Episodic Migraine Comorbidities: Avoiding Pitfalls and Taking Therapeutic Opportunities

Abstract

Migraine is a common neurologic disorder. This article will discuss a few factors that influence migraine (mostly episodic) and its treatment, such as sleep, obstructive sleep apnea (OSA), obesity, and affective disorders, as well as autoimmune diseases. Practitioners must be aware of these coexisting conditions (comorbidities) as they affect treatment. It is noted in literature that both the quantity (too much or too few hours) and the quality (OSA related) of sleep may worsen migraine frequency. An associated risk factor for OSA, obesity also increases migraine frequency in episodic migraine cases. A bidirectional relationship with migraine along with depression and anxiety is debated in the literature. Retrospective cohort studies are undecided and lack statistical significance, but prospective studies do show promising results on treatment of anxiety and depression as a means of improving migraine control. Finally, we address the topic of autoimmune diseases and migraine. While few studies exist at this time, there are cohort study groups looking into the association between rheumatoid arthritis, hypothyroidism, and antiphospholipid antibody. There is also evidence for the link between migraine and vascular diseases, including coronary and cerebral diseases. We suggest that these comorbid conditions be taken into account and individualized for each patient along with their pharmaceutical regimen. Physicians should seek a multifactorial treatment plan including diet, exercise, and healthy living to reduce migraine frequency.

http://bit.ly/2CgQhP9

The Diagnostic Performance of Ultrasonography and Computed Tomography in Differentiating Superficial from Deep Lobe Parotid Tumors

Abstract

Objectives

To validate and compare ultrasound (US) versus computed tomography (CT) criteria in the localization of superficial/deep lobe tumors of the parotid gland.

Design and Setting

This was a retrospective study of diagnostic tests performed from January 2008 to June 2017.

Participants

We included adult patients who were referred for a neck ultrasonography examination due to parotid tumors, and who subsequently underwent parotid surgery.

Main outcome measures

We assessed the location of parotid tumors, comparing the minimum fascia–tumor distance (MFTD) criterion on an US with eight CT criteria. We analyzed receiver operating characteristic (ROC) curves of the MFTD for malignant, benign, and all parotid tumors, and compared the accuracy, sensitivity, and specificity of the optimal MFTD with those of CT anatomical criteria.

Results

A total of 166 parotid tumors were included. The mean (SD) MFTD in superficial lobe tumors was significantly shorter than that of deep lobe tumors (1.2 [0.7] vs 2.8 [1.9] mm, effect size: 1.84; 95% CI, 1.27 to 2.41). The areas under the ROC curve were 0.63 for malignant tumors and 0.88 for benign tumors. The optimal MFTD cut point was 2.4 mm for the 154 benign parotid tumors and the accuracy, sensitivity, and specificity were 90%, 80% and 91%, respectively. For the 136 benign parotid tumors that underwent CT examination, three criteria had an accuracy of over 90% (FNline, tMasseter and Conn's arc), but the sensitivities were all below 50%.

Conclusions

MFTD is more feasible for benign tumors than for malignant tumors for the localization of parotid tumors. For benign parotid tumors, US is enough to guide operations.

This article is protected by copyright. All rights reserved.

http://bit.ly/2TJI90s

Computerised tomography in the investigation of otalgia of unknown origin; our experience in 100 patients

Abstract

Otalgia is a common presenting symptom in the specialty of ENT. In its primary form it is caused by conditions and diseases affecting the outer, middle or inner ear structures, thus giving rise to pain and discomfort around the ear itself. However, in its secondary form (referred), pain can be remote from the source and thus provide greater diagnostic challenge due to the possibility of occult disease that is not well visualised.

This article is protected by copyright. All rights reserved.

http://bit.ly/2D5nSNF

Prognostic significance and population dynamics of peripheral monocytes in patients with oropharyngeal squamous cell carcinoma

Abstract

Background

Several inflammatory biomarkers are considered potential prognostic factors in various cancers. This study aimed to investigate the prognostic significance and population dynamics of pretreatment inflammatory biomarker levels in patients with oropharyngeal squamous cell carcinoma (OPSCC).

