Otolaryngology–Head and Neck Surgery

BACKGROUND: Autonomic dysfunction (AD) has been independently associated with obstructive sleep apnea (OSA). Autonomic abnormalities are generally considered to be secondary to OSA. Autonomic dysfunction may also contribute to OSA. If AD contributes to OSA, we postulated that abnormalities may be present in mild OSA where the confounding causal effects of hypoxemia and sleep disruption are reduced.

OBJECTIVE: We evaluated autonomic function tests and sleep studies in a cohort of subjects with no known diagnosis of OSA.

METHODS: We prospectively enrolled a cohort without diagnosed OSA who were part of an ongoing study of vasomotor rhinitis (VMR) for testing. A battery of autonomic nervous system tests (sudomotor and cardiovagal), nonattended polysomnography, and three-site esophageal/pharyngeal pH monitoring were performed.

RESULTS: Twenty of 22 patients completed the test battery and 12 (60%) met criteria for OSA (Apnea/Hypopnea Index “AHI” >5 events/hour). AHI correlated to mean tilt table blood pressure decrease (R = 0.58, P = 0.007) and the Valsalva-mediated phase 2 mean blood pressure decrease (R = 0.52, P = 0.017). OSA severity was related to sympathetic but not parasympathetic abnormalities. No differences in blood pressure responses were related to age, oxygen desaturation nadir, gastroesophageal reflux, VMR, or sleepiness.

CONCLUSION: Autonomic abnormalities suggestive of decreased adrenergic tone are associated with mild OSA. These abnormalities may potentially be secondary but may also precede development of OSA. (Otolaryngol Head Neck Surg 2004;130: 643-8.)

OBJECTIVE: The study goal was to critically evaluate 3 popular noninvasive treatments for snoring: an oral spray lubricant applied before bedtime, a nasal strip designed to maintain nasal valve patency, and a head-positioning pillow.

STUDY DESIGN: Prospective, randomized blinded clinical trial of 3 popular noninvasive snore aids using objective acoustic snoring analysis and subjective patient and bed-partner questionnaires in 40 snoring patients. A digital recorder allowed snoring analysis with data collected in the home environment over 1 week.

RESULTS: There is neither objective nor subjective benefit to the use of tested popular noninvasive snore aids. Palatal snoring, palatal loudness, average loudness of snoring, averaged palatal flutter frequency, and respiratory disturbance index did not significantly change when comparing the 3 snoring aids with no treatment. Subjective comments and complications are reviewed as well.

CONCLUSION: This is the first prospective comparison trial of popular noninvasive snoring aids. There is no significant objective or subjective snoring improvement in the anti-snoring aids studied compared with the use of no aid.

SIGNIFICANCE: Outcome studies aid in verifying or refuting claims made by popular noninvasive snore aids. (Otolaryngol Head Neck Surg 2004;130: 649-58.)

OBJECTIVES: Continuous positive airway pressure (CPAP) improves sleep apnea survival. We tested whether CPAP is associated with better survival than uvulopalatopharyngoplasty (UPPP).

STUDY DESIGN AND METHODS: This retrospective cohort database study included all sleep apnea patients treated with CPAP or UPPP in Veteran Affairs facilities from October 1997 through September 2001. Treatment groups were compared with Cox regression, adjusting for age, gender, race, year treatment was initiated, and comorbidity. Sleep apnea severity and CPAP use data were not available.

RESULTS: By September 2002, 1339 (7.1%) of 18, 754 CPAP patients and 71 (3.4%) of 2,072 UPPP patients were dead (P < 0.001). After adjustment, CPAP patients had 31% (95% confidence interval, 3% to 67%, P = 0.03) higher probability of being dead at any time, relative to UPPP patients.

CONCLUSIONS: UPPP confers a survival advantage over CPAP, after adjustment for age, gender, race, year of treatment, and comorbidity. However, we were unable to adjust for sleep apnea severity or CPAP use. Surgical treatment should be considered in sleep apnea patients who use CPAP inadequately. (Otolaryngol Head Neck Surg 2004;130: 659-65.)

OBJECTIVE: Postoperative recovery after tonsillectomy using Coblation excision (CES) was compared with conventional electrosurgery (ES).

