areas, especially in general health, while they experienced a smaller improvement in social interaction. Age, duration of deafness, and years wearing the processor were statistically related to QoL, regardless of audiometric benefit. The authors concluded that cochlear implantation improves QoL of patients over 60 by the mere fact of having been implanted, regardless of poorer audiological benefits. Older patients, with long-term deafness experience a greater improvement in QoL after implantation. An interesting study with interesting results. However, a better study design with a larger number of patients would help in identifying the small differences between the two groups.

Reference

Cochlear implants in adults over 60: A study of communicative benefits and the impact on quality of life.
Ramos Á, Guerra-Jiménez G, Rodriguez C, et al.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(5):241-5.

COCHLEAR IMPLANTS INTERNATIONAL

How can we assess children with complex needs?
Reviewed by: Thomas Nikolopoulos
September/October 2014 (Vol 23 No 4)
 

In the early days of cochlear implantation, children with additional disorders were being excluded as poor candidates whereas today a large number of children with complex needs are being referred for cochlear implant assessment. However, the related problems include difficulties in the assessment to determine whether a particular child is suitable for cochlear implantation and post-implantation tuning of the device in order to obtain accurate threshold responses to acoustic or electrical stimuli. The behavioural and objective tests of hearing have weaknesses and this study outlines the pros and cons of these tests which should be taken into account when performing them on children with complex needs. The author reviewing all related problems concludes that just because a child has complex needs as well as deafness should not mean he / she is ruled out for consideration for cochlear implantation. However there are issues which need to be addressed with the family prior to a decision. The main problem is that there is a lack of preoperative candidature criteria and postoperative outcome measures specific to children with complex needs. A greater evidence base is needed to allow informed decisions to be made. It seems that cochlear implantation in children with additional disorders has made it more clear than ever that (re)habilitation of these children urgently needs appropriate and well designed outcome measures.

Reference

Audiological assessment of children with complex needs.
Midgley E.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(S3):s18-s19.

CURRENT OPINION IN OTOLARYNGOLOGY & HEAD AND NECK SURGERY

Sublingual immunotherapy
Reviewed by: Susan A Douglas
September/October 2014 (Vol 23 No 4)
 

This paper reviews the recent European studies on sublingual immunotherapy (SLIT). SLIT is currently widely used in Europe and is gaining popularity in the United States. It is known that longer treatment is needed with SLIT compared with subcutaneous immunotherapy (SCIT) to reduce the rhinitis symptoms in children with house dust mite (HDM) allergies. SLIT appears to be a well-tolerated and effective disease-modifying option for treating rhinitis and asthma in children and adults including the elderly. Studies on HDM, grass, and ragweed have demonstrated post-treatment efficacy in both monosensitised and polysensitised patients. The effects of treatment are lasting, providing clinical benefit even one year after SLIT is discontinued. With its roots in Europe, SLIT is now gaining attraction around the world as a viable alternative to SCIT. The advantages include an improved safety profile with no reported systemic effects, a more tolerable route of administration, and the potential to significantly improve compliance by allowing at-home self-administration. Recent studies shed light on the wider age range that may benefit from SLIT, the potential for treating a larger array of environmental allergies, and the sustained effects beyond the treatment period.

Reference

Sublingual immunotherapy: what we can learn from the European experience.
Linkov G, Toskala E.
CURRENT OPINION IN OTOLARYNGOLOGY & HEAD AND NECK SURGERY
2014;22(3):208-10.

EUROPEAN ARCHIVES OF OTO-RHINO-LARYNGOLOGY

Endoscopic myringoplasty: a promising alternative to microscopic surgery
Reviewed by: George Garas
September/October 2014 (Vol 23 No 4)
 

Endoscopes have revolutionised otitis media surgery in recent years and are increasingly used in the surgical management of cholesteatoma, sinus tympani pathology and facial nerve surgery. Despite this, the development of endoscopic myringoplasty and how this compares to its microscopic counterpart have received relatively little attention. This study aimed to assess exactly that, by directly comparing endoscopic with microscopic myringoplasty for similarly sized and positioned tympanic membrane perforations. Sixty patients were recruited and randomised between the two groups (30 endoscopic and 30 microscopic). Endoscopic myringoplasty was always performed transcanal with tympanomeatal flap elevation in all cases. On the other hand, microscopic myringoplasty was performed via a postaural approach. The use of an endoscope (0º or 30° 4mm rigid endoscope) proved to offer numerous advantages over microscope use. Firstly, no patient in the endoscopy group required canalplasty as adequate exposure of the margins of the perforation (even when very anterior) and visualisation of the incudostapedial joint complex were easily achieved with the endoscope and without the need for any posterosuperior canal wall curettage. This was despite four patients in the endoscopic group having significant canal overhangs. This was not the case in the microscopic myringoplasty group where all five patients with significant canal overhangs required canalplasty to obtain adequate exposure of the tympanic annulus and four also required curettage of the posterosuperior canal wall to obtain visualisation of the incudostapedial joint complex. Moreover, all patients in the endoscopy group (30/30) reported excellent cosmetic outcomes as the incision scar was well hidden in the hairline whereas the equivalent percentage in the microscopic group was 25/30 with the remaining five patients reporting it as only satisfactory due to the associated scar. No difference was observed in graft uptake rates which were 83.3% in both groups. The hearing outcomes were comparable between the two techniques and endoscopic myringoplasty was well received by the residents being trained in the technique. In summary, this study, albeit small, illustrates the promising role that endoscopic myringoplasty has to play as it achieved improved cosmesis, comparable tympanic membrane perforation and air-bone gap closure rates to microscopic surgery without the need for canalplasty and postaural incision even in the presence of major canal overhangs

Reference

Endoscopic vs microscopic myringoplasty: a different perspective.
Lade H, Choudhary SR, Vashishth A.
EUROPEAN ARCHIVES OF OTO-RHINO-LARYNGOLOGY
2014;271(7):1897-902.

EUROPEAN REVIEW OF ENT

The sentinel lymph nodes revisited
Reviewed by: Badr Eldin Mostafa
September/October 2014 (Vol 23 No 4)
 

The concept of sentinel lymph node sampling has been around for some time. However, its acceptability in routine head and neck practice has yet to be established. This article presents the authors’ experience in 10 patients with Merkel cell carcinoma [eight T1N0Mo, one T2N0M and one T3N0M0], which is an aggressive cutaneous neuroendocrine tumour. Lymphoscinti-graphy was performed after infiltrating the tumour surround with Tc-99m labeled NANOCIS. Sampling of the sentinel node was performed during the excision of the primary tumour and stained by HPS and immunostains. Scintigraphy-positive nodes were detected in 7/10 patients. Three patients underwent neck dissection, either because of absent marker detection during scintigraphy or the absence of a surgically detected sentinel node. All these nodes were negative for malignancy. One patient had systemic metastases, but no lymph node recurrence 12 months later. The remaining nine patients were disease-free after two years’ follow-up. The conclusion of the authors is that sentinel node sampling in such patients is useful to determine the need for simultaneous neck dissection during excision or, instead, just follow-up.

Reference

Prognostic value of sentinel lymph node in Merkell cell carcinoma of the head and neck.
Penicaud M, Cammilleri S, Giorgi R, et al.
EUROPEAN REVIEW OF ENT
2013;134(2):75-9.

FACIAL PLASTIC SURGERY

Polydioxanone in septal reconstruction
Reviewed by: Sunil Kumar Bhatia
September/October 2014 (Vol 23 No 4)
 

Septal reconstruction is a challenging problem and is undertaken for functional or cosmetic reasons, or a combination of both. Either autologous cartilage, commonly auricular, or other alloplastic material can be used. The authors describe the use of a Polydioxanone (PDS) plate for this purpose. The authors discuss extracorporeal septoplasty, indications and technique. Similarly they next discuss endonasal and then partial extracorporeal endonasal septoplasty. A very useful discussion on the indications and technique is provided. It is clear and succinct with excellent accompanying photographs. Similar sections are then provided on columellar struts, extension grafts and septal perforation repair. The final discussion is mainly on the useful applications of the PDS plate. There is some good background on the animal experiments that confirm the histoconductive effects. The authors conclude that the PDS plate is a valuable addition in difficult septal surgery. The article is of value for the seasoned nasal surgeon as well as others. This is a very well written and lucid paper, most surgeons will be able to pick some ‘tips’ and add a valuable technique to the armamentarium in correcting a difficult problem.

Reference

Use of Polydioxanone Plate in Septal Reconstruction.
Rimmer J, Saleh H.
FACIAL PLASTIC SURGERY
2013;29(6):464-72.

FACIAL PLASTIC SURGERY CLINICS OF NORTH AMERICA

Techniques in Facial Plastic Surgery: Discussion and Debate part 2
Reviewed by: Mrinal Supriya
September/October 2014 (Vol 23 No 4)
 

This edition of this popular journal is dedicated to ‘panel discussion’ on some of the most common controversies associated with ‘bread and butter’ facial aesthetic procedures. The procedures included are relevant and the aspects discussed are of practical importance to anyone involved in facial aesthetic procedures. The panel members are authorities in their field and they bring their experience to the discussion. I found the chapters well written and informative. I found the chapter discussing rhinoplasty and revision rhinoplasty particularly interesting as they discussed topics such as division of tip lobule, use of alloplast or options for dorsal augmentation, when there is no septal or auricular cartilage; these are relevant to all surgeons performing this procedure. It is heartening to see that even experienced surgeons can have divergent philosophy in tackling these tricky aesthetic and functional problems. Similar questions have been discussed for procedures such as blepharoplasty, mid face lift and chemical peel. In summary I think this issue will be beneficial to any surgeon who has a practice in facial aesthetics.

Reference

Techniques in Facial Plastic Surgery: Discussion and Debate part 2.
FACIAL PLASTIC SURGERY CLINICS OF NORTH AMERICA
2014;22(1):1-160.

HEARING, BALANCE AND COMMUNICATION

Auditory processing in children with unilateral hearing los
Reviewed by: Claudia Nogueira
September/October 2014 (Vol 23 No 4)
 

t is a common assumption that unilateral hearing loss (UHL) in children is of little consequence because appropriate development of speech and language can still occur with one normal hearing ear. Recent studies, however, suggest that there are significant differences in the cortical processing of sound between children with severe to profound unilateral hearing loss and normal hearing children. Central auditory processing was evaluated in children with UHL using the P300 component of event related potentials. Three groups of listeners participated in this prospective clinical study, listeners with UHL in the right (n=15) or left ear (n=15) and listeners with bilateral normal hearing (BNH) (n=20). Children with right UHL showed a significant reduction in P300 amplitudes in response to speech when compared to a tone stimulus. Comparing speech-evoked P300 response in the three groups revealed a significant delayed latency in the groups with UHL compared with children with bilateral normal hearing. These findings suggest that speech processing is affected in children with UHL whichever its side. The authors also suggested that a right UHL may have a greater impact on the central perception of processing of sound than a left UHL.

Reference

Auditory processing in children with unilateral hearing loss
Gabr TA.
HEARING, BALANCE AND COMMUNICATION
2014;12(2):99-104.

HEARING, BALANCE AND COMMUNICATION

Tinnitus in patients on therapy with PPI and in PPI non–users
Reviewed by: Claudia Nogueira
September/October 2014 (Vol 23 No 4)
 

Tinnitus is a chronic and debilitating condition and approximately 10% of the population is afflicted. A myriad of pharmacological treatments for tinnitus are available but only a few controlled studies have shown positive results. The relationship between proton pump inhibitors (PPI) and tinnitus is contradictory. The difficulty of a strict follow-up, due to the variable pattern of presentation of tinnitus symptoms, and the different methods of PPI application have made it difficult to draw definitive conclusions. In order to investigate the effect of PPI on tinnitus sufferers, a cohort of 120 consecutive patients aged 50-69 years were recruited in this study. Subjects were subdivided into two groups: PPI users and non-users. Each patient was instructed to complete an anonymous validated questionnaire on hearing problems. The results showed that in the age class 60-69 years, there was a significantly lower prevalence of generic tinnitus symptoms in patients on PPI maintenance therapy compared to those who did not take these drugs. The mechanism of action of PPIs in the relief of tinnitus is still unclear. Current research indicates a direct regulatory effect on inner ear homoeostasis through an action of PPIs on gastric-type proton pumps in the inner ear. The authors suggest that further longitudinal studies are required before claims can be made as to the beneficial effect of PPIs on tinnitus.

