Otolaryngology–Head and Neck Surgery

The pathogenesis of otitis media is multifactorial, but the role of evolution on its development has not been addressed. We posit that the high prevalence of middle-ear disease is most likely restricted to humans, in contrast to other wild species, because the associated hearing loss would have reduced the fitness of affected individuals as a result of predation. We present here the possible consequences of two human adaptations that may have resulted in ubiquitous otitis media: the interaction of bipedalism and increased brain size, and the loss of facial prognathism resulting from speech or cooking. As a consequence of our adaptation for bipedalism, the female pelvic outlet is constricted, which, in the context of a rapidly enlarging brain, results in humans being born 12 months too soon. Significantly, immature eustachian tube structure and function, in conjunction with an immature immune system, helps to explain the high incidence of otitis media in the first year of life. But the persistence of middle-ear disease beyond this stage is not explained by “immaturity.” The morphology of the palate changed with the adaptations that produced facial flattening, with concomitant effects on eustachian tube function. These changes resulted in relatively poor human physiologic tubal function in comparison to the nonhuman primate.

For a comparatively small island, Ireland has made a disproportionately large contribution to world literature in all its aspects. The literary lineage of those who pursue medicine and also write is long and well established. The Irish contribution to world literature in all its aspects is well documented. Less explored, however, is the prominent influence of Dublin-based otolaryngologists in the Irish literary movement at the turn of the last century. Here, we examine two such figures, Sir William Wilde and Oliver St. John Gogarty, and their pivotal roles both professionally and in establishing Ireland on the world's literary stage. During the early part of the 1800s, otology was perceived as a defunct subspecialty that could be adequately managed, without much expertise, in the primary care setting. It was through the efforts of William Wilde and others that otology gained clinical and scientific credence during the latter half of the 19th century.

OBJECTIVE: To systematically review outcomes of reinnervation techniques for the management of unilateral vocal fold paralysis (UVFP).

DATA SOURCES: Medline and Cochrane databases for English-language studies published between 1966 and 2009 on the surgical management of UVFP.

REVIEW METHODS: Studies were excluded if they reported on bilateral vocal fold paralysis, used nonhuman subjects, or did not assess clinical outcomes. Outcomes of interest were visual analysis, acoustic analysis, perceptual analysis, and electromyography.

RESULTS: Of 686 initial studies, 14 studies encompassing 329 patients were eligible for analysis. All studies had a case-series design. Of reported patients, 60.2 percent were men, with mean age of 51 years (range, 12-79 years). The most common reinnervation technique was ansa cervicalis-to-recurrent laryngeal nerve (RLN), which was most commonly performed after thyroidectomy (43.5%). Other techniques with reportable outcomes included primary RLN anastomosis, ansa-to-RLN combined with cricothyroid muscle-nerve-muscle pedicle, ansa-to-thyroarytenoid neural implantation, ansa-to-thyroarytenoid neuromuscular pedicle, and hypoglossal-to-RLN. Median postsurgical follow-up was 12 months, and mean time to first signs of reinnervation was 4.5 months (SD 2.9 months). Visual analysis of glottic gap showed the greatest mean improvement with ansa-to-RLN, from 2.25 (SD 0.886) to 0.75 (SD 0.886) mm (P < 0.01). Acoustic analysis showed greatest improvement with neural implantation, with a change in mean phonation time from seven (SD 1.22) to 16 (SD 5.52) seconds (P < 0.01). Perceptual analysis and electromyography demonstrated improvement in all studies.

CONCLUSION: Reinnervation is effective in the management of UVFP, although the specific method may be dictated by anatomical limitations. Prospective studies utilizing uniform and consistent outcome parameters are necessary.

OBJECTIVE: To investigate the histopathologic changes in intact laryngeal epithelium and mucosa exposed to endogenous gastric acid and pepsin in an experimental model of reflux.

STUDY DESIGN: Randomized trial.

SETTING: The study was conducted at the animal care facility of Haydarpasa Numune Education and Research Hospital.

SUBJECTS AND METHODS: Eighteen healthy 200- to 220-g, 20-week-old Sprague-Dawley rats were used. The animals were divided into three groups according to exposure time (1-, 4-, and 12-week exposures), and four rats were examined as controls who underwent sham operation. An experimental model of gastroesophageal reflux was induced. After exposure, the animals were euthanized, and their larynges were removed. The histopathologic changes in the larynx were observed under a light microscope.