Methods

The influence of neutrophil counts, lymphocyte counts, monocyte counts, platelet counts, lymphocyte‐to‐monocyte ratio (LMR), neutrophil‐to‐lymphocyte ratio, and platelet‐to‐lymphocyte ratio on progression‐free survival (PFS), and overall survival (OS) was analyzed. We also analyzed the peripheral blood mononuclear cells collected from patients and healthy donors (HDs).

Results

Elevated monocyte count was an independent prognostic factor for PFS. Low LMR was an independent prognostic factor for OS. The proportion of intermediate monocytes was lower, and that of classical monocytes was higher in patients than in HDs. Furthermore, PD‐L1 expression on monocytes was higher in patients than in HDs.

Conclusions

We showed the prognostic significance and population dynamics of peripheral monocytes in patients with OPSCC.

http://bit.ly/2SWh4HH

Transnasal endoscopic surgery in selected nasal‐ethmoidal cancer with suspected brain invasion: Indications, technique, and outcomes

Abstract

Background

In nasal‐ethmoidal malignancies, brain involvement is associated with dismal prognosis.

Method

Patients undergoing endoscopic resection with transnasal craniectomy and subpial dissection (ERTC‐SD) for brain‐invading nasal‐ethmoidal cancer between 2008 and 2016 were included. Complications were analyzed in all patients, whereas oncological outcomes only in patients with pathological brain invasion. The prognostic impact of previous treatments, brain edema, and histology was assessed. Hospitalization ratio was calculated.

Results

Nineteen patients received ERTC‐SD and 11 had pathological‐proven brain invasion. Histologies were 6 olfactory neuroblastomas (ONB), 3 neuroendocrine carcinomas, and 2 intestinal‐type adenocarcinomas. Mean follow‐up was 21.9 months. Three‐year overall, local recurrence‐free, and distance recurrence‐free survivals were 65.5%, 81.8%, and 68.2%, respectively. Overall and distant recurrence‐free survivals were significantly better in patients with ONB (P = 0.032 and P = 0.013, respectively). Hospitalization ratio was 4.1%. Complication rate was 10.5%.

Conclusion

In selected nasal‐ethmoidal tumors with brain invasion, ERTC‐SD can provide good local control, satisfactory survival, and limited morbidity.

http://bit.ly/2ALcTap

Sequential therapy of neoadjuvant biochemotherapy with cetuximab, paclitaxel, and cisplatin followed by cetuximab‐based concurrent bioradiotherapy in high‐risk locally advanced oral squamous cell carcinoma: Final analysis of a phase 2 clinical trial

Abstract

Background

The prognosis of advanced oral squamous cell carcinoma is poor. We investigated the effect of cetuximab‐based sequential therapy as a primary treatment.

Methods

Forty‐seven treatment‐naive patients with advanced tumors originating from the oral cavity or oropharynx were enrolled. Neoadjuvant cetuximab, paclitaxel, and cisplatin were administered, followed by cetuximab‐based radiotherapy. Immunohistochemical staining was applied to study the tissues.

Results

The best overall response rate was 70.2%, including 4 patients with a complete response and 29 with a partial response. The median progression‐free and overall survival rates were 10.3 and 15.2 months, respectively. Patients with more than 50% tumor reduction with neoadjuvant therapy had better survival outcomes. Twenty‐two patients had severe adverse events with mostly dermatological complications. Of the 16 patients who received operations, 9 had increased PD‐L1 staining compared to pretreatment biopsy in the post hoc study.

Conclusion

The regimen was effective in selected patients. Increased PD‐L1 suggested altered tumor features.

http://bit.ly/2SPk08H

Locoregional failures and their relation to radiation fields following stereotactic body radiotherapy boost for oropharyngeal squamous cell carcinoma

Abstract

Background

To investigate the location of recurrences with respect to the radiation fields in oropharynx cancer after intensity‐modulated radiotherapy and stereotactic body radiotherapy (SBRT) boost.

