Otolaryngology - Head and Neck Surgery

Shortfalls of the American Academy of Otolaryngology–Head and Neck Surgery's Clinical practice guideline: Hoarseness (Dysphonia)

Michael M. Johns, Robert T. Sataloff, Albert L. Merati, Clark A. Rosen — 2010-08-01

Abstract: The Clinical Practice Guideline (CPG) on hoarseness (dysphonia) has several shortcomings that undermine its initial intent to improve the care of patients with dysphonia. The purpose of this document is to identify and comment on those shortcomings. The guideline authors made curious and unsupported policy recommendations in some areas, such as the recommendation for performance of laryngoscopy for hoarseness. For example, the guideline provides a three-month allowance for patients with voice change prior to examination of the larynx, which is a marked change from prior American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) documents suggesting laryngoscopy after two to four weeks of dysphonia and poses a health risk to patients with dysphonia without an established diagnosis. We believe the use of laryngoscopy for the evaluation is dysphonia is primal, plays a vital role in the care of our patients, and should be strongly advocated by the CPG. A significant challenge of the CPG is rooted in its basis on a symptom as opposed to a diagnosis. The decision to confuse the difference between a symptom (hoarseness) and a diagnosis leads to several misleading statements and recommendations. Finally, problems with insufficient peer review and ineffective processes in the guideline's development are discussed.

Response to Commentary on Clinical practice guideline: Hoarseness (Dysphonia)

Seth Schwartz, Gavin Setzen — 2010-08-01

Abstract: The commentary published in this edition of the journal addresses several important issues concerning the clinical practice guideline for hoarseness, which has engendered some controversy since its publication. This response addresses those issues.

Measuring disease-specific health-related quality of life to evaluate treatment outcomes in tinnitus patients: A systematic review

2010-08-01

Abstract: Objective: To identify all disease-specific health-related quality-of-life (HR-QoL) instruments used to assess tinnitus in clinical trials and detail their psychometric properties.Data Sources: A literature search was performed in the bibliographical databases of PubMed and Embase to identify all articles using specific HR-QoL instruments in tinnitus trials.Review Methods: The HR-QoL instruments used in these articles were investigated in more detail, focusing on characteristics and psychometric values by two independent reviewers.Results: Seventeen studies were identified by the systematic search. The most used HR-QoL questionnaire was the Tinnitus Questionnaire, followed by the Tinnitus Handicap Inventory, the Tinnitus Reaction Questionnaire, and the Tinnitus Handicap Questionnaire. Internal consistency (Cronbach's α > 0.9) and reproducibility (> 0.8) were high for all questionnaires, and there was heterogeneity in responses between patients, endorsing the use of these questionnaires for discriminative purposes. However, the responsiveness, i.e., the usefulness of these questionnaires in evaluating treatment effects, is not known yet.Conclusion: The HR-QoL instruments used in tinnitus trials appear not to be validated to measure effectiveness of interventions. Using tests or instruments that are valid and reliable is a crucial component of research quality, and both should therefore be studied before final conclusions can be drawn from the questionnaires in upcoming clinical trials.

Pseudarthroses of the cornu of the thyroid cartilage

Steffen Knopke, Ingo Todt, Arneborg Ernst, Rainer O. Seidl — 2010-08-01

Abstract: Objective: Injuries to the cartilaginous larynx are rare disorders that usually undergo good spontaneous healing and rarely require surgery.Study Design: Case series with chart review from patients with pseudarthrosis of the cornu of the thyroid cartilage.Setting: ENT department of a level I trauma center.Subjects and Methods: We examined the medical records of seven patients treated for impaired healing of the cornu of the thyroid cartilage at a level I trauma center between 1997 and 2009.Results: Seven patients were treated as a result of impaired healing of injuries to the cornu of the thyroid cartilage caused by trivial trauma (e.g., car accidents). The principal symptom was odynophagia. Computed tomography was used to confirm the diagnosis. Treatment involved resecting the cornu of the thyroid cartilage. Histology showed a hypertrophic pseudarthrosis at the base of the cornu. All patients were free of symptoms 10 days after resection.Conclusion: Pseudarthrosis of the cornu of the thyroid cartilage is a previously undescribed condition. Pseudarthrosis of the laryngeal skeleton should be excluded in patients with odynophagia.

Correlating voice handicap index and quantitative videostroboscopy following injection laryngoplasty for unilateral vocal paralysis

2010-08-01

Abstract: Objective: 1) Determine the correlation between voice handicap index and quantitative videostroboscopy for patients undergoing injection laryngoplasty for unilateral vocal paralysis; 2) assess which videostroboscopy measurements correlate best with voice handicap index in patients demonstrating progressive improvement beyond six months following injection laryngoplasty.Study Design: Case series with chart review.Setting: Patients undergoing outpatient injection laryngoplasty with hyaluronic acid between 2005 and 2007.Subjects and Methods: Twenty-eight patients were assessed preoperatively and postoperatively using voice handicap index and videostroboscopy. Various videostroboscopy measurements were quantified: glottic open area (ratio of open to total glottic area during closed phase of phonation), glottic closed phase (frame ratio of closed phase to total glottic cycle), supraglottic compression (percent encroachment of supraglottis onto best-fit ellipse around glottis), wave amplitude (difference in glottic open area between open and closed phases), and wave duration (number of frames per glottic cycle). Correlation coefficients were calculated using Spearman's r.Results: One hundred seventeen separate recordings were analyzed. Correlation coefficients between voice handicap index (normalized to preoperative values) and glottic closed phase showed moderate-strong correlation (r = −0.733, P < 0.001), while glottic open area and wave duration showed weak-moderate correlation (r = 0.465, P < 0.001 and r = −0.404, P < 0.001 respectively). Other parameters showed poor correlation. A subset of 25 recordings from eight patients with progressive voice handicap index improvement beyond six months showed highest correlation with supraglottic compression (r = 0.504, P < 0.05).Conclusion: Voice handicap index correlates best with glottic closed phase, suggesting duration of vocal fold closure during the glottic cycle best represents patients' subjective outcome post-procedure. Progressive improvement in voice handicap index beyond six months may relate to gradual reduction in compensatory supraglottic compression, with moderate correlation.