RESULTS: The mean scores for inflammation in the control, one-, four-, and 12-week groups were 0.75 ± 0.50, 1.75 ± 0.50, 2.20 ± 0.45, and 1.94 ± 0.87, respectively. However, mean scores for vascular engorgement in the control, one-, and four-week groups were 0, and in the 12-week group was 2.0 ± 0.70. The mean scores for subepithelial edema in the control, one-, four-, and 12-week groups were 1.00 ± 0, 1.75 ± 0.95, 1.80 ± 0.45, and 2.20 ± 0.84, respectively. However, mean scores for keratinization for the control, one-, and four-week groups were 0, and for the 12-week group was 1.60 ± 0.55. When we compared inflammation, vascular engorgement, subepithelial edema, and keratinization mean scores between the control and study groups, there were statistically significant increases (P = 0.005, P = 0.001, P = 0.043, P = 0.002, respectively).

CONCLUSION: Our findings suggest that reflux induces significant histopathologic changes in larynx mucosa.

OBJECTIVE: Pepsin detection in throat sputum has been posited as a reliable biological marker of laryngopharyngeal reflux disease (LPRD). This study was designed to further correlate pepsin concentration with symptoms and signs of LPRD.

STUDY DESIGN: Cross-sectional study.

SETTING: Nanfang Hospital of Southern Medical University.

SUBJECTS AND METHODS: Fifty-six laryngitis patients were divided into a reflux laryngitis group and a chronic laryngitis group based on the reflux symptom index (RSI), reflux finding score (RFS), and proton pump inhibitor treatment for two weeks. Oral and hypopharyngeal secretions from the study patients and from 15 healthy subjects were collected. Thirty-six obstructive sleep apnea (OSA) patients were divided into a mild-moderate group and a severe group by the apnea-hypopnea index (AHI). Bedtime and first-morning oral secretions were collected. Enzyme-linked immunosorbent assay was used to measure the pepsin concentration.

RESULTS: In laryngitis patients, the total score of RSI and RFS (P < 0.05), and the symptoms, including clearing throat often, coughing, and sensing a lump in the throat (P < 0.006), were more severe in the pepsin-positive group. No significant differences were found between the oral and hypopharyngeal secretions. In OSA, pepsin levels in the first-morning oral secretions were correlated with AHI, mean SaO₂, and mini SaO₂ (P < 0.01). However, RSIs were not significantly correlated with these indicators.

CONCLUSION: Higher levels of pepsin in sputum were associated with higher RSI and RFS in cases of laryngitis. There was no relationship between pepsin levels and RSI in cases of OSA. There were no differences of pepsin concentration in sputum collection methods or in collection timing.

OBJECTIVE: The aim of this study was to determine the efficacy of esterified hyaluronic acid (HYAFF) on the vitality of auricular cartilage grafts used for tracheoplasty, with respect to macroscopic and microscopic parameters.

STUDY DESIGN: Prospective, controlled.

SETTING: Academic research laboratory.

SUBJECTS AND METHODS: The study included 14 New Zealand rabbits acquired specifically for the study. The rabbits were divided into two groups: the control group, in which free cartilage grafts were not exposed to any materials or additional procedures (n = 7), and the hyaluronic acid (HA) treatment group, in which auricular grafts and anastomosis lines were covered with HYAFF (n = 7). Free auricular cartilage grafts used for the reconstruction of experimentally created tracheal defects were anastomosed extraluminally. All the rabbits were sacrificed two months post surgery. Samples were collected and examined histopathologically. The sections were stained with hematoxylineosin, Masson's trichrome, and inducible nitric oxide synthase (iNOS) and examined under a light microscope.

RESULTS: Fibrosis and cartilage mass significantly differed between the control and HYAFF group (P < 0.05). Immunohistochemical examination showed that more chondrocytes stained with iNOS in the control group than in the HYAFF group, according to histologists' observations.

CONCLUSION: HYAFF catalyzed wound healing with less fibrous tissue formation, had chondroprotective and stimulatory effects on chondrocyte metabolism, and decreased nitric oxide production and apoptosis via improving the nourishment of free auricular cartilage grafts, subsequently preventing hypoxia and oxidative stress, particularly in the early postimplantation period.