Methods

Local and regional recurrences were delineated on diagnostic scans which were rigidly coregistered with treatment planning scans, then classified based on the location of the center of mass (COM) as well as volumetrically.

Results

In 195 patients, the 5‐year local and regional control were 90% and 93%, respectively. By COM, 76% of local recurrences were in‐field; 24% were out‐of‐field, significantly higher than 0%‐5% in the literature for conventional regimens (P < 0.01). Regional recurrences (19 in 12 patients) were largely within unirradiated neck levels (47%) and electively irradiated regions (42%).

Conclusions

The regimen with biological equivalent dose intensification provides excellent overall and in‐field local control. The highly conformal boost technique was, however, associated with increased out‐of‐field local failure.

http://bit.ly/2ALcS6l

Prognostic factors in patients with soft palate squamous cell carcinoma

Abstract

Background

To define the prognostic factors associated with outcome in patients with soft palate squamous cell carcinoma (SCC).

Methods

Previously untreated patients with soft palate and uvula SCC treated in our institution between 1997 and 2012 were collected. The prognostic value of clinical, hematological, and treatment characteristics was examined.

Results

We identified 156 patients, median age 58 years, with 71% drinkers, 91% smokers; 19% had synchronous cancer. Front‐line treatment was chemoradiotherapy in 58 (37%), radiotherapy alone in 60 (39%), surgery in 17 (11%), and induction chemotherapy in 21 patients (14%). The 5‐year actuarial overall survival (OS) and progression‐free survival (PFS) were 41% and 37%, respectively. In univariate analysis, T3‐T4 vs T1‐T2 stage, N2‐N3 vs N0‐N1 stage, and neutrophil count >7 g/L were associated with worse OS and PFS (P < .05).

Conclusion

In patients with soft palate SCC, inflammation biomarkers were associated with OS.

http://bit.ly/2SSnlnp

International validation of the revised European Organisation for Research and Treatment of Cancer Head and Neck Cancer Module, the EORTC QLQ‐HN43: Phase IV

Abstract

Background

We validated the new European Organisation for Research and Treatment of Cancer Quality of Life Head and Neck Module (EORTC QLQ‐HN43).

Methods

We enrolled 812 patients with head and neck cancer from 18 countries. Group 1 completed the questionnaire before therapy, and 3 and 6 months later. In group 2 (survivors), we determined test–retest reliability using intraclass correlation coefficients (ICC). Internal consistency was assessed using Cronbach's Alpha, the scale structure with confirmatory factor analysis, and discriminant validity with known‐group comparisons.

Results

Cronbach's alpha was >0.70 in 10 of the 12 multi‐item scales. All standardized factor loadings exceeded 0.40. The ICC was >0.70 in all but two scales. Differences in scale scores between known‐groups were >10 points in 17 of the 19 scales. Sensitivity to change was found to be sufficient in 18 scales.

Conclusions

Evidence supports the reliability and validity of the EORTC QLQ‐HN43 as a measure of quality of life.

http://bit.ly/2ALcODD

Visceral adipose tissue volume and CT‐attenuation as prognostic factors in patients with head and neck cancer

Abstract

Background

The aim of this study was to evaluate the relationship of the characteristics of subcutaneous adipose tissue (SAT) and visceral adipose tissue (VAT) to the disease progression‐free survival and distant failure‐free survival of head and neck squamous cell carcinoma (HNSCC).

Methods

We enrolled 152 HNSCC patients who underwent staging ¹⁸F‐fluorodeoxyglucose (FDG) positron emission tomography/CT (PET/CT). Maximum FDG uptake (standardized uptake value [SUV]) and total lesion glycolysis (TLG) of the primary tumor and volume, CT‐attenuation (Hounsfield units [HU]), and FDG uptake of SAT and VAT were measured. Survival analysis using Cox proportional hazard modeling was performed to assess the relationship between the adipose tissue parameters of PET/CT and survival.

