Otolaryngology–Head and Neck Surgery

OBJECTIVE: To study physician utilization and experience with image-guidance technology for sinus surgery.

STUDY DESIGN AND SETTING: Retrospective review of the first 1000 image-guided sinus operations performed by 42 surgeons at an academic medical center.

RESULTS: Utilization of image-guidance systems showed a dramatic increase in both number of cases performed and surgeons who used this equipment (70.6% and 92.8%, respectively) during the first 2 years of its availability. Surgical volume subsequently decreased by a mean of 9.3% per year, whereas the number of surgeons using this technology plateaued. The majority of surgeons continued to perform image-guided surgery throughout the study period for selected cases. The knowledge base gained from this experience can best be summarized as a series of lessons learned.

CONCLUSION: It is likely that the availability and utilization of image-guidance systems for sinus surgery will continue to increase in the future. Physicians who learn to use this new technology must do so with an appreciation for both its potential benefits and pitfalls.

Allergy and its relationship to chronic rhinosinusitis are important contemporary topics in the practice of otolaryngology. The relationship may go unrecognized. It is important to understand the current knowledge.

OBJECTIVE: The goal was to validate the SN-5 survey as a measure of longitudinal change in health-related quality of life (HRQoL) for children with persistent sinonasal symptoms.

DESIGN AND SETTING: We conducted a before and after study of 85 children aged 2 to 12 years in a metropolitan pediatric otolaryngology practice. Caregivers completed the SN-5 survey at entry and at least 4 weeks later. The survey included 5 symptom-cluster items covering the domains of sinus infection, nasal obstruction, allergy symptoms, emotional distress, and activity limitations.

RESULTS: Good test-retest reliability (R = 0.70) was obtained for the overall SN-5 score and the individual survey items (R ≥ 0.58). The mean baseline SN-5 score was 3.8 (SD, 1.0) of a maximum of 7.0, with higher scores indicating poorer HRQoL. All SN-5 items had adequate correlation (R ≥ 0.36) with external constructs. The mean change in SN-5 score after routine clinical care was 0.88 (SD, 1.19) with an effect size of 0.74 indicating good responsiveness to longitudinal change. The change scores correlated appropriately with changes in related external constructs (R ≥ 0.42).

CONCLUSIONS: The SN-5 is a valid, reliable, and responsive measure of HRQoL for children with persistent sinonasal symptoms, suitable for use in outcomes studies and routine clinical care.

OBJECTIVE: We investigated the role of allergic rhinitis in chronic otitis media (otitis media with effusion [OME] and chronic perforation of the tympanic membrane) in São Paulo, Brazil and whether there is any association between these diseases.

STUDY DESIGN AND SETTING: We studied 51 patients followed in the otologic group of the Otorhinolaryngology Division of the University of São Paulo Hospital. The patients were divided into 3 groups: allergic rhinitis, nonallergic rhinitis with eosinophils syndrome (NARES), and patients with types of rhinitis or without rhinitis. We analyzed the age, gender, intensity of the nasal disease, surgical procedure, and surgical results in each group.

RESULTS: We found about 50% of patients presenting with nasal disease and nasal eosinophilia (33.33% of allergic and 15.69% of NARES).

CONCLUSION: Nasal disease has an impact on otologic middle ear disease, considering that the normal nasal mucosa do not have eosinophils.

OBJECTIVE: The role of elevated cerebrospinal fluid (CSF) pressures in the pathophysiology of various CSF leaks is not clear. Empty sella syndrome (ESS) is a radiographic finding that can be associated with elevated CSF pressures and may represent a radiographic indicator of intracranial hypertension. We present our experience with CSF leaks of various causes, the prevalence of ESS in the spontaneous and nonspontaneous categories, and the potential pathophysiology and unique management issues of the spontaneous CSF leak group.

METHODS: We conducted a retrospective review of medical records, imaging studies, and surgical treatment of CSF leaks in patients treated by the senior author.

RESULTS: Sixteen patients with spontaneous CSF leaks and 12 patients with nonspontaneous CSF leaks were surgically treated from 1996 through 2002. In the spontaneous group, 15 patients had complete imaging of the sella turcica. Ten had completely empty sellae and 5 had partially empty sellae, for a total of 100% (15 of 15). In the nonspontaneous group, 9 patients had complete imaging of the sella. Only 11% (1 of 9) had a partially empty sella and that was a congenital leak. Comparison of proportions between these 2 groups was significant (P = 0.01). The spontaneous group consisted primarily of obese, middle-aged females (13 of 16 patients).