Reference

Tinnitus in patients on therapy with proton pump inhibitors (PPI) and in PPI non–users.
Piroda A, Raimondi MA, Cicero AFG, et al.
HEARING, BALANCE AND COMMUNICATION
2014;12(3):84-7.

INTERNATIONAL FORUM OF ALLERGY AND RHINOLOGY

Objective versus subjective – again!
Reviewed by: Christos Georgalas
September/October 2014 (Vol 23 No 4)
 

The use of objective measurements of nasal airflow has a long history; however, its clinical application remains, at most, patchy. The main reason for that has been the lack of convincing studies showing a good correlation between the findings of, for example, anterior rhinomanometry and nasal obstruction, as experienced by the patient. Having said that, an equally patchy relationship exists between chronic rhinosinusitis (CRS) symptoms and sinus opacification (Lund-McKay score), however no one would suggest abolishing sinus CT for the diagnosis and assessment of CRS. The key is interpretation; while the results of rhinomanometry may be insufficient to separate patients with obstruction from those with no obstruction; they appear to be useful to monitor the symptoms of individual patients over time. In this prospective study, the authors followed up 53 patients undergoing radiofrequency ablation for inferior turbinate hypertrophy with anterior rhinomanometry as well as VAS at one, three and six months. They found that objective improvement at one month correlated well with subjective improvement; however, this correlation disappeared after three months. It is very likely that other factors were also at play – with allergy and patient expectations being but two of them.

Reference

Prediction of outcome of radiofrequency ablation of the inferior turbinates.
Sahin-Yilmaz A, Oysu C, Devecioglu I, et al.
INTERNATIONAL FORUM OF ALLERGY AND RHINOLOGY
2014;4(6):470-4.

INTERNATIONAL JOURNAL OF AUDIOLOGY

Forward-going sound pressure wave with hearing thresholds
Reviewed by: Richard Navarro
September/October 2014 (Vol 23 No 4)
 

This article discusses an important and well-known point regarding the differences between coupler sound pressure measurements, used to calibrate earphones, and actual pressures delivered to the ear due to individual variances across patients. The study purports to suggest a new clinical tool; however, there is not sufficient definition of a number of key points, e.g. how is the ‘forward-going’ sound pressure wave defined? There are a number of methodological points that were not provided to help interpret the results in a meaningful way and the use of parametric statistical tests for non-parametric data raises some concern. While there may be some value to the use of a forward-going sound pressure wave, this article does not demonstrate the clinical utility with sufficient clarity to justify a wholesale change in the modus operandi for diagnostic or rehabilitative benefit. The article is worth reading as the introduction defines the issue well; however, the method needs considerable work before becoming a clinical tool.

Reference

The clinical utility of expressing hearing thresholds in terms of the forward-going sound pressure wave.
Withnell RH, Jeng PS, Parent P, Levitt H.
INTERNATIONAL JOURNAL OF AUDIOLOGY
2014;53(8):522-30.

INTERNATIONAL JOURNAL OF AUDIOLOGY

Inflammation associated with presbyacusis
Reviewed by: Richard Navarro
September/October 2014 (Vol 23 No 4)
 

Inflammaging and presbyacusis is a topic that few audiologists consider in their daily clinical routine due to lack of training in this area. Inflammaging is a chronic state of inflammation present throughout the body. The classic 1965 work by Rosen and Pikka laid the groundwork documenting the co-morbidity of hearing loss and cardio-vascular disease. The current work explores the relationship between a number of bio-markers, such as white blood count and homocysteine levels, and elevated hearing levels as measured by tonal audiometry in an aged population. They compared their results to a previous study. In both studies, they found a positive correlation with a number of biomarkers and concluded that both lifestyle and pharmacological treatment may provide prophylactic solutions to the development and progression of age-related hearing loss. This is an important paper for all audiologists because it clarifies that not all hearing loss is caused by intense noise, but that cochlear metabolism is one factor that should be considered in the treatment and prevention of hearing loss. The evolution of care provided by audiologists should be predicated on learning more about how metabolism affects hearing, balance, and tinnitus so that more effective prevention and treatment protocols may be developed. Similar studies might be improved if distortion product otoacoustic emissions were added to the research protocol as this may reveal cochlear hair cell inflammation prior to the development of permanent hearing loss.

Reference

Inflammation is associated with a worsening of presbyacusis: Evidence from the MRC national study of hearing.
Verschurr V, Agyemang-Prempeh A, Newman TA.
INTERNATIONAL JOURNAL OF AUDIOLOGY
2014;53(7):469-475.

INTERNATIONAL JOURNAL OF LANGUAGE & COMMUNICATION DISORDERS

Early habilitation for hearing impairment in children with Down syndrome
Reviewed by: Gauri Mankekar
September/October 2014 (Vol 23 No 4)
 

Approximately 40-80% of children with Down syndrome have hearing impairment in addition to speech and language impairment. The commonest cause of hearing impairment in young children is otitis media with effusion. This paper investigated the impact of early hearing loss on language outcomes in children with Down syndrome. They found that early hearing loss has a significant impact on the speech and language development of children with Down syndrome. The authors suggest that speech and language therapy should be provided when children are found to have ongoing hearing difficulties. In addition, joint audiology and speech and language therapy clinics could be considered for preschool children.

Reference

Early hearing loss and language abilities in children with Down syndrome.
Laws G, Hall A.
INTERNATIONAL JOURNAL OF LANGUAGE &
COMMUNICATION DISORDERS 2014:49(3):333-42.

INTERNATIONAL JOURNAL OF LANGUAGE & COMMUNICATION DISORDERS

Early intensive aphasia therapy in stroke patients
Reviewed by: Gauri Mankekar
September/October 2014 (Vol 23 No 4)
 

The impact of aphasia following stroke is devastating. Very early aphasia rehabilitation studies have been the subject of ongoing debate. This paper describes the comparison of a very early aphasia therapy regimen with a historical ‘usual care’ control group after therapy completion, at four to five weeks post stroke and again after six months. The authors found that an impairment-based aphasia therapy regimen, provided daily over 20 sessions (over four to five weeks) in very early stroke recovery, resulted in significantly greater communication gains in people with mild to severe aphasia. The study adds to the existing literature, suggesting that increased and intensive aphasia therapy in the very early recovery phases is important for improving the effects of spontaneous recovery.

Reference

A comparison of aphasia therapy outcomes before and after a very early rehabilitation programme following stroke.
Godecke E, Ciccone NA, Granger AS, et al.
INTERNATIONAL JOURNAL OF LANGUAGE &
COMMUNICATION DISORDERS
2014;49(2):149-61.

INTERNATIONAL JOURNAL OF LANGUAGE & COMMUNICATION DISORDERS

Early intensive aphasia therapy in stroke patients
Reviewed by: Gauri Mankekar
September/October 2014 (Vol 23 No 4)
 

The impact of aphasia following stroke is devastating. Very early aphasia rehabilitation studies have been the subject of ongoing debate. This paper describes the comparison of a very early aphasia therapy regimen with a historical ‘usual care’ control group after therapy completion, at four to five weeks post stroke and again after six months. The authors found that an impairment-based aphasia therapy regimen, provided daily over 20 sessions (over four to five weeks) in very early stroke recovery, resulted in significantly greater communication gains in people with mild to severe aphasia. The study adds to the existing literature, suggesting that increased and intensive aphasia therapy in the very early recovery phases is important for improving the effects of spontaneous recovery.

Reference

A comparison of aphasia therapy outcomes before and after a very early rehabilitation programme following stroke.
Godecke E, Ciccone NA, Granger AS, et al.
INTERNATIONAL JOURNAL OF LANGUAGE &
COMMUNICATION DISORDERS
2014;49(2):149-61.

INTERNATIONAL JOURNAL OF PEDIATRIC OTORHINOLARYNGOLOGY

Are biofilms present in deep neck abscesses?
Reviewed by: Patrick Spielmann
September/October 2014 (Vol 23 No 4)
 

Why are some cervical abscesses resistant to antibiotic treatment? The authors postulate that a biofilm develops to allow the bacteria to overcome normal host defences. They investigated the micro-environment of deep neck abscesses in a largely paediatric cohort. Biopsies of abscess walls were taken and processed for electron microscopy scanning. Twelve of 14 demonstrated cocci and rods embedded in a 3-dimensional matrix – all features of a biofilm. This may explain why so many abscesses, particularly large ones, are difficult to treat with antibiotics alone.

Reference

Potential role of biofilms in deep cervical abscess.
May JG, Shah P, Sachdeva L, et al.
INTERNATIONAL JOURNAL OF PEDIATRIC OTORHINOLARYNGOLOGY
2014;78:10-13.

INTERNATIONAL JOURNAL OF PEDIATRIC OTORHINOLARYNGOLOGY

BAHA stability measurement in children
Reviewed by: Patrick Spielmann
September/October 2014 (Vol 23 No 4)
 

This useful paper reports the experience of using resonance frequency analysis for single stage bone-conduction implants in a paediatric population. A smartpegTM is attached to the abutment and vibrated by a close quarters magnetic field. The amount of vibration is converted into an implant stability quotient (ISQ) score. The ISQ was produced for each implant at time of surgery and at follow-up intervals. The mean stability scores were good enough to accept loading on the day of surgery with marginal improvements thereafter (at four weeks and 16 weeks). This has encouraged the authors to accelerate the loading of paediatric patients to a median of six weeks (range 1-16 weeks). With improved implant design and better understanding of osseointegration the loading times are inevitably being reduced, which has to be a good thing…

Reference

Resonance frequency analysis of osseo-integrated implants for bone conduction in a pediatric population – a novel approach for assessing stability for early loading.
McLarnon C, Johnson I, Davison T, et al.
INTERNATIONAL JOURNAL OF PEDIATRIC OTORHINOLARYNGOLOGY
2014;78:641-44.

JOURNAL OF CRANIO-MAXILLOFACIAL SURGERY

Extranodal natural killer / T-cell lymphoma in the head and neck
Reviewed by: Sunil Kumar Bhatia
September/October 2014 (Vol 23 No 4)
 

The authors present a retrospective single institution review of patients with a very rare variant of non-Hodgkin lymphomas (NHL). They report on the occurrence, clinical course and outcomes of their patients with natural killer / T-cell lymphoma (NKTCL) nasal type. Sixty-three patients with NHL were treated between 2006 and 2011. Of these 11 had extranodal lymphoma with six in the head and neck; of these three had NKTCL nasal type group. They report three clinical cases leading to the diagnosis and treatment course of the disease and outcomes. Two of the three had aggressive disease resistant to chemotherapy. The authors discuss a tumour rarely found in Europeans, but highlight its aggressive nature, chemo resistance and poor clinical outcomes. Because this can present with features of upper respiratory tract infection, it could be seen by a maxillofacial or otolaryngology practitioner and authors do a good job of drawing attention to this disease.

Reference

Extranodal lymphomas of the head and neck with emphasis on NK/T-cell lymphoma, nasal type.
Coha B, Vucinic I,Mahovne I, Vukovic-Arar Z.
JOURNAL OF CRANIO-MAXILLOFACIAL SURGERY
2014;42,149-52.

