Updates in management of acute invasive fungal rhinosinusitis

Purpose of review Acute invasive fungal rhinosinusitis (AIFRS) is a rare and often fatal disease, that remains incompletely understood. Case series and literature reviews constitute most of the literature on AIFRS, and act as the standards by which we treat these extremely complex patients. This review discusses management of AIFRS, with focuses on optimal diagnostic and therapeutic strategies. Recent findings Mortality rates remain high, around 50% overall, though some recent studies have shown higher survival rates with early diagnosis and complete surgical resection. Some recent publications on AIFRS have focused on the utility of frozen section analysis both to diagnose and potentially guide the completeness of endoscopic surgical debridement. It was also recently shown that complete endoscopic resection of disease leads to higher survival than when disease was incompletely resected. Additionally, a new antifungal agent was recently approved by the FDA, which has a more favorable pharmacologic and side effect profile, though more studies are necessary to determine its utility. Summary Early diagnosis requires identification of sinusitis symptoms in immunocompromised patients, followed by intranasal biopsy and frozen section analysis. Early surgical debridement and antifungal therapy then remain the cornerstones of AIFRS management. Video abstract See Video, Supplemental Digital Content 1, http://bit.ly/2BKeblx. Correspondence to John R. Craig, MD, Department of Otolaryngology–Head and Neck Surgery, Henry Ford Health System, 2799 W. Grand Blvd, Detroit, MI 48202, USA. Tel: +1 313 971 9320; fax: +1 313 916 7263; e-mail: JCraig1@hfhs.org. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (http://bit.ly/2QPN9Uo). Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

http://bit.ly/2BGEFVj

Adenoma pleomorfo de epiglotis

Publication date: Available online 24 December 2018

Source: Acta Otorrinolaringológica Española

Author(s): Fabián Alzate Amaya, Liliana Invencio da Costa, Mercedes Álvarez-Buylla Blanco

http://bit.ly/2AfA2kV

Spontaneous pharyngeal perforation secondary to cervical osteophytosis

Publication date: Available online 24 December 2018

Source: Acta Otorrinolaringológica Española

Author(s): Miguel Mayo-Yáñez, Jaime Villares-Soriano

http://bit.ly/2SiFD11

Simultaneous Intra-operative Sclerotherapy and Surgical Resection of Cervicofacial Venous Malformations

Publication date: Available online 25 December 2018

Source: International Journal of Pediatric Otorhinolaryngology

Author(s): Carol J. MacArthur, Gary Nesbit

Abstract

Objectives

To review simultaneous intra-operative sclerotherapy (IOS) with immediate surgical resection for the treatment of cervicofacial venous malformations (VMs) at a single institution. While pre-operative sclerotherapy (POS) has been reported in the literature, simultaneous intra-operative sclerotherapy and surgery in the operating room has not.

Methods

The database from the Hemangioma and Vascular Birthmarks Clinic was reviewed. All patients in both groups had biopsy-proven VMs.

Results

IOS was used in 11 surgical patients with average age 17 years. Sclerotherapy was performed with sodium tetradecyl sulfate 3%, absolute alcohol or bleomycin. Immediately after IOS, and under the same anesthetic, all patients had either complete resection or debulking of the VMs. Eight patients had complete resolution of their VM and 3 had improvement. Average duration of the combined procedures done under a single anesthetic was 121 minutes.

The POS approach was used for 6 surgical patients with average age 7 years. Sclerotherapy agents used were absolute alcohol or sodium tetradecyl sulfate 3%. All patients underwent complete resection of the VM 24-72 hours after sclerotherapy under a separate surgical session. Five patients experienced complete resolution of their VM and one has had further sclerotherapy for recurrent disease. Interventional Radiology suite sclerotherapy times were on average 70 minutes. Surgical times were on average 142 minutes. Total combined anesthesia times for the two procedures added together were 212 min. Treatment time was significantly shorter in the IOS group (p=0.0015).

