Otolaryngology–Head and Neck Surgery

OBJECTIVES: 1) To determine factors students perceive as influential in decision to pursue otolaryngology; 2) to determine perception of importance of factors used for resident selection and individual student commitment to the match; and 3) to identify exposure to various subspecialties within otolaryngology.

DESIGN: Population survey.

METHODS: A survey was administered to students applying for otolaryngology between 2000 and 2003 at a single institution.

RESULTS: Ninety-six students were interviewed. Seventy-eight percent believed that the main factor influencing their decision to pursue otolaryngology was their exposure to the residents. Board scores and one-on-one interviews were important factors in selection of interviewees and ranking process. Interestingly, over 20% of students believed that the match should not be early because they wanted more time to commit to ENT.

CONCLUSIONS: These data underscore the importance that residents have in directing future students to our specialty. Results of the match survey may indicate an attrition rate within residency programs that may be avoided if ENT were part of the “regular” match.

EBM RATING: C

OBJECTIVE: Topical application of mitomycin C appears to be a useful adjunct in reducing cicatricial scarring of the airways. Human and animal studies have demonstrated the efficacy and safety of mitomycin C topically in the treatment of airway stenosis at concentrations ranging from 0.4 mg/mL to 10 mg/mL. Although no reports of mitomycin C toxicity have been reported in the otolaryngology literature, the ophthalmologic literature has documented serious, vision-threatening complications resulting from the use of topical mitomycin C. The purpose of this study is to report complications related to mitomycin C use in the treatment of glottic and subglottic stenosis. Risk factors associated with these complications are identified.

STUDY DESIGN AND SETTING: A retrospective chart review of all patients treated by the senior author for laryngotracheal stenosis with endoscopic CO₂ laser incisions/dilation and adjuvant topical mitomycin C was performed to determine the incidence of complications. Variables studied included patient age and gender, location and severity of stenosis, medical comorbidities, length of procedure, postoperative instrumentation of the airway, and mitomycin C concentration.

RESULTS: Eighty-five cases of adjuvant topical mitomycin C use after CO₂ laser endoscopic treatment and dilation for upper airway stenosis were identified in a total of 44 patients. Complications that were believed to be caused by the local toxicity of mitomycin C occurred in 4 cases out of 85 (or 4.7%), manifested by accumulation of fibrinous debris at the operative site, resulting in partial airway obstruction and the need for emergent airway intervention.

CONCLUSIONS: Caution should be exercised when topical mitomycin C is used in the treatment of airway stenosis.

EBM RATING: B-3

OBJECTIVE: The purpose of this study was to find the conversion factor, safety, and efficacy of type A to type B toxin for laryngeal muscles.

METHODS: Thirty-two patients with adductor spasmodic dysphonia with stable doses of A toxin to manage their symptom were given type B toxin starting at a conversion of 1 Uof BTX-A to 50 U of BTX-B. The patients were followed for 1 year, and doses adjusted according to response.

RESULTS: The conversion factor was found to be 52.3 U:1 U. The onset of action of type B was more rapid (2.09 days vs 3.2 days [P = 0.028]), with a shorter duration of benefit (10.8 weeks vs 17 weeks [P = 0.002). The safety profile for A and B toxin appeared the same, with 3 patients receiving Myobloc reporting dry mouth.

CONCLUSION: This study shows that a conversion factor of 52.3:1 Myobloc (BTX-B) to Botox (BTX-A) and that Myobloc is an effective alternative to Botox (BTX-A) for patients with spasmodic dysphonia.

EBM RATING: B-2

OBJECTIVE: To prospectively evaluate the significance of cricoid cartilage palpability as a selection criterion for bedside tracheostomy and to prospectively compare a cohort of patients undergoing bedside tracheostomy with another cohort receiving operating room tracheostomy.

STUDY DESIGN/SETTING: Prospective trial comparing 2 cohorts of patients receiving tracheostomies at a tertiary care center (university hospital). In all, 220 consecutive intubated patients selected for elective tracheostomy were enrolled. Of them, 134 patients had palpable cricoid cartilage and underwent open surgical tracheostomy at the bedside. The remaining 68 patients received open surgical tracheostomies in the operating room. Demographic data, patient anatomic features, and perioperative complications were prospectively recorded. There were no statistically significant differences in age, gender, reason for admission, indication for tracheostomy, Acute Physiology and Chronic Health Evaluation II score, number of days intubated, or time required to perform the procedure for those patients whose tracheostomies were performed in the operating room versus the intensive care unit.