Implantation of gelatin sponge combined with injection of autologous fat for sulcus vocalis

Fan Zhang, Alicia J. Sprecher, Chunsheng Wei, Jack J. Jiang — 2010-06-07

Abstract: Objective: To evaluate the effectiveness of gelatin sponge implantation combined with the injection of autologous fat for the treatment of sulcus vocalis.Study Design: Prospective cohort study.Setting: The research was conducted at the Eye, Ear, Nose, and Throat Hospital of Fudan University.Subjects and Methods: Twelve cases of sulcus vocalis were treated. The fibrotic tissue was dissected and a gelatin sponge was implanted into the affected vocal fold followed by injection of autologous fat. Videostroboscopy, maximum phonation time (MPT), and acoustic data were completed before and after surgery.Results: One month after surgery, the affected vocal fold displayed mild swelling, without evidence of a sulcus and with satisfactory glottal closure. Three months later, vocal vibration and mucosal wave were improved with the vocal fold displaying a more normal shape. Although voices did not achieve complete normalcy, the patients exhibited a better voice, with improved fundamental frequency, jitter, shimmer, normalized noise energy, and a significantly longer maximum phonation time (P < 0.05).Conclusion: Implantation of gelatin sponge combined with injection of autologous fat can be used to treat sulcus vocalis. The absorbable gelatin sponge can be used to fill the superficial lamina propria temporarily to prevent the readhesion of the detached mucosa at the bottom of the sulcus to the underlying tissue, while the injected fat adequately diminishes the insufficient glottal closure.

Comparison between videofluoroscopy and endoscopic evaluation of swallowing for the diagnosis of dysphagia in children

Andréa P. da Silva, José F. Lubianca Neto, Patrícia Paula Santoro — 2010-08-01

Abstract: Objective: To compare videofluoroscopy swallowing study (VFSS) with the fiberoptic endoscopic evaluation of swallowing (FEES) in children and to determine the accuracy of FEES in the diagnosis of specific swallowing disorders.Study Design: Cross-sectional study.Setting: Hospital da Criança Santo Antônio, affiliated with Santa Casa de Misericórdia Hospital Complex, Porto Alegre, RS, Brazil.Subjects and Methods: FEES findings were compared to those of VFSS in 30 children. Kappa coefficients for interobserver agreement were calculated. Thereafter, these coefficients were evaluated in terms of agreement between FEES and VFSS. In addition, the sensitivity, specificity, positive predictive value, and negative predictive value of FEES were calculated for four swallowing parameters (posterior spillover, pharyngeal residues, laryngeal penetration, and laryngotracheal aspiration).Results: Interobserver agreement rates greater than 70 percent were obtained for all FEES parameters analyzed, except for pharyngeal residues with puree consistency (agreement = 66.7%, κ = 0.296, P = 0.091). Laryngeal aspiration and penetration yielded the best level of agreement (100%, κ = 1) for the laryngeal aspiration of puree residues.Conclusion: The diagnostic agreement between FEES (both observers) and VFSS was low. Regarding the analyzed parameters, laryngeal penetration and aspiration yielded the highest interobserver agreement in terms of FEES, and also showed the highest specificity and positive predictive value when compared to VFSS.

Feeding status after pediatric laryngotracheal reconstruction

Steven M. Andreoli, Shaun A. Nguyen, David R. White — 2010-08-01

Abstract: Objective: To determine the influence of pediatric laryngotracheal reconstruction (LTR) on postoperative feeding status and longitudinal weight gain after surgery.Study Design: Case series with chart review.Setting: Tertiary care pediatric hospital.Subjects and Methods: We identified 30 consecutive pediatric patients undergoing LTR from November 2005 to October 2008. Demographics, stenosis grade, surgical procedure, decannulation status, preoperative feeding status and weight, discharge feeding status, and weights at follow-up were collected. Weights were plotted on standardized growth charts at surgery, during the early postoperative period (1-3 months), and during the late postoperative period (10-14 months). Growth percentiles were compared by the use of Wilcoxon signed rank test.Results: Twenty-eight patients (97%) maintained or advanced their feeding status after LTR. Twenty-one patients (72%) were oral feeders at surgery. All of these patients continued the same oral diet postoperatively. Five patients (17%) were dependent on gastrostomy before and after surgery. Three patients (10%) were fed via naso- or orogastric tubes at surgery. Two of these patients were discharged on an oral diet, and one required a gastrostomy tube. The median growth percentiles at the time of surgery, early postoperative, and late postoperative periods were nine, 18, and 32, respectively. Differences between percentiles at the time of surgery compared with early (P = 0.081) and late follow-up (P = 0.074) were not significant. In patients who were not dependent on gastrostomy, there was a significant increase in growth percentile at early follow-up (P = 0.026).Conclusion: The performance of LTR does not influence feeding status. An early increase in median growth percentile is observed in oral feeders, but overall long-term median growth percentiles remain stable after LTR.

Treatment of Frey's syndrome with botulinum toxin type B

2010-08-01

Abstract: Objective: Frey's syndrome is a frequent sequela of parotidectomy, causing facial sweating and flushing because of gustatory stimuli. Although botulinum toxin type A has become first-line therapy for Frey's syndrome, some patients become resistant. In this study, we investigated whether another serotype, botulinum toxin type B, might be an effective alternative.Study Design: Case series with planned data collection.Setting: Otolaryngology department in a university hospital.Subjects and Methods: Seven patients aged 30 to 68 years, with severe Frey's syndrome, underwent the Minor test and had 80 U of botulinum toxin type B per cm2 (mean total dose, 2354 U) injected intracutaneously in the mapped area of gustatory sweating. All patients were followed up for 12 months.Results: One month after treatment, six of the seven patients reported that gustatory sweating and flushing had resolved, and, in the remaining patient, these symptoms had decreased. The Minor test confirmed a significant improvement. The subjective benefits remained stable for six months in four patients and for nine months in the remaining three patients; 12 months after treatment, all patients still reported some improvement.Conclusion: Botulinum toxin type B afforded symptomatic relief in a small sample of patients with Frey's syndrome and might be considered a potential alternative to botulinum toxin type A.

