Retropharyngeal abscess: a clinical experience at the University College Hospital Ibadan

• Nwaorgu OG, Onakoya PA, Fasunla JA, Ibekwe TS.

Department of Otorhinolaryngology, College of Medicine University of Ibadan and University College Hospital Ibadan, Nigeria.

BACKGROUND: Infection within the retropharyngeal space could progress on to an abscess formation resulting into retropharyngeal abscess (RPA), which can either be acute or chronic. RPA can be a life-threatening emergency, with potential for airway compromise and other catastrophic complications. This review is aimed at highlighting our experience with patients with a diagnosis of retropharyngeal abscess. METHODS: Retrospective review of thirty patients with a confirmed diagnosis of retropharyngeal abscess, who were admitted and managed within an eleven-year period (1993 to 2003) in the Otolaryngology department of the University College Hospital Ibadan. RESULTS: There were fifteen males and females each with M:F ratio of 1:1, consisting of twenty-five children and five adults and their median age was 21 months and twenty three (77%) were younger than 5 years. It was observed that while the adult patients presented early for specialist treatment, the paediatric patients presented late. The major complaints were fever (87%), respiratory distress or stridor (57%), cough (53%), neck pain/swelling (43%), and refusal of feeds (30%). Other minor complaints were throat pain, difficulty in swallowing, anorexia, and weight loss. The commonest associated symptoms seen especially among the younger age group were nasal discharge, nasal blockage, tooth-ache, snoring and limitation of neck movement. CONCLUSION: The treatment of retropharyngeal space infections in children and adults should include accurate clinical diagnosis, empirical usage of broad-spectrum antibiotics, and timely surgical drainage.

       Source: Niger J Med. 2005 Oct-Dec;14(4):415-8.

The Edwin Smith Papyrus: the birth of analytical thinking in medicine and otolaryngology.

• Stiefel M, Shaner A, Schaefer SD.

Department of Otolaryngology, The New York Eye and Ear Infirmary, New York, NY, and Historical Collections, The New York Academy of Medicine, New York, NY 10003, USA. marcstiefel@nyc.rr.com

The Edwin Smith Papyrus, discovered in 1862 outside of Luxor, Egypt, is the oldest known surgical text in the history of civilization. The surviving scroll, a copy of an earlier text from around 3,000 B.C., gives us remarkable insight into the medical practice of ancient Egyptians in the Nile River bed during the dawn of civilization. The Papyrus is divided into 48 cases, most of which describe traumatic injuries. The text instructs the physician to examine the patient and look for revealing physical signs that may indicate the outcome of the injury. Although in modern medicine we take for granted that the use of physical examination and rational thinking lead to an accurate conclusion, 5,000 years ago, this was extraordinary. The Edwin Smith Papyrus cast aside the prevailing magic and mysticism of that time in favor of logic and deductive reasoning. As Egyptian civilization declined during the next millennium, the teachings of the Papyrus would be lost. It would not be until 300 B.C. when Hippocrates and his disciples in ancient Greece would once again revive logic in medical thinking and teaching. It is believed that the ancient Greeks had knowledge of the contents of the Edwin Smith Papyrus and its teachings and used them as the basis for their writings. As Europe entered the Dark Ages, so did medicine yet again, reverting to spells and prayers instead of judgment and reason. Although Hippocrates teachings were recognized by some scholars during the Middle Ages, they did not make up the basis for mainstream medical knowledge. With the dawn of the Renaissance, medicine would finally purge itself of its past supernatural foundation. Hippocratic teachings were used to form the basis of modern medicine, and medical pioneers in the 17 century studied the ancient Greek texts as the origin for their ideas. Many of the concepts physicians and patients today take as common knowledge originated in the Edwin Smith Papyrus. The authors attempt to uncover some of these fundamental ideas and trace them through time until their incorporation in our modern medical knowledge base. It is the rational, logical, and advanced thinking exhibited in the Edwin Smith Papyrus that mandates its respect from modern otolaryngologists and all physicians alike.

     

           Source:  Laryngoscope. 2006 Feb;116(2):182-8.