RESULTS: Patients with a palpable cricoid cartilage had a significantly reduced perioperative complication rate compared with those without a palpable cricoid cartilage (2% vs 22%, P < 0.001). Comparison of cervical girth, mental-to-sternum distance, and thyroid-notch-to-sternum distance showed no significant difference between the 2 groups and did not further define selection criteria.

CONCLUSION: This investigation prospectively confirms the safety of bedside tracheostomy placement in properly selected patients. Complication incidences are defined for open surgical tracheostomy at the bedside and in the operating room. Palpability of the cricoid cartilage has significant value as a selection criterion for bedside tracheostomy.

SIGNIFICANCE: These findings will aid in the development of protocols and pathways for surgical airway management in critically ill patients to maximize cost-effective, high-quality care.

EBM RATING: B-2

BACKGROUND AND OBJECTIVE: To evaluate the ability of optical coherence tomography (OCT) (a noncontact, high-resolution imaging technique that generates detailed cross-sectional images of tissue structure) to image and document acute response to trauma in the larynx.

MATERIALS AND METHODS: Porcine larynges were dissected to expose the vocal cords. Vocal cords were imaged with 1310 nanometer (nm) light source with a bandwidth of 75 nm at 1 frame/second (s). Vocal cord injuries were simulated by applying topical phenolic acid, injecting titanium dioxide into the submucosa, and carbon dioxide laser irradiation.

RESULTS: The epithelium, basement membrane, and lamina propria were clearly delineated, and the effect of each intervention could be monitored as lesions progressed. The OCT image corresponded closely with histology.

CONCLUSION: OCT is a powerful imaging tool with the potential for use in real time and has potential for multiple clinical applications in the larynx.

OBJECTIVES: Mitomycin C (MMC) is used in otolaryngological surgery to reduce complications from postoperative scarring. However, the effects of MMC on wound healing at different doses and on different wound types have not been fully described. The aim of this study was to evaluate the effects of topical MMC at 2 different doses on the healing of surgical and laser wounds.

STUDY DESIGN AND SETTING: This was a randomized study using 20 rabbits. Six full-thickness wounds were made by excision or laser vaporization on the flank skin. The wounds were randomly treated by topical MMC of 0.4 or 1.0 mg/mL or saline for 5 minutes.

RESULTS: Re-epithelialization and contraction of the original wounds were significantly delayed by the use of MMC (P < 0.01). The delayed healing effect of MMC was more prominent in the laser wounds than in the excision wounds. MMC inhibited collagen deposition and fibroblast proliferation of wounds on histological analysis. The 2 different concentrations of MMC showed no difference in gross or histological wound healing characteristics.

CONCLUSION: Our results showed that MMC delays the healing of wounds as a result of the inhibition of fibrosis, especially for laser wounds.

OBJECTIVE: Successful parathyroidectomy requires identification and excision of 1 or more abnormal parathyroid glands. The pathologist confirms or refutes the intraoperative presence of parathyroid tissue in excised material. With the advent of radionuclide scanning and rapid parathyroid hormone assays, the role of routine frozen section (FS) has once again been called into question. Our aim was to assess the need for routine FS in tissue identification during parathyroidectomy in a series of 50 consecutive cases.

METHODS: We analyzed 50 consecutive parathyroidectomies performed by a single surgeon from December 2002 to August 2003. Diagnoses on gross examination (GE) of both the surgeon and the pathologist were recorded, cytologic smears made, and FSs performed. A cost analysis was also performed.

RESULTS: Of the 50 parathyroidectomies performed (35 adenoma and 15 hyperplasia), both surgeon and pathologist's opinions on GE were concordant. Incorrect gross identification occurred by both in 6% (3) of the cases. GE is a cost-effective means of identifying parathyroid tissue.

CONCLUSIONS: Experienced parathyroid surgeons need not routinely request FS examination. The decision to omit intraoperative FS examination must be balanced against the potential implications of misdiagnosis and a repeat operative procedure.

EBM RATING: C

OBJECTIVE: Sialoscopy has developed into an important diagnostic and therapeutic tool for diseases of the major salivary glands.