OBJECTIVE: To describe a typical presentation of venous malformation within the masseter muscle, including physical findings and imaging, and to present the University of California, San Francisco's (UCSF) Vascular Anomalies and Birthmark Center's (VABC) experience with sclerotherapy for these lesions. STUDY DESIGN: Case series with chart review.

SETTING: Tertiary care medical center.

SUBJECTS AND METHODS: Retrospective chart review of all patients presenting to the UCSF VABC over a 10-year period.

RESULTS: Twelve patients with isolated venous malformations of the masseter muscle were identified. All of these patients presented with pain and facial asymmetry that was more pronounced with jaw-clenching. All underwent magnetic resonance imaging demonstrating a T2 hyperintense homogenous mass contained within the masseter muscle. Eleven of 12 had evidence on imaging of phleboliths within the mass; 10 patients underwent sclerotherapy. All treated patients had initial improvement in symptoms and/or appearance. Seven of 10 have had sustained improvement at a mean follow-up of 28 months.

CONCLUSION: Masseteric venous malformations have a typical clinical presentation and imaging characteristics that should allow clinicians to distinguish them from other abnormalities presenting in this area. Percutaneous sclerotherapy should be considered as a treatment option for these patients and can result in excellent outcomes.

OBJECTIVE: To evaluate fracture patterns of the nasal septum.

STUDY DESIGN: Cross-sectional cadaveric study.

SETTING: Synthes research laboratories, Philadelphia, PA.

SUBJECTS AND METHODS: Eighteen cadavers were divided into three groups. Group A was subjected to low-level force administered to the nasal tip. Group B underwent moderate-level force and group C high-level force. Cadavers subsequently underwent dissection of the nose and nasal septum.

RESULTS: Fracture patterns were apparent and related to the force applied. Fracture patterns were classified into three types depending on the location and extent. Group A was the most variable. Three cadavers were classified as type 1, two as type 2, and one as type 3. The average amount of force required to produce a fracture in this group was 100 N. Group B cadavers all developed type 3 fractures. Group C cadavers primarily developed type 3 fractures except for one that developed a type 1. Fractures were further classified in regard to the septum being displaced off the nasal spine.

CONCLUSION: Based on our observation, we conclude that fracture patterns of the nasal septum do exist and appear to be related to the amount of force sustained.

OBJECTIVE: To compare the cost of minimally invasive video-assisted thyroidectomy (MIVAT) with conventional thyroidectomy.

STUDY DESIGN: A cost-effectiveness study and chart review.

SETTING: Academic university hospital.

SUBJECTS AND METHODS: Pediatric and adult patients referred to the Department of Otolaryngology-Head and Neck Surgery for suspicious thyroid nodules, goiters, or known carcinomas. A tertiary care hospital's billing department was queried for all hemithyroidectomies and total thyroidectomies completed by the Department of Otolaryngology- Head and Neck Surgery between January 5, 2006, and November 1, 2007. The charges, including surgery, hospital, pathology, and anesthesia, for minimally invasive video-assisted thyroidectomy (MIVAT) and traditional or minimally invasive open thyroidectomies meeting MIVAT inclusion criteria were then reviewed retrospectively and compared statistically.

RESULTS: A total of 185 thyroidectomies were performed, 50.3 percent of which met criteria for MIVAT. Length of stay (days) was significantly shorter for patients undergoing MIVAT hemithyroidectomy (mean difference −0.8; 95% confidence interval [95% CI] −1.08 to −0.52) and not significantly different between groups for total thyroidectomy (mean difference 0.1; 95% CI −0.36 to 0.56). Mean anesthesia cost (U.S.$) was similar between groups for hemi- and total thyroidectomies. MIVAT mean pathology cost was significantly less than open thyroidectomy for hemithyroidectomy (mean difference −89.9; 95% CI −179.01 to −0.79) and approached significance for total thyroidectomy. There was no significant difference in hospital cost and total cost for hemithyroidectomy and total thyroidectomy.

CONCLUSION: In a group of matched cohorts, the cost of MIVAT appears to be equal to that of open thyroidectomy.