Conclusions

Simultaneous IOS at the time of surgical resection has been successful in our hands. IOS has the advantage of a single procedure and decreased cost to the patient. In the era of reducing pediatric exposure to anesthesia, this approach is especially attractive in the pediatric population. As well, at approximately $100/minute cost to the patient to be in either the Interventional Radiology Suite or in the operating room, the reduced length of the procedures seen in the IOS approach results in lower overall cost to the patient.

http://bit.ly/2QRtNy0

Human salivary proteins and their peptidomimetics: values of function, early diagnosis, and therapeutic potential in combating dental caries

Publication date: Available online 24 December 2018

Source: Archives of Oral Biology

Author(s): Kun Wang, Xuedong Zhou, Wei Li, Linglin Zhang

Abstract

Saliva contains a large number of proteins that play various crucial roles to maintain the oral health and tooth integrity. This oral fluid is proposed to be one of the most important host factors, serving as a special medium for monitoring aspects of microorganisms, diet and host susceptibility involved in the caries process. Extensive salivary proteomic and peptidomic studies have resulted in considerable advances in the field of biomarkers discovery for dental caries. These salivary biomarkers may be exploited for the prediction, diagnosis, prognosis and treatment of dental caries, many of which could also provide the potential templates for bioactive peptides used for the biomimetic management of dental caries, rather than repairing caries lesions with artificial materials. A comprehensive understanding of the biological function of salivary proteins as well as their derived biomimetic peptides with promising potential against dental caries has been long awaited. This review overviewed a collection of current literature and addressed the majority of different functions of salivary proteins and peptides with their potential as functional biomarkers for caries risk assessment and clinical prospects for the anti-caries application.