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Myringoplasty results in a district hospital in Botswana. Makaya IK. Moi Teaching and Referral Hospital, Eldoret, Kenya. This was a prospective study to determine the success rate of myringoplasty in a low-resource setting. Myringoplasty was performed on 85 patients and follow-up done for 6 months in order to determine the incidence of closure of the repaired tympanic membrane. The eardrum closure rate at 3 months was 88% and at 6 months 84%. There was a 62% positive change of more than 10 dB in the pure tone averages of air conduction at frequencies 500, 1000 and 2000 Hz and a 24% improvement of less than 10 dB. This compares favourably with results from other studies.          Source: Trop Doct. 2006 Jul;36(3):176-7. Codetection of serous otitis media and severe sensorineural hearing impairment in children–—the management dilemma            Olusesi A.D.*      Department of Ear, Nose & Throat, National Hospital, Plot 132, Central Area, Garki, Abuja, Nigeria Few cases of otitis media with effusion (OME) coexisting with severe to profound sensorineural hearing loss have been reported in medical literature, and beyond stressing need for awareness for early clinical detection, there is no statedguideline as to the management approach to such patients. The clinician is often in dilemma as to benefit or otherwise of myringotomy and ventilation tube placement insuch patients. We present two cases of such children attending our hearing loss clinic that both had clinical, tympanometric, and operative finding of OME. Both had bilateral myringotomy and ventilation tube placement, but showed very little improvement in hearing or speech conditions. Source: International Journal of Pediatric Otorhinolaryngology Extra (2006) 1, 56—59 Falls among institutionalized elderly in Alexandria. Makhlouf MM, Ayoub AI. Department of Family Health, High Institute of Public Health, University of Alexandria, Egypt. Falls are a common geriatric problem causing considerable morbidity, mortality, and affecting the quality of life of many elderly people. A cross sectional study was conducted to determine the prevalence and risk factors of falls among elderly people living in geriatric institutions in Alexandria. The total sample included 103 elderly females and 62 elderly males from six institutions. All participants were subjected to interviewing questionnaire to collect data about history, circumstances, outcome of falls, previous falls and history of diseases and drug intake It included also data about activities of daily living. Anthropometric measurements, blood pressure, postural hypotension assessment, complete physical examination and Tinetti scale for balance and gait could be completed for a sub-sample. The prevalence of falls was 32.1%. Most of the falls occurred during the daytime (77.4%), mainly in the bedroom or in the way from bed to bathroom (37.7% each). The most likely causes were slip/trip (41.5%) followed by dizziness/vertigo (32.1%). Fractures occurred in 20.8% of falls. Advanced age (70-79, 80 years and above), history of three or more falls, history of disability from previous falls, history of visual problem, history of cardiac and antihypertensive drug use, and mild impairment of balance and gait were significant risk factors for falls in the univariate analysis. All these factors except for the impairment of balance and gait were also significant predictors of falls in the multivariate analysis.   Source: J Egypt Public Health Assoc. 2000;75(5-6):507-28. Clinicopathological study of head and neck cancers in Ilorin, Nigeria. Ologe FE, Adeniji KA, Segun-Busari S. Department of Otorhinolaryngology, Faculty of Health Sciences, University of Ilorin, Ilorin, Nigeria. foluologe@yahoo.com Eighty-nine cases of head and neck cancers were studied over a 5-year period (1997--2001) at the University of Ilorin Teaching Hospital, Nigeria. The most common cancer affecting the head and neck region was carcinoma which constituted 70.8% of all the cases studied. It was followed by the lymphomas and blastomas which accounted for 20.2% and 9%, respectively. The nose/paranasal sinuses were the most common site of primary cancer (18%) followed by thyroid (12.4%), nasopharynx (11.3%) and larynx (4.5%). Other sites include a hypopharynx (3.4%), eye (2.2%), palate (2.2%), tongue (2.2%), skin (1.1%), lip (1.1%), salivary gland (1.1%), oropharynx (1.1%). Cervical lymph node metastasis with unknown primary lesion was seen in 10.1%.The peak age incidence was in the fifth decade of life. The improvement in locoregional control of head and neck cancers over the last decades does not appear to modify the final survival of these patients. It is crucial to understand as accurately as possible the risk factors for these malignancies in order to improve primary prevention.             Source: Trop Doct. 2005 Jan;35(1):2-4. Use of postoperative chest x-ray after elective adult tracheotomy. Smith DK, Grillone GA, Fuleihan N. Department of Otolaryngology-Head and Neck Surgery, Boston University, Massachusetts, 02118, USA. Surgeons have been creating tracheotomies since at least 124 AD, when first reported by Asclepiades (Price HC, Postma DS. Ear Nose Throat J 1983;62:44-59). Intraoperative and postoperative complications specifically associated with this procedure have been well established. The incidence of pneumothorax ranges from 0% to 17%, depending on the age group studied. To evaluate this complication, it is generally accepted that a postoperative chest film should routinely be obtained after a tracheotomy in adult patients. In adult nonemergent tracheotomies, the routine use of a postoperative chest film has a low yield for detecting a pneumothorax in patients without clinical findings of pneumothorax. To evaluate the use of postoperative chest x-ray in adult tracheotomy patients, a retrospective review of tracheotomies performed at the Boston Medical Center from January 1994 