Results

Patients with low VAT volume and high VAT HU had significantly worse progression‐free survival and distant failure‐free survival than those with high VAT volume and low VAT HU. On multivariate analysis, the volume and HU of VAT were significantly correlated with disease progression‐free survival and distant failure‐free survival after adjusting for age, sex, body mass index, TNM stage, serum C‐reactive protein, maximum SUV, and TLG.

Conclusion

The volume and CT‐attenuation of VAT were significantly correlated with disease progression‐free survival and distant failure‐free survival in patients with HNSCC.

http://bit.ly/2SMhdND

Transoral laser microsurgery for glottic cancer in the elderly: Efficacy and safety

Abstract

Background

Data about the results of transoral laser microsurgery (TLM) in elderly patients are limited.

Methods

A retrospective study of 72 consecutive cases of glottic carcinoma (63 pT1 and 9 pT2 cases) in elderly patients (≥70 years old, mean 76 years) treated with TLM was made. A systematic review of the literature was performed.

Results

Six patients (8%) had postoperative complications, but no treatment‐related deaths were observed. Local recurrences occurred in 12 patients (16.5%): nine with pT1 (14%) and three with pT2 (33%) tumors. Five‐year disease‐specific survival (DSS), overall survival, and laryngectomy‐free survival were 95%, 68%, and 88%, respectively. The literature review indicated that TLM is safe and effective treatment for these patients, with few complications and good local control (>85%) and DSS (>90%) rates.

Conclusions

Our results and the information from the literature show that TLM for glottic cancer in elderly patients can lead to satisfactory treatment results.

http://bit.ly/2ALcLrr

Value of a smartphone‐compatible thermal imaging camera in the detection of peroneal artery perforators: Comparative study with computed tomography angiography

Abstract

Background

The aim of this study was to investigate the value of a smartphone‐compatible thermal imaging camera in the mapping of the peroneal artery perforators.

Methods

Twelve consecutive patients scheduled for fibular flap reconstruction were enrolled. The lower limbs were first studied using smartphone‐based dynamic infrared thermography (DIRT). During the rewarming, the hotspots were marked, small rubber markers were taped to the registered sites, and then the patients were sent for a CT scan. The diagnostic performance of smartphone‐based DIRT was evaluated by comparing the DIRT findings with CT angiography and intraoperative findings.

Results

DIRT detected 42 of the 57 dominant perforators in 24 limbs and resulted in a sensitivity of 73.7% and a positive predictive value of 65.6%.

Conclusions

The sensitivity and positive predictive value of the smartphone‐based DIRT are low. Currently, it should be used as an adjunctive tool together with the established imaging techniques.

http://bit.ly/2SMqaX3

Apnea Hypopnea Indices Categorized by REM/NREM Sleep and Sleep Positions in 100 Children with Adenotonsillectomy for Obstructive Sleep Apnea Disease

Publication date: Available online 12 January 2019

Source: International Journal of Pediatric Otorhinolaryngology

Author(s): Asuka Nagao, Masahiro Komori, Taihei Kajiyama, Mutsumi Shimasaki, Daigo Hirakawa, Taisuke Kobayashi, Masamitsu Hyodo

Abstract

Objectives

In pediatric obstructive sleep apnea (OSA), the relationship between rapid eye movement sleep and upper airway collapse, and between sleep position and airway dimensions are well known. However, the interrelations between these factors and the obstructive apnea hypopnea index (O-AHI) have not been thoroughly investigated.

Methods

A retrospective study including 100 children who underwent adenotonsillectomy between March 2010 and July 2017. Total O-AHI was divided into four subcategories by sleep stage and position.

Results

Preoperatively 14 of 47 mild cases of OSA (1 < total O-AHI) and 17 of 18 moderate (5 < total O-AHI) had time showing severe apnea (10 < subcategorized O-AHI). Twenty-two of 24 severe cases (10 < total O-AHI) exhibited very severe apnea (30 < subcategorized O-AHI). All 11 very severe cases (30 < total O-AHI) experienced more than 50 apnea events per hour in at least one of the O-AHI subcategories. After surgery, 23 of 70 cases classified as completely resolved (total O-AHI < 1) still had mild apnea in the O-AHI subcategories, and six of 13 cases who continued to experience apnea events had moderate-to-severe apnea. Seventeen cases worsened in the O-AHI subcategories, and total O-AHI deteriorated in two cases of the 17. The amount of REM sleep and use of the supine position increased significantly postoperatively in the quartile groups with the lowest baseline values (p < 0.0001).

