American Journal of Otolaryngology - Head and Neck Medicine and Surgery

Detecting and identifying nonrecurrent laryngeal nerve with the application of intraoperative neuromonitoring during thyroid and parathyroid operation

2011-02-09

Abstract: Purpose: The nonrecurrent laryngeal nerve (NRLN) is a rare anatomical variant but associated with high risk of nerve injury during thyroid and parathyroid operations. Therefore, intraoperative detection and verification of NRLN are necessary.Method: A total of 390 consecutive patients who underwent thyroid and parathyroid operations (310 RLNs dissected on the right side and 293 nerves on the left side) were enrolled. Electrically evoked electromyography was recorded from the vocalis muscles via an endotracheal tube with glottis surface recording electrodes. At an early stage of operation, vagal nerve was routinely stimulated at the level of inferior thyroid pole to ensure normal path of RLN. If there is a negative response from lower position but positive response from upper vagal stimulation, it indicates the occurrence of a NRLN, and we localize its separation point and path.Results: Four right NRLNs (1.3%) without preoperative recognition were successfully detected at an early stage of operation. Three patients were operated on for thyroid disease, one for parathyroid adenoma and all were associated with right aberrant subclavian artery. All NRLNs were localized and identified precisely with intraoperative neuromonitoring. Functional integrity of all nerves was confirmed by the intraoperative neuromonitoring and postoperative laryngeal examination.Conclusions: Vagal stimulation at the early stage of operation is a simple, useful, and reliable procedure to detect and identify the NRLN.

Snail as a novel marker for regional metastasis in head and neck squamous cell carcinoma

2011-03-25

Abstract: Objective: Previous studies have shown Snail expression integral to the epithelial-mesenchymal transition during tumor progression. However, its behavior in clinical head and neck squamous cell carcinomas (HNSCCs) is yet undefined. We therefore sought to (1) investigate clinical and histopathologic characteristics of Snail-positive HNSCC and (2) understand the link between Snail and other commonly used HNSCC tumor markers.Study Design: A retrospective case-control study was conducted.Setting: This study was conducted in a large-scale academic center.Study Subjects: Of 51 consecutive HNSCC, 42 surgical resections were included.Methods: Two separate pathologists performed standard histopathologic reviews along with immunohistochemistries (Snail, E-cadherin, p16, epidermal growth factor receptor [EGFR]) and in situ hybridization (human papilloma virus [HPV]). Medical review for all cases was performed.Results: Twenty-two (52%) of 42 cases stained 4+ Snail (>75% staining). The remaining 20 cases were considered negative. Snail was strongly inversely related to E-cadherin expression (ρ = −0.69, P < .001), but statistically independent from HPV, p16, or EGFR expression. Snail(+) tumors were equally represented from each anatomic subsite. Snail(+) tumors were strongly associated with poor differentiation (P < .001) and basaloid classification (P = .004). Snail(+) tumors were also strongly associated with lymphovascular invasion (P = .02), but not perineural invasion. Ultimately, 11 (50%) of 22 of Snail(+) tumors demonstrated positive nodal metastasis and 11 (79%) of 14 node-positive cases were Snail(+) (P = .02).Conclusion: This pilot study provides promising evidence of Snail' role as a molecular prognostic marker for HNSCC. Snail positivity is significantly predictive of poorly differentiated, lymphovascular invasive, as well as regionally metastatic tumors. Because Snail positivity appears independent of HPV, p16, and EGFR expression, Snail may prove to improve upon these markers' predictive limitations.

Similar cellular proliferation activities in nasal polyps and adjacentinferior turbinate

2011-03-07

Abstract: Introduction: Nasal polyps (NP) are regulated by proinflammatory transcription factors such as activator protein-1 (AP-1), which comprises members of the proto-oncogene Jun and Fos protein families. The binding of AP-1 proteins to the 12-O-tetradecanoylphorbol-13-acetate (TPA)-response element can activate target genes and regulate many critical cellular processes. The proliferating cell nuclear antigen (PCNA) gene contains AP-1 sites, and its expression is regulated by AP-1 activity. In this study, NP and inferior turbinate (IT) were evaluated, compared with normal mucosa, to see if diffuse inflammation and active cellular proliferation exist.Materials and Methods: A diseased group of 20 subjects and control group of 20 subjects were enrolled in this study. NP and IT were evaluated with expression of phospho-c-Jun, c-Fos, PCNA, major basic protein by immunohistochemistry, and eosinophil numbers by cell counts.Result: The expression of phospho-c-Jun, c-Fos, PCNA, major basic protein, and eosinophil numbers showed no significant difference in IT and NP of the same patients, but all were significantly higher in IT and NP compared with normal mucosa (P < .05).Conclusion: Our result demonstrated strong evidence that diffuse mucosal inflammation and active cellular proliferation do exist in rhinosinusitis with nasal polyposis. As the degree of the disease severity increases, the difference of eosinophilic infiltration and cellular proliferation activity between NP and its adjacent mucosa decreases. An integrated anti-inflammatory treatment may be more important than surgical intervention.

Surgical management of first branchial cleft anomaly presenting as infected retroauricular mass using a microscopic dissection technique

Kai-Chieh Chan, Wei-Chieh Chao, Che-Ming Wu — 2011-02-28

Abstract: Purpose: This is a detailed description of the clinical and anatomical presentation of the first branchial cleft anomaly presenting as retroauricular infected mass. Our experience with a microscopic dissection with control of the sinus lumen from within the cyst is also described.Materials and Methods: Between 2001 and 2008, patients with the final histologic diagnosis of first branchial cleft anomaly in the retroauricular area were managed with a microscopic dissection technique with control of the sinus lumen from within the cyst. Classifications were done in accordance with Work, Olsen, and Chilla. Outcomes measured intervention as a function of disease recurrence and complications including facial nerve function was used.Result: Eight patients with a mean age of 14.2 years were enrolled, and this included 4 females and 4 males. Four type 1 and 4 type 2 lesions as per the Work's and Chilla's classification were found, and there were 5 sinuses, 2 fistulae, and 1 cyst according to Olsen's classification. All patients presented to the department with acute infection at the time of diagnosis. Five of the 8 patients had previous surgical treatment, 2 of those had up to 3 previous operations. None of the patients were complicated by disease recurrence or had surgical related complications (facial nerve paresis or paralysis, infection, canal stenosis) requiring reoperation with more than 1 year of follow-up.Conclusions: First branchial cleft anomaly presenting as retroauricular infected mass can be effectively treated by adopting a microscopic dissection technique with control of the sinus lumen from within the cyst.