to June 1996 was undertaken. Data examined consisted of age, sex, surgical indication, urgency, operating service, intraoperative and postoperative complications, difficulty of procedure, anesthetic technique, findings on postoperative chest film, signs and symptoms of pneumothorax, and specific treatment of pneumothorax if present. In total, 250 patients were identified. The main indication for tracheostomy in this study was ventilator dependence, accounting for 77% of the procedures. A complication rate of 11.6% was encountered, with no deaths. Postoperative hemorrhage was the most common complication (3.6%). Pneumothorax was documented by chest x-ray in 3 (1.2%) patients, 1 of whom had bilateral pneumothoraces. The most common symptom of a pneumothorax was tachycardia, with 8.8% of the patients exhibiting at least 1 episode. Of the 3 cases of pneumothorax in this study, only 1 was clinically relevant and required treatment. Furthermore, the clinical signs and symptoms in this patient clearly supported the diagnosis of pneumothorax before a postoperative chest film was obtained. Thus postoperative chest radiographs did not change the treatment or outcome of any of the patients undergoing a tracheotomy. This suggests that postoperative chest x-ray after adult tracheotomy is not required in routine cases. Chest radiographs should be obtained after emergent procedures, after difficult procedures, or in patients exhibiting signs or symptoms of pneumothorax. South African survey on disinfection techniques for the flexible nasopharyngoscope. Lubbe DE, Fagan JJ. The Division of Otolaryngology, Groote Schuur Hospital, University of Cape Town, South Africa. delubbe@kingsley.co.za This random survey was to determine the flexible nasopharyngoscope disinfection practice employed by South African otolaryngologists and to establish whether a breach in the disinfection process exists. The study also aimed to identify organisms most likely to be transmitted via endoscopy and to propose a protocol for the disinfection of the flexible nasopharyngoscope. A questionnaire regarding disinfection techniques used for the flexible nasopharyngoscope was sent to 90 otolaryngologists in South Africa. All provinces were equally represented in the survey. Forty-five otolaryngologists out of a total of 90 participated in the study. Many of the otolaryngologists had no access to a flexible nasopharyngoscope and were therefore not included in the study. Fewer than 50 per cent of the 45 surgeons washed the instrument with soap/detergent and water after use. Only 42 per cent of surgeons used a FDA-approved disinfectant, 52 per cent of which immersed the scope for a shorter period than the recommended contact time. Of the 58 per cent using non-FDA-approved products, 33 per cent used only a 70 per cent Isopropyl alcohol wipe, without immersion of the scope in disinfectant solution. The remaining 25 per cent used non-FDA-approved disinfectants either by wiping or limited immersion of the scope. Of the 45 surgeons, 49 per cent used a different method of disinfection for high-risk patients. Strict guidelines have been proposed for the disinfection of this semi-critical device by the Association of Professionals for Infection Control (APIC) and the Centers for Disease Control (CDC). These guidelines are currently not being followed by many South African otolaryngologists. There is therefore a real risk of transmitting infectious diseases, especially tuberculosis, via endoscopy. Pepsin assay: A marker for reflux in pediatric glue ear Ahmed M. Abd El-Fattah MDa, , , Gamal A. Abdul Maksoud MD, PhDd, Ahmed S. Ramadan MD, PhDd, Ahmed F. Abdalla MD, PhDb and Mohamed M. Abdel Aziz PhDc aDepartment of Otolaryngology, Mansoura, Egypt bDepartment of Pediatrics, Mansoura, Egypt cDepartment of Biochemistry, Gastroenterology Center, Mansoura, Egypt dFaculty of Medicine-Mansoura University, and the Department of Otolaryngology, Faculty of Medicine-Zagazig University, Mansoura, Egypt. Objective To evaluate if analysis of pepsin/pepsinogen in middle ear effusions can be considered a diagnostic marker for laryngopharyngeal reflux (LPR) in children with otitis media with effusion (OME). Material and methods Ambulatory 24-hour dual-probe pH monitoring was carried out on 31 children with OME. Middle ear effusions were collected from 17 children during myringotomy. Total pepsin/pepsinogen concentrations in effusions were measured by ELISA using antipepsin antibody. Results Dual-probe pH monitoring showed that 22/31 (71%) of the studied children had significant LPR. The concentrations of pepsin/pepsinogen in middle ear effusions, ranged from 0.085 to 5.02 ?g/ml, were found to be up to 4.5 to 231.44 times higher than the serum levels. There was a significant positive correlation between the level of pepsin/pepsinogen assayed in the effusions of the 17 children and the number of pharyngeal reflux episodes measured by pH monitoring. Conclusions Control of LPR may be an essential component in the successful management of OME in pediatric patients. Pepsin/pepsinogen analysis in effusions of children, using ELISA, can be considered a reliable marker for assessment of reflux in children with OME         Source: Otolaryngology - Head and Neck Surgery  Volume 136, Issue 3 , March 2007, Pages 464-470 [Streptococcus milleri. An early sign of cancer in otorhinolaryngologic patients?] [Article in German] Stojan T, Muller W, Pfyffer G. Klinik fur Hals-, Nasen-, Ohren- und Gesichtschirurgie, Kantonsspital Luzern 6000, Luzern 16, Schweiz. Tomislav.Stojan@ksl.ch The Streptococcus milleri group, which also includes S. anginosus, S. intermedius and S. constellatus, is found in the oropharynx and gastrointestinal tract mucosa. Recent isolations of S. milleri DNA sequences have been made from both gastric and oesophageal carcinoma. There are only a few publications on the isolation of viable bacteria and S. milleri DNA, and their role in carcinogenesis, in otorhinolaryngologic malignoma. We present four patients with a cervical abscess and the isolation of S. milleri -group bacteria, without signs of malignancy or other risk factors. After a delay of several months, squamous cell carcinoma of the oropharynx was diagnosed in three patients and a neck metastasis without primary tumor in the fourth.   