JOURNAL OF CRANIOFACIAL SURGERY

Cheek reconstruction following melanoma excision
Reviewed by: Sunil Kumar Bhatia
September/October 2014 (Vol 23 No 4)
 

Malignant melanoma occurs most commonly on the cheek and thus is usually diagnosed early, and rarely needs large reconstructions for advanced disease. This is a retrospective study looking at 26 patients that had undergone treatment for cheek melanomas between 1996 and February 2012. Reconstruction was with skin grafts (split in nine and full in three cases), seven with local flaps and seven with free flaps. The authors quantify the size of the defects and methods of reconstruction. On average the skin defect was 41.4cm2 with skin grafts, 24.9cm2 with local flaps and 76.7cm2 with free flaps. The authors discuss the range of the size of the defects and suggest the dividing line between local or free flaps as 40cm2. Skin grafts meanwhile being so much more versatile can be used for defects up to as large as 78cm2. The other considerations were exposed structures, such as bone, that cannot be grafted and tumour thickness and hence resultant defect. They suggest three factors are important in selecting a reconstruction procedure, size and aesthetic considerations. stage of the melanoma and age of the patient. The study is limited because of the patient numbers but it provides a good mental algorithm to use in assessment and planning of reconstruction.

Reference

An analysis of cheek reconstruction after tumour excision in patients with melanoma.
Hayashi T, Furukawa H, Oyama A, et al.
JOURNAL OF CRANIOFACIAL SURGERY
2014;25: e98-101.

JOURNAL OF LARYNGOLOGY AND OTOLOGY

A diagnostic survey of dizziness
Reviewed by: Madhup K Chaurasia
September/October 2014 (Vol 23 No 4)
 

The prevalence of self-reported dizziness and that requiring medical consultation is remarkably high. Cardiac and neuropathic comorbidities, often associated with these patients confuse the diagnosis. In this multicentre study, the prevalence and characteristics of various diagnostic groups, for example, Benign paroxysmal positional vertigo (BPPV), Ménière’s and likewise were studied in 1034 consecutive patients presenting with dizziness. Various diagnostic categories relating to vestibular causes were defined and patients were placed in them. The study took into account the recurrence of dizziness which was highest in patients with BPPV and migraine associated vertigo. Imaging was carried out in 151 of the 1034 patients and 24 (15.8%) had abnormalities. Of the 150 patients with vertigo of central origin, 12 had abnormal imaging results. Of the 551 with BPPV 64 were scanned and three of them had abnormal findings of which only one could be related to vertigo. Patients with vestibular neuronitis required most sick leave and night time awakening was most frequent in patients with BPPV. The diagnostic certainty was highest for patients with BPPV. Patients with BPPV provided the largest diagnostic group. A number of interesting attributes have been mentioned for BPPV. In various studies published in the literature, the percentage of patients referred for dizziness who have vestibular causes is 14-72.9%. In one study, 52.5% of patients were diagnosed with BPPV. In this study the incidence of BPPV was highest in patients between 60-79 years of age and the author emphasised that this diagnosis should not be overlooked in elderly patients because they have an increased risk of falling. Of these patients 49% are aware of their dizziness and 85% reported that symptoms were triggered by turning over in bed. There is also evidence that awareness of BPPV is insufficient in clinicians and necessary tests are not performed. The study therefore illustrates that BPPV is the underlying cause in the majority of patients presenting with dizziness, it is easily diagnosed and treated and therefore should not be missed.

Reference

Prevalence and characteristics of diagnostic groups amongst 1034 patients seen in ENT practices for dizziness.
Luscher M, Theilgaard S, Edholm B.
JOURNAL OF LARYNGOLOGY AND OTOLOGY
2014;128:128-33.

JOURNAL OF LARYNGOLOGY AND OTOLOGY

Assessment of viral aetiology in the formation of nasal polyps
Reviewed by: Madhup K Chaurasia
September/October 2014 (Vol 23 No 4)
 

The exact aetiology of nasal polyposis is not yet established although it is believed that allergic, infectious, mechanical, immunological and biochemical factors may be involved. Using the technique of polymerase chain reaction, this study assesses the role of human adenovirus, metapneumovirus, coronavirus, parainfluenza virus types 1, 2 and 3, influenza A and B virus, respiratory syncytial virus A and B and rhinovirus A and B in the formation of nasal polyps. The authors used the method of polymerase chain reaction based on nucleic acid isolation, reverse transcription, polymerase chain reaction amplification of target DNA and DNA detection with agarose gel electrophoresis. There were 30 patients with nasal polyps, 22 men and eight women, and a control group of 20 healthy patients. Nasal polyposis was diagnosed histopathologically. Tissue examination by agarose gel electrophoresis identified human coronavirus and rhinovirus in one of the patients in the control group. Another patient in this group had human respiratory syncytial virus. Influenza B virus was identified in one of the nasal polyp patients along with human coronavirus in another in this group. There was no statistically significant relationship between nasal polyposis and respiratory viruses. The study therefore does not support viral aetiology in the formation of nasal polyps. References have been made to past studies which showed a high prevalence of EBV in normal nasal pharyngeal mucus but not in nasal polyps. Therefore its role in nasal polyposis is doubtful which agrees with this study. The aetiology of this common condition therefore still remains uncertain.

Reference

Investigation of the role of major respiratory viruses in the aetiology of nasal polyps using polymerase chain reaction technique.
Aksoy F, Yenigun A, Dogan R, et al.
THE JOURNAL OF LARYNGOLOGY & OTOLOGY
2014;128(4):356-9.

JOURNAL OF LARYNGOLOGY AND OTOLOGY

Can smaller cancer centres deliver high quality care for patients with laryngeal cancer?
Reviewed by: Madhup K Chaurasia
September/October 2014 (Vol 23 No 4)
 

There is a continuing conflict between treating patients as close to their homes as possible and centralising specialised services, taking into consideration the critical mass and the multi-disciplinary expertise available. This is a report of outcomes in the treatment of laryngeal cancer in a small cancer centre serving a population of only 330,000, just about a third of what is recommended by IOG guidelines (2005). The authors looked at the survival rates of 209 consecutive patients, who presented with laryngeal cancer, over a 15 year period. These patients were prospectively entered into a standardised database. The distribution of these patients was as follows: 86 had stage one disease, 43 had stage two, 33 had stage three and 47 presented with stage four disease. A five year disease specific survival rate is reported as 100% for stage one, 76% for stage two, 87% for stage three and 46% for stage four. Of the 46 patients treated non-surgically 36 had recurrence of disease (79%). Most of these patients were treated surgically, before or after radiotherapy. The authors compare their five year tumour related survival rate of 82% and a five year overall survival rate of 59% with relative survival figures for laryngeal cancer across Europe ranging from 44% to 86%. This suggests excellent outcomes in a small cancer centre. An interesting review of the literature addresses the more recent trend for non-surgical treatment of laryngeal cancer, resulting in a non-significant decrease in the overall survival at five and 10 years. The authors attribute their 87% five year survival for Stage three disease to favouring surgical management of such advanced disease. The problems associated with radiotherapy and chemotherapy are mentioned and the role of surgery for advanced disease is supported. Less radical radiotherapy regimes are favoured. The article lends credence to the belief that laryngeal cancer can be managed reasonably well in a small, remote head and neck cancer centre, bringing care nearer to the patients’ homes.

Reference

Laryngeal cancer management in a small, rural, multi-
disciplinary team setting: 15 year review.
Hamilton DW, McMeekin PJ, Dyson P, Robson AK.
JOURNAL OF LARYNGOLOGY AND OTOLOGY
2013;127:1203-7.

JOURNAL OF LARYNGOLOGY AND OTOLOGY

Clinical value of 3 T magnetic resonance imaging after intratympanic gadolinium injection in cases of delayed endolymphatic hydrops
Reviewed by: Madhup K Chaurasia
September/October 2014 (Vol 23 No 4)
 

Recurrent vertigo can continue after severe unilateral or bilateral hearing loss. This is a condition similar to Ménière’s disease, the diagnosis of which can be difficult. In this study intratympanic injection of gadolinium-diethylenetriamine penta-acetic acid dimeglumine was done in 25 patients and followed by inner ear 3-D fluid-attenuated inversion recovery MRI 24 hours later. The distribution of Gadolinium in the labyrinth was quantitatively scored in the regions of cochlear base, middle and apex, vestibule and the three semi-circular canals. The presence of endolymphatic hydrops was evaluated with an established formula and the diagnosis was thought confirmed if the score of the function reached an accepted numerical value. The authors claim that this method diagnosed 84% (21/25 patients) of endolymphatic hydrops and thus has a higher sensitivity rate. No complications resulted with this technique. At the same time the authors performed pure tone audiometry, electrocochleography, bithermal caloric testing and VEMP potential testing. They found this MRI method to be the most sensitive. Electrocochleography is not useful in cases of severe hearing loss. Bithermal caloric testing has 72% sensitivity but is not a normal physiological vestibular stimulus and often evokes a vestibule-autonomic reflex. VEMP is limited in that it evaluates only the saccular function. The authors claim that accurate identification of the clinical type of delayed endolymphatic hydrops helps determine surgical strategy for treating these patients. If there is delayed endolymphatic hydrops in one ear and hearing loss in the other, endolymphatic sac surgery in the affected ear can maintain hearing and eliminate dizzy spells. Despite limited numbers the study does seem promising in the management of vertigo where symptoms persist years after hearing loss.

Reference

Diagnostic value of 3 dimensional magnetic resonance imaging of inner ear after intratympanic gadolinium Injection, and clinical application of magnetic resonance imaging scoring system in patients with delayed endolymphatic hydrops.
Gu X, Fang ZM, Liu Y, et al.
JOURNAL OF LARYNGOLOGY AND OTOLOGY
2014;128:53-59.

JOURNAL OF LARYNGOLOGY AND OTOLOGY

Facial paralysis risk factors in benign parotid surgery
Reviewed by: Madhup K Chaurasia
September/October 2014 (Vol 23 No 4)
 

The literature shows that the risk of facial paralysis following benign parotid surgery can be as high as 57% for temporary weakness and 7% for permanent facial nerve damage. It is generally thought that the factors involved may be related to age, sex, types of benign tumours, indications for the procedure, histological diameter, tumour location and the extent of parotidectomy. In this retrospective study involving 150 patients over a 10 year period the authors have assessed these factors and compared their findings with other studies. Of these patients, 26.7% had temporary weakness and 2.6% had permanent weakness. The age of these patients ranged from 15-80 years but this factor did not influence this risk nor did their gender. Different types of benign tumours and their size did not add to the risk of facial paralysis and the same was the case with location of the tumour in the parotid gland. The study included 10 cases in whom parotidectomy was done for sialadenitis and this did not add to the risk of facial nerve paralysis. The grade of the surgeon performing the parotidectomies was also taken into account but this did not matter thus making the authors feel reassured of the training and supervision. The most interesting aspect of this study is that facial nerve monitoring was used in only 44% of cases and authors do not feel the lack of it affects the risk of facial nerve paralysis. This does appear reassuring but how it stands from the medico-legal point of view is another matter.

Reference

Stratifying the risk of facial nerve palsy after benign parotid surgery.
Sethi N, Tay PH, Scally A, Sood S.
JOURNAL OF LARYNGOLOGY AND OTOLOGY
2014;128:150-62.