STUDY DESIGN AND SETTING: We evaluated 103 patients with chronic swelling of the major salivary glands. Routine diagnostic measures revealed no clear diagnosis. The findings of 109 sialoscopies are described. A semi-rigid endoscope (with a diameter of 1.1 mm and 2 integrated working channels) was used for sialoscopy, 51.5% of the cases in Warthon's duct and 48.5% in Stensen's duct.

RESULTS: Pathologic findings resulted in 83.0% of the submandibular and in 96% of the parotid ducts. Obstruction neither due to sialolithiasis nor stenosis was observed in 56.3%, whereas sialolithiasis was observed in 20.3% of the patients. In 36 (35%) patients, an interventional sialoscopy was performed.

CONCLUSIONS: In cases of invisible salivary duct obstruction, especially in those with low mineralized calculi, strictures, stenoses, or postinflammatory changes, sialoscopy gives immediate and direct information about causal pathologies. Moreover, further therapy can be planned within the same procedure.

EBM RATING: C

OBJECTIVE: To provide a description of surface electromyography (sEMG) of spontaneous saliva swallowing (SSS) and monitoring of swallow rate in patients with salivary gland diseases.

STUDY DESIGN: Numbers of SSS obtained during 2 hours of sEMG monitoring were compared with sialometry data for healthy volunteers (n = 100), patients with Sjögren syndrome (n = 10), and patients after parotid gland (n = 15) and submandibular gland (n = 16) surgery.

RESULTS: Normative: 1 SSS every 2 minutes and 15 seconds; Sjögren: 1 SSS every 13 minutes (P < 0.001); parotid gland surgery: 1 SSS every 3 minutes and 24 seconds (P = 0.26); submandibular gland surgery: 1 SSS every 5 minutes and 04 seconds (P < 0.05). Sjögren patients and patients after submandibular surgery had hyposalivation correlated with less SSS.

CONCLUSION: The established normal rate of SSS makes this modality applicable for evaluating salivary flow for potentially identifying and ruling out abnormalities. Parotid gland surgery does not significantly affect salivary flow rate. Sialometry combined with sEMG monitoring give a clinician more reliable data to evaluate salivary gland disorders than sialometry alone.

EBM RATING: B-2

OBJECTIVE: To evaluate the anatomic relationship between the spinal accessory nerve (SAN) and the sternomastoid branch of the occipital artery (SBOA) and its utility as a surgical landmark during a selective neck dissection (SND).

STUDY DESIGN AND SETTINGS: Consecutive patients undergoing SND for squamous cancer from October 1, 2004 to February 28, 2005 were enrolled in this study. During surgery the distance between the SBOA and the point of insertion of the SAN into the sternomastoid muscle (SMM) was measured.

RESULTS: Twenty-four patients underwent 33 SND. The distance between the SBOA and SAN ranged between 1 and 11 mm, with a mean of 6.2 mm and a median of 6 mm.

CONCLUSION: The relationship between these 2 structures has a range and constancy that is acceptable as a landmark.

SIGNIFICANCE: This article presents a useful adjunct for location of the SAN in the anterior neck during SND.

EBM RATING: C

OBJECTIVE: Analyze the influence of patients lost to follow-up in estimated survival rates calculated by the Kaplan-Meier method.

STUDY DESIGN: Only patients with previously untreated squamous cell carcinoma of the upper aerodigestive tract were selected. For the patients lost to follow-up anytime, the last medical evaluation date was collected to calculate the “estimate A” survival time. If the same patient returned to our outpatient clinic or further health information was obtained, the updated last information/evaluation date was also collected to calculate “estimate B” survival time. The survival curves considering “estimate A” and “B” survival rates were compared.

RESULTS: The overall 5 and 10-years survival rates for all patients calculated for “estimate A” were 54.0% and 46.0%, respectively; compared with 42.8% and 28.2% when were calculated considering “estimate B” (P < 0.001).

CONCLUSION: Close follow-up of the head and neck cancer patients is essential for an accurate estimate of survival by KaplanMeier method.

EBM RATING: C

OBJECTIVES: To determine the effects of combined radiation and targeted, intra-arterial (IA) cisplatin infusions (RADPLAT) in patients with advanced squamous cell carcinoma (SCC) of the tonsil.

STUDY DESIGN AND SETTING: Prospective study of treatment outcomes and toxicity of patients enrolled on the RADPLAT protocol, with specific analysis of patients with advanced SCC of the tonsil.