Source: HNO. 2006 Oct;54(10):778-80. Cryospray ablation (CSA) in the palliative treatment of squamous cell carcinoma of the esophagus   1Brooks D Cash, 2Lavonne R Johnston, 2Mark H Johnston, 1Department of Gastroenterology, National Naval Medical Center, Bethesda, MD 8901 Wisconsin Avenue, Bldg 9, Department of Gastroenterology, Bethesda, MD 20889. USA 2Lancaster Gastroenterology, Inc., 2112 Harrisburg Pike, Suite 202, PO Box 3200, Lancaster, PA 17604-3200, USA Abstract Background Esophageal carcinoma is the ninth most prevalent cancer worldwide with squamous cell carcinoma (SCCA) and adenocarcinoma accounting for the vast majority of new cases (13,900 in 2003). Cure rates in the U.S. are less than 10%, similar to lung cancer. More than 50% of patients with esophageal carcinoma present with unresectable or metastatic disease, are not surgical candidates, or display disease progression despite the addition of neoadjuvant chemoradiotherapy to surgery. Need for improved palliation exits. Case presentation: This case describes a 73-year-old African American male who presented with recurrent squamous cell carcinoma (SCCA) of the esophagus who has a achieved complete remission for 24 months via endoscopic cryospray ablation. Conclusion: Endoscopic cryo spray ablation warrants further investigation as a palliative treatment modality for esophageal cancer. This is the first reported case in the medical literature.. Source: World Journal of Surgical Oncology 2007, 5:34 Superglue in otology   H. Vishwanathan, D. W. Hamilton, E. Ibrahim, H. Youssef, A. L. Pahor   Birmingham, England, UK Correspondence to: Ahmes L. Pahor, 34 Ingham Way, Harborne, Birmingham, B17 8SN, England, UK Email: ahmesuk@yahoo.co.uk abstract Background: The use of stitches and staples for the closure of surgical wounds is associated with complications for both the surgeon and the patient. Histoacryl (butyl1-2cyanoacrylate glue) is widely used for wound closure in Accident and Emergency departments, in particular for facial and scalp wounds. Method: We have used Histoacryl for closure of various surgical incisions in a series of 50 cases and assessed the cosmetic outcome at three to four weeks. Results: There were no wound related complications in the form of infection or dehiscence. In one case however, there was formation of synechiae in the external auditory meatus following an endaural incision. Conclusion: We recommend the use of Histoacryl over traditional closure using skin suture material in otological surgery. Our experience was also successful in parotid cases. Keywords: tissue adhesives, Histoacryl Blue   Source: The Surgeon ( Journal of Royal Colleges of Surgeon of Edinburgh & Ireland ) February 2007 Vol 5 No 1 Emerging Trends in the Performance of Parathyroid Surgery Terris, David J. MD; Chen, Nan BS; Seybt, Melanie W. MD; Gourin, Christine G. MD; Chin, Edward MD Departments of Otolaryngology-Head and Neck Surgery (d.j.t., n.c., m.w.s., c.g.g.) and Medicine (Section of Endocrinology) (e.c.), Medical College of Georgia, Augusta, Georgia, U.S.A.   Objective: The management of hyperparathyroidism has evolved rapidly in the past decade with the introduction of intraoperative parathyroid hormone testing, radioguided surgery, and endoscopic surgery. Not surprisingly, there is a corresponding movement toward specialization of surgeons providing increasingly sophisticated treatments for head and neck endocrine disorders. We sought to identify trends in the disciplines performing parathyroid surgery. Design: Nonrandomized, controlled comparison of surgical caseloads and publication volumes. Methods and Materials: Two metrics designed to reflect the proportion of parathyroidectomies being performed by otolaryngologist-head and neck surgeons (OHNS) and general surgeons (GS) were chosen: the operative case logs of graduates from American training programs in OHNS and GS from 1996 through 2005 and the number of scientific papers published relating to parathyroid surgery during two timeframes (1991-1995 and 2001-2005). Results: There was a gradual increase in the mean number of parathyroid surgeries performed by GS residents from 6.0 in 1996 to a peak of 9.2 in 2004; this volume has begun to decline (to 8.5 in 2005). During the same timeframe, the mean number of parathyroidectomies performed by OHNS residents rose sharply and steadily from 1.8 in 1996 to 10.9 in 2005. The number of American GS parathyroid publications from 1991 to 1995 was 41, compared with 108 in the period 2001 to 2005. During the same timeframe, the number of American OHNS parathyroid papers increased from 1 to 27. The relative proportion of parathyroid publications authored by American otolaryngologists rose from 2.4% to 20.0% (P = .006). Conclusions: Increasingly, otolaryngologists are the primary surgeons in parathyroid operations as indicated by two surrogate metrics. Graduating chief residents in otolaryngology now perform more parathyroid procedures than chief residents in general surgery, and a growing proportion of parathyroid publications are being authored by otolaryngologists.   