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AMERICAN JOURNAL OF OTOLARYNGOLOGY-HEAD AND NECK MEDICINE AND SURGERY

High dose betahistine as effective as, but slower acting compared to intratympanic dexamethasone in intractable Meniere’s disease
Reviewed by: Rohit Verma
Vol 24 No 3
 

The management of intractable Meniere’s disease poses a complex conundrum to otolaryngologists. The focus of treatment is decreasing the severity and frequency of vertigo and tinnitus whilst trying to preserve hearing. Betahistine has been used for many years in the treatment of Meniere’s disease often in combination with dietary modification and/or diuretics. In recent years, intratympanic (IT) dexamethasone has gained popularity although there is no current consensus on a protocol for IT administration. Betahistine at high doses (144mg/day) has also been demonstrated to be effective. In this randomised study, 66 patients received either IT dexamethasone and placebo tablet or IT saline and betahistine. Tinnitus Handicap Inventory (THI) and Dizziness Handicap Inventory (DHI) were evaluated for every patient in addition to audiolological assessment. The IT injections were given once a day for three days. IT dexamethasone (1ml of 4mg/ml) was administered using a 22 gauge needle with the patient supine and affected ear facing upward for 30 minutes. Betahistine was given at 48mg TDS. Patients were followed up over one year and frequency of vertigo symptoms assessed every three months with telephone calls to check compliance and side-effect profiles. In total 14/33 patients receiving IT dexamethasone reported complete control of symptoms and only one no control. High dose betahistine resulted in 12/33 reporting complete symptom control with no control in two patients. There were no significant differences between the groups in post treatment audiological assessments. Side-effects for betahistine did not cause any patient to leave the study. This study suggests that whilst there is a current trend for intratympanic dexamethasone to treat intractable Meniere’s disease, it may still be worth trialing higher doses of betahistine before IT dexamethasone. However, IT dexamthasone works within three days whilst betahistine took three months to take effect, supporting its use in disabling vertigo spells.

Reference

Intratympanic dexamethasone versus high dosage of betahistine in the treatment of intractable unilateral Meniere disease.
Albu S, Chirtes F, Trabalzini F, et al.
AMERICAN JOURNAL OF OTOLARYNGOLOGY-HEAD
AND NECK MEDICINE AND SURGERY
2015;36(2):205-9.

AMERICAN JOURNAL OF OTOLARYNGOLOGY

Beware of GPA as a cause of subglottic stenosis
Reviewed by: Rohit Verma
Vol 24 No 3
 

Up to 92% of patients with granulomatosis with polyangiitis (GPA) have concurrent ENT manifestations of the disease. Whilst we are familiar with sinonasal and middle ear presentations of GPA, subglottic stenosis (SGS) is another important and potentially life threatening manifestation. SGS is present in up to 23% of patients with GPA and occurs more commonly in younger patients. It can occur in isolation and be the presenting feature of GPA or can occur late. Stenosis is often limited to the subglottis / proximal trachea but it may also extend distally into the proximal bronchi or affect more proximally at the larynx or glottis. The course of SGS with GPA appears to run independently from the systemic disease. This study from a single centre identified 35 patients with both GPA and SGS. Diagnosis of GPA was made using either tissue biopsy, ANCA serology or a combination of both. In 31% SGS was the presenting manifestation of GPA. The remaining patients developed SGS at a median of 2.5 years from diagnosis. Thirty-four percent had multi-level airway involvement with 23% developing vocal cord paralysis, usually from fixation at the cricoarytenoid joint. All but one patient had concurrent head and neck manifestations of disease in addition to SGS. This paper highlights that GPA should be a differential diagnosis for any patient with SGS, without a clear history of airway trauma. The authors advise on the basis of their single centre study that patients with GPA and SGS should undergo bronchoscopy at the time of any airway intervention or trachea-bronchoscopy performed regularly in any tracheostomy dependent patient.

Reference

Multilevel airway stenosis in patients with granulomatosis with polyangiitis (Wegener’s).
Guardiani E, Sheikh Moghaddas H, Lesser J, Resta-Flarer F, Blitzer A, Bhora F, Lebovics R.
AMERICAN JOURNAL OF OTOLARYNGOLOGY
2015;36(3):361-3.

AUDIOLOGY NEUROTOLOGY

Long-term results of incus vibroplasty in patients with moderate-to-severe sensorineural hearing loss
Reviewed by: Stuart Burrows
Vol 24 No 3
 

The Vibrant Soundbridge (VSB) middle ear implant is now a well-accepted and widely utilised treatment option for patients with sensorineural hearing loss unable to use standard hearing aids.  However, as a relatively recent addition to the portfolio of implants available to the otologist, there are few reports to date of long-term safety and efficacy. In this paper, the authors report a retrospective review of 122 adult ears (104 patients) that underwent VSB for sensorineural hearing loss using an incus vibroplasty technique. Cases performed for mixed or conductive hearing loss, or using other techniques for conduction of sound (i.e. round window or coupler vibroplasty) were excluded. Examining the whole group, the initial postoperative testing showed an average surgically-induced air-bone gap (ABG) of -2.7dB, though the degree of ABG was different at each frequency and was not found to be statistically significant at the most clinically important 2-4KHz frequencies. This ABG remained stable over time. A minor reduction in high frequency bone conduction (BC) levels was also seen at the initial postoperative stage, but interestingly not at follow-up beyond a year.  No significant difference in the age-related deterioration of BC thresholds over time was found between the implanted and non-implanted ear in 82 patients, including a group of 16 patients with the longest follow up (mean 11.1 years, range 8.2-13.9 years). A significant improvement in word recognition scores was seen at all stages of follow-up. These results suggest that inner and middle ear function remain stable following VSB surgery.

Reference

Long-term results of incus vibroplasty.
Maier H, Hinze AL, Gerdes T, Busch S, Salcher R, Schwab B, Lenarz T.  
AUDIOLOGY NEUROTOLOGY
2015;20:136-46.

AUDIOLOGY NEUROTOLOGY

Three years later: report on the state of well-being of patients with chronic tinnitus who underwent modified tinnitus retraining therapy
Reviewed by: Stuart Burrows
Vol 24 No 3
 

This paper reports on 130 patients with tinnitus of at least three months duration who underwent ‘Modified Tinnitus Retraining Therapy’ (MTRT). MTRT combines psychological and physical therapies with standard tinnitus retraining therapy provided as a course of multi-disciplinary treatment, as individuals and in groups, over seven days. Patients then received ongoing follow-up every three months. Patients with clinical depression and suicide risk were excluded from the study and treated separately. Study patients underwent a series of audiological and psychometric tests (tinnitus, stress and depression questionnaires as well as a global well-being scale) pre-treatment, at the end of the seven-day course, and at three years. At the initial assessment following treatment, tinnitus annoyance, overall stress perception and depressive symptoms showed significant reductions, and quality of life improved. These effects remained at three years. As might be expected, the largest improvements occurred in patients with the worst pre-treatment scores, with gender and age having a variable effect for each of the outcome measures. Interestingly, the hearing level and duration of the tinnitus had little effect on the outcome of the treatment. Whilst it is impossible to be sure that the improvements seen relate directly to MTRT, (such intensive treatment is unlikely to be routinely available in the UK National Health Service), this study highlights the need for tinnitus treatment to systematically address background psychological and physical problems.

Reference

Long-term results of modified tinnitus retraining therapy.
Seydel C, Haupt H, Szczepek AJ, Hartmann A, Rose M, Mazurek B.
AUDIOLOGY NEUROTOLOGY
2015;20:26-38.

B-ENT

Radiofrequency for tonsillectomy
Reviewed by: Sunil Sharma
Vol 24 No 3
 

This Turkish study compared the use of radiofrequency (RF) tonsillectomy to the more traditional cold steel dissection (CD) technique. The authors enrolled 114 patients undergoing tonsillectomy for chronic tonsillitis and tonsil hypertrophy (causing upper airway obstruction) over a 4-month period. Each patient underwent RF tonsillectomy on one side and CD tonsillectomy for the other side. Both patients and the surgeons were blinded as to which method was used on which side. The RF system utilises an alternating RF current which has dual functions for cutting and coagulation. The device calibrates the power output by measuring the tissue impedance, and cuts out once tissue death is achieved. Interestingly, all patients were given a 10-day prophylactic antibiotic course post-operatively and only oral paracetamol as analgesia. There was no significant difference between the two groups in terms of the mean operation time, but there was significantly lower intraoperative bleeding in the RF group. Post-operative pain was measured using a VAS scale, and throughout the post-operative period, the mean pain score was higher in the RF group compared to the CD group. Return to a painless dietary regime took four days longer in the RF group. This study describes yet another technique that can be used for tonsillectomy, but whether there is any superiority of this method over cold steel is debatable, particularly in terms of post-operative pain.

Reference

Impedance-controlled radiofrequency vs. cold dissection tonsillectomy.
Ozkul MH, Bayram O, Balikci HH, et al.
B-ENT
2014;10:285-89.

CLINICAL OTOLARYNGOLOGY

Outpatient injection laryngoplasty
Reviewed by: Andy Hall
Vol 24 No 3
 

The benefits of a local anaesthetic centred laryngoplasty service in the outpatient environment may interest surgeons and hospital managers alike. This case series looked at patients over a two-year period undergoing local anaesthetic injection laryngoplasty in outpatients. Patient-rated (Voice Performance Questionnaire) and observer rated (GRBAS score) outcomes for 57 individuals were recorded. The patient rated Voice Performance Questionnaire score showed a median improvement from 42 to 21 (P < 0.0001). Observer assessment (GRBAS) also reflected positively. The clear description of the technique used in this series is of great benefit to those with an interest in laryngology. Comparison with general anaesthetic techniques was not a focus of this series yet the potential ability to achieve auditory feedback at the time of procedure is attractive. The technical challenges of local anaesthetic procedures should not be underestimated however.

Reference

Injection laryngoplasty in the outpatient clinic under local anaesthetic: a case series of sixty-eight patients.
Powell J, Carding P, Birdi R, Wilson JA.
CLINICAL OTOLARYNGOLOGY
2014;39:224-7.

CLINICAL OTOLARYNGOLOGY

Paediatric coblation intracapsular tonsillectomy
Reviewed by: Andy Hall
Vol 24 No 3
 

The ENT-UK tonsillectomy audit in 2005 created understandable caution in the promotion of Coblation techniques. This prospective study on 100 consecutive paediatric patients looked at outcomes following ‘cold’ radiofrequency ablation (Coblation) intracapsular tonsillectomy. This series shows the technique to be associated with rapid recovery, no postoperative bleeding (early or late) or any need for re-admission. The mean T14 (Paediatric throat disorders outcome tool) score for both objective and infective domains fell dramatically. This early data suggests that Coblation intracapsular tonsillectomy is likely to become an area of great interest to ENT surgeons who regularly perform tonsillectomy in children. This is surely an area where a randomised control trial would provide invaluable information if constructed correctly. In the mean time, large scale case series such as this are piquing interest in the technique.

Reference

Our experience. Coblation® intracapsular tonsillectomy (tonsillotomy) in children: a prospective study of 100 consecutive cases.
Hadjisymeou S, Modayil PC, Dean H, et al.
CLINICAL OTOLARYNGOLOGY
2014;39(5):301-7.

COCHLEAR IMPLANTS INTERNATIONAL

Cochlear implantation in immunosuppressed patients. Is it feasible?
Reviewed by: Thomas Nikolopoulos
Vol 24 No 3
 

The effectiveness of cochlear implantation has led to a relaxation of the candidate criteria. Patients who had been rejected in the past may now be accepted and their outcomes are encouraging. However, the acceptance of immunosuppressed patients as cochlear implant candidates is rather challenging as the risk of infection may put not only the device at risk (need for explantation) but also their lives due to a possible infection that may be difficult to control. The authors describe the first reported case of successful cochlear implantation in a patient who had previously undergone successful combined liver and kidney transplant. The authors describe the precautions that they had taken in order to minimise the risk and claim that they did not have any significant complications from surgery with a very good audiological outcome at three months. However larger studies are needed in order to assess the real risk of cochlear implantation in immunosuppressed patients.