STUDY DESIGN AND SETTING: Patients aged 3 to 12 years from 3 clinical sites were randomly assigned and blinded to receive tonsillectomy using CES (n = 44) or ES (n = 45).

RESULTS: Operative parameters did not differ between groups. Return to normal diet, activity, and pain-free status were similar, although fewer CES patients contacted the physician regarding postoperative complications (33% vs 54%; p = 0.081), experienced nausea (35% vs 62%, p = 0.013), or had localized site-specific swelling (p < 0.05) during the 2 weeks after surgery. In addition, CES children tended to discontinue prescription narcotics 1 day earlier than ES patients (7 vs 8 days, p = 0.071) and took one half as many daily doses. More CES than ES parents rated the postoperative experience as ‘better than expected’ (79% vs 60%, p = 0.055).

CONCLUSION AND SIGNIFICANCE: Children who received CES tonsillectomy appeared to experience a better quality postoperative course, with no detriment to operative benefits of conventional electrosurgery. (Otolaryngol Head Neck Surg 2004;130: 666-75.)

OBJECTIVE: We sought to compare the efficacy, safety, and cost of intraoral drainage (IOD) of parapharyngeal abscesses (PPAs) in the pediatric population with those of the more commonly used external neck drainage (END).

PATIENTS AND STUDY DESIGN AND SETTING: An 11-year retrospective review was conducted of all patients admitted to a tertiary-care, university-affiliated, pediatric hospital with a diagnosis of PPA. Patients were divided into 2 groups according to the treatment received (IOD or END) and were followed to 1 month postoperatively. All children referred to our institution with a final diagnosis of PPA were included in the study.

OUTCOME: Outcome measures were duration of anesthesia, duration of postoperative intravenous antibiotics (DPOIA), length of postoperative hospital stay (LPOHS), and occurrence of complications.

RESULTS: Fifteen patients underwent IOD, and 10 patients, END. IOD shortened anesthesia time by 31.7 minutes compared with END (P = 0.0003). IOD was associated with a decrease in DPOIA and LPOHS by 1.1 days (P = 0.1931) and 1.6 days (P = 0.0649), respectively. The cost of treatment was thereby reduced. No complications were encountered in either group.

CONCLUSIONS: IOD is a safe and effective treatment for PPA in the pediatric population. It leads to decreased morbidity, shortened anesthesia time, and reduced economic burden. (Otolaryngol Head Neck Surg 2004;130:676-80.)

OBJECTIVE: We sought to determine whether highlevel disinfection renders fiberoptic laryngoscopes free of nonviral infectious microorganisms.

METHODS: Six flexible fiberoptic laryngoscopes in heavy use were subjected to surveillance cultures at the beginning, middle, and end of the clinical workday after high-level disinfection to determine if microorganisms could be recovered. Control cultures were obtained by direct contamination of the endoscope with saliva. The rate of microorganism recovery from the endoscopes after high-level disinfection was determined and compared with control specimens.

RESULTS: Among a total of 48 cultures submitted from in use but disinfected fiberoptic laryngoscopes, 1 positive culture (positive rate, 2.1%) for mold species was recovered. No positive bacterial cultures occurred. Eleven of 11 (100%) control cultures were positive for bacterial species (P < 0.001). The confidence interval for the risk of microorganism contamination of a disinfected laryngoscope ranged from 0.11% to 11.6%.

CONCLUSION: High-level disinfection provides a reasonably effective method of reducing bacterial and fungal contamination of flexible fiberoptic laryngoscopes. Appropriate surveillance technique should be used in each clinical setting with flexible fiberoptic scopes to ensure adequate disinfection effectiveness. (Otolaryngol Head Neck Surg 2004; 130:681-5.)

OBJECTIVE: Our goal was to investigate the presence of laryngeal abnormalities is patients with paradoxical vocal fold dysfunction (PVFD).

STUDY DESIGN AND SETTING: A retrospective chart review was performed of patients referred for evaluation of paradoxical vocal fold dysfunction between July 2002 and December 2002. The patients completed questionnaires at the time of the office visit. Data collected from the medical record included age, gender, duration of symptoms before evaluation, asthma, gastroesophageal reflux symptoms, and laryngoscopic findings. Exercise stress test was performed when suitable. The diagnosis of PVFD was made based on patient history and laryngoscopy.