Source: The Laryngoscope April 3, 2007 (Publish ahead of print) Indirect fluorescence laryngoscopy in the diagnosis of precancerous and cancerous laryngeal lesions C. Arens1 , D. Reußner1, J. Woenkhaus2, A. Leunig3, C. S. Betz3 and H. Glanz1 (1) Department of Otorhinolaryngology/Head and Neck Surgery, University Hospitals Giessen and Marburg, Feulgenstrasse 10, 35385 Giessen, Germany (2) Institute of Pathology, University Hospitals Giessen and Marburg, Giessen, Germany (3) Department of Otorhinolaryngology/Head and Neck Surgery, Ludwig-Maximilians-University, Munich, Germany Abstract: Indirect fluorescence endoscopy of the larynx has proven to facilitate the detection and delineation of precancerous and cancerous lesion. The different methods are easy to handle and can be performed on an outpatient basis. Early diagnosis of laryngeal cancer and its precursor lesions is simplified. The aim of the present study is to compare indirect autofluorescence laryngoscopy to 5-ALA-induced PPIX fluorescence laryngoscopy. In a prospective study, 56 patients with suspected precancerous or cancerous lesions were primarily investigated by indirect autofluorescence laryngoscopy. In a second step 5-ALA-NaCl (0.6%) was topically applied to the larynx by inhalation, and indirect fluorescence laryngoscopy repeated 2 h after application. Autofluorescence as well as 5-ALA-induced fluorescence was induced by filtered light (375–440 nm) of a xenon short arc lamp and processed by a CCD camera system (D-light-AF System, Storz, Tuttlingen, Germany). White-light and fluorescence images were digitally recorded, immediately assessed for diagnosis and finally compared to pathohistological findings. Inconspicuous laryngeal mucosa presented a typical green fluorescence signal in autofluorescence endoscopy, which turned blue during 5-ALA-laryngoscopy. Precancerous and cancerous lesions displayed a loss of autofluorescence in autofluorescence endoscopy whereas increased protoporphyrin IX fluorescence could be observed in 5-ALA laryngoscopy. Both imaging techniques were suitable to distinguish benign from precancerous or cancerous lesions. In contrast PPIX fluorescence was easily recognized in scarred vocal folds. According to our results, both non-invasive fluorescence imaging techniques are useful in the early diagnosis of laryngeal cancer. Moreover autofluorescence can be used immediately without drug application and possible side effects. 5-ALA-induced fluorescence seems to be more suited for diagnostic examination of mucosal lesions in recurrent precancerous and cancerous lesions after surgery. The role of virtual reality in surgical training in otorhinolaryngology [General otolaryngology] Fried, Marvin Pa; Uribe, José Ib; Sadoughi, Babakb aDepartment of Otorhinolaryngology – Head and Neck Surgery, USA bSurgical Simulation Center, Department of Otorhinolaryngology – Head and Neck Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA   Abstract Purpose of review: This article reviews the rationale, current status and future directions for the development and implementation of virtual reality surgical simulators as training tools. Recent findings: The complexity of modern surgical techniques, which utilize advanced technology, presents a dilemma for surgical training. Hands-on patient experience – the traditional apprenticeship method for teaching operations – may not apply because of the learning curve for skill acquisition and patient safety expectation. The paranasal sinuses and temporal bone have intricate anatomy with a significant amount of vital structures either within the surgical field or in close proximity. The current standard of surgical care in these areas involves the use of endoscopes, cameras and microscopes, requiring additional hand–eye coordination, an accurate command of fine motor skills, and a thorough knowledge of the anatomy under magnified vision. A surgeon's disorientation or loss of perspective can lead to complications, often catastrophic and occasionally lethal. These considerations define the ideal environment for surgical simulation; not surprisingly, significant research and validation of simulators in these areas have occurred. Summary: Virtual reality simulators are demonstrating validity as training and skills assessment tools. Future prototypes will find application for routine use in teaching, surgical planning and the development of new instruments and computer-assisted devices. Source: Current Opinions in Otolaryngology & Head and Neck Surgery, Volume 15(3), June 2007, p 163–169 Voice rest after microlaryngoscopy: current opinion and practice.Behrman A, Sulica L. Center for the Voice, The New York Eye and Ear Infirmary, 310 East 14th Street, 6th Floor, New York, NY 10003, USA. abehrman@nyee.edu OBJECTIVE: Although voice rest is often recommended after excision of benign mucosal vocal fold lesions, no standard of care exists regarding the use, duration, or extent of vocal restrictions. This prospective study is intended to explore current opinions and practices of otolaryngologists regarding the use of complete and relative voice rest. STUDY DESIGN AND METHODS: A 16-item survey was mailed to all active U.S. members of the American Academy of Otolaryngology-Head and Neck Surgery (n = 7,321) regarding use of complete and relative voice rest after surgical excision of vocal fold nodules, polyps, and cysts. Treatment preference questions used a Likert 5-point scale with end anchors of 1 equaling "never" and 5 equaling "always". RESULTS: The response rate was 16.5% (1,208 respondents). Differences by lesion type were not statistically significant, suggesting that surgeons consider the mucosal disruption resulting from the surgery to be similar across lesions. Approximately 51.4% (620) favored complete voice rest. Approximately 62.3% (753) favored relative voice rest. Approximately 18% (213) of the respondents who "always" recommend complete rest also "always" recommend relative rest. The most common duration for both types of rest is 7 days. CONCLUSIONS: There is a clear preference for the use of voice rest, but the specific type (complete or relative) is controversial, and a notable percentage of respondents (15%) do not favor any type of voice rest. It is likely that the lack of uniformity of opinions and practices reflects the absence of empirical data. Prospective clinical trials are needed to guide clinical standards of care. Source: Laryngoscope. 