Reference

Cochlear implantation in a patient with combined renal and liver transplantation.
Mahalingam S, Mathew R, Patel S, et al.
COCHLEAR IMPLANTS INTERNATIONAL
2014;15(6):333-6.

COCHLEAR IMPLANTS INTERNATIONAL

Neurosarcoidosis: another aetiologic factor for deafness and labyrinthitis ossificans
Reviewed by: Thomas Nikolopoulos
Vol 24 No 3
 

Very few studies describe deafness secondary to neurosarcoidosis as the latter is a rare inflammatory disorder of the nervous system usually associated with facial nerve and optic nerve disorders. This interesting case report describes a rare case of cochlear ossification as a result of neurosarcoidosis in a patient with bilateral profound sensorineural hearing loss. At the time of surgery, the cochleostomy revealed that the scala tympani was ossified and drilling did not achieve to identify a lumen. Therefore, the authors decided to proceed with a scala vestibuli insertion which was successful. Although the follow-up was rather short after the operation (four months), the outcome was encouraging. I fully agree with the authors that early imaging and monitoring of these patients is recommended and signs of cochlear obliteration should lead to timely assessment and possible surgery as an emergency.

Reference

Bilateral sensorineural hearing loss and labyrinthitis ossificans secondary to neurosarcoidosis.
Dhanjal H, Rainsbury J, Irving RM.
COCHLEAR IMPLANTS INTERNATIONAL
2014;15(6):337-40.

EUROPEAN REVIEW OF ENT

Military acoustic trauma: incidence and management
Reviewed by: Badr Eldin Mostafa
Vol 24 No 3
 

This is a retrospective study on the effects of acute acoustic trauma on the hearing thresholds of 225 military personnel. The main symptom after acute acoustic trauma due to firearm use was tinnitus. The authors consider it as the main indicator of acoustic trauma. The second symptom was hearing loss. It was commoner in the left ear with a mean loss of 33.98 dB HL at presentation. The main frequencies affected were 4 and 6 KHz. All patients were managed within 24 hours. They were hospitalised and received and IV infusion of methylprednisolone (1.5 mg/kg/day) in the morning and pentoxyfilline 300 mg twice daily. The majority were treated for five days with a maximum of 10 days. In more severe cases and those not responding within 48 hours hyperbaric oxygen therapy was added for two sessions. Audiograms were evaluated on admission, at discharge and one month later. The average audiometric gain was 13.85 dB HL at discharge and 18.28 dB HL on the later evaluation. In 40% of cases hearing loss was permanent especially if the initial loss was 40 dB or more. One of most recognised risk factors is non-compliance with the use of ear protectors. Most responders mentioned malpositions, falls and interference with their field performance by hampering auditory interaction with their environment and balance problems.

Reference

Acute acoustic trauma, a retrospective analysis about 225 military cases.
Bonfort G, Billot D, Trendel D, et al.
EUROPEAN REVIEW OF ENT
2014;135(1):25-31.

HEARING RESEARCH

Aided speech auditory brainstem response
Reviewed by: Faiz Tanweer
Vol 24 No 3
 

Auditory brainstem response (ABR) is commonly used for hearing screening and is considered as one of the important means of objective audiometry. Speech ABR is a relatively new concept and is regarded as a marker of speech encoding at the brainstem level. One of the potential uses of speech ABR is in selection and evaluation of hearing aid performance. Measurement of speech ABR can be associated with artefacts. Here authors have used wireless techniques to transmit the stimulus to the hearing aid to reduce artefacts caused by head movement. Data were recorded using a new 32 channel BrainAmp EEG system. It improved signal-to -–noise ratio and quality of speech ABR. A high quality speech ABR can provide precise spectro-temporal information on auditory processing. This research work is an improvement over previous studies using low frequency auditory steady state response (ASSR) and cortical evoked response audiometry (CERA). However, this study is based on the responses obtained from four healthy adult subjects only. Further study on a larger number of subjects is required, specifically in hearing impaired children, before the widespread use of technology. This technique can be valuable in difficult to evaluate patients who require hearing aids.

Reference

Speech auditory brainstem response through hearing aid stimulation.
Bellier L, Veuillet E, Vesson J F, Bouchet P, Caclin A, Thai-van H.
HEARING RESEARCH
2015;325:49-54.

INTERNATIONAL JOURNAL OF LANGUAGE AND COMMUNICATION DISORDERS

English language development in bilingual toddlers
Reviewed by: Gauri Mankekar
Vol 24 No 3
 

It is known that bilingual children have a smaller vocabulary in each of their two languages than monolingual children and also take a little longer to reach the same levels as monolinguals on various grammatical tasks. The authors of the article assessed 35 bilingual six year olds exposed to British English and an additional language and 36 British monolingual toddlers on the auditory component of the Preschool Language Scale, British Picture Vocabulary Scale and object naming measure. The results indicated that the proportion of exposure to English was the main predictor of the performance of bilingual toddlers and that typically developing toddlers who are bilingual in English and another language and who hear English 60% of the time or more, perform equivalently to their typically developing monolingual peers.

Reference

How much exposure to English is necessary for a bilingual toddler to perform like a monolingual peer in language tests?
Cattani A, Abbot-Smith K, Farag R, et al.
INTERNATIONAL JOURNAL OF LANGUAGE AND COMMUNICATION DISORDERS
2014;49(6)649-71.

INTERNATIONAL JOURNAL OF PEDIATRIC OTORHINOLARYNGOLOGY

How young is too young for tympanoplasty?
Reviewed by: Patrick Spielmann
Vol 24 No 3
 

This paper presents the largest series of pre-school age children undergoing tympanoplasty compared with older children. The authors have collected much prospective data on 259 children undergoing 284 surgeries so were able to perform multivariate analysis. The age groupings of two to four years, five to seven years and 8-13 years were analysed separately to look for predictors of success/failure. The very young children were shown to have a five -fold greater risk of re-perforation compared with the oldest age group even in the relatively short follow-up of (median) seven months. The authors argue that despite the improvement in quality of life and modest hearing gains, the risk of graft failure and need for revision surgery are too high so surgery should be delayed if at all possible.

Reference

The effect of age on paediatric tympanoplasty outcomes: A comparison of preschool and older children.
Duval M, Grimmer JF, Meier J, et al.
INTERNATIONAL JOURNAL OF PEDIATRIC OTORHINOLARYNGOLOGY
2015;79:336-41.

JOURNAL OF LARYNGOLOGY AND OTOLOGY

For how long is post-pinnaplasty head bandage really necessary?
Reviewed by: Madhup K Chaurasia
Vol 24 No 3
 

It is customary to put on a head bandage after pinnaplasty and the general consensus is that it should remain on for about a week to prevent haematoma and splint the reshaped pinna in place. In this review article, the authors identified 34 papers of which seven met their inclusion criteria. Only one was a randomised controlled trial (RCT), one ‘quasi’ RCT, three case series and one review article. In the RCT comprising 78 children, there was no statistically significant difference in the complication rates between children having the bandage for just 24 hours compared to those having it for a week. In the quasi RCT study, the complication rate was ten percent more in the non-bandaged group. The general observation from other studies was that putting a bandage on does not reduce complications. The authors note that discomfort, pain and need to replace the bandage within a week has not been considered as a complication. It would appear that it is not necessary to bandage after pinnaplasty for more than 24 hours considering prolonged bandaging can produce serious complications such as cartilage necrosis and pressure sores.

Reference

Should the duration of head bandaging be reduced after pinnaplasty? A systematic review.
McMurran AEL, Khan I, Mohammad S, et l.
JOURNAL OF LARYNGOLOGY AND OTOLOGY
2014;128:948-51.

JOURNAL OF THE AMERICAN ACADEMY OF AUDIOLOGY

Stimulation for tinnitus
Reviewed by: Cheka Spencer
Vol 24 No 3
 

Tinnitus is known to be inhibited by stimulation of the auditory system by stimuli such as acoustical, electrical and magnetic. Residual inhibition (RI) is when tinnitus is temporarily eliminated for a period of time lasting seconds, minutes, up to hours or even days in some people. There are various theories to explain tinnitus. Some studies hypothesise that it is a trade-off between a central gain increase and neural noise – which seeks to maintain neural homeostasis. This study sought to investigate tinnitus and RI mechanisms further; in particular alterations in auditory change detection and memory related to RI induced by electrical stimuli. This was done using a novel technique of brain mapping – mismatch negativity focusing on the fact that tinnitus is considered an alteration of neural activity. The study was well designed as a single-blind randomised controlled clinical trial with two groups: auditory electrical stimulation (AES) and placebo electrical stimulation. Thirteen of 28 participants with problem tinnitus (46.42%) indicated RI after receiving AES. All of the comparisons made in this study achieved statistical significance. One of the conclusions to be drawn is that RI induced by AES reflects the temporary reestablishment of auditory change detection in tinnitus sufferers. As tinnitus is not completely understood its treatment is also complicated. This study indicates that inducing RI could potentially provide long term relief. Further research is needed and mismatch negativity mapping is a promising tool.

Reference

Alterations in auditory change detection associated with tinnitus residual inhibition induced by auditory electrical stimulation.
Mahmoudian S,  Farhadi M,  Mohebbi M,  Alaeddini F,  Najafi-Koopaie M, Farahani ED, Mojallal H, Omrani  R, Daneshi A, Lenarz T.
JOURNAL OF THE AMERICAN ACADEMY OF AUDIOLOGY
2015;26(4):408-22.

JOURNAL OF VOICE

The laryngeal microdebrider – a useful adjunct in the surgical treatment of Reinke’s oedema?
Reviewed by: Christopher Burgess
Vol 24 No 3
 

The surgical treatment of Reinke’s oedema traditionally involves a cold steel incision placed in the lateral aspect of the vocal fold with aspiration of the characteristic gelatinous contents. In this paper, the authors compare voice outcomes in patients treated with either the carbon-dioxide laser (n = 10) or the laryngeal microdebrider (n = 16). Specifically, the carbon-dioxide laser was used in the first group for a lateral mucosal incision followed by aspiration of the vocal fold contents, whereas a cold-steel incision was used in the second group followed by microdebrider debulking of vocal fold contents and redundant mucosa. The laser settings were 1W, superpulse, continuous mode whilst the microdebrider was used in oscillation mode with a maximum speed of 800 rpm and low suction. The trial design was prospective and randomised, with the voice assessors blinded to treatment arm. Comparison of pre- and postoperative voice quality on the GRBAS scale showed consistent improvement in all parameters in both the laser and the microdebrider group, although the improvements in breathiness and strain parameters were not statistically significant in either group. Improvements in grade of hoarseness, roughness and asthenia were reported to be significantly greater after microdebrider surgery relative to laser surgery. Improvements in other acoustic voice parameters (fundamental frequency, jitter, shimmer, noise-to-harmonic ratio and maximal phonation time) were additionally significantly greater in the microdebrider group. It is debatable whether the carbon dioxide laser is an appropriate comparator to use in surgery for Reinke’s oedema. Nevertheless the use of the microdebrider to facilitate the surgical treatment of Reinke’s is conceptually appealing, and this paper would appear to confirm that good voice outcomes can be achieved.

Reference

Assessment of voice quality after carbon dioxide laser and microdebrider surgery for reinke edema.
Burduk PK, Wierzchowska M, Orzechowska M, Kaźmierczak W, Pawlak-Osińska K.
JOURNAL OF VOICE
2015;29(2):256-259.

NEUROSURGERY

Clival chordoma recurrence
Reviewed by: Showkat Mirza
Vol 24 No 3
 

Chordomas are generally slow growing and are histologically considered low grade tumours. Their high recurrence rate even after postoperative radiation renders them difficult to treat. This is particularly true for clival chordomas whose deep anatomic location and proximity to vital anatomic structures makes surgical resection challenging. This paper retrospectively reviews 50 patients over a 20 year period treated at the Centre for Minimally Invasive Skull Base Surgery in San Francisco. Thirty-four of the cases had a transphenoidal approach. Other approaches included trans-oral, craniotomy and staged approaches. Post-operative radiation included 19 cases of proton beam, seven with cyber knife, six with intensity modulated radiation therapy and 10 with external beam. At last follow-up 23 / 47 patients remained disease free or had stable residual tumour. As expected, gross tumour removal reduced chordoma recurrence. The lower third of the clivus frequently harboured residual or recurrent tumour despite staged approaches. Several investigators advocate proton beam radiation because its sharp dosimetry decline at the tumour edge minimises the radiation dose to which the surrounding normal structures are subjected. This paper found no benefit of proton based over photon based radiation, contradicting conventional presumptions.