CONCLUSION: Empty sella probably represents a sign of elevated intracranial pressure that leads to idiopathic, spontaneous CSF leaks. Spontaneous CSF leaks are strongly associated with the radiographic finding of an empty sella and are more common in obese females, similar to benign intracranial hypertension. This unique population may require more aggressive surgical and medical treatment to prevent recurrent or multiple leaks.

OBJECTIVES: The study goals were to determine the patient demographics, identify predisposing factors, and determine efficacy of treatment for nonotologic osteomyelitis of the skull base and craniovertebral junction.

STUDY DESIGN: All patients with a biopsy-proven diagnosis of osteomyelitis of the skull base treated by the author from 1997 through 2001 were retrospectively evaluated.

RESULTS: Six patients were identified on review. The average age at presentation was 56.7 years (age range, 38 to 70 years), and all except one patient had an underlying immunocompromising condition (diabetes mellitus, human immunodeficiency virus infection, steroid use). Most presented with neurologic deficits associated with a destructive lesion of the osseous skull base. Aggressive debridement of involved bone enabled through the use of broad field standard skull base approaches was associated with clinical resolution of symptoms in each case. Systemic antibacterial/antifungal therapy and medical optimization remain important adjuncts in the treatment of this group of patients.

CONCLUSION: The diagnosis of this entity may be difficult to discern from neoplastic involvement of the skull base. Standard skull base approaches are useful for both the diagnosis and the treatment of nonotologic osteomyelitis.

OBJECTIVE: We sought to evaluate surgical wound infection rates in patients undergoing skull base surgery without hair removal.

METHODS: We undertook a retrospective study of 175 skull base operations performed without hair removal. Anterior operations were conducted via the subcranial approach (n = 120) and lateral or posterior procedures via various approaches (n = 55). Wounds were examined daily during hospitalization and at routine outpatient follow-up (8 to 45 months) and classified according to the Center for Disease Control and Prevention guidelines.

RESULTS: The overall surgical wound infection rate was 1.1% (2 of 175): 0.8% (1 of 120) for anterior and 1.8% (1 of 55) for lateral or posterior procedures. It was similar for clean operations (lateral and posterior) and clean-contaminated (anterior) procedures and was less than or similar to the rates reported for skull base procedures with hair removal. No wound infection occurred among the infected (trauma, fungal infections, and brain abscess) patients.

CONCLUSIONS: Skull base surgery without hair removal is safe and not associated with increased risk of wound infection. The method may prevent additional psychologic stress, promote restoration of the patient's self-image, and accelerate his or her return to normal life.

OBJECTIVES: We sought to use a clinical decision support system (CDSS) to save costs and to improve scheduling of vestibular patients in an otolaryngology clinic.

STUDY DESIGN AND SETTING: We conducted a concurrent review of 50 vestibular patients scheduled in the University of Missouri otolaryngology clinic with or without testing based on the outcome of a CDSS. The CDSS was implemented using Web-based technology. Charges incurred by the health care system through tests determined by the CDSS were compared with those incurred using the standard procedure of ordering hearing tests and electronystagmography for all patients.

RESULTS: Thirty-nine tests were prescheduled using the CDSS. Twenty-five additional tests were ordered after the visit. The CDSS resulted in savings of $37,904.00 in charges to the health care system. The CDSS showed high specificity and variable sensitivity.

CONCLUSION: A Web-based CDSS can be used to better manage and coordinate patient encounters.

SIGNIFICANCE: One important reason to use a CDSS in health care management is to lower costs.

OBJECTIVE: We sought to test a 3-parameter model for diagnosis of dizziness based on the type and temporal characteristics of the dizziness and on hearing status.

STUDY DESIGN AND SETTING: We conducted a prospective blinded study at a tertiary referral neurotology practice. Before examination, patients completed a questionnaire reporting type and timing of dizziness symptoms and hearing status. Clinical diagnoses were compared with questionnaire results.

RESULTS: Fifty-seven patients completed the questionnaire. We were able to correctly classify 21 (60%) of the 35 subjects who had a common otogenic cause of vertigo by the diagnostic algorithm.

CONCLUSION: A simple classification of dizziness by type, timing, and hearing status can be self-reported by patients using a brief questionnaire. This classification scheme is as good as others of much greater complexity.

SIGNIFICANCE: The simple classification scheme reported here is based on history alone and facilitates triage of dizzy patients into diagnostic groups for work-up and management.