RESULTS: Thirty patients were identified. There was a 27:3 (90%) female predominance, and mean age of presentation at was 28 years (range, 12 to 67 years). The median time from the onset of respiratory symptoms to diagnosis was 4.5 years (range, 0.5 to 30 years). Of the 30 patients, 17 (56%) had asthma, 16 had laryngeal findings suggestive of gastroesophageal reflex disease, 4 (12%) had laryngoscopic findings of chronic laryngitis, and 10 (33%) had additional findings, including laryngomalacia, vocal fold motion impairment, sulcus vocalis, nodules, and subglottic stenosis, mostly in the exercise-induced group.

CONCLUSIONS: Concomitant laryngeal abnormalities are present in a many patients with PVFD, particularly in those with exercise-induced symptoms. Laryngoscopy is important in the management of these patients. (Otolaryngol Head Neck Surg 2004; 130:686-9.)

OBJECTIVES: Radiosurgery precisely delivers a single high dose or a few fractionated doses of radiation to a localized tumor via the stereotactic approach. Some head and neck sites are suitable for radiosurgery since there is minimal or no organ motion. The clinical studies were carried out to determine the accuracy of stereotactic radiosurgery and to demonstrate the effectiveness of radiosurgery in head and neck cancers.

MATERIALS AND METHODS: Thirteen patients were treated with either single-dose or fractionated radio-surgery to the tumor. All patients except one with cancer of the lip had received prior treatments including surgery, radiotherapy, and chemotherapy for the primary cancers. The dose ranged 12 to 18 Gy for single-dose radiosurgery and 30 Gy in 5 or 6 fractions twice a week for fractionated radiosurgery. Tumor localization was achieved via the stereotactic approach.

RESULTS: Accuracy of radiosurgery was within 1.5 mm. Despite the recurrent disease from previous heavy treatments, 9 patients (70%) showed a significant response (complete or >50% tumor reduction) to radiosurgery, and 3 patients had stable disease. Complete tumor response was achieved in 6 patients. All patients had excellent pain relief with functional and cosmetic preservation. There was no acute and subacute radiation toxicity detected clinically during the minimal follow-up of 6 months.

CONCLUSION: Image-guided radiosurgery is effective in achieving the local tumor control and pain relief. Radiosurgery provided excellent functional and cosmetic preservation with minimal complication. The results indicate the potential of radiosurgery in the treatment of recurrent and selected primary head and neck cancers. (Otolaryngol Head Neck Surg 2004;130:690-7.)

BACKGROUND: The c-met oncogene encodes the receptor for the hepatocyte growth factor/scatter factor (HGF/SF), which is known to have the effects of stimulation of cell motility, dissociation of epithelial sheets, invasion of cellular matrix, and induction of angiogenesis. Many studies in solid tumors have indicated a role for c-met and HGF/SF in the progression of the disease.

METHODS: The expression of c-met in tissue specimens was studied by immunohistochemical examination in 60 patients with supraglottic laryngeal squamous cell carcinoma. Patients were chosen such that there were 30 with lymph node metastases in the neck and 30 without metastases. TNM staging, differentiation, lymphovascular and perineural invasion, and growth pattern for tumors were also recorded, and their relation to lymph node metastases was analyzed.

RESULTS: Overexpression of c-met was observed in 90% of the cases at the primary site and in 83% of the cases with lymph node metastases in the neck. Lymphovascular invasion (P = 0.005) and the N stage (P = 0.001) were found to be related to lymph node metastases, but other variables—c-met over-expression, the T stage, perineural invasion, and growth pattern—were found to have no relation to lymph node metastases in multivariate analysis of the data with linear regression.

CONCLUSIONS: c-met overexpression is observed in both the primary site and the neck in supraglottic laryngeal squamous cell carcinoma. We believe that it may have a role in the progression of malignancy, but we were unable to find a definite relation between c-met expression and lymph node metastases. (Otolaryngol Head Neck Surg 2004;130:698-703.)

OBJECTIVE: We sought to demonstrate the technical aspects of the extended pericranial flap and its versatility in reconstruction of a variety of skull base defects.

STUDY DESIGN: We conducted a retrospective chart review of 32 patients who underwent reconstruction of skull-base defects with an extended pericranial flap by the senior author (Y.D.) from September 1997 to July 2003.