Reference

Factors predicting recurrence after resection of clival chordoma using variable surgical approaches and radiation modalities.
Jahangiria A, Chin AT, Wagner JR, et al.
NEUROSURGERY
2015;76(2):179-86.

OTOLOGY AND NEUROTOLOGY

Damage to the cochlear nucleus with electrocautery to the cochlear nerve
Reviewed by: Anand Kasbekar
Vol 24 No 3
 

This study is of importance to neurotologists and neurosurgeons. It is unclear why patients with NF2 have poorer outcomes with an auditory brainstem implant compared to non-tumour patients. This effect is postulated to be due to damage to certain cells in the cochlear nucleus that are needed for sound modulation either by the tumour or the surgery to remove it. This study looked at the effect transecting the cochlear nerve has on the cochlear nucleus with and without electrocautery in anaesthetised adult gerbils. They effectively showed that electrocautery close to the root entry zone caused significant cochlear nucleus cell body injury. Transection of the cochlear nerve away from the root entry zone along with distal electrocautery did not show any histopathological damage to the cochlear nucleus when sectioned and looked at under a microscope. This encourages surgeons to debulk tumours and peel them medially before applying electrocautery. It is however not very clear how this accurately translates to humans and the exact distance one would need to keep from the brainstem before electrocautery can be safely applied.

Reference

Effect of cochlear nerve electrocautery on the adult cochlear nucleus.
Iseli CE, Merwin WH 3rd, Klatt-Cromwell C, et al.
OTOLOGY AND NEUROTOLOGY
2015;36(4):670-7.

RHINOLOGY

Quality of life after FESS or balloon sinuplasty
Reviewed by: Lakhbinder Pa
Vol 24 No 3
 

This randomised control trial compared the SNOT-22 questionnaires both pre-operatively and three months post-operatively in patients with chronic rhinosinusitis undergoing either FESS or balloon sinuplasty to the maxillary sinus. Forty two patients participated in the study, 21 in each treatment group. There was a subjective improvement in symptoms after surgery in both groups. An objective improvement in the quality of life was seen as a decrease in the total SNOT 22 score. Both balloon sinuplasty and FESS significantly improved all the parameters of the SNOT-22 questionnaire, with no significant difference being found between the two groups. Since no significant difference was found between traditional FESS and balloon sinuplasty in terms of improvement in SNOT-22 parameters, the authors suggest further studies on the cost-benefit of balloon sinuplasty due to its high material costs. It should be noted that this is a short-term study as follow-up with SNOT-22 was at three months post-op only.

Reference

Quality of life after endoscopic sinus surgery or balloon sinuplasty: a randomised clinical study.
Bizaki AJ, Taulu R, Numminen J, Rautiainen M.
RHINOLOGY
2014;52:300-5.

RHINOLOGY

Quality of life outcomes in paediatric endoscopic sinus surgery
Reviewed by: Lakhbinder Pa
Vol 24 No 3
 

This prospective cohort study evaluated chronic rhinosinusitis patients aged 5-18 years undergoing endoscopic sinus surgery in terms of quality of life. General and chronic rhinosinusitis surveys were completed by the parents and the child pre-ESS and at 30-90 days post-operatively. They found that general quality of life was improved pre-operatively and sinus symptoms improve significantly one to three months after sinus surgery. Parents reported statistically worse chronic rhinosinusitis symptom scores than the children.

Reference

Comprehensive quality of life outcomes for pediatric patients undergoing endoscopic sinus surgery.
Taylor RJ, Miller JD, Rose AS, et al.
RHINOLOGY
2014;52:327-33.

RHINOLOGY

Rhinosinusitis in secondary school children - Part 2: main project analysis of MSNOT-20 Young Persons Questionnaire (MSYPQ)
Reviewed by: Lakhbinder Pa
Vol 24 No 3
 

This study used the modified SNOT-20 in Young Persons Questionnaire (MSYPQ) to evaluate the prevalence and effects of rhinosinusitis in adolescent children (aged 11-16 years). This was performed in three large secondary schools in the UK with one group completing the MSYPQ and another the ARIA-based questions for comparison. This involved face to face interviews and postal surveys. 71% scored an abnormal value on the MSPYQ for at least one symptom, 32% of those assessed suffered from symptoms compatible with rhinitis and more than 20% suffered from the effects on quality of life. Cough was one of the significant symptoms (80%), followed by nasal discharge (75%) and malodourous breath (50%). The ARIA group showed that symptoms were intermittent in 44% and confirmed significant impairment of sleep and daily activities. The authors concluded that the MSYPQ demonstrates a high prevalence and impact on quality of life of rhinitis and rhinosinustis symptoms in adolescents, with levels comparable to results from an adult population. They also concluded that the MSYPQ rhinitis subgroup of questions was concordant with ARIA-based questions.

Reference

Rhinosinusitis in secondary school children – Part 2: main project analysis of MSNOT-20 young persons questionnaire (MSYPQ).
Sami AS, Scadding GK.
RHINOLOGY
2014;52(3):225-30.

THE HEARING JOURNAL

New aminoglycosides with reduced ototoxicity risk
Reviewed by: Linnea Cheung
Vol 24 No 3
 

Aminoglycoside antibiotics are widely used for infections affecting patients of all ages and at different sites, however they carry a risk of ototoxicity, nephrotoxicity and rarely peripheral neuropathy. Preventing ototoxicity is crucial to the maintenance of auditory function and quality of life in patients treated with aminoglycosides. This short article reviews the work on assessment of the cytotoxic properties of apramycin (an aminoglycoside used widely in veterinary medicine), paromomycin (used for protazoal parasitic infections) and sisomicin (a modified biosynthetic precursor of gentamicin) tested on in vitro animal models. Apramycin resulted in significant reduction in threshold shifts and cochlear hair cell loss when compared with gentamicin. Paromomycin and sisomicin both resulted in negligible losses of hair cells. Due to the particular properties of these agents, the article concludes that aminoglycosides that do not bind effectively to eukaryotic ribosomes, or those that are modified with a methysulfonyl group, result in reduced risk of hair cell death and hearing loss. The next steps for research are to evaluate the long-term effects of administration, and identify quantities for correct dosing in the presence of infection.

Reference

Novel aminoglycoside antibiotics show reduced ototoxicity risk.
Steyger P.
THE HEARING JOURNAL
2015;68(4):32-5.

THYROID RESEARCH

Ultrasound assessment of metastatic disease
Reviewed by: Adam Shakir
Vol 24 No 3
 

This Japanese study of 10 patients over 15 years, assesses the role of ultrasonography in assessing metastatic disease to the thyroid gland, specifically renal clear cell carcinoma (RCCC). Whilst uncommon, the authors state that there is a favourable prognosis when RCCC is confined to the thyroid gland and is amenable to surgery. They used five assessment markers when evaluating thyroid glands with ultrasonography, and found that RCCC formed one or two well demarcated lesions within the thyroid gland and was not diffusely involved. With two patients, postoperative histological analysis identified previously unknown RCCC arising from the kidney. Ultrasonography was used in conjunction with fine needle aspiration cytology (FNAC), with false negatives reported in four out of 10 patients. The authors recommended in their discussion for thyroglobulin levels to be analysed in FNAC washouts to help determine primary thyroid clear cell disease or disease arising elsewhere. Their conclusion was that preoperative assessment of these patients’ thyroid glands was useful and correlated well with postoperative histological analysis.

Reference

Metastatic carcinoma to the thyroid gland from renal cell carcinoma: role of ultrasonography in preoperative diagnosis.
Kobayashi K, Hirokawa M, Yabuta T et al.
THYROID RESEARCH
2015;8:4

AMERICAN JOURNAL OF OTOLARYNGOLOGY-HEAD AND NECK MEDICINE AND SURGERY

Chemo-radiation in elderly patients with head and neck cancers
Reviewed by: Rohit Verma
Vol 24 No 2
 

Chemo-radiotherapy is the standard of care for organ preservation in stage three and four oropharyngeal cancer, prospective data on patients over 65 has not been available as they are usually excluded from randomised trials. This paper reviews the experience of a single institution on 32 patients aged between 65 and 87 (median 74). Karnofsky Performance score was >70 for all patients and co-morbidities that were adequately controlled with medical therapy were included. These co-morbidities included diabetes, coronary arterial disease, hypertension and stroke. Radiotherapy was delivered at 68-70Gy. In total 29 patients received platinum based chemotherapy, three received cituximab / nimotuzimab. Mean overall treatment time was 49.4 days (44-65 days). Response was assessed six to eight weeks after treatment was completed using RECIST criteria with toxicities measured against National Cancer Institute common toxicity criteria. Ninety percent of patients completed the planned doses of radiotherapy and at least five cycles of chemotherapy. This is higher than in other studies quoted. One patient developed septicaemia during the treatment and did not complete treatment. For acute toxicity, 6% patients experienced grade three skin toxicity, with 14 experiencing grade three mucosal toxicity. Significant late toxicity (grade 3>) was only seen in six percent of patients. Tumour response in the 31 patients completing treatment was evaluated six to eight weeks after treatment. Complete response was seen in 29 (77%) patients with partial response in seven. In the cohort of partial response, all received salvage chemotherapy and are still alive. Loco-regional control at two years was 72%, with survival at two years of 89%, better than previous studies. The authors conclude that radical chemo-radiation is a valid treatment for option for organ preservation in well elderly patients, with special emphasis on nutritional support and oral hygiene. Further stage III trials are needed to draw definitive conclusions.

Reference

Chemoradiation in elderly patients with head and neck cancers: a single institution experience.
Kataria T, Gupta D, Kumar V, et al.
AMERICAN JOURNAL OF OTOLARYNGOLOGY-HEAD
AND NECK MEDICINE AND SURGERY
2015;36(2):117-21.

AMERICAN JOURNAL OF OTOLARYNGOLOGY-HEAD AND NECK MEDICINE AND SURGERY

Seeking medical attention with tonsillectomy complications depends on who you are. Lessons from the USA
Reviewed by: Rohit Verma
Vol 24 No 2
 

In the current UK model, NHS care is free at point of access so there are no perceived economic barriers to seeking attention with postoperative complications. This study from the US examines surgical and emergency room databases from across California, Iowa, Florida and New York for 2010-11 assessing revisits within 14 days of tonsillectomy in adults. Common presenting symptoms were pain, bleeding and fever / nausea / vomiting / dehydration (FVND). Associations with age, sex, race, median household income and co-morbidity scores were analysed. Ethnicity was identified as White, Black, Hispanic or Other. 17836 tonsillectomies were performed (63.7% female, median age 29.0). Revisit rates for bleeding was 5.1%, FVND was 1.5% and pain 2.8%. Female sex was associated with lower rates of revisit for bleeding but higher rates for pain than males. Similar disparities were seen for revisit rates for pain and FVND between ethnic groups. Lower household income was associated with higher rates of revisit for pain. Multivariate analysis of revisits for bleeding reveals that only female sex was associated with a decreased bleeding rate, the other demographic factors did not impact significantly. Female sex also increased odds for revisits with pain or FVND. Increasing household income decreased the likelihood of visits for pain. Black or Hispanic ethnicity increased likelihood for revisit with pain relative to white patients but did not alter rate for revisits for FNVD. By undertaking a multi-state, cross sectional analysis, this paper highlights that statistically significant disparities exist between groups in their experience of postoperative complications and their healthcare seeking behaviour. Postoperative recovery from tonsillectomy is often difficult for patients. Identification of populations at elevated risk of complications can help to reduce the disparity and relieve some of the associated costs of revisits to the healthcare economy and to the patient.