Use of the medicinal leech for salvage of venous congested microvascular free flaps of the head and neck

Cody A. Koch, Steven M. Olsen, Eric J. Moore — 2011-03-03

Abstract: Objective: The objective of the study was to determine the utility of leech therapy in venous congested microvascular free flaps in which venous outflow could not be established or surgical revision was unsuccessful.Methods: We conducted a retrospective review of all patients at a tertiary referral center from January 2002 to December 2008 who received leech therapy for a venous congested microvascular free flap in which venous outflow could not be established primarily or failed surgical revision.Results: Six patients were identified. Leech therapy was required for a median of 9 days (4-14 days). The median lowest hemoglobin level per patient was 8.0 g/dL (5.4-9.3 g/dL). All patients (6/6, 100%) required blood transfusions during therapy. The median number of units of packed red blood cells transfused per patient was 13.5 U (4-29 U). All flaps (6/6, 100%) were successfully salvaged with leech therapy. There was one minor complication, observed as 2 episodes of syncope in the same patient, related to anemia. There were no cases of infection transmitted as a result of leech therapy.Conclusions: Leech therapy can be used to successfully salvage venous congested microvascular free flaps in the absence of primary venous outflow. Leech therapy can be used safely and with little morbidity compared with other reports.

Association of prepro-orexin polymorphism with obstructive sleep apnea/hypopnea syndrome

Weihu Chen, Jingying Ye, Demin Han, Guoping Yin, Boxuan Wang, Yuhuan Zhang — 2011-03-03

Abstract: Background: Because of the potential role of orexin neuronal circuitry in the regulation of sleep and wakefulness and arousal and breathing, it seems reasonable to speculate that abnormalities in the prepro-orexin gene could be relevant to studies of obstructive sleep apnea/hypopnea syndrome (OSAHS); and it might be a candidate gene in the pathogenesis of OSAHS.Objective: The present study investigated whether single nucleotide polymorphisms (SNPs) in the human prepro-orexin gene are associated with OSAHS in Han Chinese people.Methods: A total of 394 subjects (217 cases and 177 control subjects) were recruited from China. Diagnostic polysomnography was performed in all patients and control subjects. SNPs in potentially functional regions of the gene were identified; and genotypes, determined by direct sequencing.Results: By sequencing the promoter, 2 exons, and the exon-intron junctions of the prepro-orexin gene, the g11182C>T SNP was identified. Statistical analysis showed that there were significant differences in the genotype distribution between patients with OSAHS and the control group (χ22 = 6.437, P = .04). Variant allele T of the g1182C>T polymorphism was more commonly found in patients with OSAHS as compared with control subjects (χ21 = 5.648, P = .017; odds ratio, 1.449; 95% confidence interval, 1.0466–1.968).Conclusions: Our results suggest that the prepro-orexin gene polymorphism g1182C>T is associated with susceptibility to OSAHS in Han Chinese. This study provides insights into the genetic information for future studies regarding this gene in OSAHS.

A comparison of in vitro treatments for directing stem cells toward a sensory neural fate

Bryony A. Nayagam, Ricki L. Minter — 2011-03-25

Abstract: Purpose: Low numbers of primary auditory neurons (ANs) may compromise the clinical performance of a cochlear implant. The focus of this research is to determine whether stem cells can be used to replace the ANs lost following deafness. To successfully replace these neurons, stem cells must be capable of directed differentiation into a sensory neural lineage in vitro and, subsequently, of survival and integration into the deafened cochlea.Materials and Methods: In this study, we compared three in vitro treatments for directing the differentiation of mouse embryonic stem cells toward a sensory neural fate using neurotrophins, conditioned media from early post-natal cochlear epithelium, or media containing BMP4.Results: In all treatments, stem cells were first exposed to retinoic acid, which was sufficient to induce Brn3a-positive patterning in 8-day differentiated embryoid bodies. After a further 8 days of differentiation in adherent culture conditions, BMP4 media-treated cultures produced higher proportions of cells expressing sensory neural markers in comparison to both the conditioned media and neurotrophin treatments, including significantly greater numbers of cells expressing peripherin (P ≤ .001), tyrosine receptor kinase B (P ≤ .001), and β-III tubulin (P ≤ .001).Conclusions: This study illustrated that combined treatment with retinoic acid and BMP4 was most effective at directing differentiation of mouse stem cells into sensory-like neurons in vitro. This finding further supports the role of bone morphogenetic proteins in the differentiation of sensory neurons from neural progenitors, and provides a basis for allotransplantation studies for auditory neuron replacement in the deaf mouse cochlea.

Significance of adjunctive mitomycin C in endoscopic dacryocystorhinostomy

Thomas Prasannaraj, B.Y. Praveen Kumar, Indira Narasimhan, K.V. Shivaprakash — 2011-03-10

Abstract: Purpose: The purpose of this study is to observe the effect of intraoperative topical application of mitomycin C (MMC) on the results of endoscopic dacryocystorhinostomy.Design: This is a prospective, randomized, controlled, single-blind study.Settings: Hospitalized treatment was done in a tertiary medical college hospital and research center that deals with a predominantly rural population.Patients: Patients with primary acquired postsaccal obstruction causing chronic dacryocystitis were considered.Methods: A total of 38 patients were randomized into either a mitomycin group or a control group. Both of these groups were subjected to an identical surgical procedure, except that 0.2 mg/dL of MMC was used in the mitomycin group, whereas normal saline was used in the control group. The follow-up period was at least 6 months. An asymptomatic patient with a visible stoma at nasendoscopy and free flow of saline into the nose with lacrimal syringing after 6 months after surgery was used as criteria for defining a successful result.Results: The success rate was 82.3% when MMC was used and 85.7% among the controls (P > .05). Granulations, adhesions, and obliterative sclerosis occurred in a similar number of patients of both groups. However, granulations and adhesions did not have a bearing on the success rate in either group.Conclusion: Mitomycin C did not appear to influence the occurrence of granulations, synechiae, or obliterative sclerosis, nor did it alter the success rate significantly.

