Otolaryngology–Head and Neck Surgery

OBJECTIVE: To evaluate the level of evidence regarding the safety of outpatient pediatric tonsillectomy.

STUDY DESIGN AND SETTING: The medical literature addressing outpatient pediatric tonsillectomy was systematically reviewed. The level of evidence was assessed, and data were pooled.

RESULTS: Seventeen articles met inclusion criteria. Each article suggested that outpatient tonsillectomy was safe. The overall level of evidence was fair (grade B —). Pooled data analysis in the perioperative period showed a complication rate estimate of 8.8% (95% confidence interval [CI], 5.5%–12.1%; P ≤ 0.001) and an unplanned admission rate estimate of 8.0% (95% CI, 5.3%-10.7%; P ≤ 0.001). Subgroup analysis suggests that children under age 4 are at a higher risk of complications in the perioperative period with an odds ratio of 1.64 (95% CI, 1.16–2.31).

CONCLUSION: The level of evidence supporting the safety of outpatient pediatric tonsillectomy is fair. The analyzed data show a higher rate of early complications and unplanned admissions in children under age 4.

SIGNIFICANCE: The current evidence supports the practice of outpatient tonsillectomy in properly selected children.

EBM rating: A-1a

INTRODUCTION: Post—tympanostomy tube otorrhea is the most common complication of tympanostomy tube placement. The incidence of this problem varies from 3.4% to 74%. Trials that study post—tympanostomy tube otorrhea may involve valid randomization “by patient” or “by ear.” In an attempt to define “best practice,” we conduct a meta-analysis to quantify the benefit of using topical prophylactic antibiotic drops in the postoperative period. We then compare our findings with previous results found in the literature.

METHODS: We selected randomized studies for which antibiotic drops had been used for at least 48 hours after tympanostomy tube insertion. Nine studies, 3 “by ear” and 6 “by patient,” met our inclusion criteria. The odds ratio and 95% confidence intervals were calculated for each to conduct the meta-analysis.

RESULTS: Overall, prophylaxis appears to be effective at reducing the incidence of post—tympanostomy tube otorrhea. The odds ratios for all studies were less than 1.0. However, none of the 3 “by ear” studies and only 3 of the 6 “by patient” studies were statistically significant. The mean odds ratio was 52%, suggesting that prophylaxis may reduce the incidence of post—tympanostomy tube otorrhea by half.

CONCLUSION: This meta-analysis suggests that routine post—tympanostomy tube prophylaxis is beneficial, but this finding is dependent on selection criteria used.

EBM rating: A-1a

OBJECTIVE: Determine if passive smoke exposure (PSE) increases airway complications during outpatient mask anesthesia procedures in children.

METHODS: A prospective cohort of children who underwent surgical procedures under mask anesthesia was studied with the American Thoracic Society children's questionnaire on environmental and respiratory factors. Double-blinded outcomes with respect to adverse airway events were recorded both intraoperatively and in the recovery room for patients with and without passive smoke exposure. Multivariate comparisons assessing the likelihood of these airway complications were conducted between the PSE and nonexposed groups.

RESULTS: Of 405 children, 168 (41.5%) had PSE. The incidence of airway complications during anesthesia or postanesthetic recovery was higher for all outcome measures for PSE children (all P ≤ 0.005), except for recovery room breath holding (P = 0.086). Intraoperative laryngospasm and airway obstruction were 4.9 and 2.8 times more likely with PSE, respectively.

CONCLUSIONS: PSE significantly increases the risk of anesthesia-related airway complications during outpatient pediatric procedures.

EBM rating: A-1b

OBJECTIVE: To describe our experience with chronic sensory neuropathic cough and its response to amitriptyline in a first group of patients.

STUDY DESIGN AND SETTING: A prospective cohort of patients is described in detail. Each was referred to an academic laryngological practice after extensive prior negative workup for cough and failure to respond to various treatments. Each of these patients was treated with amitriptyline and asked to report the effect on the cough at fixed intervals by means of telephone interviews.