OBJECTIVE: We sought to determine the effectiveness in decreasing some symptoms, such as vertigo, and increasing performance of daily life skills after vestibular rehabilitation.

STUDY DESIGN AND SETTING: Patients who had chronic vertigo due to peripheral vestibular impairments were seen at a tertiary care center. They were referred for vestibular rehabilitation and were assessed on vertigo intensity and frequency with the use of the Vertigo Symptom Scale, the Vertigo Handicap Questionnaire, the Vestibular Disorders Activities of Daily Living Scale, and the Dizziness Handicap Inventory. They were then randomly assigned to 1 of 3 home program treatment groups.

RESULTS: Vertigo decreased and independence in activities of daily living improved significantly. Improvement was not affected by age, gender, or history of vertigo.

CONCLUSION: For many patients a simple home program of vestibular habituation head movement exercises is related to reduction in symptoms and increasing independence in activities of daily living.

OBJECTIVES: Two steps in stapedotomy are particularly challenging: (1) micropick fenestration of the stapes footplate (SF) and (2) crimping of the stapes prosthesis (SP) to the incus. We conducted trials to determine if experience correlates with differences in performance for these tasks.

METHODS: In a surgical model of stapedotomy, performance was measured for 3 experienced and 3 novice surgeons. For fenestration, we measured ability to target the fenestration and force applied to the SF. For crimping, we measured crimp quality, movement of the SP during crimping, and force applied to the SF.

RESULTS: Experienced surgeons demonstrated significantly better ability to target the fenestration and, during crimping, caused less SP movement and a significantly lower rate of SP dislodgment.

CONCLUSIONS: Clear differences in task performance are measurable between more and less experienced surgeons during critical steps of stapedotomy.

CLINICAL SIGNIFICANCE: The observed differences in task performance may contribute to an understanding of maneuvers that increase the risk of inadequate prosthesis placement and cochlear trauma—factors likely responsible for variable hearing results with strapedotomy.

OBJECTIVE: We sought to establish normative measurements of the inner ear using computed tomography (CT) of the temporal bone to aid in the diagnosis of inner ear malformations.

STUDY DESIGN AND SETTING: Prospective measurements of the inner ear structures were made on axial and coronal temporal bone CT scans on 15 patients with normal hearing and 15 patients with sensorineural hearing loss.

RESULTS: The vertical height of the cochlea on coronal scan and the size of the central bony island within the lateral semicircular canal on axial scan along with visual inspection identified 7 inner ear abnormalities in 6 patients: 5 cases of lateral semicircular canal dysplasia and 2 cases of cochlear hypoplasia. In contrast, visual inspection alone identified only 4 of the 7 abnormalities.

CONCLUSIONS AND SIGNIFICANCE: Routine measurement of the cochlear height and bony island of the lateral semicircular canal, in conjunction with visual inspection of CT images, will increase recognition of common inner ear malformations.

The patulous eustachian tube (pET) presents a challenging management problem. Patients with the pET disorder are disturbed to the point of mental illness by their symptoms of aural fullness and autophony, especially the echo of their own voice. Thus far, described treatment methods are often temporary or ineffective. Here, we describe a minimally invasive method for the treatment of pET that involves cauterization with autologous fat graft plugging of the ET at its nasopharyngeal orifice, in conjunction with myringotomy and ventilation tube placement. This procedure has been successful for the treatment of refractory pET in 2 patients at the House Ear Clinic with at least 1-year follow-up and we propose that it may accomplish relief of symptoms by permanent stenosis of the ET.

OBJECTIVE: The study purpose was to determine the efficacy of steroid and antiviral therapy in the management of idiopathic sudden sensorineural hearing loss (SSNHL).

STUDY DESIGN AND SETTING: We conducted a retrospective study of patients presenting to an academic tertiary care center. Fifty-one patients were evaluated. All patients were placed on the same treatment protocol.

RESULTS: Thirty-seven patients (73%) had recovery of hearing. Ninety-one percent of patients with vertigo and all patients with mid-frequency hearing loss and up-sloping hearing loss recovered with treatment (P < 0.05). Recovery was significantly related to age, onset of hearing loss, and audiogram type; however outcome was not significantly related to gender, vertigo, tinnitus, or laterality (P < 0.05).

CONCLUSION: Our treatment protocol produced a recovery rate, which exceeds the spontaneous recovery rate. Unlike prior studies, all patients with up-sloping and mid-frequency SSNHL had recovery. In addition, vertigo did not indicate a poor prognosis.