Reference

Healthcare disparities in revisits for complications after adult tonsillectomy.
Bhattacharyya N.
AMERICAN JOURNAL OF OTOLARYNGOLOGY-HEAD
AND NECK MEDICINE AND SURGERY
2015;36(2):249-53.

B-ENT

Cochlear implantation and inner ear malformations
Reviewed by: Sunil Sharma
Vol 24 No 2
 

In this study the authors attempted to compare the outcomes in children who underwent cochlear implantation (CI) with inner ear malformations to those that had normal inner ear anatomy. Sixty three children with prelingual deafness who underwent CI were included. Twelve of these patients had inner ear malformations including enlarged vestibular aqueduct, a common cavity, incomplete partition, and cochlear hypoplasia. Outcomes were measured at intervals up to two years post-surgery (pre-operatively, and at six, 12, and 24 months post-operatively) using the Categories of Auditory Performance (CAP) and Speech Intelligibility Rating (SIR) scores. In both groups the CAP and SIR scores increased with time after implantation, and there was no significant difference in the scores between the two groups at any of the four follow-up assessments. The authors compare the results to other studies, which have suggested limited improvement in patients with CI with inner ear abnormalities. These papers hypothesise that there are reduced spiral ganglion cell numbers in patients with inner ear malformations, and therefore CI is not as effective. The authors hypothesise that the reason for their seemingly good outcomes may be the fact that they have selected a group of children early in their development, as compared to some other studies. This paper demonstrates that CI in children with inner ear malformations can be of similar benefit to CI in children with normal inner ears if performed early enough in a child’s development.

Reference

Evaluation of cochlear implantation in children with inner ear malformations
Zhou H, Sun X, Chen Z, et al.
B-ENT
2014;10:265-9.

B-ENT

External auditory canal carcinoma
Reviewed by: Sunil Sharma
Vol 24 No 2
 

Although uncommon, primary malignant tumours of the external auditory canal (EAC) are associated with a poor prognosis as they often present late. In this study the authors evaluate the clinical and pathological factors associated with treatment and outcome of EAC carcinomas. They identified 23 patients over a 20-year period for inclusion, with a range of pathology from T1 to T4. Interestingly, in half of patients the main presenting complaint was otorrhoea, closely followed by otalgia. The majority of cases of EAC carcinoma were SCC (70%), followed by adenoid cystic carcinoma (22%), basal cell carcinoma (4%) and verrucous carcinoma (4%). The majority of patients underwent surgical treatment (83%), including total canal resection, lateral temporal bone resection, parotidectomy and supraomohyoidal neck dissection. Only one patient received postoperative chemoradiotherapy (CRT), whilst seven patients had postoperative radiotherapy (RT). The 5-year survival rate was 75.2% and 10-year survival was 60.2%. SCC patients had a significantly poorer prognosis compared to the other histological subtypes. As one might expect, those patients who had surgical treatment with post-operative CRT / RT had a significantly better prognosis than those patients who had unresectable disease. Although the numbers in this study are small, it highlights the importance of having a high index of suspicion of EAC carcinoma, as it presents with very non-specific symptoms. No patients in the study had cranial nerve palsies, and the presence of these suggests a very poor prognosis indeed. Perhaps the main conclusion to take away is that EAC carcinomas should be treated aggressively with complete resection and postoperative CRT.

Reference

Carcinoma of the external auditory canal: histological and treatment groups.
Hosokawa S, Mizuta K, Takahashi G, et al.
B-ENT
2014;10:259-64.

CLINICAL OTOLARYNGOLOGY

Botulinum toxin in ENT
Reviewed by: Andy Hall
Vol 24 No 2
 

This comprehensive review neatly summarises non-cosmetic uses of botulinum toxin within otorhinolaryngology, it is perhaps easy to forget the medical use of botulinum toxin has now been approved for the last thirty years. Its overall safety profile places it as an attractive minimally invasive treatment option in a wide range of conditions including voice disorders, facial scarring and dysphagia. The current evidence base for both injection sites and reported mean total doses are included, giving a practical overview to the treatments themselves. Spasmodic dysphonia is perhaps one of the areas where botulinum toxin use to inhibit laryngeal hyperkinesias has been well established. A key distinction is shown however between the abductor and adductor variants, with much higher rates of effectiveness demonstrated in the latter with duration of benefit between 6-15 weeks.

Reference

The use of botulinum toxin in otorhinolaryngology: an updated review.
Mandavia RO. Dessouky O. Dhar V, D’Souza A.
CLINICAL OTOLARYNGOLOGY
2014;39:203-9.

CLINICAL OTOLARYNGOLOGY

Unilateral vocal cord mobility impairment and laryngopulmonary physiology
Reviewed by: Andy Hall
Vol 24 No 2
 

The concept of iatrogenic recurrent laryngeal nerve injury following thyroid surgery is often considered with respect to voice change but its potential impact on airway physiology has thus far not been evaluated. A cross-sectional observational study reviewed 21 patients with unilateral vocal fold mobility impairment (UVFMI) against 53 control patients with no history of lung disease or laryngeal pathology. The authors identified a reproducible flow-volume loop pattern suggestive of selective inspiratory airway obstruction in UVFMI patients. The findings allow flow-volume loops to act as an objective measure of laryngeal abductor function. The authors recognise the potential value in confirming a diagnosis of recurrent laryngeal palsy or indeed measuring a change in airway physiology as an arbiter of success in vocal cord medialisation procedures. The hidden prevalence of UVFMI (and indeed better understanding of surgical complications) may perhaps be better understood through incorporation of this easily accessible physiological test, particularly where other surgical disciplines may not have access to post-operative laryngoscopy.

Reference

Impact of unilateral vocal fold mobility impairment on laryngopulmonary physiology.
Nouraei SA, Whitcroft K, Patel A, et al.
CLINICAL OTOLARYNGOLOGY
2014;39:209-15.

COCHLEAR IMPLANTS INTERNATIONAL

Does head trauma as aetiology of deafness affect the outcomes of cochlear implantation?
Reviewed by: Thomas Nikolopoulos
Vol 24 No 2
 

Head trauma associated with temporal bone fractures is a well known aetiological factor for deafness. The literature assessing the outcomes of cochlear implantation in such cases is rather limited. In this paper, the authors compared the performance of implantees with deafness secondary to head trauma, with controls who had another aetiology of deafness. The results of the study revealed that the performance of the group of cochlear implant adult users who have acquired hearing impairment after head trauma was globally lower than that of the group of hearing impairment with other aetiologies. Few comparisons were found statistically significant and this may be attributed to the small number of participants in the head trauma group (only 14). It seems that head trauma co-morbidities may affect the outcome and auditory rehabilitation may improve the outcome. However, better study design with more patients could clarify these rather theoretical views.

Reference

Auditory rehabilitation after cochlear implantation in adults with hearing impairment after head trauma.
Alves M, Martins JH, Moura JE, et al.
COCHLEAR IMPLANTS INTERNATIONAL
2014;15(6):312–7.

COCHLEAR IMPLANTS INTERNATIONAL

How do the rejected candidates for cochlear implantation feel?
Reviewed by: Thomas Nikolopoulos
Vol 24 No 2
 

This interesting study from the UK explored, using personal interviews, how rejected candidates for cochlear implantation feel and deal with the decision not to implant. The authors assessed 10 adult cochlear implant candidates who had undergone the evaluation process were found not eligible for implantation, mainly due to audiological reasons. Although most of their hearing was too good for implantation, as assessed by the audiologists, they themselves felt rather isolated both socially and emotionally. Moreover, they felt that their hearing loss affected their work. Finally, the participants’ general view was that speech discrimination testing and the other audiological measures in the assessment process do not reflect their everyday life and therefore were disappointed and felt that their expectations had not been met. It is clear that these views should be taken into account in a more patient orientated pathway.

Reference

The experiences of adults assessed for cochlear implantation who did not proceed.
Athalye S, Mulla I, Archbold S.
COCHLEAR IMPLANTS INTERNATIONAL
2014;15(6):301-11.

CURRENT OPINION IN OTOLARYNGOLOGY HEAD AND NECK SURGERY

Facial pain and headaches
Reviewed by: Susan A Douglas
Vol 24 No 2
 

This paper reviews the present knowledge and the recent publications on the cause, characteristics, course and treatment of chronic and recurring facial pain and headaches. Facial pain should be defined in terms of frequency, duration and severity, and also in terms of quality, site and accompanying factors such as photophobia, nausea or vomiting and exacerbation on physical exertion. Rating the intensity of the pain from zero (no pain) to 10 (unbearable pain) is helpful because higher pain levels are associated with facial migraine or cluster headache. Pain distribution is important because migraine, cluster headache and paroxysmal hemicrania are usually unilateral. Daily and constant pain is unlikely to be of rhinogenic origin. Although chronic facial pain has conventionally been considered to be due to sinusitis because of anatomical proximity, there is increasing evidence to support the contrary.
The key points are as follows:
I.     Facial pain is an uncommon symptom of chronic rhinosinusitis. Only 20% of patients with purulent sinusitis or nasal polyposis confirmed by nasal endoscopy actually complained of facial pain.
II.     A temporal correlation of episodes of facial pain with rhinogenic symptoms of nasal obstruction, rhinorrhoea and hyposmia, and the presence of endoscopic and CT scan evidence of sinusitis are important to consider the pain to be of rhinogenic origin.
III.     Chronic facial pain is most likely to be due to nonrhinogenic causes. Facial pain of nonrhinogenic origin is a diagnosis of exclusion. Chronic tension-type facial pain followed by facial migraine is the commonest type of nonrhinogenic facial pain in a community setting.
IV.    An eight week course of low-dose tricyclic antidepressants is a well tolerated and effective first line of treatment for chronic facial-tension-type pain and facial migraine. Addition of pindolol reduces analgesic consumption by reducing pain intensity.

Reference

Rhinogenic and nonrhinogenic headaches.
CURRENT OPINION IN OTOLARYNGOLOGY HEAD AND NECK SURGERY
Aguis AA, Sama A.
2015;23:15-20.

CURRENT OPINION IN OTOLARYNGOLOGY HEAD AND NECK SURGERY

Treatment algorithm for olfactory disorders
Reviewed by: Susan A Douglas
Vol 24 No 2
 

The purpose of this paper is to review the current evidence in diagnosing olfactory disorders and suggest an algorithmic approach to patients with relevant complaints. Age-associated olfactory loss is often multifactorial and requires a careful history and physical exam. A table demonstrating the common causes of olfactory disorders is given describing the aetiology under the headings - obstructive / conductive (septal deviation, nasal polyposis, sinonasal neoplasms), sensorineural (ageing, post infection, neurodegenerative) delineating anatomic obstruction and mixed (CRS, sinonasal surgery, medication). MRI is helpful for further evaluation of sinonasal tumors skull-base diseases, lesions with intracranial or facial soft-tissue extension, and confirmation of agenesis of the olfactory bulb as in Kallmann syndrome. Psychophysical tests have a role in screening patients at risk for Parkinson’s and Alzheimer’s disease, but there is lack of evidence regarding timing and patient selection. Olfactory training is suggested to be an emerging modality in patients with post-infection olfactory loss. Patients with CRS may require medical management and surgical treatment for alleviation of their symptoms.
The key points are as follows:
I.     All patients with impaired olfaction should undergo complete nasal endoscopy and psychophysical olfactory testing.
II.     At present, olfactory testing cannot be used as a guide for prognostication or to direct potential therapy.
III.     There is no unique characteristic that can be used to predict which CRS phenotype will have the greatest improvement in olfaction after endoscopic sinus surgery.
IV.    Olfactory training is a promising non-invasive treatment modality for improvement of post-infection hyposmia and anosmia.
V.    Safety counselling is an indispensable part of the treatment in patients with olfactory disorders.

Reference

An algorithmic approach to the evaluation and treatment of olfactory disorders.
Daramola OO, Becker SS.
CURRENT OPINION IN OTOLARYNGOLOGY HEAD AND NECK SURGERY
2015;23:8-14.