RESULTS: A first cohort of 12 consecutive patients with a chronic, nonproductive cough that lasted between 2 months and 20 years, with no (formerly) discernible cause is described. Purely clinical criteria of inclusion and exclusion are proposed. All patients had at least 40% reduction of self-reported symptoms, with most describing between 75% to 100% short-term relief.

CONCLUSION: Sensory neuropathic cough can be diagnosed clinically in patients with chronic idiopathic cough. A trial of amitriptyline 10 mg or of other antineuralgia type medications may be helpful. Longer term and controlled trials are warranted to validate this entity and prove efficacy of neurologic medication in chronic sensory neuropathic cough.

EBM rating: C-4

OBJECTIVE: To study the effect of local application of cidofovir in patients with recurrent laryngeal papillomatosis (RLP) by measuring the interval between recurrences and the extent of disease at each recurrence.

STUDY DESIGN AND SETTING: The study group included 10 patients with RLP. Videolaryngoscopic analysis of previous RLP operations for each patient before starting cidofovir and the number and timing of pre-cidofovir recurrences of the disease provided data for a self-control group. The cidofovir was injected with a laryngeal needle during papilloma resection operations. To evaluate the changes and the extent of the disease, the authors developed a staging system based on anatomic topography. The extent of the disease and the intervals between recurrences were analyzed and statistically compared.

RESULTS: The median interval between recurrences significantly increased from 102 days before cidofovir to 239 days after treatment. No local or systemic side effects were observed.

CONCLUSIONS: The study supports the hypothesis that cidofovir is an effective adjunct in treating recurrences of RLP.

EBM rating: C-4

OBJECTIVE: This project studies the use of airway stents coated with a cross-linked derivative of hyaluronan (HA) in a rabbit airway model of subglottic stenosis (SGS).

STUDY DESIGN AND SETTING: An acute subglottic mucosal injury and airway stent placement design were used in a rabbit model. Thirty-six rabbits were randomized to 6 different study groups. Four groups had the subglottic mucosa denuded at the cricoid, and 2 groups received no injury. Airway stents coated with Carbylan-SX, a cross-linked derivative of HA, and controls were placed for 3 weeks. After sacrifice at 6 weeks, morphometric measurements of subglottic lumen were taken.

RESULTS: In posttraumatic models, no significant differences were seen in airway area measures between groups (P = 0.86). In non-injury groups, a significant difference between Carbylan-SX versus non—HA-derivative-coated stents was seen (P = 0.05).

CONCLUSION: In this model of acute subglottic mucosal injury, the HA-derivative—coated stent did not improve healing. However, in the absence of mucosal injury, the Carbylan-SX film—coated stent yielded significantly larger airway areas compared with a noncoated stent.

SIGNIFICANCE: Stents or endotracheal tubes coated with a cross-linked derivative of HA may prevent stenosis in patients without airway injury but require long-term intubation or laryngotracheal stenting.

OBJECTIVE: This study was undertaken to evaluate the use of the Medpor (Porex Surgical, College Park, GA) implant in laryngeal reconstruction and to discuss potential indications of this material in head and neck surgeries.

METHOD: Twelve rabbits were used in this particular study. Laryngoplasties were performed by extracting 5 × 10-mm thyroid cartilage and replacing it with Medpor implant. Animals were sacrificed in the 1st, 2nd, and 4th weeks and 2, 6, and 9 months after implantation. The degree of fibrous capsule formation, histiocytic reaction, foreign body giant cell reaction, lymphocytic and neutrophilic reactions, vocal fold changes, and hyaline cartilage formation in the implant bed were evaluated.

RESULTS: Fibrous capsule was formed around the implant in 2 weeks. Four weeks after the implantation cellular reaction in the implant bed decreased significantly. Foreign body giant cell reaction was detected only the first 2 weeks after the implantation.

CONCLUSION: According to the results of this study, the Medpor implant can be safely used in laryngeal reconstruction.