http://bit.ly/2SeKcJE

Herbal Medicine in the Management of Tinnitus

AbstractTinnitus, which is commonly defined as "ringing in the ears" by the patients, is a perception of an auditory sensation without any accompanying external stimulation. It accounts for a notable part of visits in otolaryngology clinics and has been estimated to involve about 5–15% of adult population making serious problems in 3–5% of patients. Tinnitus causes a lot of problems for patients, their family, and guardians and significantly decreases quality of life of patients. Many treatment methods have been proposed and presented for Tinnitus since the first year of diagnosis. These methods range from conservative management and chemical medications to surgical methods. As the other diseases and conditions, herbal medicine has been trying to treat Tinnitus and a variety of medications have been proposed. In this chapter, we aimed to have a comprehensive review on the current herbal medications of Tinnitus from all over the world.
Keywordstinnitus herbal medicine treatment epidemiology Ginkgo bilobaChapter and author infoShow +1. Tinnitus: definition, etiology, and epidemiologyTinnitus, which is commonly defined as "ringing in the ears" by the patients, is a perception of an auditory sensation without any accompanying external stimulation [1, 2]. It accounts for a notable part of visit in otolaryngology clinics and has been estimated to involve about 5–15% of adult population making serious problems in 3–5% of patients [1, 2, 3, 4, 5].
Tinnitus causes a lot of problems for patients, their family, and guardians and significantly decreases quality of life of patients. Most of the patients have complaints with sleep disorders, depression, decreased self-confidence, and altered social communications as well as difficulties in quotidian activities [2].
Tinnitus is generally categorized into two types: subjective and objective. A majority of patients suffer from a subjective tinnitus, which means perception of an auditory sensation without any evident stimulus. In some patients, a kind of organic measurable stimulus such as glomus tumor, by making turbulence of blood flow, is the cause for tinnitus, which is called objective tinnitus [1, 2]. This type of tinnitus can be found by examiner using an ear-canal microphone or stethoscope [6].
A variety of risk factors have been reported for subjective tinnitus so far; hearing loss, depression, head trauma, and medication-related ototoxicity [7, 8, 9]. Some other conditions may have a role in predisposing patients to tinnitus such as acoustic trauma and presbycusis, and it may be associated with temporomandibular joint (TMJ) or cervical spine dysfunctions (somatic tinnitus) as well as depression and anxiety [10, 11, 12, 13, 14].
2. Current treatmentsCurrently, United States Food and Drug Administration (FDA) or the European Medicine Agency has not approved any drug for the treatment of tinnitus [15]. The complex mechanism and innate diversity in etiology of tinnitus have made its treatment a dilemma for physicians and specially otolaryngologists. Despite considerable number of researches, none of the so far presented medications and treatments has resulted in a sustained reduction in perception of tinnitus [16]. No appropriately controlled clinical trials have been successful to prove efficacy of a single drug. Thus, pharmacological treatment of tinnitus seems to be ineffective [17, 18]. Antidepressants are more frequently prescribed for tinnitus and seem to be effective but with a notable number of side effects. Anticonvulsants, benzodiazepines, lidocaine, and antispasmodics are also among commonly prescribed medications [19]. Voice therapy, using hearing aids, adjuvant therapies as well as environmental sound enrichment are the most common nonmedical approaches to Tinnitus [20].
Regarding the abovementioned issues, there are varieties of complementary and alternative medicine (CAM) treatments, which have been experimented in clinical stage for tinnitus. Herbal medicine or acupuncture, as the most popular types of CAMs therapy among people, have been shown to be effective in management of tinnitus when prescribed solely or in combination [21, 22]. Most of the CAM studies have a small sample size and few methodological pitfalls make it difficult to decide firmly about these treatments.
Some of medicinal herbs and their derivates have been evaluated in various phases of studies: in vitro, in vivo, and even in small to large scale clinical trials [23, 24, 25, 26, 27, 28, 29, 30]. In fact, people in different regions of the world have different approaches to medicinal plants and use a variety of herbal medications for treating different diseases and conditions, which have not yet been scientifically assessed [31, 32]. In this chapter, we will discuss and review current traditional and herbal medicine treatments with approved or possible effects on management of Tinnitus.
3. Ginkgo biloba (Jinko)Ginkgo biloba from the Ginkgoaceae family is a Chinese traditional medicine herb, which is being used for the treatment of asthma and bronchitis for a long time [22, 33]. It has gotten popular also in western countries as well as in Asian ones [34]. Ginkgo biloba is widely available as easily accessible, inexpensive, and relatively safe leaf extracts with various reported therapeutic benefits such as improved cognition and memory as well as sexual function [35, 36]. These improvements beside other biological effects of Jinko extracts such as improvement of microcirculation and neuroprotection are attributable to flavonoid glycosides and terpene lactones, active pharmacologic gradients of Ginkgo biloba. It should be pointed that seeds play a remarkable role in Chinese traditional medicine and they are the most commonly used parts of plants for herbal medications, while Ginkgo biloba is processed from the plants' leaves.
Jinko has been proposed for management of various central nervous system pathologies including tinnitus; however, some previous researches have reported no beneficial effects for Ginkgo biloba in treatment of tinnitus [36, 37, 38, 39, 40, 41]. Nevertheless, no certain decide can be made regarding effects of Ginkgo biloba on management of tinnitus according to its complex pharmacological profile, which shows need for further accurate researches [42].
4. Bojungikgitang and banhabaekchulchonmatang (traditional Korean medicine)Bojungikgitang and banhabaekchulchonmatang have been approved by Korea Food and Drug Administration and are being widely used in Korea for treatment of Tinnitus because of their very low rate of adverse effects [16]. These two herbal medications have found their places among Korean people and physicians. Traditional Korean medicine (TKM) believes that Tinnitus is mainly caused from irregularities in bowel and visceral (zang-fu) functioning [16]. According to TKM, gallbladder deficiency associated with tinnitus is managed by banhabaekchulchonmatang, and bojungikgitang is used to manage the pattern of qi-deficiency [21]. Both of these drugs are now fully covered by Korean National Health Insurance (KNHI).
5. Gushen PianasGushen Pianas is a novel Chinese medicinal herb, which is being used in the treatment of sensorineural hearing loss and Tinnitus. Phlegm-accumulation stasis and splenonephric hypofunction are the two main proposed mechanisms of action for Gushen Pianas in treatment of Tinnitus [43]. This medication has been developed by Institute of Otorhinolaryngology of Chinese PLA General Hospital and Wuhan Kexing Biomedical Development Co.
Effectiveness of the drug was evaluated in a phase 2 double-blind randomized clinical trial on 120 patients with sensorineural deafness associated with tinnitus. Patients received five tablets of Gushen Pianas every 8 hours and the effect was assessed after 4 weeks. The findings suggested Gushen Pianas as a suitable treatment for hearing loss with no evident adverse effects [43].
6. Panax ginseng (Jinseng)Root of the Panax ginseng, with local name of Jinseng, a Chinese medicinal plant from the Araliaceae family has been being used for treatment of Tinnitus since dawn of traditional medicine [44]. Korean red ginseng (KRG) is a traditional Korean herbal medication, which has been used for more than 2000 years, believed to have several benefits for human body [45]. It is considered that oxidative stress is the cause for idiopathic tinnitus and patients may take benefits from oral antioxidant therapy [46, 47]. So, KRG has been proposed for treatment of tinnitus as it inhibits production of reactive oxygen species (ROS) and also attenuates hydrogen peroxide-induced oxidative stress in human neuroblastoma cells [48, 49]. The effect of KRG (3000 mg/day) was evaluated in a randomized clinical trial in which the patients showed a significant reduction in tinnitus handicap inventory (THI) score and increased quality of life. Also some adverse effects have been reported for Jinseng and specially KRG in literature. Deficiency of vital energy (DE), known as qi-deficiency, is a traditional Chinese medicine syndrome, which indicates the disease emerging identity. Some studies believe that Ginseng, especially Korean Red Ginseng, might cause some adverse effects if the patient's body constitution does not match the qi-deficiency. However, others have reported the Ginseng as the treatment of qi-deficiency caused by any reasons [50].
Further researches are needed to assess beneficial and adverse effects of KRG more accurately.
7. GarlicPrevious conducted researches have reported a lipid-lowering effect for garlic and some others have counted fibrinolytic activity and lowering blood pressure as therapeutic roles of garlic. Few studies have also reported garlic to be beneficial for treatment of tinnitus [6]. Garlic's effect on tinnitus is attributable to improve blood flow of cochlea as a result of its antiplaque formation ability, stabilizing blood pressure, and augmentation in antioxidant capability of the blood. No scientific studies have been conducted for approving these effects and all of them are theoretical [51].
8. Yoku-kan-sanThere are more than 120 plants approved by Japanese ministry of health, labor, and welfare, which are now being used in practice as traditional medications [52]. Yoku-kan-san, a traditional Japanese herbal medication, is one of these approved herbal medications composed from seven plants (Angelicae Radix, Atractylodis Lanceae Rhizoma, Bupleuri Radix, Poria, Glycyrrhizae Radix, Cnidii Rhizoma, and Uncariae Uncis Cum Ramlus). This combination is more frequently used as treatment of psychological conditions such as irritability, insomnia, night terrors, and hypnic myoclonia, especially in infant patients [53]. Although, there are not enough clinical investigation and convincing data for beneficial effect of Yoku-kan-san on tinnitus, but it has been shown to be effective for tinnitus resulted from undifferentiated somatoform disorder in a 44-year-old woman [54]. There is an obvious need for more clinical researches to support such kind of case reports.
Today's world is going toward the use of medicinal plants and herbal medicines, which are now finding their place among people. Conditions with no precise pharmacologic treatment, such as tinnitus, are more probable to be resolved by herbal medications. In this chapter, we tried to review current medicinal plants for treatment of tinnitus; however, currently, there is a lack of clinical research in this issue. The effect of herbal medications on tinnitus should be investigated in more future clinical researches.
https://www.intechopen.com/online-first/herbal-medicine-in-the-management-of-tinnitus/