METHODS: Patients with skull base defects after trauma or extirpative surgery were reconstructed with either a lateral- or an anterior-based vascularized extended pericranial flap. Variables and outcomes measured included: the size and anatomical location of the defect, need for other flaps, preoperative and/or postoperative radiation therapy and/or chemotherapy, bone flap necrosis, hardware exposure, wound dehiscence, postoperative cerebrospinal fluid (CSF) leak, and meningitis.

RESULTS: There was no evidence of flap failure, 2 cases of transient (3 to 4 days) CSF leak without resultant meningitis, 3 patients with hardware exposure, and 2 patients with hydroxyapatite infection. The 2 transient cases of CSF leak both resolved without further surgical intervention or the placement of a lumbar drain.

CONCLUSION: Both the lateral and anteriorly based extended pericranial flaps are reliable and versatile flaps associated with minimal morbidity and a low rate of complications when used to reconstruct defects of the anterolateral skull base. (Otolaryngol Head Neck Surg 2004;130:704-11.)

OBJECTIVE: To review Ludwig's angina medical and surgical approach with small incisions.

STUDY DESIGN: Retrospective, open, noncomparative, longitudinal.

METHODS: All patients with Ludwig's angina who received medical, metabolic, airway management, and surgical treatment from January 1, 1983 to December 31, 2000.

STUDIED PARAMETERS: Antibiotic treatment, surgical treatment, hospitalization time, associated diseases, etiologic factors, recuperation time.

RESULTS: Age range was 18 to 87 years, with a female-to-male ratio of 1.1:1 (68 females, 53 males). Thirty patients belonged to middle or high socio-economic status. The primary site of infection was odontogenic in 107 of the patients. All the patients were managed with surgical drainage made within the first 12 hours after hospital admission. The most common antibiotic treatments were the combination of clindamycin with crystalline penicillin G. The hospital stay for more than half of patients was 6 days or less. In 62 patients we found extension into the parapharyngeal space and in 32 cases we found retropharyngeal extension of the Ludwig's angina. Forty-six patients had or were diagnosed as having diabetes mellitus. Tracheotomy was required in 34 patients. The airway of the rest of patients was controlled with nasotracheal intubation. Only 33 patients had major complications, such as mediastinitis, sepsis, or death.

CONCLUSIONS: Drainage using small incisions is a safe and effective method as part of treatment of Ludwig's angina. (Otolaryngol Head Neck Surg 2004;130:712-7.)

OBJECTIVE: Association of glutathione-S-transferase M1 (GSTM1) polymorphisms and cancer has been demonstrated. Possible underlying mechanisms and genotype-phenotype correlations are not adequately investigated. The aim of this study was to investigate the influence of the GSTM1-null-genotype on the level of GSTM enzyme concentration and on the enzyme activity of GST in patients with head and neck cancer (HNC).

METHODS: We investigated in 83 patients and 91 healthy controls the GSTM1 polymorphisms, GSTM1 protein concentration, GSTM1 protein in tumor tissues, and total GST enzyme activity.

RESULTS: Total GST enzyme activity was significantly lower in patients with HNC (208 ± 9 μmol/min1) than in controls (264 ± 11 μmol/min1, P < 0.0001) but did not depend on GSTM1-genotype (P = 0.1). GSTM protein concentration in null-genotype patients (3.6 ± 2.5 μg/mL, mean ± SE) was significantly lower than in GSTM1 allele carriers (26.7 ± 9.6 μg/ml, P < 0.0001); GSTM protein expression did not depend on GSTM1-genotype (P > 0.5).

CONCLUSION: GST enzyme activity in patients with HNC is suppressed, indicating impaired detoxification capacity of tobacco-smoke-related carcinogens. This suppression is not correlated with the GSTM1-genotype. (Otolaryngol Head Neck Surg 2004;130:718-25.)

CONTEXT: Successful outcome of complex surgical techniques depend on the surgical team's level of experience. However, unless benefit is demonstrated in the presence of cost savings, insurance companies are reluctant to approve care from highly experienced hospitals and surgical teams.

OBJECTIVE: To determine the relationship between the number of acoustic neuroma surgeries performed at California hospitals with surgical outcome and hospital stay cost.

DESIGN: Acoustic neuroma surgery information was extracted from the California hospital discharge database and was grouped according to the number of surgeries performed at each hospital.