OBJECTIVE: To determine the effects of electrical stimulation on denervated cat posterior cricoarytenoid (PCA) muscle.

STUDY DESIGN AND SETTING: This study was conducted on six cats with PCA muscle denervation. All animals were sacrificed 12 weeks after surgery and the glottal area in the live animals and the fiber diameters of PCA muscle were obtained.

RESULTS: Signals synchronized with inspiration were recorded and transmitted to stimulate PCA muscle. The abduction of the paralyzed vocal cord during inspiration was observed; this allows enough flow of air through the larynx to maintain the respiration. The stimulated fiber diameters of PCA muscle were different from that of nonstimulated (P < 0.01). Although all denervated muscles were degenerated, electrical stimulation was used to prevent muscular atrophy.

CONCLUSIONS: This study indicates that electrical stimulation of the PCA muscle synchronized with inspiration could restore the abduction of a paralyzed vocal cord and prevent the denervated muscles from atrophying.

SIGNIFICANCE: Electrical stimulation synchronized with inspiration may lead to reanimation of paralyzed laryngeal muscles.

OBJECTIVE: This study was conducted to compare an otolaryngologist's experience with a cohort of epilepsy patients implanted with a vagal nerve stimulator (VNS) to previously published data.

METHODS: Demographics, preoperative seizure frequency, medications, and complications were retrospectively collected from patients implanted by the senior author. Postoperative medications and seizure frequency were obtained from referring neurologists.

RESULTS: Seventeen patients were implanted over a 24-month period. Average age was 28.3 years. Patients presented with petit mal (n = 3), tonic-clonic (n = 6), complex partial (n = 5), and grand mal (n = 8) seizures. Mean follow-up postimplantation was 13.5 months. Most patients had at least a 50% reduction of seizure frequency, with 3 patients being seizure free. There were no postoperative infections. One patient had left vocal cord immobility. The most common side effect was voice disturbance during device activation.

CONCLUSION: Otolaryngologists are well equipped to perform VNS implantation and to diagnose and treat possible laryngeal side effects.

EBM rating: C-4

OBJECTIVES: To investigate the role of Helicobacter pylori (H pylori) infection in laryngopharyngeal reflux (LPR).

STUDY DESIGN: A prospective multidisciplinary clinical study.

METHODS: Forty-four adult patients who applied to our ENT clinic with LPR symptoms were evaluated. Then these patients underwent upper gastrointestinal system endoscopy and double probe pH monitoring. In addition, during the endoscopy multiple biopsies from the stomach were obtained to detect H pylori.

RESULTS: Results from 32 LPR positive patients were assessed (10 male and 22 female). There were no statistically significant differences between the presence of H pylori and sex, age, degree of gastritis and esophagitis, and also the number of reflux, fractional acid exposure time regarding proximal probe readings. Similarly for both proximal and distal probe readings, the average score of esophageal acid clearance was not statistically significant (P > 0.05). In addition, no statistically significant difference was found between the presence of H pylori and GERD (P > 0.05).

CONCLUSIONS: The results of this study demonstrated that there is no relationship between gastric H pylori infection and LPR.

EBM rating: B-3b

OBJECTIVE: To determine the effect of intradermal and topical mitomycin C (MMC) on skin wound healing.

STUDY DESIGN/SETTING: A prospective, controlled study in a rat wound model performed in an academic medical center.

RESULTS: Intradermal and topical MMC application decreased wound integrity when compared with saline-treated animals at 1 week, 2 weeks, 1 month, and 6 months. Skin necrosis occurred in animals that received intradermal MMC. Hemotoxylin and eosin and immunohistochemical staining showed no consistent difference between treatment arms. Fibrosis and collagen deposition were reduced in MMC-treated wounds on trichrome staining.

CONCLUSIONS: MMC-treated wounds showed decreased wound strength compared with controls. Intradermal MMC can cause skin necrosis. Histologic findings did not always correspond with clinical data.