2003 Dec;113(12):2182-6. Endoscopic management of limited attic cholesteatoma. Tarabichi M. Division of Otolaryngology, American Hospital-Dubai, Dubai, UAE. mtarabichi@ahdubai.com OBJECTIVES: Microscopic postauricular tympanomastoidectomy provides a limited exposure to the attic, especially anteriorly. In contrast, the endoscope offers wide transcanal access to the attic, allowing for complete removal of limited attic disease, possibly without interrupting the ossicular chain. This report evaluates 8 years of experience with transcanal endoscopic management of limited attic cholesteatoma. STUDY DESIGN: Case series. METHODS: Seventy-three ears with limited attic cholesteatoma underwent endoscopic transcanal tympanotomy and extended atticotomy to access and completely remove the sac. Disease was dissected off the tegmen, the medial and lateral attic walls, and the ossicles. Appropriate ossicular reconstruction was performed. The defect was reconstructed with a composite tragal graft. RESULTS: A transcanal endoscopic approach was adequate for removal of disease in all cases. There were no iatrogenic facial nerve injuries. Bone thresholds were stable. Disease was dissected off the head of the malleus and the body of incus with preservation of both in 24 ears. Mean follow-up was 43 months. Five ears required revision for recurrent disease, and eight were revised for failed ossicular reconstruction or persistent perforation. Moderate to severe retraction in other areas of the tympanic membrane was evident in 28 cases; none of these required further intervention. CONCLUSION: An endoscopic technique allows transcanal, minimally invasive, eradication of limited attic cholesteatoma. Preservation of the ossicles coupled with complete removal of disease is more likely with the endoscope. Source: Laryngoscope. 2004 Jul;114(7):1157-62. Safety and feasibility of balloon catheter dilation of paranasal sinus ostia: a preliminary investigation.Brown CL, Bolger WE. Department of Otolaryngology-Head and Neck Surgery, Alfred Hospital, Bayside Network, Melbourne, Australia. OBJECTIVES: Endoscopic sinus surgery (ESS) is an effective option for managing patients in whom medical therapy for rhinosinusitis fails. However, ESS is not always successful, and serious complications can occur. New techniques and instrumentation that improve outcomes and reduce complications would be seriously welcomed. Innovative catheter-based technology has improved treatment of several conditions such as coronary artery disease, peripheral vascular disease, and stroke. Recently, catheter devices have been developed for the paranasal sinuses. Cadaver studies confirm the potential use of these devices in rhinosinusitis. The objective of this investigation was to ascertain the feasibility and safety of these newly developed devices in performing catheter-based dilation of sinus ostia and recesses in patients with rhinosinusitis. METHODS: A nonrandomized prospective cohort of 10 ESS candidates was offered treatment with a new technique of balloon catheter dilation of targeted sinus ostia. The frontal, maxillary, and sphenoid sinuses were considered appropriate for this innovative catheter-based technology. The primary study end points were intraoperative procedural success and absence of adverse events. RESULTS: A total of 18 sinus ostial regions were successfully catheterized and dilated, including 10 maxillary, 5 sphenoid, and 3 frontal recesses. No adverse events occurred. Mucosal trauma and bleeding appeared to be less with catheter dilation than is typically observed with ESS techniques. CONCLUSIONS: Dilation of sinus ostial regions via balloon catheter-based technology appears to be relatively safe and feasible. Larger multicenter clinical trials are now warranted to further establish safety and to determine the role of this new technique. Source: Ann Otol Rhinol Laryngol. 2006 Apr;115(4):293-9   Screening patients with sensorineural hearing loss for vestibular schwannoma using a Bayesian classifier Nouraei, S.A.R.,* Huys, Q.J.M.,† Chatrath, P.,* Powles, J.,* & Harcourt, J.P.* *Department of Otolaryngology, Charing Cross Hospital, London, and Gatsby Computational Neuroscience Unit, Queen Square, London, UK Objectives: Selecting patients with asymmetrical sensorineural hearing loss for further investigation continues to pose clinical and medicolegal challenges, given the disparity between the number of symptomatic patients, and the low incidence of vestibular schwannoma as the underlying cause. We developed and validated a diagnostic model using a generalisation of neural networks, for detecting vestibular schwannomas from clinical and audiological data, and compared its performance with six previously published clinical and audiological decision support screening protocols. Design: Probabilistic complex data classification using a neural network generalization. Settings: Tertiary referral lateral skull base and a computational neuroscience unit. Participants: Clinical and audiometric details of 129 patients with, and as many age and sex-matched patients without vestibular schwannomas, as determined with magnetic resonance imaging. Main outcome measures: The ability to diagnose a patient as having or not having vestibular schwannoma. Results: A Gaussian Process Ordinal Regression Classifier was trained and cross-validated to classify cases as ‘with’ or ‘without’ vestibular schwannoma, and its diagnostic performance was assessed using receiver operator characteristic plots. It proved possible to pre-select sensitivity and specificity, with an area under the curve of 0.8025. At 95% sensitivity, the trained system had a specificity of 56%, 30% better than audiological protocols with closest sensitivities. The sensitivities of previously-published audiological protocols ranged between 82–97%, and their specificities ranged between 15–61%. Discussion: The Gaussian Process ORdinal Regression Classifier increased the flexibility and specificity of the screening process for vestibular schwannoma when applied to a sample of matched patients with and without this condition. If applied prospectively, it could reduce the number of ‘normal’ magnetic resonance (MR) scans by as much as 30% without reducing detection sensitivity. Performance can be further improed through incorporating additional data domains. Current findings need to be reproduced using a larger dataset. Source: Clin. Otolaryngol. 