Conclusions

When an unexpected AHI value is encountered, the O-AHI subcategories may be informative regarding the indications for surgery and evaluating the efficacy thereof.

http://bit.ly/2SQKzdE

Bilateral Duplication of the Internal Auditory Canals and Bilateral Cochlear Implant Outcomes and Review

Publication date: Available online 12 January 2019

Source: International Journal of Pediatric Otorhinolaryngology

Author(s): Murray R. Thompson, Catherine S. Birman

Abstract

Objectives

Bilateral duplication of the internal auditory canal (IAC) is rare and is associated with profound sensorineural hearing loss. The present study aims to review our experience with bilateral cochlear implantation (CI) in children with a duplication of the IAC and to review the literature.

Methods

The Sydney Cochlear Implant Centre database was searched for children with duplication of the internal auditory canal. Data was collected regarding clinical history, MRI and CT findings, auditory brainstem responses (ABR), tympanometry and otoacoustic emissions (OAE), visually reinforced orientation audiometry, auditory brainstem response, electrocochleography (ECochG), transtympanic electrical auditory brainstem response (ABR), aided cortical evoked potentials (CAEP) and intraoperative neural response telemetry (NRT) and CI evoked electrical auditory brainstem testing.

Results

two children with bilateral duplication of the IAC were identified who successfully underwent bilateral cochlear implantation. Audiological development was monitored for 2 and 3 years respectively, both children could spontaneously verbalise and displayed Categories of Auditory Performance (CAP) score of 5 and 6 respectively.

Conclusion

Children with duplication of the IAC, with accompanying cochlear nerve dysplasia (CND) can benefit from CI surgery, and verbal receptive and expressive language is possible.

http://bit.ly/2AJgA0c

CSF Leak After Endoscopic Skull Base Surgery in Children: A Single Institution Experience

Publication date: Available online 11 January 2019

Source: International Journal of Pediatric Otorhinolaryngology

Author(s): Javan Nation, Alexander J. Schupper, Adam Deconde, Michael Levy

Abstract

Introduction

The endoscopic expanded endonasal approach (EEA) has been shown to be a safe and effective surgical technique in the resection of pediatric skull base lesions. Cerebrospinal fluid (CSF) leaks are among the most common complications of this approach. Here we review skull base resections using EEA in pediatric patients at our single institution, to identify potential risk factors for this surgical complication.

Methods

A retrospective chart review was conducted on pediatric patients at our single institution for patients 19 years-old and under, who underwent an EEA for resection of a skull base tumor.

Results

Thirty-nine pediatric patients (ages 1-19 years) with 8 different tumor pathologies underwent an EEA for resection of their skull base tumors. 21 patients experienced an intraoperative CSF leak, of which 10 (48%) were "high-flow" leaks and 11 (52%) were "low-flow" leaks. Nasoseptal flaps were only used to repair the intraoperative "high flow" leaks (n=10), and "low flow" and "no leaks" were repaired with allograft and fat. No patients experienced a post-operative CSF leak.

Conclusion

In our pediatric series, the skull base repair algorithm of using an NSF only in cases of "high flow" intraoperative leaks was effective, and no post-operative CSF leaks occurred. Not using an NSF in cases of "low-flow" or "no leak" cases allows for decreased anatomical disruption in the growing patient.

http://bit.ly/2SXDzvu

Morphological analysis of sigmoid sinus anatomy: clinical applications to neurotological surgery

The primary objective of this study was to use high-resolution micro-CT images to create accurate three-dimensional (3D) models of several intratemporal structures, and to compare several surgically important ...

http://bit.ly/2Hhwxke

Acquired medial external auditory canal stenosis, anterior tympanomeatal angle blunting, and lateralized tympanic membrane: Nosology, diagnosis, and treatment

Publication date: Available online 11 January 2019

Source: European Annals of Otorhinolaryngology, Head and Neck Diseases

Author(s): A. Karkas, G. Badidi, P. Odinet, P. Reynard, C. Martin

Abstract

Objectives

To analyze the etiologies, auditory consequences, diagnostic tools and therapeutic results of three often confused pathologies: acquired fibrous stenosis of the medial part of the external auditory canal (EAC), fibrous anterior tympanomeatal angle blunting, and lateralized tympanic membrane.