RESULTS: Thirty patients with advanced tonsil carcinoma (17 T₄, 12 T₃, 1 T₂) were enrolled, and 24 of 30 patients completed at least 3 IA cisplatin infusions and a minimum of 63 Gy or radiation therapy (minimum therapy). Two-year estimated overall and disease-specific survival was 42% and 50%, respectively, for all 30 patients (intent-to-treat group) and 49% and 58%, respectively, for the minimum therapy subgroup. The 2-year estimated local and regional disease control was 87% and 90%, respectively, for the intent-to-treat group, and 100% and 90% for the minimum therapy subgroup. Functional organ preservation was achieved in 92% of patients.

CONCLUSIONS: Locoregional disease control achieved with this regimen appears to be significantly improved over that described in the literature for similarly staged tonsil cancer. Survival, on the other hand, remains comparable.

EBM RATING: C

BACKGROUND: Primary lymphoma of the thyroid gland is uncommon.

METHODS: The tumor registry at the Penn State Milton S. Hershey Medical Center was searched for all patients carrying a diagnosis of thyroid lymphoma. All available records for these patients were examined and information regarding patient and tumor characteristics, clinical presentation, interventions, and survival were tabulated.

RESULTS: The average age of patient in our series was 67.5 years. There was a 2.7:1 female to male preponderance. Thirteen (60%) patients presented with thyroid nodule(s). Eleven (50%) presented with aerodigestive tract obstructive symptoms. Sixteen (73%) patients had no pre-existing history of thyroid disease; none had known pre-existing Hashimoto's thyroiditis.

CONCLUSIONS: The typical thyroid lymphoma patient is female and elderly with painless thyroid enlargement. Compressive symptoms of the aerodigestive tract are common at presentation and may require urgent intervention. Treatment modalities (XRT, CHOP chemotherapy) and outcomes are distinct from other thyroid malignancies.

EBM RATING: C

OBJECTIVES: To evaluate the long-term efficacy of hydroxyapatite cement in craniofacial reconstruction, specifically examining the role (if any) of radiation, implant location, and cement type.

STUDY DESIGN: A retrospective chart review was conducted of all patients presenting to the senior surgeon (Y.D.) for craniofacial reconstruction from September 1997 to April 2004.

METHODS: Data were collected including type of cement used, size of defect, complications, need for removal of cement, reason for defect, and pathologic results of examination of removed cements.

RESULTS: One hundred two patients were identified who underwent craniofacial reconstruction with hydroxyapatite cements, 7 of whom required complete implant removal (6 Norian and 1 Mimix), and 4 (2 Norian and 2 Bone source) of whom required partial implant removal for foreign body reaction. Five of the removals were in patients who underwent postoperative radiation.

CONCLUSIONS: Hydroxyapatite cements are safe in craniofacial reconstruction. The highest risk of implant infection comes from reconstruction in the area of the frontal sinus, immediately beneath coronal incisions, and in patients who receive postoperative radiation treatment. Based on our results, there does appear to be a statistically significant difference in rates of infection and foreign body reaction between the different types of hydroxyapatite cement. We would not recommend implantation of this material in contact with the frontal sinus. Caution should be exercised when it is placed directly beneath an incision or in patients receiving postoperative radiation, particularly if a boost dose is given.

EBM RATING: C

OBJECTIVE: Human cytomegalovirus (CMV) is a commonly recognized viral cause of perinatal sensorineural hearing loss. CMV-infected infants are also at risk for developmental neurological deficits. This retrospective study assesses the impact of CMV-induced deafness on pediatric cochlear implant outcomes.

STUDY DESIGN AND SETTING: Thirteen patients from the Johns Hopkins pediatric cochlear implant database were identified with CMV-related deafness. A retrospective review of the medical records of the Johns Hopkins Hospital was performed.

RESULTS: The mean age at implantation was 5.6 years. Follow-up audiometric data ranged from 6 to 48 months postoperatively. Mean speech perception scores were 4.5 (out of 6) following implantation.

CONCLUSION: We have shown that cochlear implants can provide useful speech comprehension to patients with CMV-related deafness. Speech recognition scores were within the range established by our overall pediatric implant population.

SIGNIFICANCE: This observation underscores the importance of a multidisciplinary rehabilitation program following implantation in these patients at risk for cognitive delay.

EBM RATING: C

OBJECTIVE: To compare the final facial nerve outcomes between middle cranial fossa (MCF) vs translabyrinthine (TL) resection of size-matched vestibular schwannomas.