SIGNIFICANCE: The data suggest cautious use of MMC in clinical situations when wound breaking strength is critical.

OBJECTIVE: To test chondrogenic differentiation potential, we examined the differentiation plasticity of isolated human fetal articular chondrocytes (HFACs).

STUDY AND DESIGN SETTING: Culture-expanded human fetal articular chondrocytes (HFACs) were analyzed for chondrogenic, adipogenic, osteogenic capacity and neural differentiation ability in defined in vitro culture systems.

RESULTS: The different assays demonstrated that culture-expanded HFACs have potential to form cartilage in pellet mass culture, to form adipose cells, osteogenic cells, and neural cells in monolayer culture.

CONCLUSIONS: These results suggest that within human fetal articular cartilages there are MSC-like cells that exhibit differentiation plasticity that is comparable with that of BM-MSCs and they may be a new kind of seeding cells for head and neck cartilage reconstruction.

OBJECTIVE: To evaluate impressions and usage of sinus surgery image-guided surgical (IGS) systems by ENT surgeons in the United States.

STUDY DESIGN AND SETTING: A survey was mailed to selected practicing ENT physicians, investigating regional information, practice type, IGS usage patterns, perceived benefits and limitations, and usage of the 61795 surgery code.

RESULTS: Seventy-three percent of respondents use IGS. Nonusers respond that it provides no benefit or is too expensive. Eighty percent of respondents replied that IGS may allow for increased safety in certain procedures. Most users attempt reimbursement with the 61795 code.

CONCLUSION: IGS usage is increasing but appears to be perceived as expensive and nonbeneficial in certain situations. Most respondents, however, felt that IGS may lead to safer surgery in certain situations, including revision and frontal procedures. Several factors appear to limit routine use including ease of use, technical setup, code reimbursement, and initial purchase costs.

SIGNIFICANCE: IGS use appears to be increasing. The most frequent users appear to agree with the previously issued AAO-HNS guidelines regarding appropriate indications. Expanded use may depend on ease of use, reimbursement, and affordability.

EBM rating: D-5

OBJECTIVES: To compare the quality of life (QOL) outcome and incidence of complications following image-guided versus non–image-guided endoscopic sinus surgery (ESS).

STUDY DESIGN: The operative, office, and hospital charts of patients who underwent primary ESS for chronic sinusitis by a single surgeon with (2002–2005) or without (1997–2002) image guidance were reviewed for patient demographics, incidence of complications, and revision procedures. A telephone survey was used to administer the QOL survey to both cohorts.

RESULTS: In comparing patients who underwent image-guided (60) versus non–image-guided surgery (179), respectively, there was no statistically significant difference in the incidence of major intraoperative complications (6.6% vs 5.6%), major postoperative complications (5% vs 3.9%), revision procedures (6.6% vs 7.3%), and postoperative SNOT-20 symptom scores (23.6 vs 23.4). A higher incidence of intraoperative cerebrospinal fluid leak was noted in the non–image-guided group (0% vs 2.2%).

CONCLUSIONS: Our study does not demonstrate an improvement in the incidence of complications, need for revision procedures, or quality-of-life outcome for patients undergoing primary ESS for chronic sinusitis. The use of image guidance may result in a lower incidence of skull base trauma and cerebrospinal fluid leak.

EBM rating: B-2b

OBJECTIVE: To determine the long-term success rate of endonasal laser dacryocystorhinostomy (DCR) in our unit.

MATERIALS AND METHODS: This was a retrospective study including all the consecutive cases of endonasal laser DCR (ELDCR) between November 1996 and December 1999. Patients who underwent revision DCR were excluded. The absence or improvement of symptoms as reported by the patients was defined as successful outcome. Conversely, recurrence of epiphora was considered as failure. The results were reviewed at 1 year in the clinic and at further 3 years and 5 years by telephone consultation.