Annual temperature and the prevalence of frequent ear infections in childhood

Mia E. Miller, Nina L. Shapiro, Neil Bhattacharyya — 2011-03-17

Abstract: Objectives: The aim of this study was to determine if changes in annual temperature influence the prevalence of frequent otitis media (FOM) and respiratory allergy in children.Methods: Annual prevalence data for FOM (defined as 3 or more ear infections per year), respiratory allergy, and seizures (nonrespiratory, control condition) in children were extracted from the National Health Interview Survey for 1998 to 2006. Average US annual temperatures for the same period were recorded from the Environmental Protection Agency. Complex samples logistic regression analyses were performed to identify possible correlations between annual temperature and each of the 3 disease conditions, controlling for age and sex.Results: A total of 113 067 children were studied (mean age, 8.6 years; 51.1% girls). Overall prevalences (±95% confidence interval) were 6.3% ± 0.2%, 11.8% ± 0.2%, and 0.7% ± 0.1% for FOM, respiratory allergy, and seizures (nonrespiratory, control condition), respectively. Average annual temperatures ranged from 53.64°F to 55.09°F. Regression analysis found that annual temperature did not influence the prevalence of FOM (P = .681); male sex and younger age were associated with a higher prevalence of FOM (P = .025 and P < .001, respectively). Similarly, annual temperature did not influence prevalence of respiratory allergy (P = .883); male sex and increasing age were associated with a higher prevalence of respiratory allergy (both P < .001). Annual temperature and sex did not influence seizure prevalence; however, increasing age was negatively associated.Conclusions: Changes in average annual temperature do not appear to influence the prevalence of otitis media or respiratory allergy. This negative finding suggests that although global warming continues to affect our environment, childhood otolaryngologic disease prevalence may not be directly influenced.

Deep neck space infections: a retrospective review of 173 cases

2011-03-17

Abstract: Purpose: The purpose of this study is to review our recent experience with deep neck infections and emphasize the importance of radiologic evaluation and appropriate treatment selection in those patients.Materials and Methods: The records of 173 patients treated for deep neck infection at the Department of Otolaryngology and Head and Neck Surgery of Dicle University Hospital during the period from 2003 to 2010 were retrospectively reviewed. Their demography, symptoms, etiology, seasonal distribution, bacteriology, radiology, site of deep neck infection, durations of the hospital admission and hospital stay, treatment, complications, and outcomes were evaluated. The findings were compared to those in the available literature.Results: Dental infection was the most common cause of deep neck infection (48.6%). Peritonsillar infections (19.7%) and tuberculosis (6.9%) were the other most common cause. Pain, odynophagia, dysphagia, and fever were the most common presenting symptoms. Radiologic evaluation was performed on almost all of the patients (98.3%) to identify the location, extent, and character (cellulitis or abscesses) of the infections. Computed tomography was performed in 85.3% of patients. The most common involved site was the submandibular space (26.1%). In 29.5% of cases, the infection involved more than one space. All the patients were taken to intravenous antibiotic therapy. Surgical intervention was required in 95 patients (59.5%), whereas 78 patients (40.5%) were treated with intravenous antibiotic therapy alone. Life-threatening complications were developed in 13.8% of cases; 170 patients (98.3%) were discharged in stable condition.Conclusion: Despite the wide use of antibiotics, deep neck space infections are commonly seen. Today, complications of deep neck infections are often life threatening. Although surgical drainage remains the main method of treating deep neck abscesses, conservative medical treatment are effective in selective cases.

Septal injection of botulinum neurotoxin A for idiopathic rhinitis: a pilot study

Thomas Braun, Robert Gürkov, Matthias F. Kramer, Eike Krause — 2011-03-18

Abstract: Purpose: Botulinum neurotoxin A (BTA) is a promising therapeutic option in the treatment of idiopathic rhinitis (IR), a disease characterized by nasal obstruction and hydrous rhinorrhea. The conventional localization for the injection of BTA in IR is the nasal turbinates. In our own clinical experience, submucoperichondrial injection of BTA in the nasal septum is an alternative that is easy to perform for the therapist and also well tolerated by the patient.Material and Methods: Five patients received an injection of in total 80 mouse units Dysport (Ipsen Pharma, Ettlingen, Germany) in the nasal septum. The unpleasantness of the nasal injection of BTA was measured on a visual analogue scale. Over the course of 14 days, nasal symptoms (rhinorrhea, nasal obstruction, urge to sneeze, nasal pruritus), the number of facial tissues used daily, and possible complications were evaluated.Results: The unpleasantness of the injection of BTA into the nasal septum after local anesthesia was rated low (visual analogue scale, 0.76 on average). A good subjective symptom control was achieved in 3 patients concerning rhinorrhea and in all patients concerning nasal obstruction. The number of facial tissues used daily as a parameter for rhinorrhea was on average 21.0 before the injection of BTA, decreased in 4 patients over the course of time, and was on average 5.8 after 14 days. No patient reported any adverse effects after the injection of BTA.Conclusions: This pilot study demonstrates that septal injection of BTA in patients with IR can achieve good symptom control and patient comfort and should be compared in further studies to the conventional turbinal injection technique.

Wound healing gene therapy: cartilage regeneration induced by vascular endothelial growth factor plasmid

2011-04-29

Abstract: Aims: The identification of growth factors and cytokines with angiogenic activity has enabled new therapeutic treatments for a variety of diseases; this concept is called therapeutic angiogenesis. The vascular endothelial growth factor (VEGF) is the most critical regulator of vascular formation. In the present study, we were interested in the therapeutic angiogenesis effect using plasmid transfer of human complementary DNA VEGF165 (phVEGF165) in experimental skin and cartilage trauma.Methods: Ten BALB/c mice were used for cartilage injury model. At 6 weeks of age, all mice were ear-punched, resulting in 2-mm–diameter puncture through the center of both pinnae. Each mouse got phVEGF165 injection into the first ear and vector without insert or saline injection into the second one. The healing process was followed. The hollow diameter was measured on days 0, 14, and 42. Histological sections of experimental and control pinnae were taken from days 1, 3, 5, 7, 9, 11, 13, 15, 20, and 30 after experimental injury for hematoxylin and eosin and periodic acid Schiff staining and for human VEGF immunocytochemistry. The expression of human VEGF was also checked by real-time polymerase chain reaction in formalin-fixed, paraffin-embedded tissue sections.Key Findings: In BALB/c mouse strain, a significant angiogenesis promotion and cartilage repair were observed after phVEGF165 injection into the punched ear area.Significance: We suggest that administering phVEGF165 leads to faster cartilage regeneration even if not only on the angiogenic basis.

