Πέμπτη 9 Σεπτεμβρίου 2021

Cochlear Implantation in Inner Ear Malformations: Considerations Related to Surgical Complications and Communication Skills

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Introduction: There are particular challenges in the implantation of malformed cochleae, such as in cases of facial nerve anomalies, cerebrospinal fluid (CSF) leaks, erroneous electrode insertion, or facial stimulation, and the outcomes may differ depending on the severity of the malformation. The aim of this study was to assess the impact of inner ear malformations (IEMs) on surgical complications and outcomes of cochlear implantation. Methods: In order to assess the impact of IEMs on cochlear implant (CI) outcomes, 2 groups of pati ents with similar epidemiological parameters were selected from among 863 patients. Both the study group (patients with an IEM) and control group (patients with a normal inner ear) included 25 patients who received a CI and completed at least 1 year of follow-up. Auditory performance, receptive and expressive language skills, and production and use of speech were evaluated preoperatively and at least 1 year after implantation. Types of surgical complications and rates of revision surgeries were determined in each group. Results: In the study group, the most common malformation was an isolated enlarged vestibular aqueduct (EVA) (44.8%). Overall, the patients with IEMs showed significant improvement in auditory-verbal skills. In general, the patients who had normal cochleae scored significantly better compared to patients with IEMs (p #x3c; 0.05). The complication rate was significantly lower in the control group compared to the study group (p = 0.001), but the rate of revision surgeries did not differ significantly (p = 0.637). Conclusion: It is possible to improve communication skills with CIs in patients with IEMs despite the variations in postoperative performances. Patients with EVA, incomplete partition type 2, and cochlear hypoplasia type 2 were the best performers in terms of auditory-verbal skills. Patients with IEMs scored poorly compared to patients with normal cochleae. CSF leak (gusher or oozing) was the most common complication during surgery, which is highly likely in cases of incomplete partition type 3.
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Application and Efficiency of Transnasal Humidified Rapid‐Insufflation Ventilatory Exchange in Laryngeal Microsurgery

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Objectives/Hypothesis

This study aimed to analyze the feasibility of transnasal humidified rapid-insufflation ventilatory exchange (THRIVE) during laryngeal microsurgery (LMS) and investigated its efficiency and application according to the location of the lesion.

Study Design

Retrospective chart review.

Methods

Patients over 20 years of age who underwent LMS without underlying cardiac, pulmonary, or cerebrovascular disease were retrospectively reviewed. Overall, 54 patients with endotracheal intubation (ETI) and 44 patients with THRIVE were included. The operation and anesthesia time, induction and emergence time, oxygen saturation (SpO2), and transcutaneous carbon dioxide (TcCO2) levels were analyzed and compared between the two ventilation methods according to disease subsite.

Results

Compared with ETI, patients with THRIVE presented reduced operation time (16.3 ± 9.69 min vs. 21.9 ± 12.0 min), anesthesia time (33.6 ± 11.4 min vs. 45.4 ± 13.9 min), emergence time (6.73 ± 2.49 min vs. 8.52 ± 3.17 min), without significant decreases in SpO2 but with increased TcCO2 (10.9 ± 6.12% vs. 7.33 ± 3.86%). Comparing THRIVE to ETI for lesions at the glottis yielded similar findings, which were particularly more significant. However, lesions above the glottis presented no significant difference for any parameters between THRIVE and ETI groups. Lesions involving multiple subsites and prolonged operation time were risk factors for the intraoperative conversion of ventilation method.

Conclusion

THRIVE is reliable for maintaining oxygenation during LMS and is efficient in reducing the operation and emergence times, leading to shorter anesthesia time, especially for lesions at the glottis. However, caution is required administering THRIVE, when lesion involves multiple subsites, and when operation time is prolonged.

Level of Evidence

3 Laryngoscope, 2021

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Pain Management Following Otological Surgery: A Prospective Study of Different Strategies

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Objectives

The aim of this study was to prospectively assess pain and associated analgesic consumption after otological surgery comparing two prescription patterns.

Study Design

A prospective nonrandomized consecutive cohort study.

Methods

125 adult patients undergoing ambulatory otologic surgery-cochlear implantation and endaural middle ear surgery, were assigned (according to surgeon's preference) and prospectively studied in two arms: 1) acetaminophen 500 mg + ibuprofen 400 mg; 2) acetaminophen 500 mg + codeine 30 mg. Pain levels, medication dose, disposal patterns of opioids, and suspected side effects were evaluated.

Results

All patients reported mild to moderate pain. There was a statistically significant reduction of pain from day to day, which was on average 0.26 lower than the day before. Sufficient pain control could be achieved with both drug regimens with no significant difference in pain levels. Only 50% of patients who were prescribed opioids used them. Additionally, the median tablet intake was 3 tablets while 10 to 20 tablets were prescribed. The majority of patients (97%) did not dispose of these drugs safely.