OBJECTIVE: To evaluate the relationship of functional magnetic resonance imaging (MRI) parameters, including choline/creatine ratio (Cho/Cr) and apparent diffusion coefficient (ADC) with protein expression of 10 common tumor and prognostic markers in head and neck squamous cell carcinoma.

STUDY DESIGN: Cross-sectional study.

SETTING: University hospital.

SUBJECTS AND METHODS: The Cho/Cr and ADC obtained from 74 patients with head and neck squamous cell carcinoma were correlated with the expression level of the 10 protein markers as determined by immunohistochemistry.

RESULTS: Cho/Cr showed significant positive correlations with cyclooxygenase 2 in primary tumors (r = 0.714), and epidermal growth factor receptor in metastatic cervical lymph nodes (r = 0.522). ADC showed significant (r = −0.591) negative correlation with human epidermal growth factor receptor 2 in metastatic cervical lymph nodes.

CONCLUSION: There are relationships between protein and functional MRI markers. Future research in this direction may improve our understanding of the cancer micro-environment.

OBJECTIVE: The University of Washington Quality of Life (UW-QOL) questionnaire is one of the most widely used instruments to evaluate the quality of life of head and neck cancer patients. The aim of this study was to perform a Spanish translation and validation of the UW-QOL questionnaire.

STUDY DESIGN: A cross-sectional study.

SETTING: Three tertiary-care hospitals and a laryngectomee rehabilitation center.

SUBJECTS AND METHODS: The translation and cultural adaptation of the questionnaire were performed following accepted international guidelines. The psychometric validation was performed on a consecutive series of patients treated for squamous cell carcinoma of the upper aerodigestive tract with no signs of relapse, recruited from May 2007 to December 2008. Eligible subjects were invited to complete the Spanish version of the UW-QOL questionnaire during routine clinical consultation, and complete it again within 15 days. Subjects also completed a validated Spanish version of the Goldberg Mental Health Survey and were evaluated by the use of the Karnofsky Index.

RESULTS: A Spanish version of the questionnaire was developed in iterative fashion. In the psychometric validation process, a total of 76 patients were analyzed. Reliability was excellent, including both internal consistency (Cronbach's alpha of 0.84) and test-retest reliability (intraclass correlation coefficient between 0.91 and 0.97 with a confidence interval of 95%). Construct validity was supported by statistically significant relationships between the Karnofsky Index, the Goldberg Mental Health Survey, and the translated UW-QOL questionnaire.

CONCLUSION: The Spanish version of the UW-QOL questionnaire appears to be culturally appropriate and psychometrically valid.

OBJECTIVE: To compare the therapeutic role of surgery followed by radiotherapy (OPRT) and concurrent chemoradiotherapy (CCRT) in patients with early T (T1/T2) and advanced N (N2/N3) stage tonsillar squamous cell carcinoma.

STUDY DESIGN: Historical cohort study.

SETTING: A tertiary hospital.

SUBJECTS AND METHODS: The medical records of 42 patients who met the eligible criteria (24 patients were treated by OPRT, 18 patients by CCRT) were reviewed.

RESULTS: Mean overall survival (OS) and disease-free survival (DFS) were 49.0 months and 43.0 months in OPRT group, respectively, and 39.6 months and 35.0 months in CCRT group, respectively (P = 0.18 for OS, P = 0.29 fr DFS between the two groups). There was also no significant difference in survival estimates between OPRT and CCRT group in terms of two-year OS (P = 0.18) and two-year DFS (P = 0.45). In the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30, the scores for global health status and symptom scales did not differ between the two groups. However, the OPRT group reported better functional scales and significantly higher scores for cognitive (P = 0.008) and social function (P = 0.03). Among single items, a significantly lower score for insomnia (P = 0.007) was noted in the OPRT group. In EORTC QLQ-H&N35 modules, there were no significantly different scales between the two groups except scores for nutritional supplements, in which the OPRT group presented lower symptom scores (P = 0.02).

CONCLUSION: OPRT could be still a viable option for managing selected cases of advanced oropharyngeal cancer because one can expect comparable therapeutic outcome as well as quality of life.

OBJECTIVE: To assess the extent of research publication misrepresentation among otolaryngology residency applicants and to determine applicant attributes associated with misrepresentation.