Surgical and hearing results of the circumferential subannular grafting technique in tympanoplasty: a randomized clinical study

Farhad Mokhtarinejad, Seyyed Ahmad Reza Okhovat, Farzaneh Barzegar — 2011-04-01

Abstract: Purpose: Circumferential elevation of the anullus away from its bony seat and extension of the graft onto the anterior bony canal increase the bed of the graft anteriorly but may be associated with anterior blunting, and so, a significant conductive hearing loss may result. The purpose of this study was to compare the surgical and audiologic success rates of circumferential subannular grafting with the conventional underlay tympanoplasty.Materials and Methods: A randomized clinical study was conducted from September 2007 to December 2010 at a tertiary referral center. Thirty-eight patients underwent circumferential subannular grafting (group A), and 25 patients underwent conventional underlay tympanoplasty with extension of the anterior edge of the graft forward against the lateral wall of the Eustachian tube, and therefore, the anterior sharp tympanomeatal angle remained unbroken (group B). All patients underwent preoperative and postoperative audiogram. Blunting and lateralization of the graft were evaluated 6 months after the surgery.Results: The surgical success rate was 97% in group A and 100% in group B patients. Improvement of the air conduction thresholds in all frequencies and closure of the mean air-bone gap were significant and similar among the 2 groups. There were no cases of significant blunting and tympanic membrane lateralization in the 2 groups.Conclusion: This study showed underlay tympanoplasty with elevation of the annulus away from the sulcus tympanicus in the anterior sharp tympanomeatal angle and placement of the graft between it and anterior bony canal is not associated with increased risk of blunting and lateralization of the graft, if that sharp angle is adequately restored.

Cochlea and other spiral forms in nature and art

Slobodan Marinković, Predrag Stanković, Mile Štrbac, Irina Tomić, Mila Ćetković — 2011-07-04

Abstract: Background: The original appearance of the cochlea and the specific shape of a spiral are interesting for both the scientists and artists. Yet, a correlation between the cochlea and the spiral forms in nature and art has been very rarely mentioned.Aim: The aim of this study was to investigate the possible correlation between the cochlea and the other spiral objects in nature, as well as the artistic presentation of the spiral forms.Methods: We explored data related to many natural objects and examined 13 625 artworks created by 2049 artists. We also dissected 2 human cochleas and prepared histologic slices of a rat cochlea.Results: The cochlea is a spiral, cone-shaped osseous structure that resembles certain other spiral forms in nature. It was noticed that parts of some plants are arranged in a spiral manner, often according to Fibonacci numbers. Certain animals, their parts, or their products also represent various types of spirals. Many of them, including the cochlea, belong to the logarithmic type. Nature created spiral forms in the living world to pack a larger number of structures in a limited space and also to improve their function. Because the cochlea and other spiral forms have a certain aesthetic value, many artists presented them in their works of art.Conclusions: There is a mathematical and geometric correlation between the cochlea and natural spiral objects, and the same functional reason for their formation. The artists' imagery added a new aspect to those domains. Obviously, the creativity of nature and Homo sapiens has no limits—like the infinite distal part of the spiral.

Cutaneous Merkel cell carcinoma

2011-06-22

Abstract: Purpose: The aim of this study was to describe the treatment outcomes of patients with cutaneous Merkel cell carcinoma managed with curative intent.Materials and Methods: Between December 1984 and November 2009, 40 patients with previously untreated Merkel cell carcinoma were managed with curative intent with radiotherapy alone (3 patients) or combined with surgery (37 patients). Adjuvant chemotherapy was administered to 11 patients. Primary sites were the following: head and neck, 32 patients; extremities, 6 patients; and trunk, 2 patients. Patients were staged according to the Yiengpruksawan staging system: stage I, local disease; stage II, regional disease; and stage III, distant metastases. Twenty-four patients had stage I disease, and 16 patients had stage II disease. Median follow-up on all patients was 3.0 years (range, 0.6–15.6 years). Median follow-up on survivors was 4.2 years (range, 2.2–14.2 years).Results: The 5-year outcomes were local control, 92%; regional control, 78%; local-regional control, 79%; distant metastasis-free survival, 57%; cause-specific survival, 45%; and overall survival, 36%. The 5-year outcomes for those with stage I vs stage II disease were the following: local-regional control, 87% and 67% (P = .1607); distant metastasis-free survival, 71% and 37% (P = .0073); cause-specific survival, 58% and 27% (P = .0090); and overall survival, 48% and 18% (P = .0037). Local-regional recurrences were observed in 6 patients; one patient was successfully salvaged. Severe complications were observed in 3 patients.Conclusions: Radiotherapy alone or combined with surgery results in a high local-regional control rate. The main mode of recurrence is distant. Approximately one half of patients are cured.

A retrospective study of induction chemotherapy with docetaxel, cisplatinum, and 5-fluorouracil followed by concurrent radiotherapy with cetuximab in locally advanced head and neck cancer

2011-04-29

Abstract: Background: The objective was to study the results of induction chemotherapy followed by external beam radiation therapy with concurrent cetuximab in the treatment of locally advanced head and neck cancer.Methods: Seventeen patients with stage III or IV squamous cell carcinomas of the head and neck who received docetaxel, cisplatinum, and 5-fluorouracil followed by radiation therapy with concurrent cetuximab were retrospectively analyzed. All radiation was delivered with image-guided intensity-modulated radiation treatments. Primary end points analyzed were local control and overall survival.Results: With a median follow-up of 17 months, the approximate 2-year local control was 85%, with overall survival being 91%. At time of last follow-up, only 1 death was observed, with the cause of death unknown. Two local failures were observed, and the patients were under active management for their recurrences at time of last follow-up. No distant metastatic failures were noted among the patients.Conclusions: Induction chemotherapy with docetaxel, cisplatinum, and 5-fluorouracil followed by concurrent radiation with cetuximab provides for excellent locoregional control of disease. Future prospective studies can better establish the efficacy of this treatment regimen to current favored protocols.

