Otolaryngology–Head and Neck Surgery

OBJECTIVE: To identify trends in clinical research and levels of evidence in otolaryngology journals.

STUDY DESIGN AND SETTING: We reviewed all original research articles from 1993, 1998, and 2003, in 4 major otolaryngology journals. Levels of evidence were graded 1 (strongest) through 5 (weakest).

RESULTS: Of 2584 total articles, 1924 (75%) were clinical research. During the study period, there was increased median sample size (from 22 to 30, P = 0.06), more planned research (from 30% to 37%, P = 0.023), more internal control groups (from 36% to 43%, P = 0.011), and more articles with P values (from 26% to 45%, P < 0.001) or confidence intervals (from 1.2% to 7.6%, P < 0.001). Most evidence was level 4 (57%), but median levels increased slightly over time (P = 0.027). Therapy articles had the weakest evidence (80% levels 3 to 5) and diagnostic test assessments had the strongest (75% levels 1 and 2).

CONCLUSION: Although clinical research increased in quantity and quality, sample sizes were modest, most articles lacked controls, and confidence intervals were rare. Therapy articles would benefit from higher evidence levels.

SIGNIFICANCE: By defining the current levels of evidence in otolaryngology journals, this overview should help guide future efforts.

OBJECTIVE: The aim of this study was to develop a mouse model of chronic eosinophilic rhinosinusitis.

STUDY DESIGN: Mice were sensitized to Aspergillis fumigatus (Af) extract by intraperitoneal injection. The animals subsequently received nasal challenges with Af extract 3 times per week for 12 weeks. Sinonasal complexes were studied histologically by the study otolaryngologists and pathologists to characterize the inflammatory response.

SETTING: Animal care facility at an academic institution.

RESULTS: A chronic eosinophilic inflammatory response was evoked in all study animals. Statistical analysis was performed for inflammation, secretory cell hyperplasia, mast cells, and eosinophils. There were very significant differences (P < 0.0005) between control and study mice in all categories.

CONCLUSION: Prolonged nasal challenge of Af extract creates an inflammatory response in murine nasal mucosa that mimics human chronic eosinophilic rhinosinusitis.

SIGNIFICANCE: A murine model for chronic rhinosinusitis is reported that may facilitate future investigations into disease pathophysiology.

EBM rating: B-2

OBJECTIVE: To study intracranial extension of pediatric sinusitis, an infrequent but potentially fatal complication.

STUDY DESIGN AND SETTING: Ten-year retrospective review at a tertiary children's hospital identified 21 cases of intracranial complications of sinusitis.

RESULTS: Thirteen males and eight females with mean age of 13.3 years were identified. Overall 18 of 21 (81%) exhibited abscess formation, most commonly epidural. Only 3 of 21 (14%) had meningitis alone. All but 4 patients were managed surgically, requiring craniotomy in 13 of 21 (61.9%) and endoscopic sinus surgery (ESS) in 10 of 21 (48%). Seven patients (33%) required multiple operations during admission. Nineteen patients (90%) had a total of 30 organisms cultured. Oral flora was observed in 12 of 21 (57%). Polymicrobial infections, seen in 9 of 21 (43%), were significantly associated with the need for craniotomy (P = 0.02). Mean hospital stay was 15 days, and mean length of IV antibiotic was 5 weeks.

CONCLUSIONS: Intracranial complications of pediatric sinusitis often require craniotomy. Oral flora and polymicrobial infections were prominent in this series.

EBM rating: C-4

OBJECTIVES: To study changes in quality of life in children with chronic sinonasal disease after surgical therapy.

STUDY DESIGN AND SETTING: Prospective, nonrandomized quality of life study of children with sinonasal disease who undergo adenoidectomy or functional endoscopic sinus surgery (FESS) at an academic institution. Caregivers completed a preoperative SN-5 quality of life survey and a second survey within 6 months after surgery.

RESULTS: Twenty-two children were enrolled in the study (mean, 6.5 years; range, 1.4 to 15.9). The majority (59%) of children underwent adenoidectomy. The mean total score was 25.8 at initial presentation and 12.0 at follow-up (P > 0.001). Postoperative scores for all domains were significantly different from preoperative scores. The domains with the greatest change in mean score were nasal obstruction and emotional distress. There were no significant differences in outcome between children who underwent adenoidectomy and those who underwent FESS.