RESULTS: There were 65 patients (73 procedures) in the study cohort, with a mean follow-up period of 74 months (range, 60–97). Early failure was noted in 13 patients at 1 year. Only 28 patients (of the possible 50) were free from epiphora after 5 years postsurgery.

CONCLUSION: We found that the success rate of ELDCR has gradually declined over the years to 56% (confidence interval, 38–69) in patients who had at least 5 years of postoperative data. We do not advocate the use of laser in endonasal DCR for patients with epiphora.

EBM rating: C-4

OBJECTIVE: The aim of this study was to assess the efficacy of inhaled morphine for preemptive analgesia in patients who undergo septoplasty or septorhinoplasty.

STUDY PLAN AND METHODS: Eighty ASA I-II patients scheduled for septoplasty or septorhinoplasty were recruited and randomly divided into 2 groups that received different treatments 10 minutes prior to induction. The preemptive analgesia group (Group P, n = 40) received 65 μg kg⁻¹ morphine sulphate (a 3-mL volume) via an oral nebulizer, and the control group (Group C, n = 40) received 3 mL 0.9% sodium chloride (physiological saline) via the same type of nebulizer. Blood pressure, oxygen saturation, heart rate, time to first requirement for analgesia, and occurrence of nausea/vomiting were recorded.

RESULTS: There were no significant differences between Groups P and C with respect to age, body weight, sex distribution, or duration of surgery. There was also no significant difference between the group frequencies of postoperative nausea/vomiting. The time to first requirement for analgesia was significantly longer in Group P than Group C.

CONCLUSION: The results of this preliminary study suggest that a single dose of inhaled morphine administered preemptively prior to septoplasty or septorhinoplasty provides effective postoperative analgesia.

EBM rating: B-3b

OBJECTIVE: The pathogenesis of sinonasal polyposis (SNP) is not clear; it has been suggested that it is polygenic and multifactorial. The major histocompatibility complex is a useful tool to predict genetic susceptibility to diseases, especially to autoimmune diseases. Since such susceptibility is influenced by ethnicity, it is necessary to have a wide knowledge of the structure of the population to which the patient belongs. The purpose of the study was to determine the association of HLA-DRB1 alleles with sinonasal polyposis in the Mexican Mestizo population.

STUDY DESIGN: We studied the HLA-DR alleles in 34 adult Mexican Mestizo patients with SNP and compared them to those present in 99 healthy controls.

METHODS: Genomic DNA from mononuclear cells was obtained by using the “salting out” technique and high-resolution DNA typing of the HLA-DRB1 alleles was performed after PCR amplification.

RESULTS: We found a statistically significant increased frequency of the HLA-DRB1^∗03 allele (P = 0.03, odds ratio [OR] = 2.9, 95% confidence interval [CI]: 1.0–7.8) and of the HLA-DRB1^∗04 allele (P = 0.009, OR = 2.2, 95% CI: 1.2–4.2) in patients with SNP as compared to controls, and a statistically significant decreased frequency of the HLA-DRB1^∗08 allele (P = 0.01, OR = 0.2, 95% CI: 0.05–0.8).

CONCLUSION: The HLA-DR locus seems to be associated with the genetic susceptibility to develop SNP in Mexicans.

EBM rating: B-2b

OBJECTIVE: To investigate the independent effect of hyperostosis on outcome after endoscopic sinus surgery (ESS) in patients with chronic rhinosinusitis (CRS).

STUDY DESIGN AND SETTING: The medical records of 81 consecutive patients who had undergone primary ESS for CRS were reviewed retrospectively. Sinus CT scans were evaluated for the presence of hyperostosis to investigate the association with postoperative outcomes. The independent effect of hyperostosis on surgical outcome was analyzed, controlling for possible confounding factors with a multiple logistic regression model.

RESULTS: Sixty percent of the patients showed hyperostosis, and there was a statistically significant association between the hyperostosis and postoperative outcome (P = 0.035, χ² test), which was confirmed after adjustment for the possible confounding factors (P = 0.048, odds ratio [OR] = 3.19, logistic regression analysis).