Conclusion

Adequate analgesia was achieved in both arms of this study. Pain control following otologic surgery with a combination of acetaminophen and nonsteroidal anti-inflammatory drugs is recommended unless contraindications or chronic opioid use are present. If opioids such as codeine (30 mg) are prescribed, the amount should be reduced as low as possible, such as five tablets, based on our studied population.

Level of Evidence

Level 3—a prospective nonrandomized consecutive cohort study Laryngoscope, 2021

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Τhe combined HT-SVV and HU-SVV test could be a powerful neuro-otologic examination for detecting pathologies in the vestibular otolithic pathway.

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https://doi.org/10.1016/j.anl.2021.08.010

Abstract
Objective
We previously established the head-tilt subjective visual vertical (HT-SVV) test to evaluate head-tilt perception gain (HTPG) in addition to the original head-upright SVV (HU-SVV) test (Wada-Y et al.: Laryngoscope Investig Otolaryngol, 2020). In this study, we aimed to investigate the HU-SVV and HT-SVV abnormality rates among patients with vertigo/dizziness.

Methods
Between July 2014 and December 2020, 357 patients were hospitalized for examining the HU-SVV and HT-SVV at our vertigo/dizziness center. Among these patients, 120 had Meniere's disease (MD), 99 had unilateral vestibular disease (UVD), 76 had benign paroxysmal positional vertigo (BPPV), 14 had vestibular migraine (VM), 13 had orthostatic dysfunction (OD), 12 had bilateral vestibular disease (BVD), 12 had central dizziness (CD), 7 had vestibular schwannoma (VS), and 4 had psychogenic dizziness (PD). We determined the reference values of the absolute HU-SVV (<2.5°) and HTPG (0.80–1.25) for the sitting position and used these for calculating the HU-SVV and HT-SVV abnormality rates in each type of vertigo/dizziness.

Results
Among the 357 patients, 111 had abnormal HU-SVV results (31.1%), 132 had abnormal HT-SVV results (37.0%), and 185 had abnormal HU-SVV and/or HT-SVV results (51.8%). The modified HT-SVV test in combination with the original HU-SVV test could detect gravity perception disturbance in patients with vertigo/dizziness significantly better than the original test alone (chi-square: p=0.00019). The HU-SVV, HT-SVV, and HU-SVV and/or HT-SVV abnormality rates were significantly higher in patients with peripheral vestibular diseases, i.e., MD, UVD, BPPV, and BVD than in those with other types of vertigo/dizziness, i.e., VM, OD, CD, VS, and PD (chi-square: p=0.010, p=0.020, and p=0.0025, respectively).

Conclusion
These findings suggest that the combined HT-SVV and HU-SVV test could be a powerful neuro-otologic examination for detecting pathologies in the vestibular otolithic pathway.

Keywords
Gravity perceptionOtolith functionSubjective visual verticalHead-tilt perception gainMeniere's diseaseBenign paroxysmal positional vertigo

Publication date: Available online 8 September 2021

Source: Auris Nasus Larynx

Author(s): Masaharu Sakagami, Yoshiro Wada, Tomoyuki Shiozaki, Ichiro Ota, Tadashi Kitahara

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Efficacy of the pretreatment geriatric nutritional risk index for predicting severe adverse events in patients with head and neck cancer treated with chemoradiotherapy: Efficacy of the pretreatment Geriatric Nutritional Risk Index for predicting severe adverse events

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Publication date: Available online 9 September 2021

Source: Auris Nasus Larynx

Author(s): Masahiro Nakayama, Kayoko Ohnishi, Masahiro Adachi, Rieko Ii, Shin Matsumoto, Masatoshi Nakamura, Hidetaka Miyamoto, Yuki Hirose, Bungo Nishimura, Shuho Tanaka, Tetsuro Wada, Keiji Tabuchi

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Submental Flap in the Reconstruction of Palatal Defects

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Abstract

Amongst oral cancers, malignancies of the palate and the upper gingivo-buccal complex are relatively uncommon. Following resection, defects in the palate lead to a nasal speech and nasal regurgitation on swallowing. This is best overcome with a prosthetic obturator which occludes the palatal defect and has dentures for the upper alveolus. It may not be possible to fit a prosthetic obturator in edentulous patients and in patients with trismus. Microvascular free flaps though commonly used for such defects, are time consuming, expensive and require a specialised setup. This study assesses the submental flap for its feasibility to repair palatal defects, the sturdiness of the flap, its functional outcome and the oncological safety in using the flap. This is a retrospective analysis of 46 patients, where palatal defects for oral cancers were reconstructed with the submental flap. Oncological safety was studied in 41 patients with a median follow-up of 34.5 month s. 20 patients were studied for their functional outcomes using the parameters, adopted from the University of Washington-Quality of Life questionnaire. Complete flap loss was seen in 4 (8.7%) patients while 2 (4.35%) patients had minor dehiscence. No donor site morbidity was reported. Locoregional Recurrences and distant metastasis were noted in 13 of the 41 patients studied. The mean score was highest for speech at 95.5% while the lowest mean score was for mouth opening at 42.5%. The submental flap is an effective and reliable alternative for the reconstruction of palatal defects.