Material and methods

Retrospective study of 18 cases operated on over a 16-year period (14 patients: 7 female, 7 male; aged 11–64 years): 8 cases of medial EAC stenosis, 3 of blunting, and 7 of tympanic membrane lateralization.

Results

In all 3 pathologies, otoscopic and radiologic diagnosis was easily established, so that they could not be confused. All 3 induced > 33 dB conductive hearing loss. Medial EAC stenosis was secondary to chronic inflammation of the EAC, aggravated by surgery in 5 cases. Blunting was secondary to surgery altering the anterior tympanic annulus. Tympanic membrane lateralization was secondary to prior surgery without inflammatory process. Underlying EAC cholesteatoma was found in 3 cases of medial stenosis and in 1 case of blunting. Surgical results were disappointing in medial stenosis, with 62.5% recurrence and mean functional gain of 9 dB, and in blunting, with 66.7% recurrence and mean functional gain of 6 dB; auditory results were, however, good in these 2 pathologies when there was no recurrence of fibrosis. Results were significantly better in lateralized tympanic membrane, with 28.6% recurrence and mean functional gain of 16 dB.

Conclusion

The good results obtained in tympanic membrane lateralization seem to justify surgery in patients bothered by their hearing loss. The indication is more questionable in cases of medial fibrous stenosis and blunting, although significant auditory improvement is achieved in case of surgical success.

http://bit.ly/2FuW0nM

Anesthetic management for medialization laryngoplasty using concurrent infusions of dexmedetomidine, remifentanil, and propofol versus controls

Publication date: Available online 11 January 2019

Source: American Journal of Otolaryngology

Author(s): Kathryn S. Handlogten, Dale C. Ekbom, Megan C. Hamre, Toby N. Weingarten, Darrell R. Schroeder, Troy G. Seelhammer

Abstract

Purpose

Medialization laryngoplasty (ML) ± arytenoid adduction (AA) surgery poses a unique anesthetic challenge that requires periods of deep sedation and patient cooperation with phonation to assess voice function. The purpose of this study was to assess if the protocolized administration of dexmedetomidine, remifentanil, and propofol (DRP) is associated with reduced procedural duration and administration of other sedating medications.

Materials and methods

This was a retrospective 2:1 case matched study design; matched on age, sex, body mass index, AA, and surgical revision status. Data was obtained from the electronic medical record of a tertiary referral center. Cases underwent ML ± AA using DRP. Control subjects underwent surgery ML ± AA without DRP.

Results

58 DRP cases (43.1% AA) were matched with 116 control patients (44.8% AA). DRP was associated with decreases in fentanyl dose (50 [25, 100] vs. 100 [50, 150] mcg; p < 0.01), incidence and dose of midazolam (4 [6.9%] vs. 70 [60.3%]; p < 0.01; 1 [1, 1] vs. 2 [2, 2]; p < 0.02), operative duration (131 ± 33 vs. 160 ± 50 min; p < 0.01), and anesthetic duration (182 ± 35 vs. 219 ± 60.3 min; p < 0.01). When adjusted for timeline, it was observed that case duration was declining prior to DRP introduction; this trend persisted after DRP introduction. Hypopnea was more common with DRP (14 [24.1%] vs. 7 [6.0%]; p < 0.01).

Conclusions

DRP was associated with a substantial decrease in opioid and benzodiazepine administration. A reduction in procedural duration over time was also observed.

http://bit.ly/2Rp4jbT