Noise exposure and convertible cars

Philip Michael, Neil Opie, Michael Smith — 2010-08-01

Abstract: Objective: To investigate whether drivers of convertible cars are exposed to excessive noise levels.Study Design: Prospective.Setting: Data were collected along a main United Kingdom highway.Subjects and Methods: Seven cars were included within the study, encompassing a range in cost, power, and comfort. A calibrated, integrating noise meter was used to measure average noise levels (Leq dB) and peak levels (Lmax dB) encountered in the region of the driver's roadside ear with the convertible roof lowered. Readings were recorded at speeds of 50, 60, and 70 mph with the windows lowered and also at 70 mph with the windows raised.Results: Noise levels for all testing conditions had a range for Leq of 82 dB to 92 dB, whereas the maximum Lmax level noted for articulated lorries was 99 dB.Conclusion: A minimal trend toward increasing noise levels with speed was noted for the speeds tested. A statistically significant difference in noise reduction was found by raising the car windows. Although average levels were noted to be above the 85 dB criterion level legislated by some organizations, the length and frequency of most car journeys with the convertible roof lowered is unlikely to significantly increase the noise exposure risk of most individuals. Future studies may be able to evaluate whether a temporary threshold shift phenomenon may occur.

A simple method to predict pretracheal tissue thickness to prevent accidental decannulation in the obese

Christopher Szeto, Karen Kost, James A. Hanley, Ann Roy, Nicholas Christou — 2010-08-01

Abstract: Objective: Accidental decannulation is the most common and serious complication associated with tracheostomy in obese patients. We lack a simple way to choose appropriate-size tracheostomy tubes in this patient subset. Our purpose was to 1) establish the range of trachea-to-skin soft tissue thickness (TTSSTT) in obese patients and 2) determine which easily obtained anthropometric measurements are most predictive of TTSSTT.Study Design: Case series with planned data collection.Setting: Tertiary care center.Subjects and Methods: Forty consenting patients with body mass index ranging from 30 to 70 were evaluated. These patients, from a bariatric clinic, underwent ultrasound (US) of the neck in predetermined sitting, supine, and neck-extended positions (as for tracheostomy). US was performed by a qualified radiologist. Standard anthropometric measurements of weight, height, arm, hip, waist, and neck sizes were performed. Multiple regression analysis was used to determine which anthropometric measurements best correlated with TTSSTT.Results: The TTSSTT, as measured by US in the supine position, ranged from 0.65 to 3.53 cm. Although the anthropometric measurement most predictive of TTSSTT was waist circumference, a combination of the more practical arm and neck circumferences resulted in an equivalent correlation (r = 0.82). The average root mean squared error was 0.4 cm. From the fitted regression equation, a table predicting TTSSTT from neck and arm circumference was prepared.Conclusion: TTSSTT can be closely predicted using simple anthropometric tape measures. The predicted TTSSTT can be used to select appropriate tracheostomy tube size in obese patients. Use of this simple tool is expected to significantly reduce the incidence of accidental decannulation in obese patients.

Utility of elastography for differential diagnosis of benign and malignant thyroid nodules

Ryoji Kagoya, Hiroko Monobe, Hitoshi Tojima — 2010-08-01

Abstract: Objective: 1) To classify the appearance of thyroid nodules displayed on ultrasound elastography; 2) to explore the sensitivity and specificity of this examination for differentiating benign and malignant nodules, with histopathologic analysis as the reference standard; and 3) to evaluate its utility for avoiding unnecessary procedures.Study Design: Diagnostic test assessment.Setting: Community hospital.Subjects and Methods: Forty-seven thyroid nodules in 44 consecutive patients were examined with ultrasound elastography. The images we obtained were classified into four patterns. In addition, the mean strain index of the thyroid nodule and that of the sternocleidomastoid muscle were measured, and the nodule-to-muscle strain ratio was calculated. As the reference findings, the presence or absence of calcification, irregular margins, and hypoechogenicity of the thyroid nodules were examined using B-mode ultrasound.Results: Elastography patterns 3 and 4 were predictive of malignancy, with 73 percent sensitivity (95% confidence interval [CI]: 39%-94%) and 64 percent specificity (95% CI: 46%-79%). Additionally, all nodules without calcification and those that presented with patterns 1 or 2 were benign. A strain ratio greater than 1.5 was set as the predictor of thyroid malignancy. This criterion showed 90 percent sensitivity (95% CI: 59%-100%) and 50 percent specificity (95% CI: 33%-67%).Conclusion: Although elastography can assist in the differential diagnosis of thyroid nodules, its diagnostic performance is not ideal at present. Further improvements in the technique and the diagnostic criteria are necessary for this examination to provide a useful contribution to diagnosis.

Thyroid drains and postoperative drainage

Wade W. Dunlap, Richard L. Berg, Andrew C. Urquhart — 2010-08-01

Abstract: Objective: To evaluate postoperative drainage in patients undergoing thyroid lobectomy versus total thyroidectomy and to establish a correlation between intraoperative blood loss and postoperative drainage.Study Design: Case series with planned data collection.Setting: Tertiary medical center.Subjects and Methods: Consecutive patients (n = 100) undergoing thyroid surgery from October 2006 through November 2008 were examined. Data collected included age, gender, postoperative drainage, estimated intraoperative blood loss, type of surgery, length of hospital stay, pathology, and postoperative complications. Standard descriptive statistics were used to summarize characteristics of subjects, surgical procedures, and outcomes. Spearman rank correlation was used to evaluate association of drainage with blood loss and Kruskal-Wallis test to compare results by surgery type.Results: There were 100 surgeries performed: 52 lobectomies and 48 total thyroidectomies. Total postoperative drainage ranged from 0 to 230 mL, median was 32 mL. Estimated intraoperative blood loss ranged from 10 to 300 mL, median was 20 mL. We noted a statistically significant association of postoperative drainage with intraoperative blood loss (r = 0.39, P < 0.001), but substantial variability in drainage was observed even among patients with similar blood loss. Although there was significantly less drainage among thyroid lobectomies (P = 0.012), the distributions were quite similar apart from 10 patients (9 lobectomy) with exceptionally low drainage.Conclusion: There was a statistically significant association of postoperative drainage with intraoperative blood loss and significantly less postoperative drainage among patients undergoing thyroid lobectomies. However, the observed associations do not appear to be strong enough to accurately predict patients who will experience substantial drainage.