DYSPHAGIA

Prophylactic swallowing exercises in head and neck cancer
Reviewed by: Roganie Govender
Vol 24 No 2
 

Clinicians working in head and neck cancer will be familiar with the increased interest in prophylactic swallowing exercises to reduce the devastating impact of dysphagia experienced by patients undergoing radiation or chemo-radiation therapy. This study from Denmark is one of only a handful of RCTs designed to test the effectiveness of providing patients with exercises prior to the start of their treatment. The purpose is to maintain the function of the swallowing musculature and possibly delay or reduce long-term fibrotic changes, keeping patients eating by mouth for a longer period. The study did not show any significant benefit in the intervention group compared with the usual care control group on all of the multidimensional swallowing outcome measures at any of the multiple time points up until 11 months post radiotherapy. The primary outcome measure was the Swallowing Performance Status Scale (SPSS), but secondary measures included the EORTC, MBS, clinical measures (weight, mouth opening, tube feeding, DAHANCA dysphagia scale) and patient compliance. Findings were similar in both groups at the different time points with a similar change over time. Only 51% of patients were available at the final follow-up (dropout rate reported to be similar in both arms) with only 53% of patients reporting adherence to the exercise protocol at week five of radiotherapy and 33% at 11 months post. The authors provide a good discussion about their findings in relation to other studies as well as problems encountered in their own study. They also provide a very useful table in the supplementary information describing the current evidence for the effect of swallowing exercises on different endpoints. This paper has all the elements (methodological quality, challenges of conducting an RCT with this population, is there enough evidence yet to be “pushing” prophylactic exercises in clinical practice, lessons for future studies) for an interesting journal club discussion!

Reference

Prophylactic swallowing in head and neck cancer radiotherapy.
Mortensen HR, Jensen K, Aksglaede K, et al.
DYSPHAGIA
Published online 19 Feb 2015
DOI 10.1007/s00455-015-9600-y

EAR AND HEARING

Communication patterns during audiological rehabilitation history taking
Reviewed by: Vinaya Manchaiah
Vol 24 No 2
 

Nature of communication among patients, their communication partners and hearing healthcare professionals is an important part of audiological rehabilitation and can have some influence on the patient outcome. As history taking quite often forms the first instance of communication between patients and professionals it is an important stage in the development of relationship and in the success of subsequent shared decision making. This study was aimed at exploring the nature of verbal communication among patients, audiologists and companions during history taking and also the factors associated with communication dynamics. Video recording of 63 audiology consultations were made and the consultations were coded using the Roter Interaction Analysis System and divided into three consultation phases, which included: history, examination and counselling. Further, they analysed the history-taking phase in terms of opening structure, communication profiles of each speaker, and communication dynamics. Results suggest that on an average the history taking took about 9 minutes and a companion was present only in 27% of the consultations. The three areas of communication were: opening structure, information exchange and relationship building. Audiologists tend to control the history opening structure by using closed-ended questions in about 62% of the time. In addition, audiologists often interrupted patients. Generally, audiologists dominated the history taking session by asking 97% of the questions and asked primarily closed-ended questions including topics such as biomedical and psychosocial / life-style. Few emotionally focused utterances were observed from any speaker (less than 5% of utterances). These results provide an insight on what was overlooked from the previous literature highlighting that little involvement of patients during history taking in terms of evoking their own responses. These findings are important in implementing patient-centered audiological rehabilitation.

Reference

Communication patterns in audiologic rehabilitation history-taking: audiologists, patients, and their companions.
Grenness C, Hickson L, Laplante-Lévesque A, et al.
EAR AND HEARING
2015;36(2):191-204.

EUROPEAN REVIEW OF ENT

To monitor or not to monitor
Reviewed by: Badr Eldin Mostafa
Vol 24 No 2
 

This is a report on an e-mail based survey of 1249 otologic surgeons on their practice regarding facial nerve monitoring during ear surgery. The response rate was very low (6.6%). The majority of responders (92%) stated that they did not use facial nerve monitoring during stapes surgery, ossiculoplasty or myringoplasty. In cochlear implant surgery 78% monitored the facial nerve. As regards non-cholesteatomatous CSOM, the majority (68%) did not use the monitor. On the other hand, in primary surgery for cholesteatoma, 52% of the responders used the monitor. This proportion rose to 62% in revision cases. For the vast majority (97%) the choice to monitor was based on CT data especially if the lesion was diffuse, near the course of the facial nerve or if a bony dehiscence was suspected. One of the limiting factors for the availability and / or use of facial nerve monitors seems to be economic restraints including the initial and running costs in addition to poor coding for the procedure.

Reference

Facial nerve monitoring during middle ear surgery: results of a French survey.
Mazzaschi O, Juvanon J-M, Mondain M, et al.
EUROPEAN REVIEW OF ENT
2014;135(1):11-7.

EUROPEAN REVIEW OF ENT

Vestibular screening in occupational medicine
Reviewed by: Badr Eldin Mostafa
Vol 24 No 2
 

Occupational vestibular disorders carry a high medico legal and economic burden. The occupational medicine physician must rely on rapid, non-invasive, economical and reproducible screening tests. This article compares the simplified caloric test of Veits (CTV) with the skull vibration-induced nystagmus test (SVINT) in 87 workers. The end points were reproducibility, tolerance and duration of the examination. The mean duration of the CTV was 15 minutes whereas that of SVINT was one minute. In 69 subjects there were autonomic side-effects to CTV whereas SVINT was much better tolerated. The authors conclude that the SVINT should be included in the screening of subjects during occupational medical check-ups. It is a rapid, robust and reliable test as it is not influenced by compensation.

Reference

Benefit of skull vibration induced nystagmus test in occupational medicine.
Beatrice F, Karkas A, Bucolo S, et al.
EUROPEAN REVIEW OF ENT
2014;135(1):19-24.

HEAD AND NECK

Hyperbaric oxygen therapy and flap reconstruction: does it help?
Reviewed by: Sunil Kumar Bhatia
Vol 24 No 2
 

This is a multicentresite retrospective review from four clinics in the USA on patients who received radical debridement and free flap reconstruction for osteoradionecrosis (ORN) between 1 Jan 1995 and 30 June 2011. Patients were stratified divided based on having prior undergone prior hyperbaric oxygen (HBO) treatment or not. Eighty-nine patients received a free flap reconstruction, of these 39 had a history of HBO and 50 did not. A total of 56% with prior HBO developed complications compared with 50% without prior HBO therapy, there was no statistical difference. However there was a marginal significant increase in infections rate in patients with HBO therapy. Interestingly this group also had a lower incidence of diabetics. This is a first study that examines the association of prior HBO and postoperative complications. This data suggests that patients that have continued ORN with failed conservative therapy and HBO are at risk for postoperative infections. This may be a selection bias because these patients failed conservative and initial treatment of ORN. Also repeated debridement could account for repeated injury. The authors accept the limitations of this retrospective study and accept that causality cannot be determined by this. It is however a well written paper that brings together patients, with a fairly uncommon and difficult condition, from four large centres and is worth reading.

Reference

Comparison of complications in free flap reconstruction for osteoradionecrosis in patients with or without hyperbaric oxygen therapy.
Nolen D, Cannady SB, Wax MK, et al.
HEAD AND NECK
2014;36(11):1701-04.

INTERNATIONAL FORUM OF ALLERGY AND RHINOLOGY

Back to basics: nasendoscopy beats CT, again!
Reviewed by: Christos Georgalas
Vol 24 No 2
 

There are few otolaryngologists (or patients) who have not been confronted with a computed tomography scan referring to a deviated septum. In a very similar way to the accidental findings of sinus mucosal thickening, the clinician is left in a difficult position, trying to explain to the patient (and to the referring physician or neurologist) that the diagnosis of sinusitis is clinical and not radiological. This paper resolves, in a rather elegant way, the issue: septal deviation associated with significant nasal obstruction is a clinical diagnosis, based on thorough examination including endoscopy and clinical history. Blinded assessment of septal deviation on CT does not correlate with clinically important septal deviation, except in the area of bony septum (and then again, only poorly).

Reference

Radiographic evaluation of nasal septal deviation from computed tomography correlates poorly with physical exam findings.
Sedaghat AR, Kieff DA, Bergmark RW, et al.
INTERNATIONAL FORUM OF ALLERGY AND RHINOLOGY
2015;5(3):258-62.

INTERNATIONAL FORUM OF ALLERGY AND RHINOLOGY

Not so innocent, after all: a meta-analysis of the effects of intranasal corticosteroids on growth
Reviewed by: Christos Georgalas
Vol 24 No 2
 

The use of intranasal corticosteroids has revolutionised the management of allergic rhinitis and rhinosinusitis and there is now significant evidence of their safety. The problem with side-effects is that clinical studies are designed to demonstrate efficacy, but are underpowered to show evidence of side-effects. None of the studies pooled in this meta-analysis has shown a significant effect of intranasal corticosteroids on growth, however they all showed a consistent trend towards reduced growth velocity. This meta analysis pooling their results showing the effect to be real and consistent, albeit small, as measured by knemometry growth velocity, even after use as limited as for a few weeks. What is not clear is the long-term effect, and whether the children can later catch up. In any case, it is a study that certainly calls for exercising caution in their use and always use the lowest effective dose.

Reference

Topical intranasal corticosteroids and growth velocity in children: a meta-analysis.
Mener DJ, Shargorodsky J, Varadhan R, Lin SY.
INTERNATIONAL FORUM OF ALLERGY AND RHINOLOGY
2015;5(2):95-103.

INTERNATIONAL JOURNAL OF AUDIOLOGY

Hearing protection and hearing loss
Reviewed by: Rick Navaro
Vol 24 No 2
 

This study examined the interaction of hearing protection for noise reduction and hearing loss with speech recognition performance. Forty five subjects with four hearing loss profiles were fitted with two different level dependent hearing protectors (circumaural and inserts) in two different military noises. Each protector was tested under passive and electronic filtering. Passive protection resulted in the greatest reduction in speech recognition for the hearing impaired users but little effect for normal hearers. Circumaural devices resulted in better frontal speech recognition due to microphone placement but electronic filtering of noise resulted in better speech recognition for the hearing impaired subjects. This study has important implications in documenting that hearing impaired subjects will not understand speech as well in noisy environments but that electronic filtering helps to preserve speech recognition ability.

Reference

The interaction of hearing loss and level-dependent hearing protection on speech recognition in noise.
Giguere C, Laroche L, Vaillant V.
INTERNATIONAL JOURNAL OF AUDIOLOGY
2015;54:S9-S18.

INTERNATIONAL JOURNAL OF AUDIOLOGY

Hearing protectors and speech perception
Reviewed by: Rick Navaro
Vol 24 No 2
 

This study tested 31 subjects using hearing protectors by maintaining a constant intensity level for the speech signal while varying background noise levels. The goal was to use this test to detect speech perceptual abilities under different hearing protectors – passive vs. electronic filtering. The results showed that electronic filtering resulted in the best overall speech intelligibility. The study elucidated the various types of noise that may be encountered in workplace situations and discussed the implications of the different noises for differentiating between hearing protectors. There are many variables in trying to conduct such a study and deriving meaningful conclusions. One potential caveat is that most speakers will automatically elevate their vocal effort in noise (Lombard effect) to speak over the noise. This reduces some of the power of the study’s conclusion that the proposed test is a viable method for differentiating hearing protectors.

Reference

To measure the impact of hearing protectors on the perception of speech in noise.
Hiselisu P, Edvall N, Reimers E.
INTERNATIONAL JOURNAL OF AUDIOLOGY
2015:54:S3-S8.

INTERNATIONAL JOURNAL OF LANGUAGE AND COMMUNICATION DISORDERS

Relationship between ART and language development
Reviewed by: Gauri Mankekar
Vol 24 No 2
 

Assisted Reproduction Technology (ART) and especially more invasive techniques of ART may be associated with an increase in neurodevelopmental problems including language delay. Some studies have reported slightly worse perinatal outcomes of IVF babies compared to naturally conceived babies. The purpose of this study was to determine the language development in three to 10 year old children born following assisted oocyte activation (AOA). The authors assessed expressive and receptive language development of 20 children with a mean age of 5.4 years. They used the Clinical Evaluation of Language Fundamentals (CELF-IV-NL) for children older than five years and the Reynell Developmental Language Scale (RTOS) for children younger than or equal to five years. They found that the language development of singleton babies was significantly better than that of twins born following AOA. Further long-term follow-up studies in this population are needed to provide information on the language development of children born following ART /AOA.