CONCLUSIONS: After either adenoidectomy or FESS, caregivers report a dramatic improvement in the quality of life of children with sinonasal disease.

EBM rating: B-3b

OBJECTIVE: To investigate peripheral nasal pathology as a contributor to olfactory impairment in DS.

STUDY DESIGN: Twenty DS and 16 non-DS subjects were recruited. Nasal history and symptoms were assessed by self-report or informant. Olfactory threshold, odor identification, and nasal endoscopy were assessed on each subject.

RESULTS: DS subjects were impaired on olfactory threshold (P < 0.0001) and odor identification (P < 0.001). Although DS subjects trended toward upper-respiratory infections, sleep-disordered breathing, and nasal itching, differences were not significant (P = 0.07, 0.06, and 0.058, respectively). There were no significant differences on self-reported nasal history or symptoms. Endoscopy showed equivalent health in DS and control subjects.

CONCLUSION: This DS population shows olfactory impairment. However, nasal health is comparable in DS subjects and controls. Nasal dysfunction is unlikely to contribute to olfactory impairment in DS.

SIGNIFICANCE: Olfactory deficits in DS appear to be secondary to central, rather than rhinologic, pathology.

EBM rating: B-2b

OBJECTIVE: Assess immune and clinical changes with immunotherapy based on modified quantitative testing (MQT).

BACKGROUND: Immunotherapy promotes immunomodulation that occurs over several years. Quantitative testing offers the advantage of initiating immunotherapy with robust antigen concentrations. This study assessed whether changes in immune mediators and allergy symptoms occur rapidly using quantitative techniques.

METHODS: Sixteen allergic adults were tested using MQT. Subjects had serum drawn for immunoglobulins E and G4 (IgE, IgG4) to 3 antigens, Der p1, Der f1, and Fel d1, and for interleukins IL-1β, IL-2, IL-4, IL-5, IL-10, IL-12, and IL-13, and IL-1 receptor antagonist (IL-1RA). Subjects also completed the Sino-Nasal Outcome Test-20 (SNOT-20), the Allergy Outcome Scale (AOS), and the Rhinosinusitis Disability Index (RSDI). They underwent MQT-based immunotherapy and completed outcome measures again at 6 and 12 weeks.

RESULTS: Nine subjects completed the study. Analysis demonstrated significant increases in IgG4 levels to all antigens, significant decreases in serum levels of IL-1β and IL-5, and significant increases in levels of IL-1RA. Improvement was also noted in AOS and RSDI subscales.

CONCLUSION: Immunotherapy based on MQT demonstrates significant changes in immunoglobulin and cytokine levels by 12 weeks following initiation. In addition, improvement in symptom and quality-of-life measures occurs by 12 weeks. These findings support the rapid onset of clinical effects with MQT-based treatment of inhalant allergy.

EBM rating: C-4

OBJECTIVE: The aim of this study is to investigate dose-dependent effect of the topical application of methotrexate (MTX) in rats on the normal nasal mucosa, liver tissue, liver enzymes, and hemoglobin levels.

STUDY DESIGN: Preclinical animal study.

SETTING: Twenty male adult wistar albino rats were randomly divided into 4 groups (n = 5). A single puff of MTX (2.5 μg) was applied to both nasal cavities 2 times a day. The animals were given MTX 1 day a week in group 1, 3 days a week in group 2, and 5 days a week in group 3. Control group animals were given 1 puff of physiologic saline to both nasal cavities 5 days a week and 2 times a day. After 28 days, liver biopsies, blood samples, and 5 nasal mucosal biopsies were taken. Histological examination was made with respect to certain parameters semiquantitatively (grade 0-3). The aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels and hemoglobin counts were studied from blood samples.

RESULTS: There are no statistically significant differences with respect to histopathological parameters between the control group and the groups 1-3 (P > 0.05). Histopathological examination of liver tissue did not reveal any evident difference between the control and study groups. Mean AST and ALT as liver function tests and hemoglobin counts were within normal limits. Topical application of MTX at these doses has no toxic effect on the nasal mucosa, the liver tissue, AST and ALT levels, and hemoglobin level.