Anatomic relationship between the spinal accessory nerve and internal jugular vein in the upper neck

Matthew L. Hinsley, Gregory K. Hartig — 2010-08-01

Abstract: Objective: The goal of this study was to precisely detail the relationship between the spinal accessory nerve (SAN) and the internal jugular vein (IJV) in the upper neck, specifically at the level of the posterior belly of the digastric muscle.Study Design: Case series with planned data collection.Setting: University hospital.Subjects and Methods: This information was prospectively gathered intraoperatively in patients undergoing a neck dissection. The neck dissections were performed for the treatment or diagnosis of cancer, independent of the research goals. Eighty-six subjects underwent neck dissections, 56 unilateral and 30 bilateral. The position of the SAN was determined to be oriented lateral to the IJV, medial to the IJV, posterior to the IJV, or directly through the IJV at the level of the posterior belly of the digastric muscle.Results: Of 116 neck dissections, 112 (96%) were oriented lateral to the IJV at the level of the superior border of the posterior belly of the digastric muscle. In three necks (3%), the SAN was positioned medial to the IJV, and one (1%) traveled directly through the IJV.Conclusion: The SAN has an intimate anatomic relationship with the IJV as it travels through the neck. The SAN is nearly always oriented lateral to the IJV, and the IJV and SAN are likely at some increased risk of injury during neck dissection in cases where the nerve travels medial to or through the IJV.

Oral candidiasis in patients receiving radiation therapy for head and neck cancer

2010-04-29

Abstract: Objective: To investigate oral candidiasis in patients with head and neck cancer before, during, and after radiation therapy, and to explore its association with clinical oropharyngeal symptoms.Study Design: A cohort study.Setting: University hospital.Subjects and Methods: Subjects who received radiation therapy (RT) for the treatment of head and neck cancer were divided into two groups: an oral cavity irradiated group (OIRR group, n = 29) and an oral cavity nonirradiated group (ONIRR group, n = 17). A control group consisted of 18 healthy subjects. Patients were examined for signs of oral candidiasis before, during, immediately after, and one month after RT. Mouth and throat soreness (MTS), dysphagia, and xerostomia were evaluated by self-reported questionnaires, and associations between oral candidiasis and these symptoms were analyzed.Results: The incidence of oral candidiasis during RT was significantly higher in the OIRR group (55.2%) than in the ONIRR group (11.8%). Similarly, the occurrence of xerostomia during RT was significantly higher in the OIRR group (86.2%) than in the ONIRR group (52.9%). In the OIRR group, the mean MTS score at the 20th fraction of RT was significantly higher in patients with candidiasis (mean ± SD, 5.8 ± 2.1) than in those with RT-induced mucositis without candidiasis (3.7 ± 2.0). In the OIRR group, 65.2 percent of patients who experienced dysphagia developed oral candidiasis, compared with only 10 percent in the ONIRR group.Conclusion: Oral candidiasis concurrent with oral mucositis due to RT may increase oropharyngeal discomfort during RT.

Sleep apnea in patients with oral cavity and oropharyngeal cancer after surgery and chemoradiation therapy

Wei Qian, James Haight, Ian Poon, Dan Enepekides, Kevin M. Higgins — 2010-06-04

Abstract: Objective: To determine the point prevalence of sleep apnea in patients following oral and oropharyngeal cancer treatment at a major tertiary care referral center.Study Design: A retrospective cross-sectional survey.Subjects and Methods: Twenty-four patients with established oral or oropharyngeal cancer were submitted to overnight polysomnography. The surgical group consisted of 15 patients (11 male, 4 female; average age 64.2 yrs) having undergone primary surgery with radial forearm free flap reconstruction. The remaining patients (5 male, 4 female; average age 54.8 yrs) were treated nonsurgically with chemoradiation therapy. The fatigue-related daytime sleepiness was measured with the Epworth sleepiness scale (ESS).Results: Eleven patients in the surgical group and three in the nonsurgical group had a respiratory disturbance index (RDI) greater than 15 (odds ratio = 5.5, P = 0.092). Twelve patients in the surgical group and five in the nonsurgical group had significant oxygen desaturation during sleep hours (odds ratio = 3.3, P = 0.356). There was no observed significant correlation between RDI and oxygen desaturation (r2 = 0.28), nor was there any observed association between the RDI and ESS score (r2 = 0.18).Conclusion: This preliminary study has suggested that surgical patients in our cohort have a higher prevalence of moderate to severe obstructive sleep apnea in the postoperative period, when tested, compared with a nonsurgical group. A small sample size and incomplete matching on important cofactors of interest, such as primary site location, body mass index, and thyroid function, limit this study. A pretreatment and post-treatment analysis is obviously required to demonstrate any significant level of association between treatment type and sleep apnea status.

Preoperative planning for ear surgery using store-and-forward telemedicine

John Kokesh, A. Stewart Ferguson, Chris Patricoski — 2010-08-01

Abstract: Objective: To determine if store-and-forward telemedicine can be used to accurately plan ear surgery.Study Design: Case series with chart review.Setting: Tertiary care hospital.Subjects and Methods: Charts were reviewed for elective major ear surgeries resulting from telemedicine referrals during a 13-month period. The store-and-forward telemedicine referrals (electronic consultations) included clinical history, digital images, and audiology data. Consultants reviewed each telemedicine case and documented the recommended surgery and estimated operative time. These charts were matched with patients seen in person during a standard evaluation and had identical surgeries recommended. For the telemedicine evaluation and in-person evaluation groups, the recommended surgeries were compared with actual surgeries performed and the estimated time was compared with the actual operative time.Results: Forty-five ear surgeries were recommended by the telemedicine evaluation and were matched with 45 surgeries from the standard evaluation and included tympanoplasty with or without canalplasty, mastoidectomy, stapes surgery, and myringoplasty. Telemedicine and in-person evaluation accurately predicted the surgery 89 percent and 84 percent of the time, respectively. The average difference of “actual time” and “estimated time” for the actual surgical procedures performed was not statistically different between the two groups: 32 minutes for the telemedicine evaluation group and 35 minutes for the in-person evaluation group.Conclusion: Store-and-forward telemedicine is as effective as in-person evaluation for planning elective major ear surgery.