JOURNAL OF LARYNGOLOGY AND OTOLOGY

Hearing loss in the contralateral ear after mastoid drilling
Reviewed by: Madhup K Chaurasia
September/October 2014 (Vol 23 No 4)
 

It is difficult to conceive that most of the noise generated by drilling the mastoid would not be conveyed to the contralateral cochlea, by direct transmission through the skull bone, where the attenuation factor is only 5-10 dB. Only a few studies have been conducted to ascertain this with minimal variables in terms of the duration of drilling, speed of the drill and the size and nature of the drills used – whether diamond or cutting. In this study the authors assessed 30 patients who underwent drilling of the mastoid for cholesteatoma and had normal hearing in the contralateral ear. The hearing was tested by DPOAE and TEOAE preoperatively, in the recovery and the first two consecutive days. Pure tone audiometry was used preoperatively and in the first and second consecutive postoperative days. The speeds of the drill were 60,000 and 35,000 rpm. There was no statistically significant difference observed in the pure tone audiometry assessed as average threshold for low and high frequencies in the pre and postoperative periods. However, there were statistically significant changes in the pre and postoperative TEOAEs over both low and high frequency ranges. The DPOAE changed only in the high frequencies. The follow-up period was only 72 hours, therefore it has not been established whether or not these changes were temporary or permanent. A few studies from the literature support these findings in contrast to one which does not, but the authors explain that in that particular study only a small diamond burr (1-4mm) was used. Diamond burrs produce less noise. There were also statistically significant correlations between the burr times and changes in DPOAEs at high frequencies and TEOAEs at both high and low frequencies for cutting burrs, and changes in high frequency DPOAE only for diamond burrs. The speed of drilling did not matter. Quite understandably, this study has used a number of variables but the sample size is rather small and the assessment is collective which excludes variables such as individual susceptibility. Studies with larger sample size and longer follow-ups are required.

Reference

The effect of mastoid drilling on hearing of the contralateral ear.
Goyal A, Singh PP, Vashishth A.
JOURNAL OF LARYNGOLOGY AND OTOLOGY
2013;127:952-56.

JOURNAL OF LARYNGOLOGY AND OTOLOGY

Medical information required with requests for CT scans of the temporal bones; a two cycle audit
Reviewed by: Madhup K Chaurasia
September/October 2014 (Vol 23 No 4)
 

It is a common experience that radiology reports on the CT scans of the temporal bones do not always reach a diagnosis. Various studies have produced differing results in that detailed information may not be necessary to help reach a diagnosis by the radiologist and there are no national guidelines to this effect. However, the general consensus is that comprehensive rather than scanty information is helpful. In this two cycle audit the authors assess the extent to which accurate diagnosis was made in relation to CT temporal bone requests, firstly with random clinical information and then in the second cycle of the audit, with regulated information which unfailingly included the site, the symptoms, past medical history, audiological results, specific clinical questions asked, any suspected complications and mention of differential diagnosis. It was noted that CT reports indicating a diagnosis or excluding an important complication increased from 52 to 94 and the need for further clinical information or repeat of the imaging dropped from 12 to two. The factors which played the most significant role in this were mention of a differential diagnosis in the request, the clinical questions, the audiological findings, duration of signs and symptoms and the patient’s history. The striking aspect of this audit is that the same three neuro-radiologists delivered the reports in both cycles of this audit and were not aware of the audit itself, thus removing the element of bias quite convincingly. The study therefore strongly illustrates that, regardless of some reports in the literature stating otherwise, detailed information including the factors mentioned helps arrive at a better diagnosis and save repeat imaging.

Reference

A two cycle prospective audit of temporal bones computed tomography scan request: improving the clinical applicability of radiology reports.
Qureishi A, Garas G, Shah J, Birchall J.
JOURNAL OF LARYNGOLOGY AND OTOLOGY
2014;128:49-52.

JOURNAL OF LARYNGOLOGY AND OTOLOGY

Noise induced hearing loss caused by nightclubs
Reviewed by: Madhup K Chaurasia
September/October 2014 (Vol 23 No 4)
 

Legislation on hearing loss and tinnitus, occurring due to noise exposure at work, has been well established in terms of protection and compensation, but the same damage resulting from noise in nightclubs remains an open issue. This study, based on a questionnaire answered by 325 university students of ages ranging from 18 to 30, explores in a subjective manner the damage caused by noise exposure in nightclubs and their awareness of this possibility. Of these subjects, 46.2% attended a nightclub at least once a week. More than half the participants experienced muffled hearing and tinnitus after exposure to noise in a nightclub and in a quarter this persisted till the following morning. 86.6% had never received information about noise induced hearing loss, although awareness of this was more prevalent in medical students. Interestingly enough, there was no statistically significant difference in the level of concern between medical and non-medical students. Only 26.8% of these subjects said that knowing the link between noise in a nightclub subsequent and hearing loss would affect their attendance. The subjects however agreed that the level of noise in nightclubs should be reduced to avoid hearing damage, so they can continue to attend. The study is limited as it is based on questionnaires and is therefore purely subjective, but it opens an important issue which is presently not governed by legislation, nor is there any warning for visitors to nightclubs that their hearing may be damaged due to noise exposure.

Reference

British university students. Attitudes towards noise-induced hearing loss caused by nightclub attendance.
Johnson O, Andrew B, Walker D, et al.
JOURNAL OF LARYNGOLOGY AND OTOLOGY
2014;128:29-34.

JOURNAL OF LARYNGOLOGY AND OTOLOGY

Post tonsillectomy recovery in thermal welding method compared with recovery in cold steel method
Reviewed by: Madhup K Chaurasia
September/October 2014 (Vol 23 No 4)
 

Many different methods for tonsillectomy have emerged but whether they provide an improvement over the traditional cold steel tonsillectomy is another matter. Thermal welding is a recent method of tonsillectomy in which the tissues are simultaneously coagulated and divided. In this study the authors have made a direct comparison between the two methods of tonsillectomy in the same patient. The study comprises 40 children ranging from four to 14 years. Postoperative morbidity was measured in terms of a visual analogue scale for pain, the presence or absence and sidedness of otalgia during swallowing, drinking and speaking, bleeding and comparison of postoperative healing on the two sides. Patients were assessed on the first, third, seventh and fourteenth postoperative days. It was noted that it took less time to do the thermal welding tonsillectomy, which also had less bleeding. However in cases undergoing cold dissection, tissue healing proved to be better and the throat pain scores were significantly lower on the seventh postoperative day. There was no primary or secondary bleeding in any of the cases. The authors are aware of the pain scores being confused because of the highly subjective nature of pain. The study has its merits in that the two different methods were used on the same subject by the same surgeon and statistical analysis has been applied. The study is in agreement with many comparative studies between cold dissection tonsillectomy and newer methods and rightly makes one conscious of introducing more expensive methods in a cost effective scenario.

Reference

Post tonsillectomy morbidities: randomised, prospective controlled clinical trial of cold dissection versus thermal welding tonsillectomy.
Aydin S, Taskin U, Altas B, et al.
JOURNAL OF LARYNGOLOGY AND OTOLOGY
2014;128:163-65.

JOURNAL OF LARYNGOLOGY AND OTOLOGY

Precautions to be taken in cosmetic facial surgery
Reviewed by: Madhup K Chaurasia
September/October 2014 (Vol 23 No 4)
 

In this comprehensive write-up on precautionary measures to be taken when doing cosmetic surgery on our patients, the authors begin by emphasising that facial plastic surgery is no longer limited to celebrities and the privileged. It has extended into everyday life situations involving people who in recent years have better means to undertake this surgery. The patient selection should be done with careful emphasis on patient motivation for surgery and expectation. They should not expect to obtain dramatic results such as saving of a marriage or secure employment. These patients can have variable personalities, ranging from perfectionist and narcissistic, excessively demanding, through to passive and unfocused who remain indecisive on both the need and result of the surgery. In this scenario various psychological disorders should also be considered. Some patients simply do not like their appearance, which results in altered personality traits and in extreme cases proves a continuous obsession. A note should be made of possible eating disorders and the difference between an unhappy patient and the one who is clinically depressed should be registered and psychiatric help sought. The legal aspect of an informed consent is elaborated. One can deliver relevant information (prudent patient test) based on the patient’s values and beliefs about operations and complement this with the desired level of information. The patient’s understanding of the consenting process does remain a problem and many available solutions are difficult to implement in the NHS. Documentation of the consenting process is by no means fool proof in the present legal system. A note should be made of the author’s particular statement that ‘a well prepared lawyer will manage to circumnavigate their (surgeon’s) defence’. Medical photography helps in documentation, that should not be limited to the best results of the surgeon. With image manipulation software the patient may consider the portrayed and agreed image as a guaranteed surgical result. Revision operations should be considered very carefully and only after allowing time for the healing process to complete. The patient’s family doctor should be copied into the correspondence, but sometimes patients may desire that family doctors do not know and this has to be handled very carefully. The conclusion that can be derived from this scenario is that the patient should know what to expect and the surgeon be aware of what can be done.

Reference

Pre-operative considerations in aesthetic facial surgery.
Veer V, Jackson L, Kara N, Hawthorne M.
JOURNAL OF LARYNGOLOGY AND OTOLOGY
2014;128:22-28.

JOURNAL OF LARYNGOLOGY AND OTOLOGY

The need for pre-operative overnight pulse oximetry in children undergoing surgery for obstructive sleep apnoea syndrome
Reviewed by: Madhup K Chaurasia
September/October 2014 (Vol 23 No 4)
 

Snoring is a common occurrence in children listed for adenotonsillectomy. This may be associated with obstructive sleep apnoea syndrome, in which case the post-operative recovery of these children needs to be closely monitored. This study undertakes to assess whether an overnight pre-operative pulse oximetry can determine the need for high dependency unit (HDU) observation of these children after their operation. It is a retrospective study identifying patients from the high dependency unit admissions register over a two-year period. It was noted in which of these patients a pre-operative pulse oximetry was actually done and how it related to the post-operative overnight pulse oximetry in terms of desaturation events. The study involved 82 patients who underwent elective adenotonsillectomy, adenoidectomy or tonsillectomy for obstructive sleep apnoea syndrome (OSAS). In 59% of these patients pre-operative overnight pulse oximetry was performed and 32 were considered high risk. Thirty patients showed oxygen desaturation events. It was observed that all children who showed desaturation events pre-operatively also exhibited this in the post-operative pulse oximetry monitoring. Other children, for whom HDU was arranged post-operatively on clinical grounds but who had not undergone pre-operative overnight pulse oximetry, also showed desaturation events in SaO2 monitoring in the post-operative phase. The authors therefore highly rate the value of pre-operative overnight pulse oximetry in predicting post-operative desaturation events and suggest that this simple investigation be carried out in all children in whom OSAS is suspected so that the need for HDU may be identified. This may be a useful predictor for HDU bed requirement allowing targeted referrals for an increased level of post of care.

Reference

Pre-operative overnight pulse oximetry to predict high dependency unit intervention in children undergoing adenotonsillectomy for obstructive sleep apnoea.
Lightbody KA, Kinshuck AJ, Donne AJ.
THE JOURNAL OF LARYNGOLOGY & OTOLOGY
2014;128(4):360-4.

JOURNAL OF LARYNGOLOGY AND OTOLOGY

‘Dead ear’ after mastoid surgery
Reviewed by: Madhup K Chaurasia
September/October 2014 (Vol 23 No 4)
 

The primary aim of surgery in the management of cholesteatoma is eradication of the disease which can potentially result in serious complications such as intracranial extension, facial nerve weakness and further hearing loss. A profound hearing loss resulting postoperatively considerably compromises the outcome but is sometimes unpredicted. In this series the authors looked at 617 middle ear operations performed by a single consultant in which there were six cases of ‘dead ear’. None of these followed 83 operations for otosclerosis or 62 paediatric mastoid operations. However in 187 adults undergoing exploration of the mastoid for cholesteatoma, five (2.7% of cases) ended up with ‘dead ears’. The author has described these six cases in which the pathology ranged from fistulae of the lateral semicircular canal, granulations over the footplate, cholesteatoma covering the footplate, cholesteatoma surrounding the ossicular chain and unanticipated extensive cholesteatoma. In two of these cases surgery went satisfactorily and ‘dead ear’ was not at all predictable, but in the other four further hearing loss appeared likely in the course of surgery. It appears that in one of these cases ‘dead ear’ was definitely avoidable, in two it was probably avoidable and in the other three total hearing loss was inevitable in the process of clearance of disease. All the cases had CT scans which helped to some extent to decide on the surgical approach, but did not reliably predict hearing outcome after surgery. In this series 2% of patients had a ‘dead ear’ due to cholesteatoma itself. Therefore, the risks involved with surgery can be weighed against the disease itself causing a ‘dead ear’. This requires careful thought on whether or not to operate and its timing. The incidence of 2.7% ‘dead ear’ following cholesteatoma surgery is rather high and this calls for informed consent with very clear explanation of surgery and the possible adverse outcomes.