2007, 32, 248–254 Changes of Oral Trigeminal Sensitivity in Patients After Middle Ear Surgery  Tino Just; Susanne Steiner, Tobias Strenger, Hans W. Pau Objectives: The specific aim of this study was to re-investigate the effect of chorda tympani damage on both trigeminal sensitivity and taste ability. Study Design: Prospective study. Methods: Capsaicin-impregnated filter paper strips (5 concentrations, 0.0001–1%) were used to measure trigeminal thresholds. The strips were placed on the anterior tongue for 10 seconds. Thresholds were estimated in two ways: 1) thresholds related to sensory perception and 2) intensity-related thresholds. The test was applied to 29 patients who underwent middle ear surgery (mean age, 49 yr; 16 females, 13 males). Results were compared with those of 63 healthy subjects (mean age, 40 yr; 36 females, 29 males). In addition to trigeminal thresholds, measures of gustatory function were also obtained using both the validated “taste strips” test kit and electrogustometry. Results: For lateralized testing with capsaicin, significant differences were found between preoperative and postoperative thresholds and between the operated and nonoperated side, with thresholds being higher postoperatively on the operated side. The sensation-related thresholds from the operated tongue side exhibited a correlation with the corresponding postoperative electrogustometric thresholds. A higher degree of chorda manipulation was associated with higher postoperative capsaicin thresholds at the operated tongue side. Conclusion: Pain-related sensitivity of the tongue decreases after middle ear surgery, indicating that chorda tympani function also influences intraoral trigeminal sensitivity. Source: Laryngoscope 117: XX 2007 ENT challenges at the small scale. Coulson CJ, Reid AP, Proops DW, Brett PN. Department of Otolaryngology, University Hospital Birmingham, Birmingham, UK. chriscoulson@doctors.org.uk BACKGROUND: In this paper we consider two relatively frequently performed operations in the field of ear, nose and throat (ENT) surgery and consider how they could be improved by using robotic applications. We consider currently available robots and propose theoretical robotic solutions. METHODS: The application of robotic systems for both cochlear implantation and endoscopic sinus surgery was considered. Currently available robotic systems were reviewed and those with potential use in ENT surgery were identified. For aspects of operations where there is no available technology, hypotheses are presented on how robots could help. RESULTS: Three robotic systems were identified with potential usage in ENT: the Pathfinder neurosurgical robot, the Acrobot knee replacement system and the autonomous smart drill for drilling a cochleostomy. CONCLUSIONS: The challenge for the future of ENT is being able to perform tasks beyond the level of human perception and abilities. The examples presented here demonstrate that microtechnologies could be used to reduce complications, decrease operating time and improve clinical results Source: Int J Med Robot. 2007 Jun;3(2):91-6 Primary tumor volume calculation as a predictive factor of prognosis in nasopharyngeal carcinoma. Lee CC, Chu ST, Ho HC, Lee CC, Hung SK. Department of Otolaryngology, Buddhist Tzu Chi Dalin General Hospital, Dalin, Chiayi. Conclusions. Primary tumor volume (PTV) has a close relationship with survival rates of patients with nasopharyngeal carcinoma (NPC) who were treated with concurrent chemoradiotherapy (CCRT) or radiotherapy. Besides the current AJCC staging system, measurement of PTV may be needed to predict prognosis of NPC and adjust treatment strategy. Objectives. We conducted a retrospective study to elucidate the effect of PTV on treatment outcomes in patients with NPC who were treated with CCRT or radiotherapy. Patients and methods. A total of 66 patients with newly diagnosed NPC were enrolled in this study. Computed tomography (CT)-derived or magnetic resonance imaging (MRI)-derived PTV was calculated. The correlation between AJCC disease stage, PTV, and disease-specific survival was analyzed. Correlations between different prognostic factors were assessed using a Cox regression model. Results. The median PTV for the whole series was 12.01 ml (range 1.25-166.58 ml). The median PTV was 3.45 ml in T1 disease, 7.96 ml in T2 disease, 17.95 ml in T3 disease, and 64.73 ml in T4 disease. Disease stage and T stage carried no prognostic significance (p=0.25 and p=0.30, respectively). Four categories of PTV (<12.5 ml, 12.5-25 ml, 25-50 ml and >50 ml) had prognostic significance (p=0.02). Survival analysis demonstrated a significant difference in overall survival with larger tumor volume (risk ratio 5.447; p=0.044). Source Acta Otolaryngol. 