Masthead

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Table of contents

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Erratum

http://bit.ly/2T81bNL

Disparities in adherence to head and neck cancer follow‐up guidelines

Objectives

In this study, we aim to determine the frequency of adherence to National Comprehensive Cancer Network follow‐up guidelines in a population of head and neck cancer patients who received curative treatment. We will also assess the impact of race, ethnicity, socioeconomic status, and treatment setting on utilization of follow‐up care.

Methods

This study included patients with biopsy‐proven, nonmetastatic oropharyngeal or laryngeal cancer treated with radiotherapy between January 1, 2014, and June 30, 2016, at a safety‐net hospital or adjacent private academic hospital. Components of follow‐up care analyzed included an appointment with a surgeon or radiation oncologist within 3 months and posttreatment imaging of the primary site within 6 months. Univariable and multivariable analyses were conducted using a logistic regression model to estimate odds ratios and corresponding 95% confidence intervals.

Results

Two hundred and thirty‐four patients were included in this study. Of those, 88.8% received posttreatment imaging of the primary site within 6 months; 88.5% attended a follow‐up appointment with a radiation oncologist within 3 months; and 71.1% of patients attended a follow‐up appointment with a surgeon within 3 months. On multivariable analysis, private academic hospital treatment versus safety‐net hospital treatment was associated with increased utilization of both surgical and radiation oncology follow‐up. Non‐Hispanic black (NHB) patients, Hispanic patients, and those with a low socioeconomic status were also less likely to receive follow‐up.

Conclusion

Safety‐net hospital treatment, socioeconomic status, Hispanic ethnicity, and NHB race were associated with decreased follow‐up service utilization. Quality improvement initiatives are needed to reduce these disparities.

Level of Evidence

2b. Laryngoscope, 2018

http://bit.ly/2CwUlvY

Opioid prescription patterns and use among patients undergoing endoscopic sinus surgery

Objectives/Hypothesis

Opioid‐related deaths in the United States have increased 200% since 2000, in part due to prescription diversion from patients who had a surgical procedure. The purpose of this study was to characterize provider prescription patterns and assess patient‐reported opioid use after endoscopic sinus surgery (ESS).

Study Design

Retrospective chart review.