SIGNIFICANCE: Antiviral therapy and increased length of steroid treatment may play a role in the improved recovery rates.

OBJECTIVE: The study goal was to evaluate the association among laryngopharyngeal sensory deficits, pharyngeal motor function, and the prevalence of aspiration with thin liquids.

STUDY DESIGN AND SETTING: We conducted a prospective study of 204 consecutive patients undergoing flexible endoscopic evaluation of swallowing with sensory testing and an assessment of pharyngeal motor function (pharyngeal squeeze). Patients were divided into 6 groups depending on the results of sensory and motor testing in the laryngopharynx. Subjects were given 5 mL of thin liquid, and the prevalence of aspiration in each group was compared.

RESULTS: The mean age of the entire cohort was 65 years (58% female). The prevalence of aspiration in patients with intact laryngopharyngeal sensation was 2% (3 of 137) in persons with intact pharyngeal motor function and 29% (2 of 7) when pharyngeal motor function was impaired (P < 0.05). The prevalence of aspiration in patients with a moderate decrease in laryngopharyngeal sensation was 0% (0 of 9) in persons with intact pharyngeal motor function and 67% (2 of 3) when pharyngeal motor function was impaired (P < 0.05). The prevalence of aspiration in patients with severely diminished or absent laryngopharyngeal sensation was 15% (5 of 33) in persons with intact pharyngeal motor function and 100% (15 of 15) when pharyngeal motor function was impaired (P < 0.05).

CONCLUSION: Patients with severely diminished laryngopharyngeal sensation and pharyngeal motor function are at an extremely high risk of aspirating thin liquids (100%). Moderate sensory deficits only appear to influence the prevalence of thin liquid aspiration in the presence of pharyngeal motor dysfunction. Severe laryngopharyngeal sensory deficits are associated with the aspiration of thin liquids regardless of the integrity of pharyngeal motor function. We assume that all persons with an insensate laryngopharynx aspirate thin liquids until proved otherwise. These results emphasize the relationship between laryngopharyngeal sensation and pharyngeal motor function in the evaluation of patients for suspected aspiration.

OBJECTIVE: The study goal was to assess the use of digital laryngeal videostroboscopy (LVS) in the detection of objective improvement of the larynx after 6 weeks of proton pump inhibitor (PPI) therapy and to evaluate a clinical grading scale for findings of laryngopharyngeal reflux disease (LPRD).

STUDY DESIGN AND SETTING: We conducted a prospective analysis of digital LVS examinations from a tertiary referral center for laryngology by 3 independent blinded examiners.

RESULTS: The mean score on the Laryngopharyngeal Reflux Disease Index for experimental patients was significantly higher than that for control patients (9.50 versus 2.92, P < 0.001), and posttreatment scores were significantly lower than pretreatment scores (7.35 versus 9.50, P < 0.001). Useful items on the grading scale for assessing the presence of LPRD and improvement in LPRD included supraglottic edema and erythema, glottic edema and erythema, and subglottic edema and erythema. Nonuseful items included the presence of pachydermia, granulomas, nodules, leukoplakia, and polyps.

CONCLUSION: Objective improvement of signs of LPRD can be detected after 6 weeks of PPI therapy using digital LVS. The Laryngopharyngeal Reflux Disease Index is a useful valid clinical tool for following treatment response to PPI therapy.

OBJECTIVE: We examined staff utilization and procedure length for percutaneous and open bedside tracheostomies in an intensive care setting

STUDY DESIGN: Prospective clinical outcomes study.

METHODS: Intensive care unit (ICU) tracheostomy consults meeting criteria for bedside procedures were randomized to open or percutaneous procedures. The Cook percutaneous kit and a prepackaged tracheostomy tray were used. ICU nursing and respiratory therapy staff was present for all procedures. The total resident time, staff time, and procedure length were recorded. Twelve patients underwent percutaneous tracheostomy, and 12 received an open tracheostomy.

RESULTS: An operating room nurse was present for 7 of the open procedures. Ancillary medical staff was present for 3 open tracheostomies: anesthesia for 2 and critical care for 1. Ancillary medical staff was present for 4 percutaneous tracheostomies: anesthesia staff for 1 and critical care for 3. The average resident presence, staff presence, and procedure length for open tracheostomies were 47, 30, and 12 minutes, respectively. For percutaneous tracheostomies, the times were 39, 29, and 12 minutes, respectively. One intraoperative complication occurred during a percutaneous procedure and 2 perioperative complications occurred: 1 in the open group and 1 in the percutaneous group.