STUDY DESIGN AND SETTING: Retrospective case review at a tertiary care hospital. All patients who underwent resection utilizing either MCF or TL approaches with tumors 18 mm or smaller and complete data were included in the analysis. One hundred twenty-four patients were identified meeting the above criteria, with sixty-three in the translabyrinthine group and sixty-one in the middle fossa group. One-week-postoperative and final facial nerve examinations were compared in the two surgical groups. Patients were separately analyzed in subgroups: tumors smaller than 10 mm and those that were between 10 and 18 mm.

RESULTS: The tumor size range for the MCF group was 3-18 mm while it was 4-18 mm for the TL group. No statistically significant difference was found in facial nerve outcomes between the two surgical groups, at the first postoperative visit week and at last follow-up.

CONCLUSION: Facial nerve outcomes are similar using TL and MCF approaches for resection of vestibular schwannomas up to 18 mm in size.

SIGNIFICANCE: Patients undergoing the MCF approach for hearing preservation can be counseled that there is no increased risk of permanent facial nerve weakness, compared to the TL approach.

EBM RATING: B-3

OBJECTIVES: For the past 5 years, our group has been developing a virtual temporal bone dissection environment for training otologic surgeons. Throughout the course of our development, a recurring challenge is the acquisition of high-resolution, multimodal, and multi-scale data sets that are used for the visual as well as haptic (sense of touch) display. This study presents several new techniques in temporal bone imaging and their use as data for surgical simulation.

METHODS: At our institution (OSU), we are fortunate to have a high-field (8 Tesla) magnetic resonance imaging (MRI) research magnet that provides an order of magnitude higher resolution compared to clinical 1.5T MRI scanners. Magnetic resonance imaging has traditionally been superb at delineating soft tissue structure, and certainly, the 8T unit does indeed do this at a resolution of 100-200 μm³. To delineate the bony structure of the mastoid and middle ear, computed tomography (CT) has traditionally been used because of the high signal-to-noise ratio delineating bone signal from air and soft tissue. We have partnered with researchers at other institutions (CCF) to make use of a “microCT” that provides a resolution of 214 × 214 × 390 micrometers of bony structure.

RESULTS: This report provides a description of the 2 methodologies and presentation of the striking image data capable of being generated. See images presented.

CONCLUSIONS: Using these 2 new and innovative imaging modalities, we provide an order of magnitude greater resolution to the visual and haptic display in our temporal bone dissection simulation environment.

OBJECTIVES: To investigate factors affecting the prognosis of sudden sensorineural hearing loss (SSNHL).

STUDY DESIGN AND SETTING: This is a retrospective study of patients with SSNHL hospitalized at an academic medical center. All patients in this study were treated with prednisolone and dextran. We compared a new 7-pattern classification for audiometric pattern and prognosis analysis with Sheehy classification.

RESULTS: We analyzed 148 affected ears in 146 patients. Occurrence of SSNHL was associated with changes in season. The best prognosis was with the midtone pattern of the 7-pattern classification and with the low-tone pattern of Sheehy classification. The older patients, those with vertigo, or those treated after 6 days had a poor prognosis. There was no significant association between ESR level and prognosis.

CONCLUSIONS: SSNHL patients with midtone loss have the best prognosis. This study of the audiometric patterns and prognostic factors of SSNHL allow us to better predict its outcome.

EBM RATING: B-2

OBJECTIVE: To assess clinical safety and efficacy of the erbium: yttrium-aluminum-garnet (Er:YAG) laser in the stapes surgery; to define and optimize parameters that render the procedure safe for the inner ear.

STUDY DESIGN: Retrospective study.

MATERIAL AND METHODS: A microscope-integrated Er: YAG laser stapedotomy was performed on 29 patients and a conventional stapedotomy on 41 patients. An early (within 1 to 3 days after stapes surgery) and late (at least 6 weeks) pure-tone bone-conduction threshold audiogram was obtained.

RESULTS: No statistically significant differences were found by Student's t test over all measured frequencies between pre- and postoperative bone-conduction thresholds in each group. There was no statistically significant difference for all frequencies between early (3 days) and late postoperative mean bone-conduction thresholds.

CONCLUSIONS: The results of our preliminary clinical study showed that erbium laser poses no risk to inner ear function. However, the lack of standardization obliges further investigation to establish safe clinical parameters of the Er:YAG laser.