CONCLUSIONS: These results have been encouraging to investigate use of the topical application of MTX in nasal manifestation of autoimmune disease or addition of the topical application of MTX to the steroid treatment in cases with massive nasal polyposis resistant to steroids and prone to recurrence.

OBJECTIVE: To analyze the impact of snoring, independent of obstructive sleep apnea syndrome on patients referred for home sleep studies and to report a new technology for the reporting of snoring, using sophisticated sound collection and noise-canceling technology.

STUDY DESIGN AND SETTING: A retrospective statistical review of consecutive anonymous data compiled from questionnaires and digital data of snoring loudness and duration measured at the upper lip during unattended home sleep studies in 4,860 patients referred for snoring and sleep-disturbed breathing.

RESULTS: A strong relationship exists between a history of snoring and complaints of daytime sleepiness (80%), obesity (73%), and chronic fatigue (78%) (all yield P < 0.001). By contrast, only 42% to 48% of patients without these symptoms complain of snoring. In 3 multiple-regression analyses, the percent of time snoring, average loudness, and peak loudness are all significantly predicted by the apnea hypopnea index (all P < 0.003), body mass index (all P < 0.001), and age (P = 0.014). Daytime sleepiness was strongly predicted by percent time snoring (P = 0.014), weakly by average loudness (P = 0.046), and not at all by peak loudness (P = 0.303).

CONCLUSION: By using a pair of microphones placed at the upper lip, one that samples breath sounds and the other ambient sound and artifact noise, the NovaSOM QSG measures snoring while canceling ambient noise. The clinical impact of snoring on the patient as well as the bed partner, independent of obstructive sleep apnea syndrome, is an unrecognized factor in sleep-disturbed breathing.

SIGNIFICANCE: Measurable criteria to define snoring are suggested. Snoring loudness is not measured in most laboratory Polysomnograms.

EBM rating: B-3b

OBJECTIVE: To estimate the predictable value of histopathologic parameters in chronic rhinosinusitis (CRS) for response to endoscopic sinus surgery (ESS).

STUDY DESIGN: Symptomatology was rated in 100 patients prior to as well as 12 and 24 months after surgery. Specimens taken during the procedure were examined and scored for goblet cells, subepithelial thickening, mast cells, and eosinophils. Multiple regression analysis was performed to predict the total score of subjective symptoms before treatment by histopathologic parameters. The correlation between histopathologic parameters and postoperative symptoms was then evaluated.

RESULTS: Goblet cells were the best predictor correlating with 5 symptoms. Subepithelial thickening correlated with 4 symptoms. Mast cell infiltration correlated with 3 symptoms. Eosinophilic infiltration correlated with only one symptom (P < 0.05).

CONCLUSION: Certain histopathologic parameters in CRS are predictive of favorable response to ESS.

SIGNIFICANCE: Pathologic evaluation may help the ENT surgeon to predict the persistence of certain CRS symptoms after ESS, even in patients at low risk for surgical failure.

EBM rating: C-4

OBJECTIVE: To determine the prevalence of radiographic empty sella in patients with spontaneous cerebrospinal fluid (CSF) otorrhea.

STUDY DESIGN AND SETTING: Retrospective case series of adult patients with CSF otorhinorrhea at an academic tertiary medical center. Patients with history of skull base surgery, trauma, tumor, or chronic ear disease were excluded. Available imaging studies were reviewed with attention to the sella turcica.

RESULTS: Eight patients were diagnosed with spontaneous CSF otorrhea. Five of seven patients with adequate imaging studies (71%) had a radiographic empty sella. Seven of eight patients were clinically obese, with a body mass index BMI >30 kg/m 2 .

CONCLUSIONS: Empty sella is a common radiologic finding in patients with spontaneous CSF otorrhea. This supports the theory that increased intracranial pressure contributes to development of spontaneous CSF otorrhea.

SIGNIFICANCE: Radiographic empty sella predicts elevated intracranial pressure, which may require further evaluation and treatment in patients with spontaneous CSF otorrhea.