The influence of various registration procedures upon surgical accuracy during navigated controlled petrous bone surgery

2010-08-01

Abstract: Objective: The goal of this study was to investigate the dependence of surgical accuracy with a navigated controlled (NC) drill on selected registration procedures.Study design: The target registration error of the instrument and the maximum proximity to a typical high-risk structure (facial nerve) were determined within an artificial petrous bone.Setting: The studies took place in two groups: group 1, navigation bow with six integrated markers and attachment at the upper jaw, and group 2, landmark registration with four titanium microscrews. Measurement of the target registration error took place at three targets (3 titanium screws) with 20 repeated registration procedures via evaluation of the deviation between a target and the indicated position in the navigation data.Subjects and Methods: For measurement of the conversion accuracy of the planned cavity, 20 petrous bone models were milled by inexperienced test subjects. The evaluation of 20 cavities was conducted via a microscope by five jurors.Results: Registration accuracy showed a maximum deviation between the actual position achieved and the computed position in the navigation system of 1.73 mm in group 1 and 0.93 mm in group 2. In group 1, the nerve in five of 20 cases was damaged, and a maximum penetration into the nerve of 1.5 mm (0.25 mm SD; milled beyond) was measured. In group 2, the facial nerve was not damaged at all, and a maximum deviation of 0.5 mm (0.63 mm SD; stopped before) was measured.Conclusion: The results for registration and conversion accuracy are significantly better for the landmark-based registration than with the registration of the patient model with registration bow on the upper jaw.

Antioxidant enzymes, presbycusis, and ethnic variability

2010-08-01

Abstract: Objective: A proposed mechanism for presbycusis is a significant increase in oxidative stress in the cochlea. The enzymes glutathione S-transferase (GST) and N-acetyltransferase (NAT) are two classes of antioxidant enzymes active in the cochlea. In this work, we sought to investigate the association of different polymorphisms of GSTM1, GSTT1, and NAT2 and presbycusis and analyze whether ethnicity has an effect in the genotype-phenotype associations.Study Design: Case-control study of 134 DNA samples.Setting: University-based tertiary care center.Subjects and Methods: Clinical, audiometric, and DNA testing of 55 adults with presbycusis and 79 control patients with normal hearing.Results: The GSTM1 null genotype was present in 77 percent of white Hispanics and 51 percent of white non-Hispanics (Fisher's exact test, 2-tail, P = 0.0262). The GSTT1 null genotype was present in 34 percent of control patients and in 60 percent of white presbycusis subjects (P = 0.0067, odds ratio [OR] = 2.843, 95% confidence interval [95% CI] = 1.379-5.860). The GSTM1 null genotype was more frequent in presbycusis subjects, i.e., 48 percent of control patients and 69 percent of white subjects carried this deletion (P = 0.0198, OR = 2.43, 95% CI = 1.163-5.067). The NAT2*6A mutant genotype was more frequent among subjects with presbycusis (60%) than in control patients (34%; P = 0.0086, OR = 2.88, 95% CI = 1.355-6.141).Conclusion: We showed an increased risk of presbycusis among white subjects carrying the GSTM1 and the GSTT1 null genotype and the NAT*6A mutant allele. Subjects with the GSTT1 null genotypes are almost three times more likely to develop presbycusis than those with the wild type. The GSTM1 null genotype was more prevalent in white Hispanics than in white non-Hispanics, but the GSTT1 and NAT2 polymorphisms were equally represented in the two groups.

Endolymphatic pseudohydrops of the cochlear apex

Andres Makarem, Jose N. Fayad, Fred H. Linthicum — 2010-08-01

Abstract: Objective: To demonstrate that what appears to be endolymphatic hydrops of the apical scala media is normal anatomy.Study Design: Computer-generated three-dimensional reconstruction of the cochlear apex and tabulation of the number of cases with arched Reissner's membranes (pseudohydrops) versus flat membranes.Setting: Temporal bone laboratory consisting of 809 documented pairs of temporal bones.Subjects and Methods: Archival temporal bone sections from 107 bones (65 patients) were used to determine the percentage of arched (pseudohydrops) versus flat Reissner's membranes. Two bones, one of each membrane shape, were randomly selected for computer-generated three-dimensional reconstructions showing the cochlear apical anatomy.Results: An arched Reissner's membrane was found in 48.6 percent of bones. In the cochlear apex, Reissner's membrane appears to be distended, simulating hydrops, due to its transition from a conical structure to a triangle bounded by the basilar membrane with the organ of Corti, the stria vascularis, and Reissner's membrane. Membrane findings were similar in both ears in 73.8 percent of the bilateral cases studied. There were no significant relationships between membrane type and clinical characteristics.Conclusion: What appears to be endolymphatic hydrops of the cochlear apex is the transition area of the cochlear duct from a conical shape at the extreme apex to the triangular shape found in the rest of the cochlea. The appearance of distension is dependent upon the cochlear length and the level of the microscopic section.

Ocular vestibular-evoked myogenic potentials to bone-conducted vibration in superior vestibular neuritis show utricular function

Leonardo Manzari, AnnaRita Tedesco, Ann M. Burgess, Ian S. Curthoys — 2010-08-01

Abstract: Objective: To determine whether the first negative component (n10) of the ocular vestibular-evoked myogenic potential (oVEMP) to bone-conducted vibration (BCV) is due primarily to activation of the utricular macula.Study Design: The n10 was recorded in response to brief BCV at the midline of the forehead at the hairline (Fz). If the n10 is due primarily to utricular activation, then diseases that affect only the superior division of the vestibular nerve in which all utricular afferents course (i.e., superior vestibular neuritis [SVN]) should reduce or eliminate n10 beneath the contralesional eye, whereas the n10 beneath the ipsilesional eye and the sacculo-collic cervical vestibular-evoked myogenic potential (cVEMP) on the ipsilesional side should be preserved.Setting: A prospective study at a tertiary neurotological referral center.Subjects and Methods: The n10 component of the oVEMP was measured in 133 patients with unilateral SVN but with inferior vestibular nerve function preserved, as shown by ipsilesional cVEMPs.Results: The n10 to Fz BCV of 133 SVN patients was reduced beneath the contralesional eye relative to the ipsilesional eye so that there was an n10 asymmetry that was significantly greater than the n10 asymmetry in the 50 healthy subjects. In terms of predicting the affected side (shown by canal paresis), using an n10 asymmetry ratio (asymmetry ratio for the relative size of the n10 of the oVEMPs for the two eyes [AR]) of 46.5 percent, the n10 AR has a diagnostic accuracy of 94 percent.Conclusion: The n10 component of the oVEMP to BCV is probably mediated by the superior vestibular nerve and so mainly by the utricular receptors. The n10 AR is almost as good as canal paresis in identifying the affected side in patients.