EBM RATING: B-3

OBJECTIVE: To determine the effects of transtympanic injections, with a mixture composed of gentamicin and fibrin tissue adhesive (FTA), on vestibular function of patients with intractable unilateral Menière's disease.

STUDY DESIGN: This was an open, prospective study.

SETTING AND PATIENTS: The study was performed at 2 tertiary referral centers. Twenty-six patients affected by “definite” unilateral Menière's disease, unresponsive to medical therapy for at least 6 months, were enrolled.

INTERVENTION: A buffered gentamicin solution mixed with FTA was injected in the middle ear until the development of bedside vestibular hypofunction signs and/or caloric weakness in the treated ear.

MAIN OUTCOME MEASURE: Vestibular function was evaluated by 3 bedside vestibular tests (observation of spontaneous nystagmus, head shaking test, and head thrust test) and by a caloric test. Tests were performed on days 10 and 30 after completion of treatment. Tests were also performed 3, 6, and 12 months from completion of the gentamicin-FTA protocol. The effects of treatment were also assessed in terms of hearing levels, control of vertigo, and disability status.

RESULTS: In 22 of the 26 patients, only 1 gentamicin-FTA injection was necessary to obtain 1 or more signs indicating a reduction of the vestibular function in the treated ear. Four patients needed another treatment because of the persistence of their incapacitating symptoms during the follow-up. Four patients needed more than 1 injection to obtain a vestibular hypofunction. None of the patients who received 1 or 2 injections presented hearing loss in direct temporal relationship to the treatment.

CONCLUSIONS: A mixture of gentamicin and fibrin glue makes it possible to considerably reduce the number of administrations in patients with intractable unilateral Menière's disease. Spontaneous nystagmus, post head shaking nystagmus, and a head thrust sign are the clinical signs that indicate onset or progression of unilateral vestibular hypofunction. These signs were obtained with only 1 injection in 81% of patients.

EBM RATING: C

OBJECTIVE: To determine the outcome of endoscopic repair of cerebrospinal fluid (CSF) rhinorrhea with and without computer assisted surgery.

STUDY DESIGN: A review of all patients undergoing endoscopic closure of CSF rhinorrhea at a tertiary care medical center between 1994 and 2003. Charts from the 24 patients were reviewed for indications, location of leak, type of surgical closure, number of prior closure attempts, graft materials, use of computer assisted surgery, complications, and need for revision surgery. Analysis was performed to determine a possible correlation between success of CSF leak repair and use of computer assisted surgery.

RESULTS: The etiology of the leak was previous sinus surgery in 10 patients (41.7%), trauma in 5 patients (20.8%), spontaneous leak in 5 patients (20.8%), and skull base surgery in 4 patients (16.7%). The most common sites of leak were the fovea ethmoidalis in 10 patients (41.7%), cribriform plate in 8 patients (33.3%), and sphenoid sinus in 6 patients (25%). Image guidance was employed in 66.7% (16 patients) of our first attempted repairs. Six patients underwent a total of 9 revision procedures. At last follow-up, 96% of patients had no evidence of CSF rhinorrhea. A comparison of patients in the 2 groups failed to reveal a statistically significant difference in the rate of CSF leak closure.

CONCLUSION: Endoscopic closure of CSF rhinorrhea represents a minimally invasive and highly successful procedure. The use of computer assistance may improve the confidence of the surgeon and is a valuable adjunct in this procedure. Our study, however, did not demonstrate an improvement in the rates of successful closure with the use of computer assistance.

EBM RATING: C

OBJECTIVE: Determine the efficacy of computerized tomography (CT) in detecting the intranasal distribution of sprayed radio-enhanced particles and the effects of topical decongestion on particle distribution.

STUDY DESIGN: Sinonasal distribution of a radio-enhanced spray solution was studied using CT imaging in 14 adults with no sinonasal symptoms. One nostril was sprayed with oximetazoline 5 minutes prior to particle application. Serial CT imaging of the sinonasal cavity in approximately 11 minutes was carried out to detect particle distribution into the nasal vestibule, turbinate surfaces, middle meatus and osteomeatal complex area, and the nasopharynx.