STUDY DESIGN: Prospective study.

SETTING: A single otolaryngology residency program.

SUBJECTS AND METHODS: Electronic Residency Application Service (ERAS) applications to the incoming 2010 class of an otolaryngology residency program were reviewed for peer-reviewed journal publications reported as “provisionally accepted,” “accepted,” or ”in print.“ Publications were verified by searching PubMed, Google Scholar, and electronic journals. Applicants with remaining unverified publications were e-mailed before announcing interviews. Erroneously reported or unverifiable publications were considered misrepresented.

RESULTS: There were 432 publications reported by 173 of 325 applicants (53.2%). Twenty-two publications (5.1%) were misrepresented by 17 applicants (9.8%). Contacting applicants verified 26 publications and identified 10 errors. Seven publications were inappropriately reported as provisionally accepted, three articles were not peer-reviewed, and applicants were erroneously listed as first author on two publications. Ten publications remained unverifiable. Multivariate logistic regression models showed that being an international medical graduate (P = 0.002) and male gender (P = 0.040) were predictors of misrepresentation after adjusting for potential confounders. Among international medical graduates alone, no attributes were associated with misrepresentation. All U.S. applicants with misrepresented publications were male (P = 0.033) and were from a medical school not ranked in the top 50 by U.S. News & World Report for research (P = 0.002) or primary care (P = 0.018).

CONCLUSION: Misrepresentation of research experience exists among otolaryngology residency applicants. ERAS should develop standardized definitions for publication statuses to help reduce inadvertent misrepresentation.

OBJECTIVE: The aim of this study was to characterize our clinical population of patients suffering with post-traumatic migraine-associated dizziness (PTMAD) and determine any associations with medical interventions and vestibular testing metrics to help predict response to treatments.

STUDY DESIGN: Retrospective chart review.

SETTING: Tertiary referral center.

SUBJECTS AND METHODS: The electronic medical records of 83 patients presenting to a tertiary referral center who were given a diagnosis of PTMAD and who had been treated were retrospectively reviewed. General characteristics, clinical treatment, pre- and post-vestibular therapy testing metrics, and success and failure outcomes were assessed. Patients were assigned into responder and nonresponder groups related to their headaches and evaluated at two specific time points. Medication failures and vestibular test metrics were compared to identify and predict clinical outcomes.

RESULTS: Seventy-two of 82 patients (88%) were analyzed at two time points. Use of verapamil, topiramate, gabapentin, amitryptiline, and valproic acid showed no comparative treatment benefit in responders compared to nonresponders (P = 0.294). Findings associated with successful treatments include response to initial medication (P = 0.001), final dynamic gait index (DGI) scores (P = 0.029), final vertical dynamic visual acuity test (DVAT) scores (up, 0.007; down, 0.006), and both final and change in computerized dynamic posturography-sensory organization test (CDP-SOT) scores (P = 0.001, P = 0.032). The antipsychotic quetiapine was specifically associated with outcome failures (P = 0.003).

CONCLUSION: Specific prophylactic antimigraine medications were not associated with improved outcomes in PTMAD patients. Initial clinical responses and vestibular test metrics may guide physicians to predict successful outcomes.

OBJECTIVE: Determine the correlation between the hearing threshold and the serum levels of vitamin B12 (cobalamin) and folic acid among elderly subjects (> 60 years) with age-related hearing loss (ARHL).

STUDY DESIGN: Cross-sectional.

SETTING: Community.

SUBJECTS AND METHODS: Subjects included elderly who were found apparently healthy following repeated examination by physicians. The pure tone average (PTA) for the speech and high frequencies, and the serum folate and cobalamin were determined and the correlation found.