Reference

Language development of children born following intracytoplasmic sperm injection (ICSI) combined with assisted oocyte activation (AOA).
D’haeseleer E, Meerschaut FV, Bettens K, et al.
INTERNATIONAL JOURNAL OF LANGUAGE AND COMMUNICATION DISORDERS
2014;49(6):702-9.

INTERNATIONAL JOURNAL OF LANGUAGE AND COMMUNICATION DISORDERS

Specific language impairment in bilingual vs monolingual children
Reviewed by: Gauri Mankekar
Vol 24 No 2
 

Research has focused mainly on the specific language impairment (SLI) in monolingual children. This article focuses attention on the SLI in bilingual children. The study was conducted with bilingual children from Luxembourg and monolingual children from Portugal who all had Portuguese as their first language. The bilingual group performed equally well compared with their peers on measures of visuospatial working memory but had lower scores than both control groups on tasks of verbal working memory. The authors’ results support the position that SLI is not a language specific disorder. In fact, bilingualism may represent a protective factor against some of the cognitive limitations associated with SLI in monolinguals.

Reference

Specific language impairment in language –minority children with low income families.
Pascale MJ, de Abreu E, Cruz-Santos A, Puglisi ML.
INTERNATIONAL JOURNAL OF LANGUAGE AND COMMUNICATION DISORDERS
2014;49(6):736-47.

INTERNATIONAL JOURNAL OF PEDIATRIC OTORHINOLARYNGOLOGY

Bone anchored hearing devices in very young children
Reviewed by: Patrick Spielman
Vol 24 No 2
 

This paper presents results of BC devices in very young children and helps inform an honest discussion of risks / benefit with prospective parents. The authors of this article from Starship Children’s Hospital, Auckland, New Zealand have a series of 24 children (26 ears) aged under five years who have had BAHA implantation. Most had two-stage surgery with a 3mm screw and skin thinning techniques, more recent patients had minimal or no soft tissue reduction surgery. Similarly three generations of implants were used as the series spans 11 years. A wide range of aetiologies were treated, typically isolated microtia. Benefit was assessed using a children’s version of the Glasgow Benefit Inventory with very high scores reported and a 75% response rate. Good hearing outcomes were also demonstrated with a Parents’ Evaluation of Aural perfomance of Children questionnaire. The authors have collected much detail on the complications encountered and present a comprehensive analysis: including a 42% return to theatre rate for skin problems, a 53% Holgers skin reaction grade three or worse and 10% implant loss. Despite these problems and the multiple repairs, only three children stopped using their implant suggesting significant benefit is gained and the audiologic benefits are clear. The benefit is clear but the complications may reinforce the argument for the use of semi-implantable or completely implantable devices for such children. It is a valuable addition to the BC device literature.

Reference

Experience of bone-anchored hearing aid implantation in children younger than five years of age.
Amonoo-Kuofi K, Kelly A, Neeff M, Brown CRS.
INTERNATIONAL JOURNAL OF PEDIATRIC OTORHINOLARYNGOLOGY
2015;79:474-80.

JOURNAL OF INTERNATIONAL ADVANCED OTOLOGY

Leptin has no role in idiopathic sudden sensorineural hearing loss
Reviewed by: Emma Stapleton
Vol 24 No 2
 

This paper from Turkey claims to be the first study dealing with the relationship between leptin and idiopathic sudden sensorineural hearing loss (ISSHL). I remember leptin being a fashionable topic in obesity research, when leptin deficiency was thought to be an aetiological factor in obesity. Who could forget those photos of obese, leptin-deficient white mice? So what is its relevance to hearing loss? Leptin is a proinflammatory cytokine secreted mainly from adipocytes, is responsible for the regulation of energy metabolism and raises the sensation of satiety by acting on the hypothalamus. It is a member of the IL-6 cytokine subgroup and its effects on body weight and energy metabolism are mediated by receptors in the central and peripheral nervous system. The authors explain that they were looking for a relationship between IL-6 cytokines and ISSHL in order to identify potential treatment options. Their results, from 33 patients with BMI <30 and ISSHL, indicated that serum leptin levels in the ISSHL patients were not different from un-matched controls.

Reference

Serum leptin levels in patients with idiopathic sudden sensorineural hearing loss.
Ural A, Alver A, Işık AÜ, İmamoğlu M.
JOURNAL OF INTERNATIONAL ADVANCED OTOLOGY
2014; 10(3): 201-4.

JOURNAL OF PLASTIC, RECONSTRUCTIVE AND AESTHETIC SURGERY

Surgical indications for infantile haemangiomas
Reviewed by: Sunil Kumar Bhatia
Vol 24 No 2
 

Infantile haemangiomas are embryonal tumours and represent the most common tumour of infancy, with an estimated incidence 4-5%. There is well-described natural history, usually becoming apparent in the first few weeks of life and proliferating rapidly in the first few weeks of life with 80% reaching their maximal size by five months of age. This is followed by involution without scarring. There is however a subset that have severe morbidities such as pain, bleeding, scarring and psychosocial issues. Currently treatment is medical with Propanolol and intervention with LASER or surgical excision. There is paucity of data reviewing the predictive risk factors associated with a need for surgery. This is a good retrospective review of a single surgeon’s series of 112 patients from 2004 to 2011. Of the 112 patients 97 underwent one procedure, 14 patients two, and one patient three procedures. This is a good look at the surgical demographics of this cohort but it is a selected group, and many lesions may not have been referred if intervention was not required. It is also a small series of an individual surgeon and the authors accept both these limitations. The majority were also treated prior to the widespread use of Propanolol. This paper suggests there will always be a role for the surgeon and this study may be used as a comparison with a series of patients undergoing treatment with oral Propranolol.

Reference

A retrospective study to classify surgical indications for infantile haemangiomas.
Lee AHY, Hardy KL, Goltsman D, et al.
JOURNAL OF PLASTIC, RECONSTRUCTIVE AND AESTHETIC SURGERY
2014;67:1215-21.

JOURNAL OF THE AMERICAN ACADEMY OF AUDIOLOGY

Noise’s effect on ageing memory
Reviewed by: Cheka Spencer
Vol 24 No 2
 

Working memory is used everyday by individuals of all ages. The authors of this study sought to compare the effect of background noise on the memory of either young adults or middle aged adults. They did this by recruiting 10 young adults aged 22-30 years old (mean of 25 yr) and 10 middle aged adults 46-60 years old (mean 55.1 yr). Each participant listened to lists composed of five pairs of words in quiet and in a 20-talker babble. When cued with one word they were required to write down the second word of that pair. As was hypothesised both groups did better at recalling the first and last items which is termed the primacy effect and the recency effect respectively. There was a significant main effect of age group [F(1,18) = 7.054, p = 0.016]. Interaction effects of background noise by age group [F(1,18) = 3.620, p = 0.073] was not statistically significant but the older age group did not perform as well in the presence of background noise. This was an interesting experiment whose results make sense and are biologically plausible. Long-term memory has been shown by various studies to deteriorate with age and it is no surprise that with the extra pressure of background noise performance in any age group would deteriorate. The clinical relevance of this paper is that the majority of our patients are middle aged adults who complain of difficulty understanding speech in noisy listening environments. Their audiological assessments are often normal in spite of this. This article suggests that this may be due to certain central processes including auditory processing which are not tested with our conventional techniques. Nonetheless a solution to this problem is difficult.

Reference

The effect of background babble on working memory in young and middle-aged adults.
Neidleman M, Wambacq I, Besing J, et al.
JOURNAL OF THE AMERICAN ACADEMY OF AUDIOLOGY
2015;26(3):220-228.

JOURNAL OF THE AMERICAN ACADEMY OF AUDIOLOGY

Treating benign positional paroxysmal vertigo
Reviewed by: Cheka Spencer
Vol 24 No 2
 

Benign positional paroxysmal vertigo (BPPV) is one of the most common causes of dizziness. Its treatment is the repositioning of displaced otoliths by the canalith repositioning manoeuvre (CRM). Post manoeuvre restrictions are commonly given to the patient. Their benefit has been widely debated as many people feel that these are unnecessary. This paper was a randomised controlled trial which sought to determine the efficacy of the epley manoeuvre, a hybrid manoeuvre called the Ganz manoeuvre (GRM) and post manoeuvre restrictions. Forty-five patients were randomised into three treatment groups matched for gender: CRM with post manoeuvre restrictions; GRM alone; and GRM with post manoeuvre restrictions. They had weekly interventions until their symptoms were objectively and subjectively resolved. This took on average two visits in the GRM with post manoeuvre restrictions, 1.7 in the GRM alone and 1.6 in the CRM group. There was no statistical significant difference between the three groups. This may suggest that the GRM is as effective as CRM and that post manoeuvre restrictions add no extra clinical benefit. This is in keeping with other published studies that negate the need for these restrictions. Patients find these difficult on their everyday lives while shopping or driving and this study suggests that they can be advised to return to normal activities. Furthermore, the fact that GRM was as effective as CRM is useful knowledge in the management of the many elderly patients with BPPV with neck problems, or those with a history of trauma, as there is no need for cervical hyperextension. Additionally, whilst the small sample size of this study is questionable, its positive results could be translated to routine ENT and audiology practice.

Reference

Effect of a hybrid maneuver in treating posterior canal benign paroxysmal positional vertigo.
Badawy W, El-Mawla E, Chedid A, Mustafa A.
JOURNAL OF THE AMERICAN ACADEMY OF AUDIOLOGY
2015;26(2):138-144.

JOURNAL OF VESTIBULAR RESEARCH

Selective otolith dysfunctions objectively verified
Reviewed by: Fiona Barker
Vol 24 No 2
 

Three cases of patients with acute onset vertigo are presented here. The presenting symptoms are described for each case along with the results of vestibular and audiologic examination. This paper focuses on the results of vHIT in the plane of the horizontal and vertical canals, cVEMPs and oVEMPs. The results of the tests make a good case for exploiting the ability of these tests to give information about the function of the whole vestibular system. These three patients all had abnormal VEMPs (cervical, ocular or both) but normal vHIT responses which the authors’ state shows selective otolith dysfunction. Call me old fashioned, which I’m sure many of you will (including the eminent authors of this paper), but I was left wondering what the caloric results looked like. None of the patients cited here had calorics. I completely accept that there are severe limitations to caloric testing, which are outlined in this paper, but in my own practice I see patients reasonably often who have normal vHIT results but an asymmetry on calorics that is consistent with their symptom profile or other assessment such as VEMPs. I am aware that factors other than horizontal canal function may influence a caloric result but, taking into account any of these as far as they can be known in an individual case, I would still consider a caloric asymmetry to be evidence of abnormal horizontal canal function, albeit at low frequency, especially when it is consistent with other findings. I would be more convinced of selective otolith dysfunction in these cases had caloric testing (where appropriate) also been normal in addition to vHIT. I support the argument for using the newer tests to explore vestibular function beyond the horizontal canal and these cases provide a good example of how this can yield additional information. I’m just not quite sure I am ready to abandon the older tests yet. It will also be interesting to see how this extra information regarding dysfunction supports management decisions and prognosis.

Reference

Selective otolith dysfunctions objectively verified.
L Manzari, HG MacDougall, AM Burgess, IS Curthoys.
JOURNAL OF VESTIBULAR RESEARCH
2014;24:365-73.