Intended single-modality management of T1 and T2 tonsillar carcinomas: retrospective comparison of radical tonsillectomy vs radiation from a single institution

2011-06-22

Abstract: Background: T1 and T2 tonsillar squamous cell cancer with limited neck disease can be managed with single-modality radiation or surgery. Over 11 years, 17 patients underwent radical tonsillectomies; and 33 patients underwent radiation-based treatments for T1 and T2 and N0 to N2a tonsil cancer. Patients were intended to receive single-modality treatment based on presentation; however, some ultimately received adjuvant treatments.Methods: A retrospective chart review to compare overall survival (OS), disease-specific survival (DSS), and locoregional control (LRC) between the groups was used.Results: In surgical group, of 17 patients, 11 underwent surgery alone, 3 underwent surgery and radiation, and 3 underwent surgery with concurrent chemoradiation. Five-year OS for the surgical and radiation groups was 93% and 72%, respectively (no significance achieved). Five-year DSS rates (93% and 80%) and LRC (69% and 89%) similarly did not yield any significant difference.Conclusion: Surgery remains a viable option in the management of T1 and T2 tonsillar cancers with comparable LRC, OS, and DSS.

Early death from papillary thyroid carcinoma

2011-06-09

Abstract: Purpose: The natural history of papillary thyroid carcinoma (PTC) is characterized by a slow growth rate and an excellent prognosis at 20 and 30 years. However, there is a small subset of patients with poorer outcome.Methods: Twenty patients who died of PTC within 10 years of diagnosis were studied to identify prognostic indicators and biological markers of early death. Findings were statistically compared with a previous review of all patients with PTC treated in the same institute and studies in the literature.Results: The study group included 6 men and 14 women with a mean age of 65 years at diagnosis. Average tumor size was 3.6 cm; 16 patients had extracapsular extension. All tumor samples studied histologically stained poorly for p53, Ki67, and CD34. Regional metastases were present in half the patients, and distal metastases in all. All patients had an advanced disease stage (Tumor, Node, Metastases classification), and only 4 had a low score on the Metastases, Age, Completeness of resection, local Invasion, tumor Size risk stratification. Analysis of the findings against data in the literature for the whole population of patients with PTC, who had a considerably better survival (<8% mortality within 8-15 years vs 100% within 10 years in our sample), yielded significant differences for rates of extrathyroidal extension (P = .0001), regional metastases (P = .016), and distant metastases (P = .0001).Conclusion: Extrathyroid extension, late regional metastases, and distant metastases may be risk factors for early death from PTC.

Topical sucralfate for pain after oral CO2 laser surgery: a prospective, randomized, controlled trial

Chau-Shiang Guo, Hui-Ching Chuang, Chih-Yen Chien — 2011-06-09

Abstract: Purpose: The aim of this study was to assess the effect of topical sucralfate on postoperative pain scores and other secondary outcomes including the frequency and duration of analgesic use and postoperative bleeding episodes after CO2 laser treatment of oral leukoplakia.Patients and Methods: In this prospective trial, a total of 80 patients were randomized into the sucralfate group (n = 40) or the control group (n = 40). Postoperative pain scores, the frequency and duration of analgesic requirements, and postoperative wound bleeding episodes were compared between the 2 groups from the operative day to postoperative day 6.Results: Patients in the sucralfate group experienced significantly less postoperative pain on postoperative days 1 and 2. Although there was no significant difference in frequency and duration of analgesic use between the 2 groups, a trend toward lower frequency and fewer days of analgesic use in the sucralfate group was observed.Conclusions: This study demonstrated the efficacy of topical sucralfate application in diminishing postoperative pain after CO2 laser therapy for oral leukoplakia. Topical sucralfate can be considered a feasible adjuvant medication for the control of pain after CO2 laser treatment of oral leukoplakia.

The tough tracheoesophageal puncture

Michele P. Morrison, Neil N. Chheda, Gregory N. Postma — 2011-06-09

Abstract: Educational Objective: At the conclusion of this presentation, the participants should be aware of the technique and success of in-office transnasal esophageal (TNE)–guided tracheoesophageal puncture (TEP) placement in patients who have failed prior attempts in the operating room or are not healthy enough to undergo general anesthesia.Objectives: The aim of this study was to demonstrate the technique of TEP, which can be completed safely in an office setting when patients are not able to undergo general anesthesia due to medical comorbities or have previously had an unsuccessful attempt at TEP placement in the operating room due to anatomical reasons.Study Design: This study is a retrospective chart review from 2007 to 2011.Methods: A total of 13 outpatient adults with a history of total laryngectomy presenting to the laryngology clinic for TEP after either failing prior placement in the operating room or not being able to undergo general anesthesia due to medical comorbities were identified. In-office TNE-guided TEP placement was performed on all 13 patients.Results: All subjects underwent successful TNE-guided TEP placement in the office. Complications included 1 possible false passage and 1 case of cellulitis.Conclusions: Patients who could not undergo TEP placement in the operating room due to poor exposure or medical comorbities were able to successfully undergo the procedure in an office setting with good results.

Epistaxis after partial middle turbinectomy: the role of sphenopalatine artery ligation

Michele Cassano, Pasquale Cassano — 2011-06-27

Abstract: Purpose: Extensive nasal polyposis could involve the middle turbinate inducing the surgeon to partially remove it. We initiated this retrospective study to evaluate the effect of a partial middle turbinectomy (PMT) on postoperative epistaxis and if sphenopalatine artery ligation (SPAL) could reduce the risk of bleeding in patients without nasal packing.Material and Methods: Twenty-seven patients with extended bilateral nasal polyposis and submitted to primary functional endoscopic sinus surgery (FESS) with PMT on 40 sides were retrospectively selected. Postoperative bleeding and other complications were evaluated and compared with those of a control group of 27 patients who underwent FESS with middle turbinate preservation on 40 sides. The study group was furthermore divided into 2 groups according to the execution of SPAL. The incidence of postoperative bleeding of both groups and of the 2 parts of the study group was compared using the Fisher exact test.Results: A SPAL was necessary to stop intraoperative bleeding in 21 (52.5%) sides of the study group patients and in 7 (17.5%) of the control group patients. After surgery, epistaxis occurred in 8 cases (20%) in the PMT group (1 submitted to SPAL) and in 2 (5%) of the control group. The comparison with the Fisher exact test confirmed the major tendency of postoperative bleeding in the study group and in those not submitted to SPAL (P < .05).Conclusions: Partial middle turbinectomy causes a higher incidence of postoperative bleeding in patients who are not packed during the FESS operation. The execution of SPAL greatly reduces this risk.