CONCLUSIONS: There was no significant difference in procedure length, resident time, or staff time between the 2 procedures. Ancillary staff was occasionally used but was not thought to be necessary for the majority of procedures. Both procedures can be safely and expediently performed in the ICU.

OBJECTIVE: The study purpose was to determine survival and prognostic factors for differentiated thyroid carcinoma (DTC).

METHODS: Cases of DTC were extracted from the Surveillance, Epidemiology and End Results database from 1988 through 1998. Kaplan-Meier survival analysis was conducted for papillary, follicular, and medullary histologies. Cox proportional hazard analysis was used to examine the influence of age, gender, tumor size, local extension, and cervical node involvement on overall survival.

RESULTS: A total of 18,118 cases were identified, including 15,820 (87.3%) papillary carcinomas, 1799 (9.9%) follicular carcinomas, and 499 (2.8%) medullary carcinomas. Mean survival (10-year survival) was 122 (87.7%), 117 (80.2%), and 108 (73.7%) months for papillary, follicular, and medullary tumors, respectively. For each histology, increasing age, male gender, and degree of local extension substantially reduced survival. Cervical metastasis did not influence survival for papillary or follicular carcinomas but approached significance for medullary carcinoma (P = 0.065).

CONCLUSIONS: Degree of local extension in thyroid carcinoma should be subclassified to more accurately determine prognosis. Treatment of the neck should be considered for medullary thyroid carcinoma.

OBJECTIVE: The aim of this work is to study the chronology in the biological covering of the hydroxyapatite bioprostheses in the healthy middle ear of the rat.

STUDY DESIGN AND SETTING: Dense hydroxyapatite is implanted into the middle ear of 45 Long-Evans rats, between stapes and tympanic membrane. The sample was divided into 3 groups for morphologic, functional, and chemical studies at 15 days, 3 months, and 6 months after surgery, respectively.

RESULTS: The short-term studies reveal that the prostheses is surrounded by a fibrous epithelial tissue referred as the interface; it presents a marked inflammatory reaction that decreases gradually in the medium-term and long-term studies; in this way, we observe a progressive adhesion between implant and the contact tissues.

CONCLUSIONS AND SIGNIFICANCE: This model has enabled us to study the cell reaction produced by the contact of the prostheses with bone and soft tissue and their impact on the functional qualities of the prostheses.

OBJECTIVES: Matrix metalloproteinases-2 and -9 (MMP-2 and MMP-9) are proteolytic enzymes that digest collagen type IV and other components of the basement membrane. They play a key role in local invasion and the formation of distant metastases by malignant tumors. The aim of this study was to evaluate the activity of MMP-2 and MMP-9 in stage III and IV laryngeal cancers.

STUDY DESIGN: In the study we used specimens of laryngeal cancer and surrounding normal mucosa obtained from 23 patients undergoing surgical treatment as a primary therapy. After extraction of MMP-2 and MMP-9 from tissue samples, their activity was assessed with zymography.

RESULTS: Greater activity of MMP-2 and MMP-9 and a higher active/latent MMP-2 ratio were found in cancer compared with normal mucosa. Moreover, N2 tumors revealed greater activity of MMP-2 in comparison with N1 and N0 tumors.

CONCLUSIONS: Results of the study indicate that both MMP-2 and MMP-9 may be involved in the expansion of laryngeal cancer. MMP-2 may also play an important role in the lymphatic spread of some laryngeal tumors.

OBJECTIVE: Mandibulotomy is an important surgical approach to oral cavity and oropharynx. The objective of this study was to evaluate the related complications of 2 common mandibulotomies: midline (osteotomy between 2 central incisors) and paramidline (osteotomy between lateral incisor and canine).

STUDY DESIGN: Ninety-six patients who had cancer in the oral cavity or oropharynx had preoperative evaluation of the mandible with panoramic films. Among them, 42 patients underwent mandibulotomies: midline for 19 patients and paramidline for 23.

RESULTS: Twenty (47.6%) of 42 patients had mandibulotomy-related complications, including 9 (21.4%) minor complications and 11 (26.2%) major complications. There were 6 (31.6%) major and 4 (21.1%) minor complications in the midline mandibulotomy and both 5 (21.7%) major and minor complications in the paramidline mandibulotomy.

CONCLUSION: There was no significant difference in the mandibulotomy-related complication rate between midline and paramidline mandibulotomies. Paramidline mandibulotomy, which preserves the geniohyoid and genioglossus muscles, should be a better function-preserving operation than midline mandibulotomy.