JOURNAL OF VOICE

Gardasil vaccination – an effective adjuvant therapy for RRP?
Reviewed by: Christopher Burgess
Vol 24 No 2
 

The clinical manifestations of recurrent respiratory papillomatosis (RRP) can vary hugely from individual to individual. Whilst some affected children will outgrow the disease, a subset of patients will experience frequent recurrences and require multiple surgical procedures over the course of their lifetime, even as frequently as once a month. Several adjuvant therapies have been trialled to improve the clinical course of severe RRP, but none have achieved universal acceptance. Cidofovir and bevacizumab (Avastin) are the most commonly used adjuvants in the USA. The restricted availability and expense of these treatments limit their clinical utility in the NHS however. Gardasil is a quadrivalent vaccine against HPV types 6, 11, 16 and 18. By combining viral capsid proteins with adjuvants such as aluminium, a much higher antibody titre is achieved after vaccination than with a natural infection. It has therefore been hypothesised that administration of this vaccine to patients with RRP could help to achieve clearance of the disease, or at least extend periods of remission. In this paper, a retrospective chart review was conducted for 20 patients (12 male, median age 43) with established RRP who received Gardasil vaccination in addition to standard care at the Medical University of South Carolina. Eight patients (40%) experienced complete remission following vaccination. In the remainder, a significant increase in inter-surgical interval from 4.9 to 8.0 months was observed (p = 0.006). The absence of a control group and the variability in the natural course of RRP mean that the change in disease course following vaccination cannot conclusively be attributed to the effects of the vaccination alone. Nevertheless the results are certainly encouraging and merit further research, especially given the comparatively low cost and excellent side-effect profile of Gardasil vaccination relative to other adjuvant treatments for RRP.

Reference

The use of the quadrivalent human papilloma virus vaccine (Gardasil) as adjuvant therapy in the treatment of recurrent respiratory papilloma.
Young DL, Moore MM, Halstead LA.
JOURNAL OF VOICE
2015;29(2):223-229.

LARYNGO-RHINO-OTOLOGIE

Inpatients versus Outpatient: septoplasty cost analysis in Germany
Reviewed by: Anna Slovick
Vol 24 No 2
 

Although the vast majority of septoplasties in the UK are performed as day surgery procedures, the authors of this article highlight the differences in healthcare in Germany. The authors calculated a yearly cost reduction of 180 million euros if the operation was performed as an outpatient procedure. There seems to be little incentive for German hospitals to move towards outpatient septoplasty due to current poor outpatient remuneration. The authors recommend an adjustment of the remuneration to encourage change in practice and overall cost savings.

Reference

Potenzialanalyse und Kostenbewertung bei der ambulanten Durchführung der Septumkorrektur.
Schuldt T, Ovari A, Olzowy B.
LARYNGO-RHINO-OTOL
2015;94:18-24.

LARYNGO-RHINO-OTOLOGIE

The Impact of sleep endoscopy for paediatric obstructive sleep-disordered breathing
Reviewed by: Anna Slovick
Vol 24 No 2
 

Paediatric obstructive sleep apnoea (OSA) is not always resolved or improved with adenotonsillectomy. Persistent or complex cases of paediatric OSA may be due to sites of obstruction in the airway other than the tonsils and adenoids. Investigation of paediatric obstructive sleep apnoea (OSA) by drug-induced sleep nasendoscopy (DISE) may be of help in determining the level of obstruction and planning targeted therapy, but evidence is weak. The authors performed a retrospective review of the medical records of children (n=25) who underwent polysomnography and DISE (05/2012-12/2013). After DISE, the initial management plan changed in five patients (20%). The authors suggest this is a promising technique to help guide OSA treatment, but suggest further studies are required to predict persistent OSA based on this tool.

Reference

Bedeutung der Schlafendosckopie bei obstruktiv-schlafbezogener Atmungsstörung im Kindes- und Jungenalter.
Quante M, Merkenschlager A, Kiess W, et al.
LARYNGO-RHINO-OTOL
2015;93:831-39.

NEUROSURGERY

Choosing Wisely
Reviewed by: Gauri Mankekar
Vol 24 No 2
 

This article focuses on the prickly topic of healthcare costs and specifically on reducing spending on neuroimaging for headaches. Epidemiological studies indicate that the prevalence of lifetime headaches is 93 to 99% and accounts for 1.5% of all primary care visits. The cost of neuroimaging for headaches and migraines between 2007 and 2010 in the United States was a whopping $1.2 billion! The Choosing Wisely initiative guidelines by the American College of Radiology and Consumer Reports focuses on reducing healthcare spending and suggests avoiding imaging for uncomplicated headaches. The authors of this article argue that these guidelines are inconsistent with the neurosurgeon’s experience of patients with brain tumours who frequently present with minimal symptoms or isolated headache syndromes. They recommend further research for the development of validated and tested clinical decision rules on the neuroimaging for headaches. This article highlights the problems dividing population-driven healthcare methods and individualised patient tailored medicine.

Reference

Choosing wisely: a neurological perspective on neuroimaging for headaches.
Hawasli AH, Chicoine MR, Dacey RG.
NEUROSURGERY
2015;76(1):1-6.

NEUROSURGERY

Comparing surgical freedom of four transsphenoidal approaches to the sella
Reviewed by: Gauri Mankekar
Vol 24 No 2
 

Four transspenoidal approaches to the sella were performed and studied by the authors on eight silicon-injected cadaveric heads. Surgical freedom, that is, the ability of the surgeon to move his or her hands in a fixed space, was determined with stereotactic image guidance using previously established techniques. The authors studied not only the ability to move at the target point but also at the ability to move when one is fixed on the target point with the instrument and one wants to move one’s hand at the point where one is holding the instrument. Their results show that the endoscopic bi-nostril approach had the greatest surgical freedom at the pituitary gland and ipsilateral and contralateral internal carotid arteries compared to the other three approaches – microscopic sublabial; endoscopic uni-nostril and microscopic endonasal approach. The axial angle of attack was greatest for the microscopic sublabial approach while endoscopic bi-nostril was superior to the other three approaches for the saggital angle of attack. For standardisation, the authors used only straight instruments and 00 endoscopes. Angled instruments may provide different and greater surgical freedom.

Reference

Evaluation of Surgical Freedom for Microscopic and Endoscopic Transsphenoidal Approaches to the Sella.
Elhadi AM, Hardesty DA, Zaidi HA, et al.
NEUROSURGERY
2015:11(S2):69-79.

NEUROSURGERY CLINICS OF NORTH AMERICA

Argh! Facial pain! What to do??
Reviewed by: Gentle Wong
Vol 24 No 2
 

We often come across patients with presentation of facial pain, but unless this is sinugenic in origin, our understanding and management of it can often be found wanting. Craniofacial pain is in fact highly complex and encompasses a wide range of causes including trigeminal neuralgia, and atypical facial pain (aka persistent idiopathic facial pain). Treatment with medications alone can often have suboptimal results. Tolerance, dependence and side-effects of these medications often provide patients with an impetus to steer towards the surgical options. This review aims to cover the surgical alternatives and discusses patient selection, risks, and benefits associated with each of these therapies. The interest in management of craniofacial pain has gained momentum in recent years within neurosurgical circle and is being explored at a rapid pace. As a specialty, it’s important for us to be able to appreciate that beyond amitriptyline, gabapentin and pregabalin, our neurosurgical colleagues might just have that extra trick in their sleeves in peripheral nerve stimulation (PNS), ganglion stimulation (e.g. sphenopalatine ganglion), microvascular decompression (for trigeminal neuralgia) and deep brain stimulation.

Reference

Surgical options for complex craniofacial pain.
Sharma M, Shaw A, Deogaonkar M.
NEUROSURGERY CLINICS OF NORTH AMERICA
2014;25(4):763-76.

OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY

Experience of the Sophono transcutaneous bone conduction system
Reviewed by: Suzanne Jervis
Vol 24 No 2
 

This article is a frank discussion of the authors’ experience implanting these devices. The principle of the device is surgical implantation of a bilobed magnet within a bony well in the cranium (similar position to BAHA). The implant is a magnet only and the external device transmits sound via its baseplate, vibrating the surrounding tissues to both ears. Due to the diminution of sound, the candidacy for the Sophono is less than the BAHA (up to 45dB vs. up to 65dB for BAHA.) The surgical technique for insertion is described with explanations for implant placement and therefore the incision considerations. There are certain areas where the authors admit to deviating from the surgical manual, which include advocating skin thickness of 1cm rather than the advised 4-6mm, for the reasons of reducing postoperative pain and improving wearability. Interestingly, they also describe their experience with placement of the external device. They found that placing these too soon required stronger magnets (to overcome the post-operative swelling) which then ultimately resulted in skin irritation and decreased wear. They therefore advocated external placement six weeks post op and a graduated period of wear to avoid these issues. Their complications were outlined, which were few and included a haematoma (resolved conservatively), an infection (resolved with antibiotics) and a paediatric case with limited skull thickness such that Alloderm was used to provide increased soft tissue thickness to prevent skin irritation post op. This article was a truly helpful and honest description of their experience, especially for those embarking on fitting these implants at the early stages. Of particular note was their list of ‘pearls’ – key points of tried and tested surgical usefulness for this technique!

Reference

Surgical implantation of the Sophono transcutaneous bone conduction system
Friedland DR, Runge CL, Kerschner JA.
OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY
2014:25(4);344-7.

ORL

Combined endoscopic and transcutaneous approach for removal of parotid stones
Reviewed by: Zi Wei Liu
Vol 24 No 2
 

The authors describe a small case series (n=8) of patients with obstructive symptoms from sialolithiasis of the parotid gland. A combined endoscopic and transcutaneous approach was used. The position of the stone in Stensen’s duct was identified by endoscopic transillumination. The stone was subsequently removed through either an incision made directly over the duct itself for distal stones, or a traditional S-shaped parotidectomy flap was raised and the duct dissected out from the parenchyma of the gland. Facial nerve monitoring was used as there is a theoretical risk of injury to the buccal branch of the facial nerve. The procedure was performed as a day case and 75% of patients were symptom free afterwards. Salivary fistulae have not been reported, although one case of post operative infection was noted. One patient went on to have a superficial parotidectomy for multiple stones. The authors recommend the combined approach for patients with large stones (>5-6mm), or where the stones are in an unfavourable position for endoscopic removal (e.g. hilum of the gland). This applies to 10-15% of parotid salivary stones. This approach is most useful for single large stones where lithotripsy or sialoendoscopy have failed. The patient can be spared a superficial parotidectomy and risk of injury to the facial nerve is minimal. The patient group that would benefit from the combined approach is well defined in this study. However, support from some one experienced in sialoendoscopy is essential and joint cases may not be feasible in all centres.

Reference

Retrospective analysis of a combined endoscopic and transcutaneous technique for the management of parotid salivary gland stones.
Numminen J, Sillanpää S, Virtanen J, et al.
ORL
2014;76:282-7.

OTOLARYNGOLOGY – HEAD AND NECK SURGERY

Evidence for balloon eustachian tuboplasty
Reviewed by: Thomas Jacques
Vol 24 No 2
 

Balloon eustachian tuboplasty is an emerging intervention aimed at the management of eustachian tube dysfunction (ETD) and its sequelae. The authors acknowledge that ETD is a common but frequently ill-defined problem, with no well-established direct treatment. They performed a systematic review of the evidence for balloon eustachian tuboplasty, finding that no randomised controlled or case-control studies exist in the current literature. Considerable heterogeneity in the nine included studies precluded the pooling of data for meta-analysis. Results suggested a tendency to improvement of subjective (ETDQ-7 questionnaire) and objective (e.g. tympanometry) measures. However, many patients underwent adjunctive interventions, introducing a high risk of bias. No severe adverse outcomes were reported. A safe and effective intervention for troublesome ETD is highly desirable, particularly because of the theoretical ‘upstream’ improvements in the pathogenesis of chronic middle ear disease. However at present, no high-quality evidence exists to support the use of eustachian tuboplasty. The lack of diagnostic criteria and reliable outcome measures mean that the indications for tuboplasty are currently unclear. Of course this does not mean that the technique has no value, but larger more rigorous trials are needed before widespread adoption. If proven successful, the technique could impact upon a significant number of otological conditions. Until then, informed consent should include a frank discussion of the current state of the evidence.

Reference

Balloon eustachian tuboplasty: a systematic review.
Randrup TS, Ovesen T.
OTOLARYNGOLOGY – HEAD AND NECK SURGERY
2015;152(3):383-92.