CONCLUSIONS: Our study suggests that patients with CRS who have hyperostosis may have a poorer surgical outcome than those without hyperostosis.

EBM rating: B-2b

OBJECTIVE: To examine the effects of estrogen suppression on age-related changes in distortion product otoacoustic emissions (DPOAEs) and contralateral suppression (CS) of DPOAEs in CBA mice.

STUDY DESIGN AND SETTING: Young CBA mice received a slow-release shoulder implantation of either tamoxifen or placebo. Serial DPOAEs and CS of DPOAEs were obtained at 3-week intervals over a period of 9 weeks.

RESULTS: Although DPOAEs were maintained over the study interval, CS of DPOAEs decreased significantly with age in the experimental group. No such declines were observed in either the control animals or the untreated male mice.

CONCLUSIONS: Estrogen suppression negatively affects the MOC efferent feedback system.

SIGNIFICANCE: Our results support the hypothesis that estrogen plays an important role in the maintenance of auditory integrity. Additionally, our findings raise intriguing questions about auditory effects of hormonal shifts in humans resulting from menopause, hormone supplements such as oral contraceptives, and hormone replacement therapy as well as antiestrogens.

OBJECTIVE: A review of the treatment of pediatric acute mastoiditis requiring surgical intervention managed with and without PICC therapy postoperatively.

STUDY DESIGN AND SETTING: Retrospective study of 42 cases from 1989 to 2004 treated at a regional children's hospital.

RESULTS: Sixteen patients received postoperative PICC therapy and 26 received a course of oral antibiotics. The PICC group received on average 12.12 days of intravenous antibiotics compared to only 3.53 days for the non-PICC group (P < 0.001). No differences were observed between the two groups in treatment outcomes. One patient from each group required rehospitalization. One minor complication was experienced in a patient in the PICC group. There were no surgical complications. The total cost for outpatient PICC therapy increased treatment costs by approximately $1500 to $2500.

CONCLUSIONS: Oral antibiotic therapy is sufficient after surgical intervention for acute pediatric suppurative mastoiditis without intracranial complications and does not result in adverse treatment outcome.

SIGNIFICANCE: Use of PICC therapy after surgical intervention for mastoiditis should be limited.

EBM rating: B-3b

OBJECTIVES: Proteases have been shown to play a role in the pathogenesis of otitis media. Inhibition of these proteases can improve treatment outcomes in certain conditions. The goal of this study was to determine if intratympanic administration of a single dose of the protease inhibitor, recombinant alpha 1-antitrypsin (rAAT), can facilitate resolution of acute otitis media (AOM) in the chinchilla.

METHODS AND MEASURES: Pneumococcus was injected into both middle ears of 12 chinchillas. After 3 to 4 days, middle ears were cultured, systemic antibiotics were initiated, and rAAT or its vehicle was administered into the middle ears of all animals. Serial tympanic membrane (TM) scoring, tympanometry, and auditory-evoked brain stem response testing were performed. Animals were sacrificed at varying timepoints and temporal bones studied for objective measures of OM.

RESULTS: Although not reaching statistical significance, there was a trend to more rapid resolution of AOM in rAAT-treated ears. Tympanometry, auditory thresholds, and quantitative histologic parameters did not differ between rAAT and vehicle treated ears.

CONCLUSIONS: A single dose of intratympanic rAAT likely does not facilitate the resolution of antibiotic-treated pneumococcal AOM in the chinchilla model. Serial administration of this protease inhibitor may be necessary to see a significant treatment effect.

OBJECTIVE: To quantify the rate of basal cell division for keratinizing epithelium (KE) of the tympanic membrane (TM) and external ear canal (EAC) in spontaneous and induced gerbilline cholesteatomas.

STUDY DESIGN AND SETTING: Cholesteatomas (3 spontaneous and 5 by induction) were labeled with tritiated thymidine for autoradiography and a KE proliferation index (PI) was determined. The PI was defined as the average number of labeled cells/mm overall and per anatomic region.