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Recurrent Giant Mucoepidermoid Carcinoma of the Parotid: A Case Report and Review of Literature

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Abstract

Mucoepidermoid carcinoma is the most common salivary gland malignancy and about one third occurs in the parotid gland. The peak incidence is commonly seen between the third and fifth decades of life. It routinely presents as a fixed, painless mass below the ear. However, its presentation as a giant mass is exceedingly rare. Here, we report a case of a recurrent giant exophytic mucoepidermoid carcinoma in a young male. He underwent Revision Total Parotidectomy with Modified Radical neck dissection with Sural nerve grafting and an Anterolateral thigh flap reconstruction followed by Adjuvant radiotherapy. The rarity of the clinical presentation and the management challenges faced in a young male are being discussed in this case report.

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Is Revision Surgery Necessary for Patients With High Risk of Recurrence After Parotidectomy? A Multicenter Retrospective Study

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Ann Otol Rhinol Laryngol. 2021 Sep 8:34894211045269. doi: 10.1177/00034894211045269. Online ahead of print.

ABSTRACT

OBJECTIVES: Close margin is a frequent situation after parotidectomy. The need for systematic prophylactic revision surgery is a question that arises regularly for malignant tumors, as it exposes to a high risk of facial palsy, while oncological benefits are unclear.

STUDY DESIGN: retrospective study.

SETTING: Multicentric.

SUBJECTS AND METHO DS: We included all patients operated for systematic revision surgery in case of close margins after parotidectomy for a malignant tumor and analyzed the rate of tumor residue and its risk factors.

RESULTS: A tumor residue was identified in 43.5% of 23 cases, but none in case of initial complete excision with supra-millimetric margins. Invaded lymph nodes were identified in 6 cases, but none in case of low-grade tumors.

CONCLUSIONS: Systematic revision seems mandatory in case of infra-millimetric margins and high-grade tumors or positive lymph node; further studies are needed to confirm whether it can be spared for T1-T2/N0 low-grade tumors, with close margins but complete initial excision.

PMID:34496666 | DOI:10.1177/00034894211045269

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Neck Mass in an Adolescent

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Neck Mass in an Adolescent
Saikrishna C. Gourishetti, MD1; Jamie Hittman, MD2; Kevin D. Pereira, MD, MS1,3
Author Affiliations
1Department of Otorhinolaryngology–Head and Neck Surgery, University of Maryland School of Medicine, Baltimore
2Department of Pathology, University of Maryland School of Medicine, Baltimore
3Department of Pediatrics, University of Maryland School of Medicine, Baltimore
JAMA Otolaryngol Head Neck Surg. Published online September 9, 2021. doi:10.1001/jamaoto.2021.2314

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Text
A 13-year-old male presented to the pediatric otolaryngology clinic with a 2-year history of a right neck mass that had slowly increased in size. He denied any associated symptoms of pain, fevers, chills, malaise, night sweats, unintentional weight loss, prior history of neck masses, recent upper respiratory tract infections, or skin lesions. He was the product of a full-term pregnancy with up-to-date immunizations. Physical examination revealed a 2.5-cm firm, ovoid, mobile, and nontender mass at the apex of the posterior triangle of the right neck without any associated overlying skin changes. The remainder of the head and neck examination was unremarkable. Doppler ultrasonography revealed a 1.9 × 1.8 × 0.9-cm hypoechoic mass, and subsequent fine-needle aspirates demonstrated cells with elongated nuclei and eccentric blue cytoplasm in a background of myxoid stroma. The mass was excised in entirety without issue. At the time of surgery, the deep surface of the mass was foun d to be adherent to the sternocleidomastoid muscle. The lesion was resected with a cuff of muscle and sent for permanent histopathological examination. This revealed proliferation of bland spindle cells with plump nuclei and eosinophilic cytoplasm arranged as loose fascicles in a background of myxoid stroma (Figure 1). These cells were positive for mucin 4 (MUC4), epithelial membrane antigen (EMA), and transducing-like enhancer of split 1 (TLE1) immunohistochemical stains. Fluorescence in situ hybridization (FISH) revealed a positive FUS (16p11) gene rearrangement.