Waiting for the evidence: VEMP testing and the ability to differentiate utricular versus saccular function

Miriam S. Welgampola, John P. Carey — 2010-08-01

Abstract: The advent of cervical vestibular evoked myogenic potentials (CVEMPs) marked a milestone in clinical vestibular testing because they provided a simple means of assessing human otolith function. The availability of air-conducted (AC) sound and bone-conducted vibration (BCV) to evoke CVEMPs and development of a new technique of recording ocular vestibular-evoked myogenic potentials (OVEMPs) have increased the complexity of this simple test, yet extended its diagnostic capabilities. Here we highlight the evidence-based assumptions that guide interpretation of AC sound– and BCV-evoked VEMPs and the gaps in VEMP research thus far.

Evaluation of optical rhinometry for nasal provocation testing in allergic and nonallergic subjects

Amber Luong, Esther J. Cheung, Martin J. Citardi, Pete S. Batra — 2010-08-01

Abstract: Objective: Optical rhinometry is a new method that quantifies light extinction in optical density to assess nasal blood volume as a measure of nasal patency. The purpose of this study is to evaluate optical rhinometry as an objective evaluation of nasal patency using nasal provocation testing with histamine and oxymetazoline.Study Design: Prospective pilot.Setting: Academic tertiary rhinologic practice.Subjects and Methods: Convenience sample of five adult subjects with allergic rhinitis and five adult normal subjects who underwent challenge with histamine and oxymetazoline. Patients underwent challenge with increasing concentrations of histamine to determine the amount of histamine needed to cause a positive optical rhinometry reading. The same subjects then underwent histamine challenge with this amount followed by oxymetazoline. Nasal patency was assessed subjectively after each challenge with the visual analog scale.Results: The median histamine amount needed to cause a positive response was statistically lower in allergic rhinitis as compared with nonallergic subjects at 150 μg and 300 μg, respectively (P = 0.04). When comparing the optical rhinometry with subjective nasal congestion after histamine and oxymetazoline challenges, there was a statistically significant correlation with r = 0.79 (P = 0.00003).Conclusion: This initial study demonstrates a correlation between subjective symptoms of nasal patency and objective measurements with the optical rhinometer. Less histamine amount necessary to incite nasal congestion in allergic rhinitis suggests that these patients may be primed to the effects of histamine. These preliminary data suggest that optical rhinometry is able to assess changes in nasal patency during challenges with histamine and oxymetazoline.

Comparison of optical rhinometry to acoustic rhinometry using nasal provocation testing with Dermatophagoides farinae

2010-06-07

Abstract: Objective: To evaluate optical rhinometry (ORM) as an objective evaluation of nasal patency using nasal provocation testing with Dermatophagoides farinae (Df) as compared with acoustic rhinometry.Study Design: Prospective pilot.Setting: Academic rhinologic practice.Subjects and Methods: Five adult healthy controls and five adult subjects with allergic rhinitis (AR) underwent nasal provocation testing with increasing concentrations of Df while undergoing ORM. The minimum concentration of Df causing a positive reading was recorded. Nasal cross-sectional area was measured before and after testing using acoustic rhinometry. Nasal patency was assessed subjectively after each challenge with the visual analogue scale.Results: The median amount of Df causing a positive response on ORM was less in AR patients as compared to healthy controls, at 5000 AU/mL and greater than 10,000 AU/mL, respectively. There was a statistically significant correlation between the change in optical density in ORM and subjective nasal congestion after increasing Df challenges (r = 0.63; P = 0.0007). Similarly, there was a statistically significant correlation between change in optical density by ORM and both minimum cross-sectional areas as measured by acoustic rhinometry (r = −0.60, P = 0.03; and r = −0.64, P = 0.02, respectively).Conclusion: This is the first study to show a correlation between optical rhinometry and acoustic rhinometry during nasal provocation testing with Df. In addition, the data support a correlation of optical rhinometry to subjective symptoms of nasal congestion. These preliminary data suggest that optical rhinometry is able to assess changes in nasal patency during challenges with Df.

Imaging of granulomatous and chronic invasive fungal sinusitis: Comparison with allergic fungal sinusitis

C. Ekambar Eshwara Reddy, Ashok K. Gupta, Paramjit Singh, Sher B.S. Mann — 2010-08-01

Abstract: Objective: To study the radiological features of chronic/granulomatous invasive fungal sinusitis (IFS) and identify differentiating characteristics, if any, from allergic fungal sinusitis (AFS).Study design: Prospective radiological study.Setting: Tertiary hospital in northern India.Subjects and methods: Subjects were nonacute fungal sinusitis patients with orbital involvement presenting between January 1999 and December 2003. Seventeen IFS and 12 AFS patients with mean age 27 years (range 7-59 years) underwent computed tomographic scan (CT) and magnetic resonance imaging (MRI) of paranasal sinuses with contrast. These were operated within one month of doing the scans and had histologically confirmed fungal sinusitis. Outcome measures were characteristics of opacity produced by the diseased tissue on CT and MRI, side and number of sinuses involved, expansion of sinuses, areas of bone erosion, and extra-sinus extension.Results: IFS showed homogenous opacity (isodense or hyperdense to muscle tissue) on CT and isointense and hypointense signal on T1- and T2-weighted MR images respectively. IFS showed involvement of one or two sinuses only, homogenous contrast enhancement, lack of expansion of sinuses, and bone erosion localized to the area of extra-sinus extension, and the extra-sinus component of the disease was more than the intra-sinus component. AFS showed heterogenous opacities with hyperattenuation areas on CT, isointense/hypointense to signal void on T1- and T2-weighted MR images. Expansion of sinuses, extensive bone erosion, lack of contrast enhancement, multiple sinus involvement, and major bulk of disease being intra-sinus rather than extra-sinus were other characteristics of AFS.Conclusion: Radiological features of IFS are described that are different from AFS.