EBM rating: C-4

OBJECTIVE: Evaluate possible role of Helicobacter Pylori in pathogenesis of otitis media with effusion (OME).

STUDY DESIGN AND SETTING: Randomized controlled trial, tertiary referral center.

STUDY GROUP: Middle ear fluid was aspirated, a biopsy was taken from the promontorium of 22 children with OME.

CONTROL GROUP: A small biopsy was taken from the promontorium of 20 children with normal otologic findings. For both groups, 5 mm deep tissue specimens were obtained from tonsil and adenoid.

RESULTS: H pylori presence in the middle ear, the tonsillar and adenoid tissues by culture and PCR was significantly more frequent in the study group compared to the control group (P < 0.05).

CONCLUSIONS: This study is the first to grow H pylori in middle ear in OME. Significantly increased colonization by H pylori of the middle ear, and tonsillar and adenoid tissue in patients with OME indicates that the bacteria might be involved in the pathogenesis of OME.

EBM rating: A-1b

OBJECTIVE: We sought to determine the accuracy of an electromagnetic image guidance surgical navigation system in localizing the midpoint of the internal auditory canal (IAC) and other structures of the temporal bone through the middle cranial fossa approach.

MATERIALS AND METHODS: Seven fresh cadaveric whole heads were dissected via a middle cranial fossa approach. High-resolution CT scans were used with an InstaTrak 3500 Plus electromagnetic image guidance system (General Electric, Fairfield, CT). We evaluated the accuracy of identifying several middle cranial fossa landmarks including the midpoint of the IAC; the labyrinthine segment of the facial nerve; and the arcuate eminence, the carotid artery, and foramen spinosum.

RESULTS: We were able to identify the middle of the IAC within 2.31 mm (range 0.65-7.52 mm, SD 2.39 mm). The arcuate eminence could be identified within 1.86 mm (range 1.49-2.37 mm, SD 0.36 mm). We noted some interference when the handpiece was within 6 to 8 cm of the microscope.

CONCLUSION: Although computer-aided navigational tools are no substitute for thorough knowledge of temporal bone anatomy, we found the InstaTrak system reliable in identifying the midpoint of the IAC to within 2.4 mm through a middle fossa approach.

OBJECTIVE: To determine the efficacy of a high-dose steroid regimen for patients with sudden sensorineural hearing loss (SSNHL) and to evaluate the relationship between outcome and initial steroid dose.

STUDY DESIGN AND SETTING: We conducted a retrospective study of 112 patients presenting to Saitama Medical Center. Patients received tapering courses of hydrocortisone (HC) with an initial dose of either 1200 mg or 600 mg.

RESULTS: More than 87% of patients had recovery of hearing. When hearing stabilized, there were no significant differences between the 1200 mg and 600 mg groups in terms of hearing outcome (P > 0.05). However, at completion of treatment, the 1200 mg group exhibited significantly superior complete recovery rate and improvement rate (P < 0.05).

CONCLUSION: Application of our treatment protocol of a tapered course of 1200 mg HC significantly and rapidly improves recovery outcomes in patients of SSNHL.

EBM rating: C-4

OBJECTIVE: To determine the migration rate and pattern for keratin on the tympanic membrane (TM) of the gerbil and guinea pig in comparison to human data and determine which species is an appropriate model for investigating the relationship of epithelial clearance to cholesteatoma formation.

STUDY DESIGN AND SETTING: Ink drops were placed on the TM and their locations plotted daily.

RESULTS: Gerbils demonstrated a radial migration pattern away from the umbo, identical to that reported for humans, although the rate was 0.32 mm/day—3 times the human rate of 0.1 mm/day. Guinea pigs were significantly different from gerbils and humans, with a rate of 0.79 mm/day and a pattern of superior/inferior migration without anterior-posterior movement.

CONCLUSION: Gerbils more closely resemble humans in rate and pattern of epithelial migration.

SIGNIFICANCE: Gerbils represent the most appropriate model for determining the relationship between keratin migration and cholesteatoma formation.

OBJECTIVE: Assess parental perceptions of their child's sensorineural hearing loss care.