Methods

Patients who underwent ESS between May 2017 and May 2018 were included. Opioid prescription, operative details, and postoperative opioid use data were extracted. The Massachusetts Prescription Awareness Tool (MassPAT) was queried to determine if patients filled their prescription.

Results

One hundred fifty‐five patients were included. Nearly all patients received an opioid prescription (94.8%). An average of 15.6 tablets was prescribed per patient. Among 116 patients with MassPAT data, 91.4% filled their prescription. Among 67 patients who reported the number of tablets they had used at the time of first follow‐up appointment, 73.1% reported taking no opioids. Mean number of tablets prescribed was significantly greater among patients who underwent primary versus revision surgery (16.5 vs. 13.5, P = .0111) and those who had splints placed (21.5 vs. 15.1, P = .0037). Predictors of opioid use included concurrent turbinate reduction (58.3% vs. 14.3%, P < .0001) and concurrent septoplasty (45.5% vs. 21.6%, P = .039).

Conclusions

Nearly all patients who underwent ESS were prescribed an opioid, and nearly all patients filled their prescription. However, the vast majority of patients did not require any opioid medication for postoperative pain control. As the opioid epidemic continues to persist, these findings have immediate relevance to current prescribing patterns and pain management practices.

Level of Evidence

4 Laryngoscope, 2018

http://bit.ly/2TcSiCP

Implication of Fusobacterium necrophorum in recurrence of peritonsillar abscess

Objective

Peritonsillar abscess (PTA) is a common infectious complication of pharyngeal infection managed by otolaryngologists and emergency room physicians. Streptococcus and Fusobacterium (e.g., Fusobacterium necrophorum, FN) species are commonly isolated pathogens. The aim of this study was to determine the implication of culture results on abscess recurrence following drainage.

Methods

Single‐institution retrospective review of patients treated at the University of Michigan between 2000 and 2017. Demographic and clinical outcome data were analyzed, including treatment details, culture data, and recurrence.

Results

One hundred fifty‐six of the 990 patients in our study developed recurrence of their abscess (16%). The age ranges most susceptible to recurrence included adolescent (22.9%) and young adult groups (17.1%). Recurrent patients were more likely to have experienced acute progression of symptoms (79% vs. 71%, P = 0.03), trismus (67% vs. 55%, P = 0.006), voice changes (65% vs. 57%, P = 0.04), and dysphagia (72% vs. 61%, P = 0.01) compared to nonrecurrent patients. They were also more likely to have clinical lymphadenopathy noted on initial examination (67% vs. 56%, P = 0.009). Culture data was sent for 852 patients (86%). The presence of FN was significantly more prevalent in the recurrent group (P < 0.0001).

Conclusion

There is a high observed prevalence of FN species within PTA aspirates in the recurrent PTA population. PTA aspirate should be sent for anaerobic growth to screen for Fusobacterium species. In addition, follow‐up and lower threshold for subsequent tonsillectomy should be considered in this at‐risk group.

Level of Evidence

3. Laryngoscope, 2018

http://bit.ly/2CxhkqP

Voice outcomes following medialization laryngoplasty with and without arytenoid adduction

Objective

Voice outcomes following medialization laryngoplasty (ML) for unilateral vocal fold paralysis (UVFP) were compared to those who underwent ML plus arytenoid adduction (AA) (ML+AA).

Methods

Single institution retrospective review of patients with UVFP undergoing ML and ML+AA (2009–2017). Demographic information and history of laryngeal procedures were collected. Preoperative and postoperative Voice Handicap Index‐10 (VHI‐10) and Consensus Perceptual Auditory Evaluation of Voice (CAPE‐V) were assessed.

Results

Of 236 patients, 119 met study criteria. Of those, 70 (59%) underwent ML and 49 (41%) underwent ML+AA. Significant differences between groups at baseline were found for age at time of thyroplasty (P = 0.046), VHI‐10 scores (P < 0.001), and CAPE‐V scores (P = 0.007). Baseline VHI‐10 scores for ML+AA (28 ± 7) were greater than those for ML alone (24 ± 7). At 12 months, overall VHI‐10 scores improved compared to baseline for both groups (ML+AA = 9 ± 7, ML = 16 ± 9); however, there was greater improvement for the ML+AA group compared to ML group (P = 0.001). CAPE‐V scores at 3 or 12 months improved, but differences between the groups were not statistically significant once controlled for covariates.

Conclusion

Based on current findings, patients who undergo ML+AA likely have greater voice handicap at baseline compared to those undergoing ML alone. Patients selected for ML+AA improve as much or more than those who underwent ML alone. This highlights the importance of appropriate selection of candidates for AA.