Evaluation of the efficacy of caffeine cessation, nortriptyline, and topiramate therapy in vestibular migraine and complex dizziness of unknown etiology

Anthony A. Mikulec, Farhoud Faraji, Laurence J. Kinsella — 2011-06-27

Abstract: Objective: The aim of this study was to evaluate the efficacy of a therapeutic pathway for vestibular migraine (VM) and complex dizziness of undetermined etiology (CDUE) with caffeine cessation and pharmacotherapy.Study Design: This study is a retrospective chart review.Intervention(s): Patients were recommended to stop intake of caffeine and other putative migraine-triggering agents. Pharmacotherapy was initiated with nortriptyline or topiramate if symptoms persisted despite diet modification.Main Outcome Measure: Self-reported dizziness is the main outcome measure.Results: Vestibular migraine and CDUE were considered contributing factors to dizziness in 34 and 10, respectively, of 156 patients. Fourteen percent of patients reported improvement in symptoms upon caffeine cessation, whereas 46% of patients reported a reduction in dizziness after nortriptyline therapy (P = .007). Topiramate reduced symptoms in 25% of patients. In total, 75% of VM patients and 56% of patients with CDUE received sufficient benefit from this therapeutic pathway to not progress to other treatments.Conclusions: Vestibular migraine and CDUE can be treated effectively with a therapeutic pathway consisting of caffeine cessation followed by pharmacotherapy.

Single photon emission computed tomography/computed tomography of the skull in malignant otitis externa

2011-07-18

Abstract: Malignant otitis externa is a severe, rare infective condition of the external auditory canal and skull base. The diagnosis is generally made from a range of clinical, laboratory, and imaging findings. Technetium 99m methylene diphosphonate bone scintigraphy is known to detect osteomyelitis earlier than computed tomography. The authors present a patient with bilateral malignant otitis externa where the extent of skull base involvement was determined on 3-phase bone scintigraphy with single photon emission computed tomography/computed tomography.

Human papillomavirus, smoking, and head and neck cancer

Parul Sinha, Henrietta L. Logan, William M. Mendenhall — 2011-05-06

Abstract: Aims: Smoking and human papillomavirus (HPV) are both distinct risk factors for head and neck cancer, but the nature of interaction between these 2 risk factors in the development of head and neck cancer remains unclear. The purpose of this review is to determine the potential effect of smoking in causation of HPV-related head and neck carcinoma.Method: A literature search was carried out using the keywords human papillomavirus, head and neck cancer, smoking, tobacco, and cervical cancer. The English-language articles, references, and other relevant studies evaluating the association of smoking, HPV, and risk of head and neck cancer were collected and analyzed.Conclusion: Overall, our review points to smoking tobacco posing an additional risk for development of head and neck cancer in the presence of HPV infection. This is consistent with available laboratory data that show evidence of biological plausibility for interaction between smoking and progression of HPV infection to carcinogenesis. It is therefore important that cessation of smoking is promoted in smokers with HPV infection.

The use of robotics in otolaryngology–head and neck surgery: a systematic review

Zeshaan N. Maan, Nick Gibbins, Talal Al-Jabri, Alwyn R. D'Souza — 2011-06-09

Abstract: Background: Robotic surgery has become increasingly used due to its enhancement of visualization, precision, and articulation. It eliminates many of the problems encountered with conventional minimally invasive techniques and has been shown to result in reduced blood loss and complications. The rise in endoscopic procedures in otolaryngology–head and neck surgery, and associated difficulties, suggests that robotic surgery may have a role to play.Objective of Review: To determine whether robotic surgery conveys any benefits compared to conventional minimally invasive approaches, specifically looking at precision, operative time, and visualization.Type of Review: A systematic review of the literature with a defined search strategy.Search strategy: Searches of MEDLINE, EMBASE and CENTRAL using strategy: ((robot⁎ OR (robot⁎ AND surgery)) AND (ent OR otolaryngology)) to November 2010.Evaluation Method: Articles reviewed by authors and data compiled in tables for analysis.Results: There were 33 references included in the study. Access and visualization were regularly mentioned as key benefits, though no objective data has been recorded in any study. Once initial setup difficulties were overcome, operative time was shown to decrease with robotic surgery, except in one controlled series of thyroid surgeries. Precision was also highlighted as an advantage, particularly in otological and skull base surgery. Postoperative outcomes were considered equivalent to or better than conventional surgery. Cost was the biggest drawback.Conclusions: The evidence base to date suggests there are benefits to robotic surgery in OHNS, particularly with regards to access, precision, and operative time but there is a lack of controlled, prospective studies with objective outcome measures. In addition, economic feasibility studies must be carried out before a robotic OHNS service is established.

Balloon dilation of the pediatric airway: potential for disaster

Anil Gungor — 2011-07-25

Abstract: Objective: The aim of this study was to report on a serious adverse event during balloon dilation of pediatric subglottic stenosis.Method: This study is a case report on safety and risk.Results: Airway balloon dilation risk and consideration of serious complications were re-evaluated.Conclusions: Airway balloon dilation carries the risk of acute and complete airway obstruction by the development and persistence of subglottic edema. The surgeon has to be aware of the risk and be ready to intervene. Guidelines and precautions outlined for use of balloons should be carefully observed.

Cochlear implantation after renal transplantation

Kenneth Charles Iverson, Brian John McKinnon — 2011-02-23

Abstract: Objective: Cochlear implantation after renal transplantation is uncommon and poses unique challenges that have only recently been described in the medical literature. This work reports our experience with cochlear implantation in patients who have undergone renal transplantation.Study Design: A retrospective review was performed.Setting: This study was performed in a tertiary academic medical center.Patients: Two patients were identified as having undergone cochlear implantation after renal transplantation.Interventions: Uneventful unilateral cochlear implantations were performed.Main Outcome Measures: Postoperative complications to include wound infection or dehiscence were reported as well as audiometric data.Results: Cochlear implantation was completed uneventfully in both patients without postoperative complications. One patient expired two years after the procedure as a result of multiple comorbidities. Both patients achieved successful use of their device.Conclusions: This study adds to the growing evidence that successful cochlear implantation can be achieved in appropriately selected renal transplant patients. Decision making should rely on surgical candidacy as well as assessment of surgical risk in collaboration with the transplant service.