METHODS: Families of pediatric patients diagnosed with a sensorineural hearing loss from 2000 to 2004 were sent a survey asking about their experiences with their child's hearing loss.

RESULTS: One hundred eight of 389 families surveyed were studied. Thirteen percent did not know the results of the newborn screening. Twenty-two percent of the primary care physicians were not involved in the child's hearing evaluation. Forty percent of the patients underwent 4 or more audiologic tests before a diagnosis. The most common reason for delayed diagnosis was difficulty in obtaining an appointment with an audiologist. Sixty-two percent of families had difficulties obtaining hearing aids, and 58% noted difficulties obtaining cochlear implants.

CONCLUSIONS: Families reported multiple obstacles to obtain timely diagnosis and treatment. Otolaryngologists may need to be more involved in the evaluation and treatment of these patients.

EBM rating: C-4

OBJECTIVES: To describe our preclinical experience with Cone Beam CT (CBCT) in image-guided surgery of the temporal bone.

STUDY DESIGN AND SETTINGS: A mobile isocentric C-arm (PowerMobil, Siemens Medical Systems, Erlangen, Germany) modified to include a flat-panel detector (Varian Imaging Products, Palo Alto, CA) and a motorized orbit was developed to acquire multiple projections in rotation about a subject. Initial experiments imaging steel wire in air were used to investigate the system's spatial resolution in 3D image reconstruction. Subsequently temporal bone dissection was performed on five cadaver heads using the modified C-arm as an image guidance system.

RESULTS: We obtained a spatial resolution of 0.85 mm. The image acquisition time was 120 seconds and the radiation dose approximately one-tenth of a conventional CT scan.

CONCLUSION: CBCT provided submillimeter accuracy at high speed with low radiation dosage to offer utility as an intraoperative imaging system.

SIGNIFICANCE: CBCT offers technology that approximates “near-real-time” image guidance.

EBM rating: C-4

OBJECTIVE: This study describes the long-term outcome of patients suffering from sudden sensorineural hearing loss (SSHL) after an initial combined therapy of steroids with vasodilators.

STUDY DESIGN AND SETTING: Eighty cases were retrospectively reviewed to evaluate the long-term audiometric data and to statistically assess the value of specific clinical parameters. The persistent long-term otoneurologic manifestations associated with SSHL were also reported.

RESULTS: In the long-term period, hearing level remained stable 2 months after the onset of SSHL. Patients complained of persistent tinnitus (36%), fluctuant hearing loss (8.7%), dizziness (8.7%), and classical Meniere's triad in 2.5% of cases. Profound and total SSHL associated with vertigo are poor prognostic indicators.

CONCLUSIONS: In terms of cost-effectiveness, a steroid-vasodilator therapy for SSHL for >2 months is not recommended because no additional effect was evidenced. Persistent otoneurologic manifestations, mainly tinnitus or dizziness are relatively common, particularly in patients with severe to total SSHL.

EBM rating: C-4

OBJECTIVE: To evaluate outcomes of stapedectomy surgery for congenital stapes fixation.

STUDY DESIGN: Retrospective chart review.

METHODS: The charts of 463 stapedectomies performed by 1 surgeon from 1996 to 2003 were reviewed. Patients with a history of childhood hearing loss and operative findings consistent with congenital fixation of the stapes were included. Patients with a history of trauma or chronic otitis media and those with otosclerosis were excluded. Thirty-six patients underwent stapedectomy for congenital fixation. Revision cases and those with inadequate postoperative bone or air conduction data were excluded. Inclusion criteria were met for 25 patients. Operative findings and hearing outcomes were evaluated.

RESULTS: The study group was comprised of 25 stapedectomies. Closure of the air-bone gap to less than 10 dB was achieved in 48% of cases, and 80% had closure within 20 dB. A gap of more than 30 dB remained in 3 cases. There were 2 cases of sensorineural hearing loss with worsening of the bone conduction thresholds by 15 dB and 30 dB. There were no instances of perilymph gusher. In addition to an excluded case that was not reconstructed because of facial nerve position, 3 of the included patients were found to have a dehiscent facial nerve at surgery. There were no facial nerve injuries, and fixation of the malleus or incus was not found in any of the included patients. When hearing outcomes were compared with our results for otosclerosis over the same time period, rates of closure to within 10 dB and 20 dB were significantly worse in the congenital group.