Proinflammatory mediators in nasal lavage of subjects with occupational rhinitis

2010-08-01

Abstract: We sought to investigate the type and kinetics of late-phase nasal inflammatory response after nasal challenge with occupational allergens. Participants were 10 subjects experiencing work-related rhinitis symptoms who underwent specific inhalation challenge and tested positive for occupational rhinitis. During challenge, we monitored changes in inflammatory cells, eosinophil cationic protein, myeloperoxidase, and interleukin-8 in nasal lavage samples. The challenge with the active agent induced a significant increase in the percentage of eosinophils at 30 minutes as compared with prechallenge values (P = 0.04). A significant increase in eosinophil cationic protein levels after challenge with the control (P = 0.01) and active agent (P = 0.02) was observed in the late phase after challenge. No significant changes in nasal levels of neutrophils, myeloperoxidase, and interleukin-8 were observed on both control and active challenge days. Our results suggest a predominant nasal eosinophilic inflammatory response after occupational allergen challenge.

Application of diffusion tensor imaging after glossectomy

2010-08-01

Difficulty in visualizing the intricate architecture of the tongue has limited our understanding of its function during speech, mastication, and swallowing, as well as its adaptation to surgical procedures. Tractography visualization using diffusion tensor imaging (DTI), a semiautomatic technique, can detect and display the spatial distribution of the muscle fiber bundle orientations as three-dimensional (3D) trajectories in human and calf tongues. DTI is a magnetic resonance imaging (MRI) technique that measures the diffusivity of water in different directions and estimates fiber bundle orientation at each voxel, mathematically measuring the spatial distribution of diffusion tensors. It has been successfully applied to the study of neurologic conditions, including stroke, multiple sclerosis, brain tumors, and dementia. We have combined DTI with structural MRI as a means of observing residual tongue anatomy and yielding insight into the tongue's reconstruction after tumor resection in a glossectomy patient.

Early results with semisynthetic total ossicular replacement prosthesis

Giuseppe Malafronte — 2010-08-01

The objective of this article is to describe a new semisynthetic total ossicular prosthesis (ssTORP). The ssTORP is obtained by assembling a synthetic shaft with an autolog cartilage head. To make the shaft, we used an adjustable-length stapedotomy prosthesis made of platinum and polytetrafluoroethylene (PTFE) (7 mm in total length and 0.4 mm in diameter). The base of the hook is cut. In this way, a shaft made of platinum and PTFE, 4 mm in length and 0.4 mm in diameter, is obtained. It represents an artificial stapes superstructure. The shaft is supplied with a blunt platinum tip 1 mm in length and 0.2 mm in diameter. The blunt tip is completely inserted into the cartilage head of the prosthesis. The PTFE base of the shaft is positioned on the footplate. The head of the prosthesis can be made from one, two, or three blocks of tragal cartilage. This cartilage is ideal because it is flat and usually 1 mm thick. The 5-mm long ssTORP has a head made of one square block of tragal cartilage. The surgeon judges the size fitting on the basis of each individual case. The perichondrium is left on both sides of the cartilage block. In the middle of the block, just in the perichondrium, a small hole is made using an insulin needle. The blunt tip of the shaft is inserted into the perichondrium hole. By exerting a slight force on the shaft, the tip penetrates completely into the cartilage, fixing the shaft firmly into the cartilage block. The 6–mm-long ssTORP has a head made from two blocks of cartilage. A double cartilage block is obtained by taking a rectangle (2 × 5 mm) from the tragal cartilage. The perichondrium is left on both cartilage sides. The cartilage is cut in half, avoiding transection of the perichondrium on the opposite side. A small hole is made in the perichondrium in the middle of the block. Next, the blunt tip of the shaft is inserted into the cartilage block. The cartilage is then folded back on itself with the intact perichondrium layer doubled between the two cartilage blocks. This acts as a hinge, keeping the blocks from slipping. The obtained 6–mm-long ssTORP is positioned between the tympanic membrane and the footplate (A). The 7–mm-long ssTORP is obtained by assembling a triple cartilage block with a shaft (B). The average time to take cartilage and to prepare the ssTORP is approximately five minutes.

Lateral pharyngeal diverticulum

Seung-Won Lee, Jae-Yong Lee — 2010-08-01

A 43-year-old man presented with halitosis and the sensation of a foreign body in the right throat for 10 years. He complained that the symptoms worsened after meals and disappeared occasionally on rubbing his right neck with his fingers. He had no history of trauma or surgery on the neck. On flexible laryngeal fiberscopic examination, a pharyngeal pouch filled with food material was observed in the right anterolateral pharyngeal wall above the pyriform sinus (). Barium esophagography demonstrated a lateral pharyngeal diverticulum with pooling of contrast material (). The pharyngeal diverticulum was approximately 2 cm wide, with a narrow isthmus. The patient underwent endoscopic diverticulotomy, which removed the inferior wall of the diverticular opening. The patient's symptoms disappeared after the procedure, and he is well without discomfort. This case was approved for publication by the Institutional Review Board of the Soonchunhyang University College of Medicine.

Tularemia presenting as a cervical abscess

Marcella M. Alsan, Harrison W. Lin — 2010-08-01

A 40-year-old man presented with two months of progressive left neck swelling, night sweats, and fatigue. He worked as a hunting guide in New Mexico and reported multiple bites from insects, including deer flies, on the job. He had been treated with penicillin, cephalexin, and clindamycin, but his symptoms persisted. On presentation to our institution, his examination was notable for a temperature of 97.4°F, clear throat, and a 4 × 5-cm erythematous, mildly tender mass in the left neck with an area of fluctuance superiorly (). Fine needle aspiration revealed necrotizing acute inflammation without granulomas; cultures were negative, and smears were negative for acid-fast bacilli. Chest x-ray was clear, and a tuberculin skin test was negative. A contrast-enhanced computed tomography (CT) scan was obtained shortly after the mass spontaneously drained and revealed a 1.8 × 0.8 × 2.4-cm subcutaneous fluid collection at the level of the platysma, but no lymphadenopathy (, available online at www.otojournal.org). A serum titer for tularemia was sent and returned four days later, and was highly positive at 1:8192 (normal, < 1:128). Following a four-week course of oral ciprofloxacin 750 mg twice daily and doxycycline 100 mg twice daily, his symptoms resolved.