Bilateral renal cell carcinoma metastasis in the oral cavity

Brian Schwab, Walter T. Lee — 2011-03-03

Abstract: Cancer metastases to the oral cavity are reported infrequently. Renal cell carcinoma has a high metastatic potential, with approximately one third of patients presenting with metastatic disease. New lesions in the oral cavity often rely on preoperative biopsy to establish the diagnosis. However, we report an unusual case in a setting of known renal cell carcinoma disease, where initial pathology and culture data were misleading. Appropriate follow-up and a high index of suspicion will remain necessary. Surgical excision is the treatment of choice.

Delayed postmastoidectomy bleed from anterior tympanic artery and its management using endovascular microcoils

Virad Kumar, Ravi Meher, Vijay Trehan, Amit Pal Singh, Aditi Chopra — 2011-03-10

Abstract: Bleeding during mastoidectomy usually occurs because of injury to the dura mater and/or sigmoid sinus, which, in most cases, can be controlled easily. The other important cause is damage to the internal carotid artery during its course in the middle ear. Bleeding from the external carotid artery or a branch of it is very rare and unknown. We hereby report an extremely rare and first case of delayed torrential bleeding after modified radical mastoidectomy, which was because of infective necrosis and subsequent blowout of the anterior tympanic branch of superficial temporal artery and its management using microcoils via an endovascular approach.

Lemierre syndrome: a case report

U. Kisser, R. Gurkov, W. Flatz, A. Berghaus, O. Reichel — 2011-02-23

Abstract: Introduction: Lemierre syndrome, also known as postanginal sepsis, is caused by Fusobacterium necrophorum. This rare disease is usually characterized by thrombophlebitis of the jugular vein and septic embolism after a history of sore throat.Objective: Here, we discuss a case of Lemierre syndrome in a 22-year-old man with thrombophlebitis of the facial vein and fusobacteria growth in the blood culture but no obvious focus of inflammation.Method: Case report.Conclusion: Severe facial infection with high fever and a general feeling of malaise after a history of sore throat should raise the diagnostic possibility of facial vein thrombophlebitis due to F. necrophorum infection.

Bilateral peritonsillar abscess: case report and literature review

Viet Pham, Anil Gungor — 2011-03-03

Abstract: Although uncommon, bilateral peritonsillar abscess (PTA) may still present with symptoms found in unilateral cases but lack hallmark findings such as an asymmetric tonsillar bulge and uvular deviation. We present the case of an 18-year-old woman deemed to have a bilateral PTA based on physical examination and radiographic imaging. She underwent successful surgical drainage with needle aspiration, followed by incision and drainage. A computed tomography with intravenous contrast should be obtained when a patient displays signs suggestive of a bilateral PTA but the diagnosis is not certain. To our knowledge, this is the first report of 2 different bacterial species cultured from contralateral abscesses during the same encounter.

Unique case of malignant transformation of a vestibular schwannoma after fractionated radiotherapy

2011-06-22

Abstract: Objective: Malignant transformation of vestibular schwannoma is considered a rare clinical entity. Radiotherapy, as a treatment option for vestibular schwannoma, is regarded as a potential risk factor for secondary malignancy. Recently, radiotherapy with dose fractionation has been proposed, intended to diminish the risk of radiation-induced neuropathy.Case Presentation: The aim of the present study is to report the first case, to the best of our knowledge, of malignant transformation of a residual vestibular schwannoma 19 years after fractionated radiotherapy, describing its characteristics with regard to those previously reported in the literature.Conclusions: The main purpose of the present work is to state that the knowledge of the iatrogenic potential pitfalls of any technique of radiotherapy in clinical oncology is becoming a necessity. Finally, our report demonstrates that the irradiated patients must be monitored for life because a secondary malignancy may appear after a very long delay.

Hypopharyngeal cancer in a pregnant woman

Leyla Kansu, Erdinc Aydin — 2011-06-09

Abstract: Cancer in pregnant women is a very difficult clinical condition that profoundly affects patients and their families, as well as the medical staff who provide their care. Diagnostic and therapeutic decisions must balance adequate treatment and fetal risk. In developed societies, cancer in pregnant women has become more common during the last 30 years because of an increase in the number of relatively older women who give birth. The most common malignancies in pregnant women are melanoma; lymphoma; leukemia; and breast, cervical, ovarian, gastrointestinal, and genitourinary cancers. Cancer of the head and neck in pregnant patients is very rare. In this article, we describe a rare case of advanced squamous cell carcinoma of the hypopharyngeal area in a young pregnant woman, and we discuss the diagnosis and treatment of cancers of the head and neck in pregnant patients.

Inadvertent insertion of nasogastric tube into the brain stem and spinal cord after endoscopic skull base surgery

2011-06-29

Abstract: A significant number of neurosurgical patients require feeding tube placement via a nasogastric route. It is used as a temporary access for enteral feeding until patients are able to swallow or receive permanent access. Despite how commonly feeding tubes are used, they are not without potential complications. We report a case of inadvertent placement of small-bore feeding tube into the brain stem and spinal cord in a patient with a history of previous endoscopic transnasal resection of clival chordoma. We discuss the management of this complication and the strategies that have been developed to avoid this complication in the future.

Superior oblique muscle palsy after frontal sinus mini-trephine

Jim Bartley, Ngaire Eagleton, Paul Rosser, Saad Al-Ali — 2011-06-22

Abstract: Objective: The aim of this study is to present a case of superior oblique muscle dysfunction after a frontal sinus mini-trephine.Methods: This is a case report of an 18-year-old woman where a mini-trephination approach and endoscope were used to open and marsupialize a symptomatic, opacified type IV cell within the left frontal sinus. After surgery, the patient developed a persisting diplopia; a left superior oblique muscle palsy was diagnosed. Nine cadaveric dissections of the trochlea were undertaken to clarify mechanisms for potential trochlear damage.Results: Cadaveric dissection reveals that the trochlea is more than a simple pulley; it is a complex structure in close proximity to the orbital rim. The superior oblique tendon telescopes and is surrounded by a vascular sheath that could be easily traumatized.Conclusion: Damage to the trochlea could occur, as the periosteum is elevated from bone or during healing. Alternatively, prolonged traction on soft tissue near the trochlea could cause swelling of the vascular sheath, fibrosis, and hypomobility of the superior oblique tendon. Careful siting of the incision for external frontal sinus surgery as well as careful retraction of skin flaps and periosteal elevation are all techniques used, which should reduce the risk of damage to the trochlea.