RESULTS: The mean ± SD values of serum folate among the subjects with normal PTA in the speech frequencies (0-30 dB) was 412.3 nmol/L ± 17.6 nmol/L, while among those with hearing loss (HL), it was 279.1 nmol/L ± 17.2 nmol/L (P = 0.01). In the high frequencies, the mean ± SD values among the subjects with normal PTA was 426.3 nmol/L ± 17.6 nmol/L, while among those with HL, it was 279.14 nmol/L ± 171.2 nmol/L. The serum cobalamin among the subjects with normal PTA within the speech frequencies was 49.7 pmol/L ± 9.4 pmol/L, while among those with speech-frequency HL, it was 42.6 pmol/L ± 10.2 pmol/L. However, for high frequencies, the mean ± SD values among the subjects with normal PTA was 47.4 pmol/L ± 7.3 pmol/L, while among those with HL, it was 41.3 pmol/L ± 9.2 pmol/L. Spearman's correlation revealed that low folate (correlation coefficient = −0.27, P = 0.01) and cyanocobalamin (correlation coefficient = −0.35, P = 0.02) were significantly associated with increasing hearing threshold in the high frequencies. After adjusting for age, serum folate (correlation coefficient = −0.01, P = 0.01) was significant, while vitamin B12 (correlation coefficient = −0.01, P = 0.74) was not.

CONCLUSION: Serum folate was significantly lower among elderly with ARHL. Trials on nutritional supplementation may substantiate the role of serum folate in ARHL.

OBJECTIVE: The aim of this study was to evaluate the efficacy of pharyngeal packing in reducing postoperative nausea and vomiting (PONV) after nasal surgery by taking into consideration the surgery types.

STUDY DESIGN: A prospective, randomized, controlled trial.

SETTING: A tertiary referral center.

SUBJECTS AND METHODS: After the study was approved by the local ethics committee, this study was conducted in the Otorhinolaryngology clinic with the collaboration of the Anesthesiology clinic. The development of PONV within 24 hours after surgery was evaluated in patients who were applied a pharyngeal pack (Group 1) or not (Group 2) during nasal surgery.

RESULTS: There were 104 adult patients for routine nasal surgery included in the current study, yielding 100 (group 1, n = 50; group 2, n = 50) evaluable subjects. No significant difference was found in the incidence of PONV between the two groups at two (P = 0.41), four (P = 0.54), eight (P = 0.51), and 24 hours. According to surgery type, the incidence of PONV after two hours was 71 percent in septorhinoplasty, 68 percent in endoscopic sinus surgery, and 50 percent in septoplasty; after four hours it was 59 percent in septorhinoplasty, 53 percent in endoscopic sinus surgery, and 37 percent in septoplasty; and after eight hours it was 35 percent in septorhinoplasty, 39 percent in endoscopic sinus surgery, and 21 percent in septoplasty. PONV was not seen at 24 hours. Compared to the septoplasty group for which pharyngeal packing was used, significantly lower rates of PONV at four and eight hours were found in the septoplasty group in which pharyngeal packing was not used (P = 0.02).

CONCLUSION: Pharyngeal packing in nasal surgery has no impact on PONV.

OBJECTIVE: It is not known how many olfactory receptor neurons should be intact to maintain olfaction in mouse models treated with 3-methylindole. The aim of this study is to investigate the relationship between a simple olfactory test outcome and the olfactory neuronal population.

STUDY DESIGN: Mouse model.

SETTING: Animal laboratory of the Seoul National University Bundang Hospital.

SUBJECTS AND METHODS: Olfactory dysfunction was induced by intraperitoneal injection of 3-methylindole in 38 six-week-old female C57BL6 mice. Olfactory function was evaluated by a food-finding test following 72-hour starvation. The olfactory neuronal population was quantified by olfactory marker protein (OMP) expression.

RESULTS: The average time for finding food was 8.1 seconds in control mice. It was 13.4, 84.4, 90.1, and 111.4 seconds for mice injected with 100, 200, 300, and 400 μg/g of 3-methylindole, respectively. Harvesting the whole olfactory neuroepithelium, densitometric analysis showed significant decrease of OMP in the 300- and 400-μg/g groups as compared with controls (18.8% and 17.5% of relative density, respectively). In the olfactory bulb, there was a significant decrease of OMP in the 200-, 300-, and 400-μg/g groups (44.5%, 37.0%, and 9.0% of relative density, respectively). The food-finding time had a significant reverse correlation with the relative density of OMP both in the olfactory bulb and in the olfactory neuroepithelium.

CONCLUSION: Our study showed that olfactory impairment was correlated with olfactory neuronal population in mice treated with 3-methylindole. The food-finding test would be a useful tool that could be easily performed without special training in the 3-methylindole-treated C57BL6 anosmic mouse model.