RESULTS: Particle detection within the nasal vestibule was possible in all cases while distribution into the anterior nasal chamber was visible in 22 cases. Particles could be detected on the inferior turbinate in 7 nasal cavities (25%) and in only 2 cases on the middle turbinate (7.5%). Particles were detected in the middle meatus in 1 case and in no instances in the osteomeatal complex area. Oximetazoline application reduced the amount of particle deposition on the inferior turbinate but did not enhance distribution on the middle turbinate or into the middle meatus.

CONCLUSION: Detection of radio-enhanced sprayed particles within the sinonasal cavity using CT imaging can be a reliable method to study the principles of intranasal particle distribution. Our study failed to show particle distribution into OMC, or any positive effects of nasal decongestion on particle distribution.

EBM RATING: C

OBJECTIVE: It is proposed to test the practicality of septopalatal protraction in the unilateral cleft palate infant for purposes of straightening the nasal septum and thus relieving nasal airflow obstruction and its detrimental sequelae.

METHODS: Alternate infants affected with complete unilateral palatal clefts had septopalatal protraction for a period of 6 to 8 weeks (protraction group; n = 4). Septal deviation was measured by a standardized technique that used computed tomography scans. The remaining infants had no protraction and served as controls (nonprotraction group; n = 5). Septal deviation was measured in the nonprotraction group from palatoseptal dental molds.

RESULTS: A total of 9 patients were studied. All patients in the nonprotraction group had worsening of nasal septal deviation over a period of 8 weeks compared with the protraction group, which had complete nasal septal straightening. Differences in septal angle deviation between the protraction group and nonprotraction group at the end of the study were statistically significant (P ≤ 0.01) as measured by the paired Student t test.

CONCLUSIONS: Septopalatal protraction in the newborn appears to provide a means for correcting nasal septal deviation in complete unilateral cleft palate infants. Septopalatal protraction in the newborn is relatively easy and safe.

EBM RATING: B-2

OBJECTIVE: To evaluate repelling magnetic implants to treat obstructive sleep apnea (OSA) using a canine model.

STUDY DESIGN AND SETTING: Magnetic forces equivalent to effective CPAP were estimated with benchtop studies. An acute canine model was used to simulate pharyngeal collapse. Tolerance, safety, and stability of the implants were evaluated in a chronic series of 10 dogs observed over 6 months.

RESULTS: Equivalence to CPAP (10-12 cm H₂0) was achieved with low-force (<10 g/cm length), light (approximately 2 gram) implants. Magnetic implants prevented airway collapse in the acute canine. Normal behavior, swallowing, and oral intake were noted in the chronic canine over 6 months. Implant extrusion was 10%. Histology showed fibrous encapsulation without chronic inflammation.

CONCLUSIONS: Repelling magnets successfully maintained a patent airway and were well tolerated in the canine.

SIGNIFICANCE: Repelling magnets could represent an implantable alternative to CPAP if human studies reveal similar findings.

OBJECTIVES: To conduct a prospective randomized controlled study presenting and comparing bipolar radiofrequency dissection tonsillectomy (BRDT) to cold dissection tonsillectomy (CDT) regarding intra-operative blood loss, operative time, postoperative pain, and postoperative complications including hemorrhage.

MATERIALS AND METHODS: From January 2004 to March 2005, 200 children planned to undergo tonsillectomy were included in this study. Children were prospectively randomized into two equal groups: bipolar radiofrequency dissection tonsillectomy and cold dissection tonsillectomy. The operative time and intraoperative blood loss were recorded. Children were asked to record their pain on a standardized visual analog scale on days 1, 4, 7, and 14. All children were reviewed on the 4th, 7th, and 14th day after surgery. Postoperative complications were recorded and dealt with.

RESULTS: There was a shorter operative time (mean 8.5 minutes, P < 0.001) in the radiofrequency group. BRDT showed a decrease of 7 minutes in the mean when compared to the CDT group. The amount of blood lost during BRDT was minimal (mean 13 cc), with a mean difference of 69 cc when compared to CDT (P < 0.001). There was no statistical significant difference in pain score between the two groups except in the first postoperative day where the BRDT demonstrated a statistically significant lower parameters (P < 0.05). No evidence for statistically significant difference between the two groups regarding postoperative complications.

CONCLUSION: BRDT is a new, easy, and safe technique that offers a complete eradication of the tonsillar disease, short operating time, minimal intra-operative blood loss, and a suitable cost with no additional increase in postoperative pain and hemorrhage when compared to the conventional CDT. Our experience promotes BRDT as the preferred method of tonsillectomy.