SETTING. A database review of California hospitals.

PATIENTS: Persons (n= 1,213) undergoing acoustic neuroma surgery at a California hospital between 1996 and 1998.

MAIN OUTCOME MEASURES: Outcome measures included discharge status (routine vs. not routine), medical procedures indicating surgical complications, total cost of hospitalization, and average cost per hospitalization day. Odds ratios were used to compare the hospital volume groups on likelihood of a routine surgical outcome.

RESULTS: The frequency of routine surgical outcome increased as hospital acoustic neuroma surgical volume increased, ranging from 68% among patients in the lowest volume group to 97% in the highest hospital volume group. Patients in the highest hospital volume group were 15 times more likely to have a routine surgical outcome than patients in the lowest hospital volume group. Patients in the second highest volume group were 5 times more likely to have a routine surgical outcome than in the lowest volume group. The two highest volume hospital groups had lower total charges and average charges per day than the two lower volume hospital groups.

CONCLUSIONS: Acoustic neuroma surgeries at higher volume hospitals had higher frequency of routine discharge, lower frequency of apparent complications, and lower average cost of hospitalization. (Otolaryngol Head Neck Surg 2004;130:726-35.)

OBJECTIVE: Comparison of topical ciprofloxacin/dexamethasone otic suspension (CIP/DEX) to ofloxacin otic solution (OFL) for treatment of granulation tissue in children with AOMT.

STUDY DESIGN: 599 children aged ≥6 months to 12 years with AOMT of up to 3 weeks' duration were enrolled. Patients received either CIP/DEX 4 drops twice daily for 7 days or OFL 5 drops twice daily for 10 days. Granulation tissue severity was graded at clinic visits on days 1, 3, 11, and 18.

RESULTS: Granulation tissue was present in 90 of 599 AOMT patients (15.0%) at baseline. CIP/DEX treatment was superior to OFL for reduction of granulation tissue at the day 11 visit (81.3% compared with 56.1%, P = 0.0067) and the day 18 visit (91.7% compared with 73.2%, P = 0.0223). Both topical otic preparations are safe and well tolerated in pediatric patients.

CONCLUSION: CIP/DEX was superior to OFL in the treatment of granulation tissue in children with AOMT. (Otolaryngol Head Neck Surg 2004;130: 736-41.)

OBJECTIVE: To investigate the use of contact diode laser myringotomy (C-LAM), combined with topical mitomycin C, as an alternative method for prolonged middle ear ventilation in children with otitis media with effusion.

STUDY DESIGN AND SETTING: Prospective study at a tertiary care pediatric institution.

METHODS: Fifteen children enrolled in the study. Mitomycin C was applied to the intact tympanic membrane in the right ears, whereas saline on the left side was used for controls. C-LAM was then performed in all ears. Outcome measures included healing rate and scarring, ear infection, and long-term audiometric follow-up.

RESULTS: There was no significant difference in median healing rate. In each group, the median was between the third and fourth month. Normal hearing thresholds were obtained in all children at 2-year follow-up.

CONCLUSION: C-LAM proved to be an effective method for medium-term ventilation, but topical mitomycin C before C-LAM did not prolong patency rate in our patients. No significant complication was encountered at 2-year follow-up. (Otolaryngol Head Neck Surg 2004;130:742-6.)

OBJECTIVE: To detect the relationship between food allergy and otitis media with effusion (OME).

MATERIALS AND METHODS: This study was performed on three different groups. The patient group was made up of 56 patients with OME (group I). There were 28 patients with food allergy in group II and these patients were investigated for OME. The control group consisted of 28 patients without any complaints concerning food allergy or OME (group III).

RESULTS: Food allergy was detected in 25 patients with OME (44.6%) (group I). In patients with food allergy (group II), OME was detected in 7 patients (25%). In the control group (group III) food allergy was diagnosed in 5 patients (18%) and OME in 1 patient (3%). The incidence of food allergy in OME group was statistically significant when compared to the normal group (P > 0.05).

CONCLUSIONS: This study demonstrates that food allergy may play a role in the etiopathogenesis of OME. (Otolaryngol Head Neck Surg 2004;130: 747-50.)

OBJECTIVE: To evaluate tone perception performance in Cantonese-speaking prelingually hearing-impaired children with cochlear implants.