2007 Aug 22;:1-5 External auditory canal closure: an alternative management for the refractory chronically draining ear Naohiro Yoshida, MD, PhD, Calhoun D. Cunningham III, MD, andJohn T. McElveen Jr, MD, Raleigh, NC; and Sendai, Japan OBJECTIVE: To discuss the surgical technique and evaluate the effectiveness of external auditory canal (EAC) closure in patients with refractory chronically draining ears. STUDY DESIGN AND SETTING: A retrospective case review of seven patients who underwent EAC closure for chronically draining ears at a private tertiary otologic referral center between 2001 and 2004. Three patients underwent concomitant placement of a BAHA implant, and one patient underwent cochlear implantation during a second-stage procedure. RESULTS: All seven patients had successful closure of the external auditory canal with elimination of chronic drainage. The follow- up interval ranged from 10 to 35 months. There were no cases of iatrogenic cholesteatoma formation or breakdown of the ear canal closure. CONCLUSION AND SIGNIFICANCE: In patients with refractory chronically draining ears, EAC closure, alone or in conjunction with a bone-anchored implant, may be a treatment option. A BAHA implant can be placed during the initial procedure or staged. Source: Otolaryngology–Head and Neck Surgery (2007) 137, 766-771 Deferring Planned Neck Dissection Following Chemoradiation for Stage IV Head and Neck Cancer: The Utility of PET-CT. Nayak JV, Walvekar RR, Andrade RS, Daamen N, Lai SY, Argiris A, Smith RP, Heron DE, Ferris RL, Johnson JT, Branstetter BF 4th. From the Departments of Otolaryngology (j.v.n., r.r.w., n.d., s.y.l., r.l.f., j.t.j., b.f.b.), Radiation Oncology (r.s.a., r.p.s., d.e.h.), Hematology–Oncology (a.a.), and Radiology (b.f.b.), University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA. OBJECTIVE:: To determine whether combined positron emission tomography and computed tomography (PET-CT) may be of value in deferring planned neck dissections for patients with advanced head and neck squamous cell carcinoma (HNSCC). STUDY DESIGN:: Observational study of patients with de novo cervical >/=N2 regional spread of HNSCC in a tertiary care academic medical center. METHODS:: Forty-three patients were identified who underwent post-treatment PET-CT within 6 months of completing neoadjuvant chemotherapy combined with radiation therapy (CRT). The PET-CT was "positive" if the radiologist recommended tissue sampling or resection of cervical lymph nodes, or if there was progressive neck disease in the setting of distant metastatic disease. Patients who had positive PET-CT underwent confirmatory biopsy given clinical suspicion for regional cervical metastasis without distant disease. Patients with negative PET-CT were followed clinically and radiographically for a minimum of 5 months (median 18.1 months) after CRT. RESULTS:: Ten (22%) of the 43 post-treatment PET-CT studies were positive. Seven of the 10 PET-CT scans (70% of positives) were true-positive given histologically-confirmed residual viable tumor or progressive disease including disease in the neck. The 3 remaining studies (30% of positives) were false-positive PET-CT results,given resolution of fluorodeoxyglucose (FDG) avidity on subsequent imaging or tissue sampling demonstrating absence of viable tumor cells. Of the 33 patients with negative PET-CTs in the neck, 1 patient had absence of FDG-avidity in the setting of malignant disease in the neck (3% false negatives); otherwise, patients with an initially negative PET-CT scan had no recurrences during the study (97% true negatives). This corresponds to a sensitivity of 87.5% (7/8), a specificity of 91% (32/35), a positive predictive value of 70% (7/10), a negative predictive value of 97% (32/33), and accuracy of 91% (39/43) for PET-CT scans in the detection of cervical metastatic disease after CRT. Overall, 37 (86%) of 43 patients were spared neck dissection using this technology without evidence of recurrent disease in the neck at extended follow-up. CONCLUSIONS:: Our results suggest that planned neck dissection after CRT for HNSCC may be deferred in favor of serial PET-CT imaging, and that sampling of areas of suspicious FDG-avid uptake can be rationally considered prior to therapeutic neck dissection. These data also suggest that negative PET-CT scans are highly reliable for the absence of residual cervical nodal disease. Source: Laryngoscope. 2007 October 4 [Epub ahead of print] Auditory brainstem implants. Schwartz MS, Otto SR, Shannon RV, Hitselberger WE, Brackmann DE. House Clinic, Los Angeles, California 90057. The development of cochlear implantation has allowed the majority of patients deafened after the development of language to regain significant auditory benefit. In a subset of patients, however, loss of hearing results from destruction of the cochlear nerves, rendering cochlear implantation ineffective. The most common cause of bilateral destruction of the cochlear nerves is neurofibromatosis type 2 (NF2). The hallmark of this genetic disorder is the development of bilateral acoustic neuromas, the growth or removal of which causes deafness in most patients. Patients with NF2 may benefit from direct stimulation of the cochlear nucleus. We describe the development, use, and results of the auditory brainstem implant (ABI), which is typically implanted via craniotomy at the time of tumor removal. Most patients with the implant have good appreciation of environmental sounds, but obtain more modest benefit with regard to speech perception. The majority of patients make use of the implant to facilitate lip reading; some can, to varying degrees, comprehend speech directly. We discuss future directions in central implants for hearing, including the penetrating ABI, the use of ABI in nontumor patients, and the auditory midbrain implant. Source: Neurotherapeutics. 2008 Jan;5(1):128-36. Purinergic signaling in the inner ear Jun Ho Lee a, Daniel C. Marcus b a Department of Otorhinolaryngology, Seoul National University College of Medicine, Seoul National University Hospital, 28 Yeongon-dong, Chongro-gu, Seoul 110-744, Republic of Korea b Department of Anatomy and Physiology, Kansas State University, 126 Coles Hall, 1600 Denison Avenue, Manhattan, KS 66506-5802, USA Abstract: Epithelial cells of the inner ear coordinate their ion transport activity through a number of mechanisms. One important mechanism is the autocrine and paracrine signaling among neighboring cells in the ear via nucleotides, such as adenosine, ATP and UTP. This review summarizes observations on the release, detection and degradation of nucleotides by epithelial cells of the inner ear. Purinergic signaling is thought to be important for endolymph ion homeostasis and for protection from acoustic over-stimulation Source: Hearing Research 235 (2008) 1–7.