Reference

An audit of ‘dead ear’ after ear surgery.
Prinsley P.
JOURNAL OF LARYNGOLOGY AND OTOLOGY
2013;127:1177-83.

JOURNAL OF PLASTIC, RECONSTRUCTIVE AND AESTHETIC SURGERY

Comparing gracilis free flap and pectoralis major after salvage laryngectomy
Reviewed by: Sunil Kumar Bhatia
September/October 2014 (Vol 23 No 4)
 

A pharyngocutaneous fistula (PCF) following total laryngectomy is the most common and challenging complication. Reported incidence varies widely 5-65% and there are multiple factors implicated, but their significance is still controversial. The current practice is of organ preservation with initial chemoradiation followed by salvage laryngectomy for recurrence. This practice increases the risk of a PCF by a factor of 2.6. Muscle flaps are often used in the prevention and treatment of PCF. Commonly pedicled flaps such as the pectoralis major or other free flaps are employed such as radial forearm free flap or the antero-lateral thigh free flap. The authors report their results with the gracilis muscle free flap, compared with the pedicled pectoralis major flap. They report 49 patients with post radiation recurrent laryngeal carcinoma over 10 years that underwent salvage laryngectomy, with 22 free gracilis free flaps and 27 patients with pectoralis major flaps. There were 12 complications in the pectoralis major group and eight in the gracilis group but fistula rates were similar. They discuss the advantages and disadvantages of both flaps and make a good case for immediate initial repair with a free flap and leaving the pectoralis major muscle for a future need. The authors present their experience clearly and suggest the gracilis free flap is a good alternative to the pedicled pectoralis major flap in the prophylaxis or treatment of PCF.

Reference

A comparison between the free gracilis muscle flap and pedicled pectorlis major flap reconstructions following salvage laryngectomy.
Jing SS, O’Neill O, Clibbon JJ.
JOURNAL OF PLASTIC, RECONSTRUCTIVE AND AESTHETIC SURGERY
2014;67:17-22.

JOURNAL OF PLASTIC, RECONSTRUCTIVE AND AESTHETIC SURGERY

The use of Integra™ to allow early cover wounds
Reviewed by: Sunil Kumar Bhatia
September/October 2014 (Vol 23 No 4)
 

The authors present the use of Integra™ in a unique cohort of patients. Seven patients ages 21-31 in a six month period treated in one hospital. These were a very fit group of patients that had injuries caused by improvised explosive devices and had limb and trunk injuries. With better medical evacuation and field services, more service personnel survive injuries that were fatal previously. Unfortunately, when first evacuated they have significant injuries apart from the massive soft tissue injuries. There is a relative lack of skin that can be used to close open wounds / amputation. These patients, whilst previously very fit, are now unable to undergo the complex surgery. This is in distinction to the more commonly encountered vascular patient with compromised physiology and motivation. The authors describe the use of Integra™ for early closure of the defects. Seven patients with 11 wounds were treated. Good take was noted in eight wounds and there was only one complete loss. Partial take was noted in two wounds. While this is a small number of patients, anything that helps in the treatment of this unique cohort of patients and these injuries in useful. There is also an introduction to this type of war injury and difficulty in treating it.

Reference

Integra™ permits early durable coverage of improvised explosive device (IED) amputation stumps.
Foong DPS, Evriviades D, Jeffery SLA.
JOURNAL OF PLASTIC, RECONSTRUCTIVE AND AESTHETIC SURGERY
2013;66:1717-24.

JOURNAL OF PLASTIC, RECONSTRUCTIVE AND AESTHETIC SURGERY

Use of atenolol to treat infantile haemangiomas and comparison with propranolol group
Reviewed by: Sunil Kumar Bhatia
September/October 2014 (Vol 23 No 4)
 

The authors present a prospective blinded series of 30 consecutive patients with infantile haemangioma (IH) treated with Atenolol, a selective beta-1 blocker. This is the first study comparing two different beta blockers. They achieved good results and they suggest this is because Atenolol is a more selective beta-1 blocker with fewer side-effects. All patients had significant IH. Prior to therapy all patients were screened for contraindications and an ECG was performed. Atenolol was administered to all patients with IH, orally. Patients were evaluated around two, eight and 20 weeks, weight, BP and heart rates as well as photographic records were noted. Side-effects were determined and documented. The data was compared with the propranolol group. The accepted treatment of IH is with beta-blockers. This study proposes fewer side-effects and significantly fewer serious side-effects, such as hypoglycaemia or bronchial hypersensitivity. While an interesting study, there still remains a number of questions. Although the authors do correct for age, the Atenolol group were treated at a younger age. It is a small group of patients with promising initial results and needs more investigation. This is echoed by the authors themselves.

Reference

Treatment of infantile haemangiomas with atenolol: comparison with a historical propranolol group.
de Graaf M, Raphael MF, Breugem CC, et al.
JOURNAL OF PLASTIC, RECONSTRUCTIVE AND AESTHETIC SURGERY
2013;66:1732-40.

JOURNAL OF PLASTIC, RECONSTRUCTIVE AND AESTHETIC SURGERY

Wide local excisions for dermatofibrosarcoma protuberance
Reviewed by: Sunil Kumar Bhatia
September/October 2014 (Vol 23 No 4)
 

The authors present a viable alternative treatment for Dermatofibrosarcoma protuberance (DFSP). They show that wide local excision for DFSP can achieve a good result, saving the patient multiple visits to undergo Mohs surgery. The accepted method of treatment is surgery, be it Mohs or wide local excision (WLE). Mohs surgery has been suggested as the standard of care. The advantage of WLE is the single procedure. The authors present a retrospective analysis of 10 years of all cases of DFSP treated with WLE by a single operator. Twenty patients were identified; all patients had excision and reconstruction as one procedure. There were no incomplete excisions and no recurrences were recorded. They do not report any post complications or recurrences over 5.6 years of follow-up. Apart from the excisions none of the patients had any other treatment. It is a sound study with a good discussion. The authors accept it being a small group and a very diverse one, as the sites include head, torso and limbs. One can identify with their statement, ‘WLE with immediate reconstruction offers complete excision of DFSP and allows safe, reliable excision of the tumour without the need for a two staged operation without compromising the long-term outcome.’

Reference

To Mohs or not to Mohs.
Kokkinos C, Sorkin T, Powell B.
JOURNAL OF PLASTIC, RECONSTRUCTIVE AND AESTHETIC SURGERY
2014:67 23-6.

JOURNAL OF ULTRASOUND IN MEDICINE

Ultrasound and MRI for NPC
Reviewed by: Badr E. Mostafa
September/October 2014 (Vol 23 No 4)
 

The traditional radiological evaluation of patients with suspected nasopharyngeal carcinoma (NPC) is CT and MRI. The authors compared MRI and ultrasonography of the nasopharynx of patients with biopsy proven disease. Both sonography and MRI had good diagnostic performance for nasopharyngeal carcinoma. There was no significant difference in the rate of tumor detection between sonography and MRI (p= 0.12); the specificities of sonography and MRI were also similar (p= 0.22). However, sonography is less expensive and easier to perform. The results of this study also suggest that nasopharyngeal sonography could be used for the initial investigation of primary nasopharyngeal carcinoma. This is a very attractive alternative to MRI but the main disadvantage of ultrasound remains: it is highly operator dependant.

Reference

Diagnostic Accuracy of Sonography Versus Magnetic Resonance Imaging for Primary Nasopharyngeal Carcinoma.
Gao Y, Zhu SY, Dai Y, et al.
JOURNAL OF ULTRASOUND IN MEDECINE
2014;33(5):827-34.

JOURNAL OF VESTIBULAR RESEARCH

Discussion of the dizziness handicap inventory
Reviewed by: Fiona Barker
September/October 2014 (Vol 23 No 4)
 

This paper purported to be a review of the dizziness handicap inventory. The authors start (and finish) by stating that the DHI is the most widely used self-report scale used to assess handicap in context of vestibular dysfunction. While this is probably the case this statement was not referenced or justified and, as this paper did not compare studies which used the DHI versus other measures, this review failed to add to the evidence in this regard. It was not clear whether this was meant to be a review of the validity, reliability and consistency of the DHI or whether it was attempting to review its effectiveness as an outcome measure. I’m afraid it did neither. The paper begins by stating that 227 articles met the inclusion criteria but only 74 were reviewed. The inclusion criteria for the review were rather ‘woolly’. It was not clear on what basis this selection of 74 studies was made. Not a great start! The main body of the paper appeared to be a list of studies using the DHI. There was no narrative or meta-analysis and no assessment of study quality despite the fact that some of the individual studies contradicted each other. In short, there was an absence of critical appraisal which is an essential element of a review of any body of evidence. This was a summary of evidence at best rather than a review. As a clinician, what I would like to know from a paper like this is whether the DHI measures what we think it measures and whether it is any good as an outcome. I’m afraid this paper did not answer either question for me.

Reference

Discussion of the dizziness handicap inventory.
Matlu B, Serbetcioglu B.
JOURNAL OF VESTIBULAR RESEARCH
2013;23:271-7.

JOURNAL OF VESTIBULAR RESEARCH

Using the international classification of functioning disability and health (ICF) in the context of vestibular rehabilitation
Reviewed by: Fiona Barker
September/October 2014 (Vol 23 No 4)
 

There should be something of interest in this paper for those interested in measuring outcome in vestibular rehabilitation. The paper introduces and describes the ICF and how it is being applied in this context. As the ICF is a global health classification system many of its categories do not apply in the context of vestibular work and the author describes how a relevant core set of classifications has been defined. This breaks the huge scope of the ICF into more manageable chunks that can be applied in clinical practice and to inform research. In particular the author suggests that this framework might be useful in the development of future outcome measures for vestibular rehabilitation that might more comprehensively capture the range of impairments, participation restrictions, activity limitations, barriers, facilitators and personal factors that impact on outcome. Using an agreed theoretical framework such as this to inform future research can only be a good thing and this paper presents a good introduction for those not familiar with the ICF.

Reference

Introduction to the international classification of functioning disability and health – ICF – in the context of vestibular rehabilitation.
Graziano M.
JOURNAL OF VESTIBULAR RESEARCH
2013;23:293-6.

LARYNGOSCOPE

Vascularised tissue in salvage total laryngectomy
Reviewed by: Mark Puvanendran
September/October 2014 (Vol 23 No 4)
 

Chemoradiation (CRT) has become the mainstay for locally advanced laryngeal cancer since the RTOG 91-11 trial. Unfortunately there is still a substantial demand for salvage laryngectomies, which have a higher complication rate, the most notable being pharyngocutaneous fistula (PCF). Several small studies have suggested that using vascularised tissue from outside the radiation field reduces the risk of PCF; this systematic review aims to identify evidence for this. The authors are a distinguished international group, who have carried out a vigorous systematic review. The search strategy is clearly described; inclusion criteria and excluded studies are clearly detailed. The outcome considered, the presence or absence of PCF, is not subject to bias. Ultimately seven articles (591 patients) made the grade and were included in the analysis. The PCF incidence was 31.2% in the primary closure group compared with 22.2% in the flap reconstruction group. PCF carries a significant morbidity, increases hospital stay and may lead to death. The reduction of the incidence by one-third is a significant finding; this paper is essential reading for all head and neck surgeons and should inform future practice in salvage total laryngectomy.