RESULTS: For all regions combined, the PI was 27.3 in ears with cholesteatoma and 4.1 in normal ears (P < 0.0001). Additionally, there were significant regional differences in the PI in both normal ears and ears with cholesteatoma.

CONCLUSION: The KE of cholesteatomas in gerbils proliferates at approximately 7 times the rate measured in control ears.

SIGNIFICANCE: Hyperproliferation of keratinocytes is a causative factor in the development and progression of spontaneous and experimental cholesteatomas in gerbils.

OBJECTIVE: To present the clinical experience during an 18-year period of a series of 11 cases of pigmented nevus of the external auditory canal (EAC).

STUDY DESIGN AND SETTING: Retrospective medical review of 11 consecutive patients with lesions seen in 2 departments of otolaryngology in Taiwan.

RESULTS: 12 pigmented nevi, 2 to 12 mm (average, 6.4 mm) in diameter, were excised under otomicroscopy, and the EAC was packed with a temporary Penrose stent. One large lesion developed a postobstructive external auditory canal cholesteatoma (EACC). Histopathologic examination revealed 11 intradermal nevi and 1 compound nevus. There have been no recurrences or stenoses of EACs after 3 months to 17 years (average, 6 years) of follow-up.

CONCLUSION: If a pigmented nevus causes symptoms, especially when it is large enough to obstruct the lumen of the EAC and has the possibility of developing into an EACC, it should be excised.

EBM rating: C-4

INTRODUCTION: Reports in literature suggest that tumor volume, cartilage invasion, and cartilage sclerosis are independent prognostic factors for tumor control in radiotherapy as primary treatment of laryngeal carcinomas.

OBJECTIVE: Assessment of the interobserver variability and prognostic value in the measurement of tumor volume, cartilage invasion, and sclerosis.

MATERIALS AND METHODS: Retrospective analysis of 55 CT scans by three independent observers. Volume measurements and determination of cartilage invasion, cartilage sclerosis, and tumor localization were calculated. Correlation between the prognostic factors and radiotherapy was calculated for each observer.

RESULTS: Values for interobserver agreement varied substantially; cartilage invasion (κ value: −0.02 to 0.66), cartilage sclerosis (κ value: 0.13 to 0.57), tumor localization of subsites (κ value: 0.03 to 0.60), and tumor volume (correlation: 0.34 to 0.73). The found interobserver variation makes it impossible to establish accurate prognostic factors.

CONCLUSION: Determination of tumor volume, cartilage invasion, and cartilage sclerosis on the basis of CT imaging shows considerable interobserver variation; clinical significance appears to be limited.

EBM rating: B-3a

OBJECTIVE: Assess the amplification of CCND1, EMS1, PIK3CA, ERBB1, and ERBB2 oncogenes in ethmoid sinus adenocarcinomas.

STUDY DESIGN AND SETTING: Tissue samples from 13 primary ethmoid adenocarcinomas and 2 recurrences were studied at Hospital Central de Asturias, Oviedo, Spain, between July 1998 and February 2002. A semiquantitative evaluation of CCND1, EMS1, PIK3CA, ERBB1, and ERBB2 amplification was performed by multiplex polymerase chain reaction.

RESULTS: Three (23%) cases presented CCND1 amplification, one of them with a concurrent PIK3CA amplification. EMS1 was amplified in the 2 studied recurrences. ERBB1 was amplified in 1 case (8%), whereas none presented ERBB2 amplification. Oncogenic amplifications were only detected in advanced (stage III) tumors; however, no prognostic value could be shown for them.

CONCLUSIONS: CCND1, EMS1, PIK3CA, and ERBB1 amplifications are uncommon and appear to be late events in the development of ethmoid sinus adenocarcinoma.

SIGNIFICANCE: New information on the carcinogenesis of this infrequent sinonasal tumor is presented.