Sigmoid sinus thrombosis associated with a parapharyngeal deep lobe parotid gland tumor causing seizure

James K. Fortson, Michael Rosenthal, Jennifer S. Lin, Gillian Lawrence — 2010-08-01

Deep lobe tumors of the parotid gland comprise less than 10 percent of all parotid gland tumors, and less than one percent of parotid gland tumors fill the parapharyngeal space. We present an unusual case of a deep lobed parotid gland tumor that occupied the parapharyngeal and pterygomaxillary space with extension to the skull base, causing occlusion of the jugular vein with subsequent thrombosis of the sigmoid and transverse sinuses. The resultant intracranial venous hypertension caused symptoms of tonic-clonic seizures that, to the best of our knowledge, have not been previously reported.

A pharyngeal foreign body presenting as a painful neck mass

Natalie M.W. Leung, Hing Sang Chan, Alexander C. Vlantis, Michael C.F. Tong — 2010-08-01

One of the most common consultations requested by the accident and emergency department of an otorhinolaryngologist is for a foreign body ingestion. Fish bones are the most common foreign body ingested by adults, and most of them are found lodged in the oropharynx. Many of them can be identified and retrieved as an outpatient consultation. In symptomatic cases where the initial clinical findings are negative, other modalities of investigation, such as an esophagogastroduodenoscopy and imaging, should be considered. Patients with a history of foreign body ingestion should be carefully attended to prevent the development of serious complications. To highlight the potential dangers of this condition, we present a case of retained fish bone that presented as a painful subcutaneous neck mass.

Dysgenesis of the middle turbinate: A unique cause of nasal airway obstruction

Wesley M. Abadie, Jonathan L. Arnholt, Lee A. Miller — 2010-05-05

We present a unique case of nasal airway obstruction resulting from dysgenesis of the middle turbinate that has not been previously described. A 33-year-old woman presented to our clinic with a long history of right nasal airway obstruction refractory to medical management with nasal steroid sprays and antihistamines. She denied both epistaxis and rhinodynia, and had no history of nasal surgery. Additionally, she had never been nasally intubated for any other surgical procedure and had no history of nasal manipulation or trauma to the face. Nasopharyngoscopy demonstrated the absence of a normal middle turbinate (MT) and an obstructing mass in the posterior right nasal cavity that completely occluded the right choana (). A computed tomography (CT) scan of the paranasal sinuses revealed a pedunculated nasal mass occurring at the posterior attachment of the malformed right MT (). Clinical biopsy specimens were conclusive for benign respiratory mucosa, and the patient consented to operative removal of the mass. Intraoperatively, the mass was transected at the pedicle and easily delivered through the nasopharynx into the oral cavity for removal. The mass was sectioned and noted to have a firm bony rim, with a fluid-containing mucocele in the center. The patient had complete resolution of her symptoms postoperatively, and three months later she remained asymptomatic and without recurrence.

Effects of traditional Chinese acupuncture in post-viral olfactory dysfunction

Earl V. Wilkinson — 2010-08-01

I was pleased to see the original research article “Effects of traditional Chinese acupuncture in post-viral olfactory dysfunction” in the April issue of the journal. I applaud Dr. Vent for her efforts to find solutions for this frustrating problem. Six points were documented, but 10 insertion points were used. Point descriptions Di20, Ma36, and Ni3 are not clear and cannot be used to duplicate or verify this study.

Response to: Effects of traditional Chinese acupuncture in post-viral olfactory dysfunction, from Earl V. Wilkinson

Julia Vent, Djin-Wue Wang, Michael Damm — 2010-08-01

Thank you, Dr. Wilkinson, for your helpful comment. Indeed, we used the nomenclature applied by our Chinese colleague, and we may thus correct the points used to the internationally valid nomenclature:

2010-08-01

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2010-08-01

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Otolaryngology - Head and Neck Surgery

Shortfalls of the American Academy of Otolaryngology–Head and Neck Surgery's Clinical practice guideline: Hoarseness (Dysphonia)

Response to Commentary on Clinical practice guideline: Hoarseness (Dysphonia)

Measuring disease-specific health-related quality of life to evaluate treatment outcomes in tinnitus patients: A systematic review

Pseudarthroses of the cornu of the thyroid cartilage

Correlating voice handicap index and quantitative videostroboscopy following injection laryngoplasty for unilateral vocal paralysis

Implantation of gelatin sponge combined with injection of autologous fat for sulcus vocalis

Comparison between videofluoroscopy and endoscopic evaluation of swallowing for the diagnosis of dysphagia in children

Feeding status after pediatric laryngotracheal reconstruction

Treatment of Frey's syndrome with botulinum toxin type B

Noise exposure and convertible cars

A simple method to predict pretracheal tissue thickness to prevent accidental decannulation in the obese

Utility of elastography for differential diagnosis of benign and malignant thyroid nodules

Thyroid drains and postoperative drainage

Anatomic relationship between the spinal accessory nerve and internal jugular vein in the upper neck

Oral candidiasis in patients receiving radiation therapy for head and neck cancer

Sleep apnea in patients with oral cavity and oropharyngeal cancer after surgery and chemoradiation therapy

Preoperative planning for ear surgery using store-and-forward telemedicine

The influence of various registration procedures upon surgical accuracy during navigated controlled petrous bone surgery

Antioxidant enzymes, presbycusis, and ethnic variability

Endolymphatic pseudohydrops of the cochlear apex

Ocular vestibular-evoked myogenic potentials to bone-conducted vibration in superior vestibular neuritis show utricular function

Waiting for the evidence: VEMP testing and the ability to differentiate utricular versus saccular function

Evaluation of optical rhinometry for nasal provocation testing in allergic and nonallergic subjects

Comparison of optical rhinometry to acoustic rhinometry using nasal provocation testing with Dermatophagoides farinae

Imaging of granulomatous and chronic invasive fungal sinusitis: Comparison with allergic fungal sinusitis

Proinflammatory mediators in nasal lavage of subjects with occupational rhinitis

Application of diffusion tensor imaging after glossectomy

Early results with semisynthetic total ossicular replacement prosthesis

Lateral pharyngeal diverticulum

Tularemia presenting as a cervical abscess

Sigmoid sinus thrombosis associated with a parapharyngeal deep lobe parotid gland tumor causing seizure

A pharyngeal foreign body presenting as a painful neck mass

Dysgenesis of the middle turbinate: A unique cause of nasal airway obstruction

Effects of traditional Chinese acupuncture in post-viral olfactory dysfunction

Response to: Effects of traditional Chinese acupuncture in post-viral olfactory dysfunction, from Earl V. Wilkinson

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