Level of Evidence

4. Laryngoscope, 2018

http://bit.ly/2T7LVAD

Common practices in botulinum toxin injection for spasmodic dysphonia treatment: A national survey

Objectives/Hypothesis

Although no clear guidelines exist, protocols in the treatment of spasmodic dysphonia (SD) vary among physicians. Previously published work comes from relatively few centers.

Study Design

A descriptive survey among experts (laryngologists who practice Botulinum toxin injections for SD).

Methods

An online 58‐item survey was sent to all otolaryngologists who self‐identify as laryngologists on the American Academy of Otolaryngology–Head and Neck Surgery website. Items surveyed included botulinum toxin injection technique, laterality, and dosage.

Results

An 80% response rate was achieved (70 completed the survey). Participants collectively reported treating >4,000 SD patients in the past year (mean, 71 ± 68 patients/laryngologist). Eighty‐seven percent perform injections exclusively in the office; the remainder both in the office and operating room. For adductor SD injections, 88% use electromyographic (EMG) guidance alone via cricothyroid approach. The remainder use anatomical landmarks alone (9%) or EMG with endoscopic guidance (3%). Sitting is the preferred patient position (70%; supine, 30%). A substantial majority (87%) begin with bilateral injections (starting dosage mode, 1.25 units/side). For abductor SD injections, 67% use EMG guidance alone and 31% use endoscopic guidance with or without EMG. Sitting is the preferred patient position (84%; supine, 16%). The preferred approach is anterior‐translaryngeal (51%), followed by lateral‐retrolaryngeal with rotation (34%). A considerable majority (79%) begin with unilateral injections (starting dosage mode, 5 units). When deciding on initial dosage, the most influential factor was balancing patients' desire/needs, followed by patients' frailty and risk of aspiration. The typical planned interval between injections is 3 to 4 months.

Conclusions

Laryngologists follow fairly uniform protocols in the treatment of SD with some important and previously unpublished differences. This study documents areas of agreement and discordance among laryngologists in the United States for the treatment of SD.

Level of Evidence

4 Laryngoscope, 2018

http://bit.ly/2CzynZn

Recurrent laryngeal nerve paralysis after thyroid cancer surgery and intraoperative nerve monitoring

Objectives/Hypothesis

This study aimed to investigate the risk of postoperative recurrent laryngeal nerve paralysis (RLNP) with and without the use of intraoperative nerve monitoring (IONM) during thyroid cancer surgery.

Study Design

Retrospective cohort study.

Methods

This study utilized a nationwide claims database in Japan. Patients who underwent thyroid cancer surgery with and without IONM were included, and postoperative RLNP incidence was compared.

Results

The study included 5,804 patients. Multivariable logistic regression analysis revealed that use of IONM was not associated with increased RLNP risk (odds ratio: 1.15; 95% confidence interval: 0.67‐1.96). There was no significant effect on RLNP prevention when stratified by tumor or nodal classification. Rather, the patients who had T4 or N1b classifications who received IONM had higher incidences of RLNP.

Conclusions

Use of IONM did not significantly reduce the risk of RLNP. The results for the T4 and N1b populations may be explained by indication bias or unmeasured confounders.

Level of Evidence

NA Laryngoscope, 2018

http://bit.ly/2T4jYJY

Systemic safety of serial intralesional steroid injection for subglottic stenosis

Objectives/Hypothesis

Serial intralesional steroid injection (SILSI) has recently been proposed as an effective scar‐modifying therapy for subglottic stenosis (SGS). We aimed to explore the systemic absorption of steroid following SILSI and to characterize the magnitude and chronicity of any effect observed. Specifically, we aimed to show that any effect resolves prior to the next intralesional injection.

Study Design

Prospective, observational pilot study.

Methods

Patients were injected intralesionally with 40 to 200 mg triamcinolone. Serum cortisol, as well as white cell counts and inflammatory markers were measured at day 0 (baseline), 1, 7, and 28. Salivary cortisol was measured at baseline and for 7 consecutive days following injection.

Results

Six patients with idiopathic SGS were recruited. At baseline, serum cortisol measured 284.0 ± 61.4 nmol/L and fell significantly to 15.5 ± 4.3 nmol/L 1 day following triamcinolone injection (P = .03). At day 7, serum steroid levels showed significant recovery to 221.8 ± 78.9 nmol/L (P = .03) and further rose to 279.5 ± 29.9 nmol/L at 28 days (P = .07). Salivary cortisol exhibited a similar pattern with significant recovery by day 6 (P = .04) and suggestion of exponential clearance of triamcinolone systemically. White cell counts were also affected by systemic absorption of exogenous steroid. No significant change in inflammatory markers was observed.