Reference

Vascularized tissue to reduce fistula following salvage total laryngectomy: A systematic review
Paleri V, Drinnan M, van den Brekel MW, et al.
THE LARYNGOSCOPE
2014;124(8):1848-53.

NEUROSURGERY

Caffeine consolidates memory?
Reviewed by: Gauri Mankekar
September/October 2014 (Vol 23 No 4)
 

Although caffeine has been touted as a cognitive enhancer, promoting vigilance, improving reaction times, and facilitating passive learning, the role of caffeine on short memory has been inconsistently described while studies on long-term memory are few. The authors of this paper conducted a randomised, double-blind, placebo-controlled trial at Johns Hopkins exploring memory consolidation in caffeine-naïve, healthy young volunteers. After performing an incidental encoding task involving visual images in an indoor-outdoor judgment paradigm, participants received either placebo or a dose equivalent to one short, eight-ounce cup of Pike Place Starbucks coffee. Baseline, 1-hour, and 3-hour saliva samples were obtained to measure caffeine metabolite levels. Participants returned to perform a second task to evaluate their recognition performance. The study showed that a one-time dose of caffeine administered after an incidental learning task enhanced a participant’s ability to differentiate similar images in a task 24 hours later, suggesting that caffeine intake improves long-term memory consolidation. The authors conclude that although further research is needed into the effects of caffeine on memory consolidation, the current evidence indicates that caffeine has benefits beyond prevention of neuronal loss.

Reference

Morning Joe or after-dinner espresso? Improved memory consolidation after caffeine administration.
Kelly KM, Mikell CB, McKhann GM
NEUROSURGERY
2014:74(6)N8-N11.

NEUROSURGERY

Flexible neuroendoscopic management of hydrocephalus
Reviewed by: Gauri Mankekar
September/October 2014 (Vol 23 No 4)
 

Neuroendoscopy has revolutionised the management of intracranial clinical conditions and its applications are continuously expanding. In this article, the authors have described their 17 year experience using a flexible neuroendoscope to manage fourth ventricle outflow obstruction in patients with hydrocephalus. Traditionally, patients with fourth ventricle outflow obstruction are managed with a ventriculoperitoneal shunt or endoscopic third ventriculostomy. The authors performed endoscopic transventricular transaqueductal Magendie and Luschka foraminoplasty in 30 patients. Of these, 26 patients had long-term follow-up; 17 (65.3%) of these had clinical improvement and did not require further procedures. Nine (34.7%) did not improve. Of these, eight required another procedure (seven shunts, and one endoscopic procedure) and one patient died. The authors describe the procedure as safe, feasible and with minimal risk of periaqueductal injury.

Reference

Endoscopic transventricular transaqueductal magendie and luschka foraminoplasty for hydrocephalus.
Torres-Corzo J, Sánchez-Rodrıguez J, Cervantes D, et al.
NEUROSURGERY
2014:74:426-36.

NEUROSURGERY CLINICS OF NORTH AMERICA

Occipital nerve modulation for chronic migraine
Reviewed by: Gauri Mankekar
September/October 2014 (Vol 23 No 4)
 

Chronic migraine is a source of significant disability, loss of productivity and impairment in health related quality of life. Pharmacotherapy of migraine includes preventive agents and abortive agents. Preventive agents include anticonvulsants, anti-depressants, beta-adrenergic blockers and serotonin antagonists. Abortive agents include non-steroidal anti-inflammatory agents, tryptans, opioids, ergot compounds and sedatives. This review article discusses the role of peripheral neuromodulation in the treatment of chronic migraine. Traditional neurosurgical procedures like dorsal root entry zone lesioning, dorsal root ganglionectomy, peripheral neurolysis and neurectomy have not gained any favour. On the other hand, occipital nerve stimulation is a non-destructive alternative. Although the mechanism of peripheral neuromodulation is unknown, two theories have been proposed for its mechanism of action – the first theory is similar to the pain gate theory implicated in the mechanism of spinal or peripheral nerve stimulation for somative neuropathic pain. The second theory is based on PET imaging which suggests that occipital nerve stimulation results in retrograde modulation of the brainstem nuclei involved in the trigeminal vascular system thus inhibiting migraine headaches.

Reference

Peripheral neuromodulation for treatment of chronic migraine headache.
Tavanaiepour D, Levy RM.
Neurosurgery Clinics of North America
2014:25(1):11-14.

NEUROSURGERY QUARTERLY

Artificial dura for sellar reconstruction
Reviewed by: Gauri Mankekar
September/October 2014 (Vol 23 No 4)
 

Transsphenoidal pituitary adenoma removal is often associated with large skull base defects and cerebrospinal fluid (CSF) leaks. This article adds to the existing literature on repair of the skull base defects to prevent CSF leaks. The authors used absorbable hemostatic cotton and gelatin sponge for intrasellar packing and a double layer of artificial dura mater and fibrin glue to manage CSF leaks. This obviated the need for tissue grafts. The authors suggest that over packing should be avoided to prevent compromise of the vascular supply, pituitary or optic chiasm function. The artificial dura used is water tight and is gradually absorbed to be replaced by connective tissue, thus forming a dura-like tissue to repair the sellar floor defect. The authors had an incidence of 1.3% CSF leaks postoperatively using this repair.

Reference

Sellar reconstruction using biomaterials after transsphenoid surgery in 449 cases of pituitary adenomas.
Du J, Qui B, Wang Y, et al.
NEUROSURGERY QUARTERLY
2014;24(1):22-6

NEUROSURGERY QUARTERLY

Familial glossopharyngeal neuralgia
Reviewed by: Gauri Mankekar
September/October 2014 (Vol 23 No 4)
 

The authors report the unusual occurrence of glossopharyngeal neuralgia in a 73-year-old male and his female sibling. The patients had bouts of sharp stabbing pain on the right side of the chin, ear, posterior tongue and pharynx lasting five to 10 seconds. The female sibling had syncopal attacks with paroxysmal pain. MRI scans showed a dolichoectatic vertebral artery compressing the glossopharyngeal nerve. 10 % lidocaine spray to the pharynx provided temporary relief. Pregabalin 150mg twice daily relieved the male patient’s symptoms and the female patient did not have any more syncopal attacks. This must be a one of the first reports of familial glossopharyngel neuralgia.

Reference

Glossopharyngeal neuralgia due to familial dolichoectatic vertebral artery.
Çöven Í, Çoban G, Horasanh B, Ílik MK.
NEUROSURGERY QUARTERLY
2014;24(1):44-6.

NEUROSURGERY QUARTERLY

Post-traumatic pseudoaneurysm causing near fatal epistaxis
Reviewed by: Gauri Mankekar
September/October 2014 (Vol 23 No 4)
 

This case report describes a rare case of near-fatal epistaxis with loss of consciousness in an 18-year-old boy, two months after head injury. The patient had repeated episodes of profuse epistaxis associated with loss of consciousness requiring blood transfusion. CT scan and MRI showed a destructive midline giant mass in the skull base lateralising to the left side, eroding the skull base, reaching the sphenoid sinus and posterior nasal boundaries. Initial CT angiography showed a giant aneurysm originating from the infraophthalmic segment (cavernous portion) of the left internal carotid artery. Carotid stenosis, unusual for an 18 year old, was noted at the origin of the pseudo aneurysm. The patient underwent transcervical ligation of the left carotid in the neck after angiography supported a good collateral circulation. Despite this procedure the epistaxis continued and a subsequent angiogram revealed small feeder vessels from the ophthalmic artery feeding the neck of the pseudoaneursym. The patient underwent a left carotid artery ligation (supraclinoidal) with exclusion of the ophthalmic artery via a left pterional craniotomy. Although traumatic carotid pseudoaneursyms are a rare cause for epistaxis, clinicians should be able to make early diagnosis, split second decisions and manage the situation promptly as the mortality rate can be as high as 50%.

Reference

Near-fatal epistaxis from traumatic giant carotid artery pseudoaneursym: a case report.
Rashad S, Hassan T, Eldawoody HF.
NEUROSURGERY QUARTERLY
2014;24(1):56-62.

ORL

TORS for OSA: outcomes and bench-marking
Reviewed by: Zi Wei Liu
September/October 2014 (Vol 23 No 4)
 

This is a large multicentre retrospective observational study of the outcomes of transoral robotic surgery (TORS) for obstructive sleep apnoea (OSA) in 243 cases. Tongue base and supraglottic level obstruction is the main indication for TORS in OSA patients. Postoperatively, patients experienced significant improvements in apnoea-hypopnoea index (AHI), Epworth sleepiness score (ESS) and lowest O2 saturation without a significant change in BMI. 53.8% of patients were no longer continuous positive airway pressure (CPAP) dependent (AHI <15 and ESS <10) and 66.9% had a significant reduction in daytime somnolence and cardiovascular risk factors (AHI <20, ESS <10). The most common complication is temporary mild hypogeusia. Forty-five percent of patients received a temporary tracheostomy as routine practice in some centres. In this series TORS was performed as part of a multi-level procedure in 86% and patients also received nasal surgery (59%), tonsillectomy (60%) and uvulopalatopharyngoplasty (UVPP) (60%). Follow-up time was short (minimum three months) and long-term efficacy of TORS cannot be determined from these data alone. The multifactorial nature of OSA is reflected in the need for multi-level procedures and accurate pre-operative assessment of key contributory factors to OSA is crucial to successful outcomes. However, it is difficult to establish the effects of TORS alone given most patients require multiple procedures. Long-term follow-up data is required on efficacy and rates of recurrence.

Reference

Clinical outcomes and complications associated with TORS for OSAHS: a benchmark for evaluating an emerging surgical technology in a targeted application for benign disease.
Vicini C, Montevecchi F, Campanini A, et al.
ORL
2014;76(2):63-9.

ORL

Which patients habituate to tinnitus? The role of trigger factors and success of tinnitus retraining therapy
Reviewed by: Zi Wei Liu
September/October 2014 (Vol 23 No 4)
 

Tinnitus arises from perception of electrical activity in the auditory system without external stimulus. Although a very common symptom, few patients are sufficiently troubled by tinnitus to seek medical attention. Those that do are said to associate tinnitus with negative emotional states through a learning process, generating a conditioned reflex. This study looked at the effectiveness of tinnitus retraining therapy (TRT) when related to severity of tinnitus, presence of hyper- and hypoacusis and identifiable trigger factors. A total of 294 patients who had experienced incapacitating tinnitus for at least six months were treated, followed up for a minimum of 18 months and had outcomes assessed using a visual analogue scale and Tinnitus Handicap Inventory (THI). Eighty percent of patients improved following treatment and all those with mild or recent onset of symptoms improved. Where the main symptom is tinnitus, 90% improve following treatment. With associated hyperacusis, 78% of patients improve. Where hearing loss is associated with tinnitus, only 59% of cases improve. The study group was able to identify factors which precipitated tinnitus onset in 66% of patients. They were able to show significantly better habituation where a trigger factor was identified (91% vs 56%). In patients with hypoacusis and absence of trigger factors, the outlook was worst (28% improvement). The authors suggest TRT should be adapted in patients without trigger factors correlating with tinnitus and that hearing aids should be used to complement therapy where necessary.

Reference

Impact of Identifying Factors Which Trigger Bothersome Tinnitus on the Treatment Outcome in Tinnitus Retraining Therapy.
Molini E, Faralli M, Calzolaro L, Ricci G.
ORL
2014;76(2):81-8.

OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA

“I’ve got sinus”
Reviewed by: Charlie Giddings
September/October 2014 (Vol 23 No 4)
 

This edition of the journal tackles headaches in otolaryngology, especially those thought to be rhinogenic in origin. For patients presenting with “sinus headache” symptoms a comprehensive history, detailed examination of the nose and correlation with imaging is essential. Meticulous investigation is as important as a close working relationship with a neurologist. International classifications of headache support acute rhinosinusitis as a cause of secondary headache if in conjunction with appropriate clinical findings. The literature is less clear with regard to chronic sinusitis, and this edition of the journal is a must read for any budding rhinologist. The review recognises conflicting literature as there is cross over between primary headache symptoms, and many studies lack strict diagnostic criteria and outcome measurements. Some studies have suggested that up to 90% of sinus headaches may be migraine, others studies reveal that migraine headache may not present in isolation. Much needed consistency in the management of this group of patients is needed and the article is a reiteration that surgery is far from the first choice treatment. Further quality literature would be welcome to define if headache attributed to disorders of the nasal mucosa, turbinates or septum, formerly “intranasal mucosal contact point headache”, is a remote justification for surgery.

Reference

What do we know about rhinogenic headache?
Mehle ME, Schreiber CP.
OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA
2014;47:255-68.

OTOLARYNGOLOGY-HEAD AND NECK SURGERY

Confirmation that Epley is more effective than watchful waiting for p-BPPV
Reviewed by: Hannah Blanchford
September/October 2014 (Vol 23 No 4)
 

This systematic review of eight papers posed the question ‘What is the effectiveness of watchful waiting compared to the Epley manoeuvre (EM) in patients diagnosed with posterior canal benign paroxysmal positional vertigo (BPPV) regarding symptom relief?’. Posterior semicircular canal BPPV (p-BPPV) is the most common form of BPPV, a disorder that has a significant impact on daily living. Up to 37% of patients cannot work and 18% avoid leaving their homes. This review of eight papers suggested that for ‘subjective symptom relief’ at one week, all studies showed a strong effect (varying from 20% to 59%) in favour of the EM. This effect was found to decrease over a longer follow-up period. The authors highlight the discrepancy in study protocols, with some advocating repeated cycles of the manoeuvre, which may account somewhat for the wide variation in efficacy. The authors conclude that, given the low cost and low risk of side-effects, the EM should be considered in every patient with p-BPPV and suggest increasing training for general practitioners to perform this procedure in the community.

Reference

Rapid systematic review of the Epley Maneuver for treating posterior canal benign paroxysmal positional vertigo.
Van Duijn JG, Isfordink LM, Nij Bijvank JA, et al.
OTOLARYNGOLOGY-HEAD AND NECK SURGERY
2014;150(6):925-32.

OTOLARYNGOLOGY-HEAD AND NECK SURGERY

How to make a quinsy simulator
Reviewed by: Hannah Blanchford
September/October 2014 (Vol 23 No 4)
 

This study evaluated the success of a peritonsillar abscess simulator for training residents in the skill of abscess drainage. Although not technically difficult, the authors concede that new residents may be intimidated by the prospect of having to perform this procedure during their first on-call. Simulators allow for safe repetition and a controlled environment to develop one’s confidence without having to manage patient anxiety and distress at one’s first attempt. A latex mould with indentations representing the tonsils and uvula was created over a clay cast. This was secured at the end of a 2.5 inch diameter pipe to simulate the limited space of the oropharynx. A small balloon filled with vanilla pudding and placed behind 3mm-thick polyurethane foam simulated the abscess lying behind mucosa and submucosal space. Lips were created from clay and the oral opening was 3cm high and 5cm wide. A rubber tongue taken from a mannequin was secured in the oral cavity. A flexible scope was mounted with video recording. The pilot study evaluated residents and medical students in performing abscess drainage and evaluated their responses. All participants felt that the simulator replicated the skills necessary to drain a quinsy. Ninety percent agreed that the simulator helped in learning how to anaesthetise the area and aspirate the abscess. Fifty percent felt it was a good anatomical representation. The authors claim an initial cost of 10 dollars, with disposable parts costing 25 cents, and demonstrate their simulator to be a low-cost tool for providing training whilst minimising risk to patients.

Reference

Novel peritonsillar abscess task simulator.
Taylor SR, Chang CWD
OTOLARYNGOLOGY-HEAD AND NECK SURGERY
2014;151(1):10-3.

OTOLARYNGOLOGY-HEAD AND NECK SURGERY

Sparse evidence for benefit of hearing aids for tinnitus
Reviewed by: Hannah Blanchford
September/October 2014 (Vol 23 No 4)
 

This section of the journal helpfully highlights a recent Cochrane review. It aims to help clinicians evaluate the effectiveness of interventions for tinnitus. The authors of the Cochrane review, for which only one randomised controlled trial met the inclusion criteria, concluded that current evidence for prescribing hearing aids for tinnitus is limited. This RCT of 91 patients with hearing loss above 2kHz compared hearing aids with sound generators and found no difference in outcomes (measured by the Tinnitus Handicap Inventory). As only one paper was eligible for inclusion, the authors highlight the deficit of robust evidence in this field. The commentators suggest the authors should have concluded that patients with tinnitus and mild hearing loss who receive tinnitus retraining therapy (TRT) and either a sound generator or an open hearing aid find an improvement in their tinnitus over time, but that current research does not allow us to define whether this is due to the sound generators, hearing aids, TRT or none of these. Also, if part of the improvement is due to sound generators or hearing aids, there is no evidence to suggest that one is better than the other. The authors suggest that, despite the absence of evidence in favour of hearing aids for tinnitus, where the only significant downside of hearing aids is cost, and the patient accepts this, it may still be reasonable to offer a trial of hearing aids.

Reference

Cochrane corner: amplification with hearing aids for patients with tinnitus and co-existing hearing loss.
Schilder AGM, Burton MJ, Eby TL, Rosenfeld RM.
OTOLARYNGOLOGY - HEAD AND NECK SURGERY
2014;150(6):915-18.

Otology & Neurotology

Fine tuning!
Reviewed by: Anand Kasbekar
September/October 2014 (Vol 23 No 4)
 

This neat little study provides us with evidence to quote when we are asked to find that elusive tuning fork on the postoperative ward round after tympanomastoid surgery. Essentially the authors, from Wolverhampton, UK, compared the Weber test with the scratch test in 56 major tympanomastoid operations and found that the scratch test is better! Overall, Weber's test had a sensitivity of 73.2% and specificity of 100% compared with a sensitivity of 89.3% and specificity of 100% for the scratch test. Bear in mind that a head bandage needs to be present and the ‘scratch’ should be performed over the centre of the forehead on the bandage.

Reference

How reliable is the "scratch test" versus the Weber test after tympanomastoid surgery?
Iacovidou A, Giblett N, Doshi J, Jindal M.
OTOLOGY & NEUROTOLOGY
2014;35(5):762-3.

Otology & Neurotology

Myringoplasty in children with cleft palate
Reviewed by: Anand Kasbekar
September/October 2014 (Vol 23 No 4)
 

Although we know that cleft palate (CP) patients generally have poor eustachian tube function, little is known on how these patients fare after myringoplasty when compared to the general population. Do they really perform worse? Previously published literature has mixed views. This well-conducted French retrospective study compares the results of underlay cartilage myringoplasty in children with and without CP. Both groups had an average age of 10.5 years at operation. Thirty-two CP patients had 32 matched non-CP controls and the closure rate of the perforation was the same in both groups (84%), helped by the cartilage support I suspect. The authors state that the matching process selected control patients with greater otologic disease hence the closure rate was the same and not better than in CP patients. Hearing results were however significantly worse in the CP group, but they were worse to begin with. Overall the message seems to be that if cartilage is used, the anatomical closure rate should be the same. Hearing outcome is likely to be worse in CP patients whichever method of grafting one uses.

Reference

Results of myringoplasty in children with cleft palate: a patient-matched study.
Harterink E, Leboulanger N, Kotti S, et al.
OTOLOGY & NEUROTOLOGY
2014;35(5):838-43.

PEDIATRIC ALLERGY AND IMMUNOLOGY

Is there a link between rhinitis and depression?
Reviewed by: Evangelia Tsakiropoulou
September/October 2014 (Vol 23 No 4)
 

Rhinitis and asthma are global health problems, increasingly common in childhood. There is a growing interest on the impact of respiratory allergies on quality of life, however, the association between allergic rhinitis and psychologic characteristics in children remains poorly understood. This study from Italy explored if there was a connection between rhinitis and depression in 1283 subjects aged 10-13 years old. Depressive and anxious mood states were assessed using the Depression and Anxiety in Youth Scale, along with spirometry and skin prick tests. Anxiety (16%) and depression (13.6%) rates were higher than comparable literature when rhinitis was present. Additionally, female gender was directly linked to anxiety but not with depression.. The authors state that female gender is an indirect risk factor for both depressive state and rhinitis. The authors recognise the self-reported data as a study limitation. Furthermore they did not explore any other psychological or environmental variables that could influence the relation between rhinitis and mood. The introduction of mood management in clinical care along with control of rhinitis could reduce disease burden.

Reference

Rhinitis as a risk factor for depressive mood in pre-adolescents: a new approach to this relationship
Audino P, La Grutta S, Cibella F, et al.
Pediatric Allergy and Immunology
2014:25(4):360-5.

RHINOLOGY

Bacterial biofilms in patients with chronic rhinosinusitis: a confocal scanning laser microscopy study
Reviewed by: Lakhbinder Pabla (Bal)
September/October 2014 (Vol 23 No 4)
 

Biofilms on sinonasal mucosa have been implicated in the development of chronic rhinosinusitis. Current methods to investigate biofilms on sinonasal mucosa include traditional light microscopy, electron microscopy and confocal microscopy. This study investigates the presence of biofilms in 61 patients with chronic rhinosinusitis and septal deviation undergoing primary functional endoscopic surgery, and 25 controls (no chronic rhinosinusitis but septal deviation present), using confocal scanning laser microscopy. Bacterial biofilms were detected in 90% of patients with chronic rhinosinusitis, significantly more than in controls, in which 56% were biofilm positive. The point prevalence of biofilms in the control group was found to be relatively high compared to other similar studies. A possible explanation for this was that patients undergoing septoplasty were used as the controls in this study whereas in other studies reporting low prevalence of biofilms in the control group were completely free of nasal complaints (undergoing skull base surgery). This may point to a role for biofilms in the pathogenesis of patients with nasal obstruction without chronic rhinosinusitis. However, further studies are required.

Reference

Bacterial biofilms in patients with chronic rhinosinusitis: a confocal scanning laser microscopy study.
Danielsen KA, Eskeland O, Fridrich-Aas K, et al.
RHINOLOGY
2014;52(2):150-5.

RHINOLOGY

External nasal valve collapse: validation of a novel outcome measurement tool
Reviewed by: Lakhbinder Pabla (Bal)
September/October 2014 (Vol 23 No 4)
 

In this study, the authors devised a grading system that measures external nasal valve collapse in each nostril both at rest and on deep inspiration. This is based on a subjective measurement score ranging from 0-4. This grading system was then validated by firstly assessing reliability (inter-rater agreement and test-retest repeatability) using sixteen rhinologists scoring clinical photographs separately on two occasions one year apart. Secondly, its clinical relevance in patients undergoing septorhinoplasty for external nasal valve collapse was evaluated with a prospective observational case series of twenty-six patients who were scored pre- and post-operatively. The devised scoring system was found to be reliable with substantial agreement between 16 surgeons which were reproducible over time. All patients in the prospective series showed significant improvement in their external valve score. The quality of life measured by the SNOT-22 tool also showed significant improvement after surgery. This is the first study to propose a scoring system for external nasal valve collapse and to validate it

Reference

External nasal valve collapse: validation of novel outcome measurement tool.
Poirrier Al, Ahluwalia S, Kwame I, et al.
RHINOLOGY
2014;52(2):127-32.