Non-Hodgkin lymphoma with hemorrhagic necrosis of the nasopharynx mimicking an abscess

Kyu-Sup Cho, Hak-Jin Kim, Chang-Hun Lee, Hwan-Jung Roh — 2011-07-18

Abstract: Radiologic feature of primary nasopharyngeal lymphoma is a predominantly homogenous, nonnecrotic large tumor with no or minimal deep tissue invasion. To the best knowledge, nasopharyngeal lymphoma has not been presented with hemorrhagic necrosis. Thus, we report 2 cases of nasopharyngeal lymphoma with hemorrhagic necrosis mimicking an abscess. The patients had bleeding diathesis such as aplastic anemia or idiopathic portal hypertension.

Aggressive sinonasal natural killer/T-cell lymphoma with hemophagocytic lymphohistiocytosis

Justin H. Turner, Myriam Loyo, Sandra Y. Lin — 2011-07-18

Abstract: Extranodal natural killer/T-cell lymphoma of the nasal cavity is a rare malignancy with poor overall prognosis. We report the case of a rapidly fatal natural killer/T-cell lymphoma of the nasal cavity complicated by the concominant development of hemophagocytic lymphohistiocytosis. This disorder is marked by clinical findings such as fever and splenomegaly, a multitude of abnormal laboratory findings, and a profound proliferation of circulating macrophages. Left untreated, multi-organ failure and death are common. Prompt diagnosis is essential to the successful management of this disorder and for subsequent recovery.

Misleading article on septoplasty

Ronald Eccles — 2011-03-18

Re: Gandomi, B, Bayat, A, Kazemei, T. Outcomes of septoplasty in young adults: the nasal obstruction septoplasty effectiveness study (2010) 31:180-192. I was concerned to find that the above study by Gandomi et al only discusses septoplasty in the title and abstract and concludes that septoplasty provides subjective benefit to patients without mentioning in the abstract that 72% of the patients also underwent turbinate manipulation such as turbinectomy. The title and abstract of the article are misleading as the great majority of the patients in the study underwent both turbinate surgery and septoplasty, making it impossible to conclude the isolated benefit of any septoplasty. The authors do mention turbinate surgery in the results and discussion, but the article will be quoted as supporting the benefits of septoplasty alone, when, in fact, this is not the case. The subjective benefits provided by the surgery are not compared with any control as mentioned in the discussion, and this further weakens the case that the surgery provides any objective benefit above that of the placebo effects of surgery. Septoplasty can provide substantial benefits to correctly selected patients as demonstrated in previous work in this area using objective measures to select patients and demonstrate the efficacy of the surgery , but the present study only confuses the literature on the topic, especially for those who only read the title and abstract of published work.

Editorial Board

2012-01-01

Guidelines for Contributing Authors

2012-01-01

American Journal of Otolaryngology - Head and Neck Medicine and Surgery

Detecting and identifying nonrecurrent laryngeal nerve with the application of intraoperative neuromonitoring during thyroid and parathyroid operation

Snail as a novel marker for regional metastasis in head and neck squamous cell carcinoma

Similar cellular proliferation activities in nasal polyps and adjacentinferior turbinate

Surgical management of first branchial cleft anomaly presenting as infected retroauricular mass using a microscopic dissection technique

Use of the medicinal leech for salvage of venous congested microvascular free flaps of the head and neck

Association of prepro-orexin polymorphism with obstructive sleep apnea/hypopnea syndrome

A comparison of in vitro treatments for directing stem cells toward a sensory neural fate

Significance of adjunctive mitomycin C in endoscopic dacryocystorhinostomy

Annual temperature and the prevalence of frequent ear infections in childhood

Deep neck space infections: a retrospective review of 173 cases

Septal injection of botulinum neurotoxin A for idiopathic rhinitis: a pilot study

Wound healing gene therapy: cartilage regeneration induced by vascular endothelial growth factor plasmid

Surgical and hearing results of the circumferential subannular grafting technique in tympanoplasty: a randomized clinical study

Cochlea and other spiral forms in nature and art

Cutaneous Merkel cell carcinoma

A retrospective study of induction chemotherapy with docetaxel, cisplatinum, and 5-fluorouracil followed by concurrent radiotherapy with cetuximab in locally advanced head and neck cancer

Intended single-modality management of T1 and T2 tonsillar carcinomas: retrospective comparison of radical tonsillectomy vs radiation from a single institution

Early death from papillary thyroid carcinoma

Topical sucralfate for pain after oral CO2 laser surgery: a prospective, randomized, controlled trial

The tough tracheoesophageal puncture

Epistaxis after partial middle turbinectomy: the role of sphenopalatine artery ligation

Evaluation of the efficacy of caffeine cessation, nortriptyline, and topiramate therapy in vestibular migraine and complex dizziness of unknown etiology

Single photon emission computed tomography/computed tomography of the skull in malignant otitis externa

Human papillomavirus, smoking, and head and neck cancer

The use of robotics in otolaryngology–head and neck surgery: a systematic review

Balloon dilation of the pediatric airway: potential for disaster

Cochlear implantation after renal transplantation

Bilateral renal cell carcinoma metastasis in the oral cavity

Delayed postmastoidectomy bleed from anterior tympanic artery and its management using endovascular microcoils

Lemierre syndrome: a case report

Bilateral peritonsillar abscess: case report and literature review

Unique case of malignant transformation of a vestibular schwannoma after fractionated radiotherapy

Hypopharyngeal cancer in a pregnant woman

Inadvertent insertion of nasogastric tube into the brain stem and spinal cord after endoscopic skull base surgery

Superior oblique muscle palsy after frontal sinus mini-trephine

Non-Hodgkin lymphoma with hemorrhagic necrosis of the nasopharynx mimicking an abscess

Aggressive sinonasal natural killer/T-cell lymphoma with hemophagocytic lymphohistiocytosis

Misleading article on septoplasty

Editorial Board

Table of Contents

Guidelines for Contributing Authors