CONCLUSION: Closure of the air-bone gap in this population differs from our results in stapedectomy done for otosclerosis. This difference likely reflects subtle anatomic variations in the congenital group that affect the effectiveness of the prosthesis. Despite the difference in results, stapedectomy for congenital fixation remains an effective method to achieve significant hearing improvement in the majority of patients.

EBM rating: B-3b

OBJECTIVE: Well-differentiated thyroid carcinoma is considered an indolent malignant disease. Although rare, extrathyroidal invasion is associated with a worse prognosis and increased risk of morbidity. Management remains controversial, with some authors advocating conservative treatment with preservation of midline structures and others, aggressive extensive en bloc resection. The aim of this study was to report our 40-year experience with invasive thyroid carcinoma, with emphasis on the clinical characteristics and the effect of different treatment modalities on survival.

STUDY DESIGN AND SETTING: A retrospective study including a file review of 1,200 patients with a diagnosis of well-differentiated thyroid carcinoma of whom 49 (5%) showed involvement of an adjacent structure (larynx, trachea and esophagus) (study group). Type of surgery, radiation treatment, radioiodine treatment, and patient demographics were evaluated.

RESULTS: Compared to the rest of the patients, the study group was characterized by a higher rate of male patients (39% vs 25%), and older average age (58 vs 45 years). Average size of the primary tumor was 3.7 cm. Sixteen patients underwent radical surgery and 33 conservative surgery followed by radio-iodine treatment. Five-year survival and recurrence rates for the whole group were 78% and 52%, respectively. The only statistically significant factor for survival was large tumor size. Distant metastases developed in 46% of patients, all in the lungs. Ten of 14 deaths were due to distant metastases. External radiation, used in 52% of the patients, was associated with worse prognosis.

CONCLUSION: Conservative procedures followed by radioiodine treatment are associated with similar survival rates as aggressive techniques, with less perioperative mortality and lower overall morbidity.

SIGNIFICANCE: This study provides further evidence that in cases of invasive thyroid tumors the extent of the primary surgery seems to have no influence on survival.

EBM rating: C-4

OBJECTIVE: The purpose of the study was to evaluate the effectiveness of a U-shaped pectoralis major myocutaneous flap (PMMF) to reconstruct a large circumferential defect involving the oro- and hypopharynx.

STUDY DESIGN AND SETTING: Retrospective case series.

RESULTS: Twelve patients with advanced oro- and hypopharyngeal cancer (stage IV) underwent surgery resulting in a circumferential defect of pharyngoesophageal segment (PES). Those defects were reconstructed using a U-shaped PMMF. Four pharyngocutaneous fistulas were observed postoperatively and healed spontaneously within 3 to 7 weeks. Eight patients were able to resume a regular diet. A voice prosthesis was functional in 5 patients.

CONCLUSION: This preliminary study shows that this technique is a simple and effective method with acceptable morbidity rate and satisfactory functional results. We demonstrate that this procedure allows the reconstruction of large defects involving the oro- and hypopharynx in irradiated patients. This technique could be an interesting alternative for surgical teams suffering from the absence of a microsurgical team.

EBM rating: C-4

OBJECTIVE: To illustrate the safety and efficacy of the endoscopic laser approach for cricopharyngeal myotomy (CPM) compared to the traditional transcervical approach.

STUDY DESIGN AND SETTING: Retrospective chart review of 22 patients undergoing CPM from 1996 to 2003 at the Mayo Clinic, Jacksonville.

RESULTS: The laser CPM technique was used in 14 patients, and an open approach in 8. The mean hospital stay and operative times were shorter for the laser group. Functional outcome analyses showed improvement in both groups. There were no major complications in the laser group, while 1 patient in the transcervical group had a pharyngocutaneous fistula.

CONCLUSIONS: The laser technique is at least as effective as the transcervical approach for CPM to improve dysphagia symptoms in the properly selected patient, with a low risk of major complications.