OBJECTIVE: The benefit of postoperative radiation for advanced primary parotid carcinoma has been reported previously, whereas studies to evaluate the usefulness of postoperative radiation for T1 and T2 parotid carcinomas have never been performed.

STUDY DESIGN AND SETTING: Retrospective analysis on 58 previously untreated patients with T1 and T2 parotid carcinomas. In 34 patients, postoperative radiation was included in the treatment protocol and in 24 patients, no postoperative radiation was applied.

RESULTS: A local recurrence was observed in 8 of 24 (33%) patients withoht and in 1 of 34 (3%) patients with postoperative radiation (P < 0.5). The 5-year actuarial and disease-free survival rate was 83% and 70% for patients without postoperative radiation and 93% and 92% for patients with postoperative radiation.

CONCLUSION AND SIGNIFICANCE: Local recurrence was less often observed in patients with postoperative radiation. Nevertheless, prospective randomized studies are needed to confirm the usefulness of postoperative radiation in early carcinomas.

EBM rating: B-3b

OBJECTIVE: To evaluate the response to steroid and radiation therapy in inflammatory pseudotumor (IPT) involving the skull base.

STUDY DESIGN AND SETTING: Eight patients with IPT of the skull base were evaluated. Six patients were diabetic. All patients underwent initial high-dose steroid therapy. Seven of 8 patients underwent subsequent low-dose steroid maintenance. Additional low-dose radiation therapy was performed in 6 patients. We reviewed the medical records and radiologic findings of the patients to evaluate their responses to the steroid and radiation therapy.

RESULTS: In all patients, the initial response to steroid therapy was fair. However, 7 patients showed symptom recurrence after cessation of steroid therapy. In 5 of 6 patients, low-dose radiation therapy resulted in recurrence. On follow-up MRI, none of the patients showed complete remission of the disease.

CONCLUSION: This study shows aggressive clinical behavior of IPT involving the skull base and its poor response to steroid therapy and low-dose radiation therapy. For improving control, more aggressive initial efforts including high-dose radiation therapy with or without concurrent steroid therapy might play a role.

EBM rating: C-4

OBJECTIVES: To determine if nasal septal papilloma is responsive to intralesional cidofovir injections.

METHODS: Five adult males, ages 37 to 57, presented with nasal septal or columellar papilloma. Three lesions had been previously excised with the laser and recurred. The lesions were injected with cidofovir on a monthly basis until complete resolution or any residual lesion was excised afterwards with the laser.

RESULTS: All patients achieved disease remission sustained over 10 to 24 months. Overall doses were much lower than those described for laryngeal papillomatosis and no toxic effects were observed.

CONCLUSIONS: Office-based intralesional injections of cidofovir may show benefit in the treatment of nasal septal papilloma.

EBM rating: C-4

OBJECTIVES: Utilizing an endaural approach, we described the surgical treatment of 29 cases of sinus tympani retraction cholesteatoma in 1996. The purpose of this paper is to provide long-term results in this group of patients.

STUDY DESIGN AND SETTING: A retrospective chart analysis of 29 previously reported patients was undertaken in an effort to identify hearing results and the risk of cholesteatoma recurrence following sinus tympani retraction surgery.

RESULTS: The follow-up period ranged from 9 to 16 years (mean of 13.2 years). Speech discrimination (SD) and conductive hearing (CH) decline occurred in 23 of 28 patients, but only on the average of 5.6% and 9 dB throughout the speech frequencies, respectively. Speech discrimination and conductive hearing improved in 5 of 28 patients; one patient was lost to follow-up. One patient developed a recurrent cholesteatoma requiring a canal wall—down mastoidectomy.

CONCLUSIONS: The endaural approach for sinus tympani cholesteatoma provided stable hearing in most of the patients in this series. One cholesteatoma recurrence required conversion to a canal wall—down mastoidectomy. This developed in a noncompliant patient, whose pars tensa retraction deepened as a result of failure to have his ventilation tube replaced. Semiannual office visits are recommended in patients who undergo this otologic approach for sinus tympani cholesteatoma.