RHINOLOGY

Patient comfort following FESS and Nasopore® packing: a double blind, prospective, randomised trial
Reviewed by: Lakhbinder Pabla (Bal)
September/October 2014 (Vol 23 No 4)
 

This study aimed to determine patient comfort associated with nasal packing (a self-dissolving polyurethane foam pack) and the parameters of post-operative bleeding, nasal breathing, a feeling of pressure, headache, and general well-being and sleep disturbance, compared to no packing. One side was packed with Nasopore® after bilateral FESS whilst the opposite was not packed, thus acting as the control. A total of 57 patients were included across two centres and the observation period included the days of the inpatient stay. There were no significant differences between sides for post-operative bleeding and nasal breathing. The feeling of pressure was slightly less on the side packed with Nasopore® on post-operative days two and three. The authors suspect that this result was attributed to increased crusting in the absence of a pack. No trend could be observed regarding which side patients described as subjectively better. The main strength of this study is its methodology, in that it is a double-blind, prospective, randomised trial. Overall, this study concluded few differences between the side packed with Nasopore®, and the unpacked side, and suggests further studies to evaluate this.

Reference

Patient comfort following FESS and Nasopore® packing, a double blind, prospective, randomized trial.
Kastl KG, Reichert M, Scheithauer MO, et al.
RHINOLOGY
2014;52(1):60-5.

SAUDI JOURNAL OTO-RHINO-LARYNGOLOGY & HEAD & NECK SURGERY

The role of budesonide saline solution for nasal irrigation in the management of allergic fungal rhinosinusitis: a prospective study
Reviewed by: B Viswanatha
September/October 2014 (Vol 23 No 4)
 

Allergic fungal rhinosinusitis is a non-invasive form of rhinosinusitis that often recurs despite aggressive treatment. This prospective trial was conducted from February to August 2009 and included seventeen patients. The study employed budesonide saline solution as nasal irrigation on a twice-daily protocol for three weeks. All patients underwent pre- and post-endoscopic assessment using the Kupferberg staging system, and patient questionnaires (the Modified Arabic Sinonasal Outcome Test (MA-SNOT)). The important findings were: budesonide saline irrigation improved the overall well-being of all the patients both objectively and subjectively; endoscopic staging showed significant improvement when this treatment protocol was utilised; endoscopic examination revealed a decrease in allergic mucin; patient symptom scores, assessed by the MA-SNOT, improved significantly for all categories; and an improved sense of smell and decreased rhinorrhoea was observed in many patients. The authors state that this is the first study reported in the literature on the treatment of allergic fungal rhinosinusitis using budesonide saline solution, and conclude that it is a useful tool in the management of allergic fungal rhinosinusitis.

Reference

The efficacy of budesonide on management of allergic fungal rhinosinusitis.
Osma M, Amen A ,Tariq AF, et al.
Saudi Journal Oto-Rhino-Latyngology & Head & Neck Surgery
2014:16(1):20-23

SLEEP AND BREATHING

Positional therapy and surgery for OSA
Reviewed by: Vik Veer
September/October 2014 (Vol 23 No 4)
 

Every woman instinctively seems to know that if you roll a male sleeping companion on their side, they tend to sound less like a hog. The medical literature is finally catching up; an ever increasing catalogue of articles now describe this manoeuvre as ‘positional therapy’ (PT). An Amsterdam centre performed a retrospective analysis of its surgical outcome data on obstructive sleep apnoea (OSA) patients. The authors then performed a subgroup analysis based on whether the OSA severity was dependant on sleeping position or not. 48.9% of the 139 study population had positional OSA, but all patients were treated with a form of palatoplasty with or without radiofrequency ablation to the tongue base. It seems that surgery in patients with non-positional OSA resulted in a more pronounced reduction in the apnea-hypopnea index (AHI) than in patients with positional-type OSA. In positional OSA patients, the use of PT in some cases ‘cured’ patients bringing the AHI to below five. PT also greatly augmented the benefit gained from surgery in this patient group. The authors illustrated their case rather imaginatively by creating a theoretical flowchart for patients in their retrospective study. They exposed the fact that by having prior knowledge of positional OSA status, patients were able to effectively cure themselves with PT, thereby avoiding any surgery. Patients with non-positional OSA treated with surgery could also be converted to positional OSA patients post-operatively, allowing them the option of PT and further improving their results. The final message is clear; look carefully at the AHI results in different sleeping positions, and consider PT a valid treatment option in OSA patients.

Reference

Theoretical approach towards increasing effectiveness of palatal surgery in obstructive sleep apnea: role for concomitant positional therapy?
van Maanen JP, Witte BI, de Vries N.
SLEEP AND BREATHING
2014;18(2):341-9.

SLEEP AND BREATHING

Tonsillectomy for OSA
Reviewed by: Vik Veer
September/October 2014 (Vol 23 No 4)
 

This study describes the outcome of tonsillectomy in 34 adult obstructive sleep apnoea (OSA) patients who had grade three or four tonsils. The idea was to quantify the benefit of tonsillectomy in OSA patients compared to tonsillectomy in conjunction with more traditional OSA operations such as palatoplasty. In short, the results were very good when compared to most OSA surgery outcomes. A surgical response rate (defined as a 50% or greater reduction in the apnoea-hypopnoea index (AHI)) was seen in 71.4% of severe OSA patients, 77.7% of moderate OSA patients and 75% of mild OSA patients. Similar results were seen when analysing the respiratory disturbance index (a measure of events that disturb the sleep of the patient). The classic Freidman case series described the results of tonsillectomy with palatal surgery, which achieved roughly an 80% surgical response rate. One would wonder then how clinically beneficial palatal surgery is in these patients? The authors did attempt some subgroup analysis; however the numbers become rather small and difficult to comment on. Ideally the polysomnography results in each category would have been available (including for grade 1 and 2 tonsils), or enough power to do a subgroup analysis with a palatal surgery cohort followed by a crossover arm. These and other ideas, however, would make a modern ethics panel baulk in protest. In conclusion, I think most people know that removing big tonsils helps people breathe. This study is another step towards defining that with greater precision.

Reference

Effects of tonsillectomy on sleep study parameters in adult patients with obstructive sleep apnea - a prospective study.
Tan LT, Tan AK, Hsu PP, et al.
SLEEP AND BREATHING
2014;18(2):265-8.

THE HEARING JOURNAL

Potential hearing advantages in bilingual individuals
Reviewed by: Linnea Cheung
September/October 2014 (Vol 23 No 4)
 

In this short article by two American professors of neuroscience, the potential benefits of the bilingual brain over that of the monolingual in neural speech encoding are explored. They go on to review the work carried out by a group from the Northwestern University Institute of Neuroscience (one member of whom is also the author of this article) on this very topic in brief detail. This research of auditory neural responses to one syllable shows that a group of bilingual adolescents demonstrate better subcortical encoding of speech when compared with IQ and socioeconomically matched monolingual adolescents, both in quiet and in noise conditions, with a more marked effect in noise. Follow-up results illustrated greater consistent brainstem and cortical responses in the bilingual group compared to the monolingual group. There was positive correlation between response to signal with language proficiency as well as with selective attention in the bilingual group. Logical suggestions to explain these relationships include the presence of competing languages when subjects are trying to accurately perceive the speech signal in the presence of noise, and that the activation and suppression of different languages in the bilingual brain might strengthen efferent connections between the frontal cortex and brainstem. The research raises further questions regarding whether the effect of ageing and hearing loss may have an impact on speech-in-noise performance between bilinguals and monolinguals given that we already know speech-in-noise performance declines with age. It would be interesting to see how multilingual brains (i.e. more than two languages) compare even to bilingual individuals' performance, and with testing a variety of syllables, before we can decide whether it is truly advantageous to speak more than one language.

Reference

Bilingualism enhances neural speech encoding.
Kraus N, Anderson S.
THE HEARING JOURNAL
2014;67(7):40.

THE LANCET RESPIRATORY MEDICINE

The mighty allergy
Reviewed by: Badr Eldin Mostafa
September/October 2014 (Vol 23 No 4)
 

The coexistence of eczema, rhinitis and asthma was studied in a prospective cohort of children aged four and eight years in 12 European countries. The diseases were documented by a questionnaire and serum specific IgE to six allergens. The aim of the study was to determine whether the coexistence of these diseases was IgE related or a chance finding. The absolute excess of any comorbidity was 1·6% for children aged four years and 2·2% for children aged eight years; 44% of the observed comorbidity at age four years and 50·0% at age eight years was not a result of chance. Children with comorbidities at four years had an increased risk of having comorbidity at eight years. The final conclusion was the coexistence of all three diseases in children is more than expected by chance alone and that IgE hypersensitisation is not the dominant causal mechanism of comorbidity. Other factors seem at play and these should be studied as well.

Reference

Comorbidity of eczema, rhinitis, and asthma in IgE-sensitised and non-IgE-sensitised children in MeDALL: a population-based cohort study.
Pinart M, Benet M, Anesi-Maesano I et al.
THE LANCET RESPIRATORY MEDICINE
2014;2(2):131-40.

ACTA OTOLARYNGOLOGICA

Day case stapes surgery under local anaesthetic in Finland
Reviewed by: Victoria Possamai
July/August 2014 (Vol 23 No 3)
 

The authors start by stating that the common occurrence of postoperative vestibular disturbance may preclude day case stapes surgery. They carried out a prospective study of 20 patients undergoing stapedotomy under local anaesthetic and measured postoperative symptoms and recorded nystagmus with video-oculography, 30 minutes postoperatively. The nystagmus and vestibular symptoms showed no correlation. Nine patients had spontaneous horizontal nystagmus without gaze fixation (seven of nine showing an irritative pattern). Seven patients described nausea, though only one vomited. Nine experienced vestibular symptoms immediately postoperatively (vertigo in five, floating sensation in two and unspecific dizziness in two). All but one described this as mild-moderate. In five of these patients this had fully resolved within the first 50 minutes, however the duration of symptoms in the remaining four patients is not stated, and is highly relevant to the validity of the conclusion reached; that day case stapes surgery is a feasible approach.

Reference

Immediate postoperative nystagmus and vestibular symptoms after stapes surgery.
Hirvonen TP, Aalto H.
ACTA OTOLARYNGOLOGICA
2013;133:842-5.

AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY

Topical steroid sprays: importance of physical and chemical characteristics
Reviewed by: Edward W Fisher
July/August 2014 (Vol 23 No 3)
 

Topical nasal corticosteroids are so widely prescribed that perhaps the otolaryngologist’s thoughts are dominated more by efficacy than the differences between formulations and delivery method. We should take more interest in this subject. This paper from Memphis reviews the subject of side-effects, formulations and the volume of the agents. I would recommend this article, as I learned much that I perhaps should already have known. Subjects such as the reported incidence of adverse effects in all sprays (5-10%), candidiasis, the (doubtful) link with septal perforations, the effects of alcohol or thixotropic agents, potassium sorbate and the adherence of sprays (and its importance) are all covered. The aqueous versus aerosol difference seems to have been overplayed in the past, with little evidence that one causes more epistaxis than the other.

Reference

Intranasal corticosteroids topical characteristics: side effects, formulation and volume.
Petty DA, Blaiss MS.
AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY
2013;27(6):510-13.

AUDIOLOGY NEUROTOLOGY

Alternative middle ear implant fixation
Reviewed by: Stephen James Broomfield
July/August 2014 (Vol 23 No 3)
 

This cadaveric temporal bone study examined the function of a Vibrant Soundbridge device, when the floating mass transducer (FMT) was attached to the short process of the incus rather than the long process. Fixation of the FMT to the short process of the incus confers the advantage of avoiding a posterior tympanotomy, whilst also reducing the risk of facial nerve and chorda tympani damage. Laser doppler vibrometry was used to measure movement of the stapes footplate and rou