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This case report describes a 13-year-old male who presented with a 2-year history of a right neck mass that had slowly increased in size. What is your diagnosis?
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Evaluation of Nocturnal Enuresis After Adenotonsillectomy in Children With Obstructive Sleep Apnea

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Do children with nonsevere obstructive sleep apnea experience resolution of nocturnal enuresis after adenotonsillectomy?

Findings In this econdary analysis of a randomized clinical trial including 393 of the 453 totally enrolled children, those with nonsevere obstructive sleep apnea, those who underwent adenotonsillectomy were more likely to experience resolution of nocturnal enuresis compared with children who did not receive surgery. Nocturnal enuresis was less frequent in girls; other clinical factors, such as age, obesity, and severity of sleep apnea, were not associated with improvement of nocturnal enuresis.

Meaning The findings of this study suggest that it may be useful for clinicians to inquire about nocturnal enuresis in children with obstructive sleep apnea and counsel caregivers on the potential benefit associated with adenotonsillectomy.

Abstract
Importance Children with obstructive sleep apnea (OSA) are at increased risk for nocturnal enuresis (NE). However, randomized clinical trials assessing NE outcomes in children randomized to adenotonsillectomy (AT) vs watchful waiting are lacking.

Objective To assess the outcomes of AT vs watchful waiting in children with nonsevere OSA who experience NE.

Design, Setting, and Participants Secondary analysis of data from a multicenter randomized clinical trial conducted at tertiary children's hospitals was performed. Participants included 453 children aged 5.0 to 9.9 years with nonsevere OSA who were randomized to either watchful waiting or AT as part of the multicenter Childhood Adenotonsillectomy Trial. Caregivers completed the Pediatric Sleep Questionnaire, which includes a binary item on bed-wetting, at baseline and 7-month follow-up. The trial was conducted between October 2007 and June 2012. Evaluation in this secondary analysis involving NE occurred from October 2019 to March 2021.

Interventions Adenotonsillectomy vs watchful waiting in children with NE.

Main Outcomes and Measures Prevalence of NE as defined by parental response to the Pediatric Sleep Questionnaire bed-wetting item at baseline and 7-month follow-up.

Results Of the 453 children enrolled, 393 were included in analysis; of these, 201 were girls (51.1%). Mean (SD) age at baseline was 6.54 (1.40) years. At baseline, the number of children with NE was similar (2.6%; 95% CI, −0.12% to 0.07%) between the AT (59 [30.7%]) and watchful-waiting (67 [33.3%]) groups. The odds of NE in the watchful-waiting group were approximately 2 times higher than the AT group after 7 months (odds ratio, 2.0; 95% CI, 1.3 to 3.1). Following AT, there was a decrease (−11.0%; 95% CI, −16.3% to −5.7%) in the number of children with NE (n = 38). The prevalence of NE did not change significantly (−0.5%; 95% CI, −5.4% to 6.4%) in the watchful-waiting group (n = 66) at follow-up. Although NE was less frequent in girls (adjusted odds ratio, 0.53; 95% CI, 0.33-0.85), other clinical factors, such as age, race and ethnicity, obesity, and apnea-hypopnea index, were not associated with improvement of NE.

Conclusions and Relevance In this secondary analysis of a randomized clinical trial, AT for the treatment of pediatric OSA appears to result in improvement in NE. Further research is needed to assess whether AT is associated with long-term benefits for NE compared with watchful waiting.

Trial Registration ClinicalTrials.gov Identifier: NCT00560859

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This secondary analysis of a randomized clinical trial of children who underwent adenotonsillectomy for nonsevere obstructive sleep apnea evaluates the prevalence of nocturnal enuresis after the operation.
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Nodular Mass in the Earlobe of an 18-Month-Old Girl

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An 18-month-old girl presented with a 1-year history of a slow-growing mass in the right earlobe. There were no symptoms, such as tenderness or discharge, associated with the mass. She had no history of underlying medical disease or trauma. On physical examination, a 1.5 × 1.0–cm, firm, nodular, angulated, pinkish, nontender mass was observed in the posterior aspect of the right earlobe (Figure, A). The skin over the mass was semitransparent, and the mass moved freely beneath the skin. Under suspicion of a tumorous lesion, complete excision was performed after the patient received general anesthesia. Histopathologic findings were characteristic for 2 cell types; basaloid cells with a nucleus were present in the periphery, and ghost cells without a nucleus were present in the center (Figure, B). Six months after surgery, the wound had healed well, and there has been no recurrence.

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An 18-month-old girl presents with a firm, nodular, angulated, pinkish, nontender mass in the posterior aspect of the right earlobe. What is your diagnosis?
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