STUDY DESIGN AND SETTING: The ability to discriminate and identify Cantonese tones was evaluated on 17 native Cantonese-speaking prelingually hearing-impaired children. Performance was correlated to factors like age of implantation and general communication ability.

RESULTS: Subjects' performance in discrimination and identification tasks was slightly above chance level. Although variations in the contour fundamental frequency of the tones provided some cues for tone discrimination, these distinctions proved insufficient for subjects to perform well. Tone 6 (low level tone) was the most difficult to identify. Subjects' performance did not correlate with gender, age of implantation, duration of implant use, frequency of auditory training session, or general communication ability.

CONCLUSION: Although some children were able to discriminate and/or identify Cantonese tones, their performance was poor. Further studies are needed to understand how tone perception relate to daily speech understanding.

SIGNIFICANCE: Cochlear implant speech coding strategies may need modification to optimize tone perception. (Otolaryngol Head Neck Surg 2004; 130:751-8.)

OBJECTIVE: This study was undertaken to revise the diagnostic characteristics of tuberculous otitis media (TOM), a disorder that is often diagnosed late, leading to delay in specific treatment.

STUDY DESIGN AND SETTING: Retrospective study of a longitudinal series of 10 TOM patients over a 7-year period at an institutional referral center.

RESULTS: Most patients showed intractable otorrhea, moderately severe hearing loss, and necrotic eardrums with granulation tissue and single perforations. Multiple perforations, facial palsy, and cervical adenopathies were rare (<10% of patients). CT generally showed soft tissue involvement of the middle ear without bone erosion. The most effective laboratory test microbiological culture of exudate (diagnostic efficacy 71%). Specific antibiotic treatment was effective in all cases.

CONCLUSION: The diagnosis of TOM remains a significant challenge for otorhinolaryngologists.

SIGNIFICANCE: If there are strong clinical grounds for suspicion, standard laboratory tests for tuberculosis should be repeated even if initially negative. (Otolaryngol Head Neck Surg 2004;130:759-66.)

OBJECTIVE: The purpose of this study was to analyze the effect of coal dust particles on nasal mucociliary function in coal mine workers.

METHOD: Using the saccharin method, nasal mucociliary clearance was determined for 77 subjects, of which 39 who worked in a coal mine were actively exposed to coal dust whereas 38 were unexposed control subjects. The measurements were performed in the coal mine, at the level of 170 m below sea level.

RESULTS: The average saccharin nasal transit time in coal mine workers, 12.61 (SD: 4.30) minutes, is longer than that of the control subjects, 10.97 (SD: 3.22).

CONCLUSION: Although the findings of this study demonstrate that the coal particles affect the nasal mucociliary clearance, the difference in saccharin nasal transit time between the two groups (exposed vs unexposed) is not statistically significant (P = 0.063). (Otolaryngol Head Neck Surg 2004;130: 767-9.)

This paper reports on an evidence-based review of laryngeal electromyography (EMG) as a technique for use in the diagnosis, prognosis, and treatment of laryngeal movement disorders including the laryngeal dystonias, vocal fold paralysis, and other neurolaryngological disorders. The authors performed a systematic review of the medical literature from 1944 through 2001 on the clinical application of EMG to laryngeal disorders. The review yielded 584 articles of which 33 met the predefined inclusion criteria. The evidence demonstrated that in a double-blind treatment trial of botulinum toxin versus saline, laryngeal EMG used to guide injections into the thyroarytenoid muscle in persons with adductor spasmodic dysphonia was beneficial. A cross-over comparison between laryngeal EMG-guided injection and endoscopic injection of botulinum toxin into the posterior cricoarytenoid muscle in abductor spasmodic dysphonia found no significant difference between the 2 techniques and no significant treatment benefit. Based on the evidence, laryngeal EMG is possibly useful for the injection of botulinum toxin into the thyroarytenoid muscle in the treatment of adductor spasmodic dysphonia. There were no evidence-based data sufficient to support or refute the value of laryngeal EMG for the other uses investigated, although there is extensive anecdotal literature suggesting that it is useful for each of them. There is an urgent need for evidence-based research addressing other applications in the use of laryngeal EMG for other applications. (Otolaryngol Head Neck Surg 2004;130: 770-9.)