EBM RATING: A

OBJECTIVE: The association between OSAS and patient history and physical exam findings is previously established; however, to our knowledge there are no studies that evaluate the role of tongue scalloping as a reliable clinical indicator for OSA, snoring, or the presence of other sleep pathology as evidenced by polysomnography. This study evaluates the hypothesis that such an association exists.

SUBJECTS AND METHODS: Sixty-one otolaryngology clinic patients were evaluated by history and physical exam for the presence and degree of tongue scalloping, snoring, and other previously established clinical indicators for sleep-disordered breathing and obstructive apnea. Twenty-five of the 61 study patients were additionally evaluated by overnight polysomnography to provide conclusive diagnosis of sleep pathology. The degree of tongue scalloping was graded from 0 to 3 and its significance as a screening, diagnostic, and predictive factor for sleep pathology was then statistically determined.

RESULTS: Twenty-seven patients (44%) had known or newly documented OSA and 47 (77%) had a history of snoring. Twenty-seven patients (44%) had some degree of tongue scalloping (1-3) and 74% of these patients were male. The presence of any degree of tongue scalloping (grade 1-3) in patients with known or newly documented OSA showed sensitivity, specificity, PPV, and NPV of 52%, 68%, 70%, and 50% respectively. The presence of tongue scalloping in patients with either known snoring history or newly documented snoring showed sensitivity, specificity, PPV, and NPV of 47%, 64%, 81%, and 26% respectively. Presence of tongue scalloping was 71% specific for abnormal sleep efficiency (<85%), 70% specific for abnormal AHI (>5), and 86% specific for nocturnal desaturation >4% below baseline. Presence of tongue scalloping also showed PPV of 67% for abnormal AHI, 89% for apnea or hypopnea, and 89% for nocturnal desaturation. Presence and severity of tongue scalloping showed positive correlation with increasing Mallampati and modified Mallampati airway classification.

CONCLUSIONS: In high-risk patients we found tongue scalloping to be predictive of sleep pathology. Tongue scalloping was also associated with pathologic polysomnography data and abnormal Mallampati grades. We feel the finding of tongue scalloping is a useful clinical indicator of sleep pathology and that its presence should prompt the physician to inquire about snoring history.

EBM RATING: C

OBJECTIVES: Inferior turbinate hypertrophy is one of the major causes of nasal airway obstruction. Medical treatment often produces insufficient improvements. In these cases, surgical reduction of inferior turbinates can be proposed. Many different techniques are currently available. We prospectively evaluate the safety and effectiveness of radiofrequency volumetric tissue reduction (RFVTR) compared with the traditional surgical technique.

METHODS: The study was conducted on 3 groups of 75 patients with symptoms and signs of nasal obstruction associated with inferior turbinate hypertrophy refractory to medical therapy. In group A, the turbinoplasty (TP) was performed using the classical surgical submucosal resection; in group B, the RFVTR was applied to inferior turbinate; and group C patients were not treated and served as control subjects. Nasal endoscopy, visual analogue scale (VAS), anterior active positional rhinomanometry, and saccharin tests were used to assess treatment outcomes at the end of week 1 and months 1 and 3 after surgery.

RESULTS: Turbinate edema and secretions decreased significantly (P < 0.05) in groups A and B from 1 month after surgery. The secretions in group A increased temporarily on the seventh day after surgery. Concerning the nasal obstruction and related symptoms, significant improvement was observed at 1 month after treatment in all patients (P < 0.05) and continued up to 3 months after surgery (P < 0.0001). Rhinomanometric measurements demonstrated a significant nasal flow increase at 3 months (P < 0.0001). The nasal mucociliary transport time increased in group A at week 1. The difference among the 3 groups at month 1 was observed not significant.

CONCLUSION: In this study, we demonstrated that both RFVTR and TP are effective in improving nasal obstruction and related nasal symptoms. In support of the RFVTR, different factors are important: it can be performed in local anaesthesia; it does not require a nasal package; it does not cause either a change of mucociliary function or an increase of secretions and crusts; and the patient can be discharged immediately after treatment. Therefore, we suggest that the RFVTR offers an efficient, gentle, and function-maintaining alternative to TP. However, because of the short follow-up, future investigations are needed for a more exhaustive evaluation of equivalency of the 2 turbinate procedures.

EBM RATING: B-2