Conclusions

Our findings demonstrate systemic absorption of steroid following SILSI, with acute hypothalamic–pituitary–adrenal (HPA) axis suppression. However, normalization of HPA axis function by day 7 suggests that although acute steroid side effects should be discussed with patients, no cumulative systemic steroid side effect would occur with serial injections.

Level of Evidence

2 Laryngoscope, 2018

http://bit.ly/2CzQj65

Type I thyroplasty: A safe outpatient procedure

Objectives/Hypothesis

Overnight hospitalization is routinely advocated following type I thyroplasty (TP) because of concerns for airway compromise. Hospitalization increases cost and patient inconvenience, and may not necessarily be appropriate. This study evaluated complications following surgery and identified predictors for same to assess which patients benefit most from hospitalization.

Study Design

Retrospective chart review.

Methods

A study was conducted on patients who underwent TP with or without arytenoid repositioning procedures between June 2008 and March 2017. The demographic data of the subjects, characteristics, etiology of glottic insufficiency, interventions performed, and subsequent complications were evaluated.

Results

Of 147 patients reviewed, 100 underwent TP alone, 41 underwent TP with arytenoid adduction, and six patients underwent TP with adduction arytenopexy. Iatrogenic vocal fold paralysis was the most common indication. Major complications, which included transient airway compromise and hematoma requiring reoperation, occurred in 7% of patients. Revision surgery and thyroplasty combined with arytenoid repositioning maneuvers were associated with increased risk of major complications.

Conclusions

In general, TP is a safe procedure, with a major complication rate that is lower than that of outpatient thyroidectomy. Overnight hospitalization should be considered in patients undergoing revision surgery and in those requiring concurrent arytenoid repositioning procedures.

Level of Evidence

4 Laryngoscope, 2018

http://bit.ly/2T7LGWf

Drug‐induced sleep endoscopy: new insights in lateral head rotation compared to lateral head and trunk rotation in (non)positional obstructive sleep apnea patients

Objective

To compare the effect of lateral head rotation to lateral head and trunk rotation on upper airway patency during drug‐induced sleep endoscopy (DISE) in nonpositional obstructive sleep apnea (OSA) patients (NPP) and positional OSA patients (PP).

Methods

Prospective cohort study.

Results

In total 92 patients were included. Seventy‐five patients were male (82%) with a mean age of 47.2 ± 11.3 years, a body mass index of 27.0 ± 3.3 kg/m², and a median apnea–hypopnea index of 16.7 per hour (8.7, 26,5). Of all patients, 75% were PP. Lateral head rotation and lateral head and trunk rotation findings are similar in NPP at each possible level of obstruction, with exception of the oropharynx but not in PP. In PP, lateral head rotation and both lateral head and trunk observations were different at every possible obstruction site.

Conclusion

The effect of lateral head rotation and lateral head and trunk rotation on upper airway patency during DISE is significantly different in PP. In NPP, similar results regarding the degree of upper airway obstruction were found at the level of the velum, tongue base, and epiglottis.

Level of Evidence

2B Laryngoscope, 2018

http://bit.ly/2CxhTAJ

Issue Information

http://bit.ly/2ENsXMC

Primary Ewing sarcoma of the squamous temporal bone with intracranial and extracranial extension: A rare cause of sudden sensorineural hearing loss

Abstract

Background

Primary Ewing sarcoma of the cranial bone is rare, accounting for only 1% of all Ewing sarcomas. Primary Ewing sarcoma arising in the squamous temporal bone is particularly rare.

Methods

A 16‐year‐old male was seen with signs of sudden sensorineural hearing loss (SSNHL). After 1 week of SSNHL and new‐onset headache, imaging studies showed a mass that originated in the left squamous temporal bone with intracranial and extracranial extension. Histopathological study revealed that the mass was a Ewing sarcoma.

Results

The patient manifested the diagnostic EWSR1 mutation and was treated with adjuvant multidrug chemotherapy and focal radiotherapy after surgery according to the Children's Oncology Group interval compression arm of AEWS0031 with a regimen of vincristine, doxorubicin, and cyclophosphamide alternating with ifosfamide/etoposide.