SIGNIFICANCE: In this report, we provide the reader with data to support the safety and efficacy of laser CPM.

EBM rating: B-3b

OBJECTIVES: To evaluate the relationships between laryngeal inflammation assessed using the Reflux Finding Score (RFS), laryngeal sensory function, and apnea severity in patients with obstructive sleep apnea (OSA).

METHODS: Endoscopic sensory testing (EST) was performed with subsequent blinded scoring from video of RFS. An RFS > 7 was indicative of increased inflammatory change.

RESULTS: Of 34 patients evaluated, 29 had OSA (apneahypopnea index [AHI] ≥ 15 events/h) at polysomnography. Increased inflammation was present in 26/29 (90%), with changes suggestive of laryngopharyngeal reflux. There were significant correlations between: inflammation and OSA severity (eg, RFS vs AHI, r = 0.57, P < 0.001); inflammation and laryngeal sensory impairment (EST detection threshold and pressure required to elicit the laryngeal adductor reflex, LAR); and the degree of sensory impairment and OSA severity.

CONCLUSIONS: Laryngeal inflammation is prevalent among OSA patients and correlates with laryngeal sensory dysfunction, attenuation of the LAR, and apnea severity.

EBM rating: C-4

OBJECTIVE: To determine if subglottic development is at least partially under local control and to determine which tissue layer(s) is predominantly responsible.

DESIGN: The suglottises of 12 day-3 CD1 mice were grown in whole organ culture. The 12 subglottises were divided into 3 individual groups: + + +, − + +, and − − −. Group + + + had all tissue layers of the subglottis intact: luminal epithelium, cricoid cartilage, inner and outer perichondrium. Group - + + had all layers intact with the exception of luminal epithelium. Group − − − had all layers removed (luminal epithelium, inner and outer perichondrium) resulting in cricoid cartilage-only rings. All rings were grown in basic medium without the use of growth factors or serum for 15 days. Measurements of the rings were taken before and after organ culture growth.

RESULTS: Group +++ was the only group that experienced growth. Only luminal growth was statistically significant although all rings experienced growth in both the luminal and external diameter. Group - + + did not experience any growth. Group — lost structural integrity with collapse of the ring and did not experience growth of any dimension of the cartilage.

CONCLUSIONS: Growth of the subglottis is under local control but may have additional influences from the outside that were not investigated here. Removal of just the epithelium stunts growth of the entire ring, but preferentially the lumen more so than the external diameter. Removal of all tissue layers around the cricoid cartilage results in a structural collapse of the ring, suggesting that the cartilage in this age group is dependent on surrounding tissues for structural integrity.

PRINCIPLES AND METHODS: Upper respiratory tract (URT) involvement is rare in sarcoidosis. In this descriptive study, we retrospectively evaluated the clinical and demographic features of 12 (2.19%) patients with URT involvement out of the 546 sarcoidosis patients with follow-up visits at our center within the last 40-year period.

RESULTS: Out of the 546 patients, 12 (2.19%) had upper respiratory tract involvement, 5 (0.91%) had laryngeal involvement, 4 (0.73%) had sinonasal tract involvement, 2 (0.36) patients had salivary gland involvement, and 1 patient had tonsillary involvement. The number of stage 0 subjects among other sarcoidosis patients was significantly lower than that among those with URT involvement.

CONCLUSIONS: URT involvement is rarely diagnosed in patients with systemic sarcoidosis. The most common site for URT involvement among the Turkish population is the larynx, followed by the sinonasal tract.

EBM rating: C-4

OBJECTIVES: To compare postoperative complication rates of coblation and electrocautery adenotonsillectomies.

STUDY DESIGN: Retrospective chart review.

RESULTS: From January 2000 to June 2004, 1997 pediatric patients underwent adenotonsillectomy. 745 coblation, and 1252 electrocautery tonsillectomies were performed. Primary bleed, secondary bleed, and dehydration were seen in 3, 35, and 23 coblation, and 9, 41, and 64 electrocautery tonsillectomies, respectively. Data analysis revealed no significant difference in primary and secondary hemorrhage rate, but a higher dehydration rate in the electrocautery group (P = 0.0423). A total of 602 coblation, 763 curette/cautery, and 632 electrocautery adenoidectomies were performed. Neck pain was seen in 0, 17, and 3 patients, respectively. Data analysis showed a higher incidence of neck pain with the curette/cautery technique compared with coblator and cautery techniques (P = 0.0006 and P = 0.0119, respectively).