Conclusions

This case showed an extremely uncommon location, as well as unusual symptoms of primary Ewing sarcoma.

http://bit.ly/2EKSmpg

Changes in incidence and prevalence of human papillomavirus in tonsillar and base of tongue cancer during 2000‐2016 in the Stockholm region and Sweden

Abstract

Background

Tonsillar and base of tongue squamous cell carcinoma (TSCC/BOTSCC) has increased. In Stockholm, the proportion of human papillomavirus (HPV)‐positive cases and the incidence of TSCC rose between 1970 and 2006 then stabilized. Here, HPV‐prevalence, and TSCC/BOTSCC incidence 2000‐2016, in Stockholm and Sweden were followed.

Methods

Incidence data for 2000‐2016 were obtained from the Swedish Cancer Registry. TSCC/BOTSCC biopsies, 2013‐2016 from Stockholm, were examined for HPV DNA and p16^INK4a, or data obtained from medical reports. For cases 2000‐2012, data were available from previous studies.

Results

The incidence of TSCC/BOTSCC has continued to rise in Stockholm and Sweden 2000‐2016, especially after 2008. HPV DNA and p16^INK4a analysis was determined for 795 Stockholm cases from 2000 to 2016, with 72% being HPV DNA and p16^INK4a positive 2013‐2016, and 70% positive 2000‐2016.

Conclusion

During 2000‐2016, especially after 2008, the incidence of TSCC/BOTSCC has continued to increase in Stockholm and Sweden, with an HPV‐prevalence of approximately 70% in Stockholm.

http://bit.ly/2EMcwA5

Outcomes of parathyroidectomy for primary hyperparathyroidism with nonlocalizing preoperative imaging

Abstract

Background

The purpose of this study was to evaluate our surgical experience in patients with primary hyperparathyroidism (PHPT) with nonlocalizing sestimibi and ultrasound scans.

Methods

A retrospective review of 521 patients treated from April 2005 to July 2017 at Loma Linda University Medical Center who received parathyroidectomy for PHPT. One hundred forty‐seven patients (28%) had double negative localization (nonlocalizing sestamibi and ultrasound).

Results

Surgical cure for PHPT was 97.3% and 99.2% with nonlocalized and localized disease, respectively, and complication rates were similar between groups. Preoperative parathyroid hormone and gland weight were significantly lower with nonlocalization. The incidence of multigland disease (MGD) was greater in patients with nonlocalization on sestamibi and ultrasound.

Conclusion

Nonlocalization of parathyroid glands was not associated with decreased cure rate or increased morbidity. The presence of MGD and requirement for more extensive surgery were greater in patients with nonlocalizing disease.

http://bit.ly/2EHsUkm

Recurrent unilateral peripheral facial palsy in a patient with an enlarged styloid process

Abstract

Background

Recurrent peripheral facial paresis is a rare symptom that may be caused by multiple pathologic conditions.

Methods

We report a case of recurrent peripheral facial palsies caused by an ipsilateral enlarged styloid process. A surgical excision of the process was performed.

Results

The treatment was well tolerated. Postoperatively, no further recurrent paresis was observed.

Conclusion

To the best of our knowledge, this is the first case study of an enlarged styloid process with facial paresis. A detailed workup, including imaging, should be performed in cases with recurrent facial paresis and/or cases with a history of trauma and facial paresis and, of course, to exclude a neoplastic etiology.

http://bit.ly/2EOnyES

Tumor multifocality with vagus nerve involvement as a phenotypic marker of SDHD mutation in patients with head and neck paragangliomas: A 18F‐FDOPA PET/CT study

Abstract

Background

¹⁸F‐FDOPA PET/CT was proved to be a highly sensitive imaging method for detecting head and neck paraganglioma (HNPGL). The primary aim of the study was to evaluate the relationship between tumor characteristics and the SDHx‐mutational status in a large series of patients with HNPGL evaluated by ¹⁸F‐FDOPA PET/CT.

Methods

A total of 104 patients with HNPGL (65 sporadic/39 SDHx‐mutated) were included.

Results

In comparison to SDHB/SDC/SDHx‐negative cases, patients with SDHD were younger at diagnosis and had a higher rate of multifocal, vagal, and carotid paraganglioma. In patients with SDHD, vagal paraganglia represented the primary site of tumor origin. Multicentric involvement of the vagus nerve alone or in association with other locations was found to be a typical feature of SDHD cases compared to other cases (odds ratio = 59.4).

Conclusion

The present study shows that tumor multifocality within the vagus nerve is a phenotypic marker of SDHD mutation. This information is essential in the choice of the therapeutic strategy.

http://bit.ly/2EMojgL