CONCLUSIONS: Coblation tonsillectomy had similar rates of primary and secondary hemorrhage when compared with electrocautery tonsillectomy but a lower incidence of postoperative dehydration. Coblation adenoidectomy caused less postoperative neck pain than curette/cautery adenoidectomy without significant advantage over cautery adenoidectomy.

EBM rating: B-3b

OBJECTIVE: This study investigated the outcome of the hyoid suspension as a part of a multilevel surgery protocol.

STUDY DESIGN AND SETTING: Eighty-three patients with obstructive sleep apnea (OSA) underwent a multilevel surgical treatment because of continuous positive-airway pressure intolerance, 67 with the hyoid suspension and 16 without the hyoid suspension. All patients underwent a pre- and postoperative polysomnography in the sleep laboratory.

RESULTS: The mean preoperative apnea hypopnea index (AHI) was 36.4 ± 21.2 and 19.4 ± 19.7 postoperatively for all patients (P < 0.0001). Further statistically significant changes were found for the arousal index, the oxygen saturation, and the daytime sleepiness. No statistically significant change was found for body mass index. In the group of patients treated without the hyoid suspension, the AHI did not decrease statistically significant. After surgery, 59.7% of the subjects with the hyoid suspension were regarded as cured.

CONCLUSION: Multilevel surgery including the hyoid suspension is an effective treatment in subgroup of OSA patients.

EBM rating: C-4

OBJECTIVE: This article focuses on establishing communication between a functional muscle and a denervated muscle using a radiofrequency communications link. The ultimate objective of the project is to restore the eye blink in patients with facial nerve paralysis.

STUDY DESIGN AND SETTING: Two sets of experiments were conducted using the gastrocnemius leg muscles of Sprague-Dawley rats. In the initial tests, varying magnitudes of voltages ranging from 0.85 to 2.5 V were applied directly to a denervated muscle to determine the voltage required to produce visible contraction. The second set of experiments was then conducted to determine the voltage output from an in vivo muscle contraction that could be sensed and used to coordinate a signal for actuation of a muscle in a separate limb. After designing the appropriate external communication circuitry, a third experiment was performed to verify that a signal between a functional and a denervated muscle can be generated and used as a stimulus.

RESULTS: Voltages below 2 V at a 10-millisecond pulse width elicited a gentle, controlled contraction of the denervated muscle in vivo. It was also observed that with longer pulse widths, higher stimulation voltages were required to produce sufficient contractions.

CONCLUSION: It is possible to detect contraction of a muscle, use this to generate a signal to an external base station, and subsequently cause a separate, denervated muscle to contract in response to the signal.

SIGNIFICANCE: This demonstration in vivo of a signaling system for pacing of electrical stimulation of 1 muscle to spontaneous contraction of another, separate muscle, using radiofrequency communication without direct connection, may be used in numerous ways to overcome nerve damage.

OBJECTIVE: Image fusion software creates composite images from computed tomography (CT) and magnetic resonance (MR) images.

STUDY DESIGN AND SETTING: CT-MR fusion studies between August 2004 to July 2005 were reviewed. CT scan images (1-mm axial) were obtained on a multi-detector CT scanner. MR images (1-mm axial) were obtained with a T₁-weighted, volume acquisition technique. CT-MR fusion images were created on the Instatrak 3500 Plus or CBYON Suite.

RESULTS: A total of 25 patients had 27 CT-MR image fusion studies. CT-MR fusion accuracy was 2 mm or better. During preoperative planning and intraoperative navigation, CT-MR fusion facilitated the delineation of the anatomic relationships between the lesion and the skull base.

CONCLUSIONS: CT-MR image fusion yields composite images that combine features of each component imaging modality. Image fusion, when combined with surgical navigation, further enhances potential skull base applications for minimally invasive endoscopic surgery.