OTOLARYNGOLOGY – HEAD AND NECK SURGERY

Local dexamethasone infiltration in tonsillectomy
Reviewed by: Thomas Jacques
Vol 24 No 2
 

Intravenous dexamethasone is routinely given during tonsillectomy for its effects on postoperative pain and nausea. This Chinese randomised study divided 240 children undergoing tonsillectomy into three groups, receiving either no steroid, intravenous dexamethasone, or the same amount of dexamethasone infiltrated into the upper, middle and lower poles of the tonsils. The same volume of saline was infiltrated into the tonsils in the first two groups as a control, and to maintain surgeon blinding. The authors found that postoperative pain scores were significantly affected by the technique used: the highest pain scores in the non-steroid group, significantly lower in the IV steroid group, and significantly lower again in the local infiltration group. These children also had lower opiate (fentanyl) requirements postoperatively. However, postoperative nausea and vomiting was lower in the IV group than the local group, presumably due to lower systemic absorption. Readmission rates for vomiting or pain control were not affected. Local infiltration of steroid is not common UK practice, although local anaesthetic infiltration is used in some centres. This well-conducted study demonstrates a useful adjunctive measure in tonsillectomy symptom control. The authors intended, but were unable to, perform blood assays of steroid concentration in the study participants. Presumably, a future study including these measurements might lead to development of a dual IV+local steroid protocol, with appropriate safe dosing, thus improving postoperative pain whilst eliminating the need for compromise of nausea prevention.

Reference

Comparison of local and intravenous dexamethasone for postoperative pain and recovery after tonsillectomy.
Gao W, Zhang QR, Jiang L, Geng JY.
OTOLARYNGOLOGY – HEAD AND NECK SURGERY
2015;152(3):530-5.

OTOLOGY AND NEUROTOLOGY

Consider PCR testing in culture negative necrotising otitis externa
Reviewed by: Anand Kasbekar
Vol 24 No 2
 

Necrotising otitis externa (NOE) often does not yield identification of a causative organism to treat although in 90% of cases it is a member of the pseudomonas species. The incidence of fungal NOE is not to be forgotten and this group from Israel looked at cases of refractory NOE who had been initially treated with ciprofloxacin and did not respond. In a six year period, 19 patients were diagnosed with NOE of which five had negative microbiology cultures for causative organisms. Patients were taken to theatre and deep biopsies for histology and culture were obtained. PCR analysis testing was undertaken for a range of bacteria and fungi. All five cases had likely causative fungi isolated on PCR although sensitivities were not possible as fungi and bacterial cultures were negative.
Empirical antifungal treatment (directed by local microbiology knowledge), was started while anti-bacterials were halted. All patients clinically and radiologically improved and were discharged home on average after 39 days. Systemic treatment was for a total of eight weeks. Gallium scan, blood tests and clinical follow-up proved complete cure. Had it not been for the PCR tests, continued treatment with anti-pseudomonals would have continued with further deterioration. Other methods of diagnosing fungal infection were not used and often required skilled personnel. PCR testing is expensive but can test for several fungi in a short space of time without expert mycologists. Your hospital laboratory may be able to perform this PCR with the kit they already have for your next case of refractory NOE.

Reference

Clinical utility of a polymerase chain reaction assay in culture-negative necrotizing otitis externa.
Gruber M, Roitman A, Doweck I, et al.
OTOLOGY AND NEUROTOLOGY
2015;36(4):733-6.

OTOLOGY AND NEUROTOLOGY

The effect on taste buds due to severing of the chorda tympani nerve
Reviewed by: Anand Kasbekar
Vol 24 No 2
 

The long-term histological effect on taste buds following cutting of the chorda tympani in humans is not clear. Confocal laser scanning allows in-vivo examination of the same group of taste buds and is aiding our understanding of why patients recover from their taste disturbance. This clever group of surgeons and scientists from Japan looked at seven patients’ taste buds before and after the chorda was cut during tympanoplasty. Electrogustometry was used to assess gustatory function and showed no response within one month after surgery. All taste buds were calculated to disappear by 50 days after surgery. The first step is the disappearance of the taste pores followed by atrophy of the taste buds. Their next study is looking at regeneration of taste buds which starts at about three months after surgery and is likely to vary between individuals. It would be nice to know if there is any preoperative measurement that would enable us to tell how severely affected an individual will become after chorda sacrifice and how long it will last.

Reference

Degeneration process of fungiform taste buds after severing the human chorda tympani nerve - observation by confocal laser scanning microscopy.
Saito T, Ito T, Ito Y, et al.
OTOLOGY AND NEUROTOLOGY
2015;36(3):539-44.

OTOLOGY AND NEUROTOLOGY

When should we decompress the facial nerve in Bell’s Palsy?
Reviewed by: Anand Kasbekar
Vol 24 No 2
 

It has been over three decades since Fisch popularised facial nerve (FN) decompression for Bell’s Palsy. Studies further exploring this have been few since, partly due to the major complications that can occur following this type of surgery. The current study looked at a retrospective cohort of 14 Bell’s patients with grade six HB FN palsy that are known to have poorer FN prognosis. Surgical criteria included greater than 90% degeneration on ENoG testing and no voluntary EMG potentials. This would normally mean at best a 50% chance of recovery to HB one or two. Previous studies have shown the meatal foramen and the labyrinthine segment to be the narrowest segment of the bony canal and it is these parts of the facial nerve that were decompressed via the middle fossa approach. High dose steroids were given as routine and surgery carried out within 14 days of onset. Results were impressive with no major complications and match other studies. Three patients experienced gustatory hyperlacrimation. Ten patients (71%) regained good FN function (HB one or two) within a year, the remaining to HB three. Patients over 60 years of age did worse, when compared to decompression over 14 days, results were significantly better when surgery was undertaken within 14 days (only 20% return to HB1/2 if surgery over 14 days). ENoG needs to be undertaken within two weeks to be predictive and also enable early surgery. There was no change in hearing pre and post surgery. This is a convincing argument for early investigation and intervention and I wonder how many skull base surgeons would be keen to adopt this protocol?

Reference

Facial nerve outcomes after middle fossa decompression for Bell’s Palsy.
Cannon RB, Gurgel RK, Warren FM, Shelton C.
OTOLOGY AND NEUROTOLOGY
2015;36(3):513-18.

RHINOLOGY

Four (more) ways to reduce turbinates
Reviewed by: Jo Rimmer
Vol 24 No 2
 

Setting aside the issue of when/if to reduce inferior turbinates, the issue of how to reduce turbinates is a never-ending story. This edition of rhinology carries two articles looking at this subject, both prospective randomised trials comparing two different methods – four (more) ways to skin a turbinate. Hegazy et al compared coblation in 40 patients with the microdebrider in 30, over a six month follow-up period. Kisser et al compared laser diode and radiofrequency treatment in 26 patients, randomising each patient to receive laser on one side of the nose and radiofrequency on the other; follow-up was three months. Nasal symptoms, as rated by visual analogue scores (VAS), improved significantly following surgery in all patients, with no difference between the treatments in each study. Postoperative pain was significantly worse in the microdebrider group (compared to coblation) and the radiofrequency side (compared to the laser side). There was no significant difference in complications between the treatment modalities in each study, although bleeding occurred in 77% of turbinates treated with radiofrequency (compared to none with the laser). Kisser et al also compared objective measures including acoustic rhinometry and rhinomanometry, and found no difference between treatments (or, indeed, before and after treatment). Interestingly, although radiofrequency was more painful than laser, 50% of patients would have radiofrequency treatment repeated compared to only 23% for the laser; 19% would have both again and 8% neither. So all four treatment modalities resulted in a significant improvement in subjective nasal symptoms, with no difference between them in each study. The search for the most effective method of turbinate reduction continues...

Reference

Inferior turbinate reduction; coblation versus microdebrider – a prospective, randomised study.
Hegazy HM, El Badawey MR, Behery A.
RHINOLOGY
2014;52(4):306-14.
Diode laser versus radiofrequency treatment of the inferior turbinate – a randomized clinical trial.
Kisser U, Stelter K, Gurkov R, et al.
RHINOLOGY
2014;52(4):424-30.

RHINOLOGY

The association of frontal recess anatomy and mucosal disease on the presence of chronic frontal sinusitis: a computed tomographic analysis
Reviewed by: Lakhbinder Pabla
Vol 24 No 2
 

Ostial obstruction is a primary pathophysiological mechanism contributing to sinusitis, which can be caused by anatomical variations, mucosal inflammation or both. This retrospective case series aimed to identify anatomical factors and inflammatory areas relating to chronic frontal sinusitis on nasal / paranasal CT scans. 240 sides of CT scans in adult patients with chronic rhinosinusitis underwent logistic regression analysis to compare distribution of various frontal recess cells and surrounding inflammatory conditions in patients with and without sinusitis. Opacification of the frontal recess and sinus lateralis was found to be associated with a significantly increased risk of frontal sinusitis and developing blockage of drainage pathways – evidence that mucosal inflammation in these two areas is an important factor in leading to chronic frontal sinusitis. They also showed that the presence of septal deviation and suprabulbar cells tended to correlate with a higher frequency of frontal sinusitis, although there was no significant association between these anatomical factors and the presence of frontal sinusitis. The patients with frontal sinusitis also had shorter AP diameters of the frontal ostium and frontal recess in comparison to those without frontal sinusitis. These findings highlight the potential role of anatomy of the frontal sinus drainage pathways to the development of chronic frontal changes.

Reference

The association of the frontal recess anatomy and mucosal disease on the presence of chronic frontal sinusitis: a computed tomographic analysis.
Lai WS, Yang PL, Lee CH, et al.
RHINOLOGY
2014;52(3):208-14.

SAUDI JOURNAL OTO-RHINO-LARYNGOLOGY & HEAD & NECK SURGERY

Sulcus vocalis in patients attending voice clinics: A retrospective study
Reviewed by: B Viswanatha
Vol 24 No 2
 

Sulcus vocalis was first described by Giacomini. This includes a variety of anatomic indentations of the vocal fold, ranging from shallow longitudinal furrows to deep vocal cord pits.
This retrospective study was conducted at King Saud University between 2006 and 2011.There were 105 patients in this study. The aim of the study was to identify the prevalence of sulcus vocalis among voice patients at King Saud University, and to describe the different voice presentations of this disorder along with exploring different treatment modalities offered.
Inclusion criteria were the diagnosis of true vocal fold sulcus. Exclusion criteria were:
1.    Patients associated with other associated vocal fold lesions.
2.    Patients with incomplete medical charts.
The results of this study show that the prevalence of sulcus vocalis in this study group was 3.8%. Family history of sulcus vocalis was reported in 9.5% of patients. Thirty one percent of the study group had true vocal fold augmentation. There was significant post operative improvement in these patients. However the difference between the pre-and post operative gap sizes did not reach a significant level. Author is of the opinion that the sulcus vocalis is not rare in Saudi population and suggests further genetic studies in this population.

Reference

Prevalence of sulcus vocalis in patients visiting outpatient voice clinics at King Saud University.
Malki KH.
SAUDI JOURNAL OTO-RHINO-LARYNGOLOGY & HEAD & NECK SURGERY
2014;16(1):24-30.

SEMINARS IN HEARING

Hearing aid standards and test systems
Reviewed by: Vinaya Manchaiah
Vol 24 No 2
 

Hearing aids are the most used management / rehabilitation option for people with hearing loss. Generally, hearing instrument manufacturers perform the hearing aid performance measurements and provide its specification in terms of functionality. However, it is also common for government agencies or hearing aid dispensing professionals to perform such measurements at least in a sample of the hearing aids they purchase. In addition, hearing aid dispensers also perform such measurements routinely to test hearing aid functioning and to troubleshoot any problems. There are various documents that provide standards and good practice guidelines for such measurements. These standards are aimed at ensuring robust measurements techniques are used based on evidence and also the measurements are performed uniformly across practices. American National Standards Institute (ANSI) and International Electrotechnical Commission (IEC) are the two organisations that provide most of the standards in this area. This article provides an overview of various acoustic and electromagnetic compatibility parameters and describes several test systems available.

Reference

Hearing aid-related standards and test systems.
Ravn G, Preves D.
SEMINARS IN HEARING
2015;36(1):29-48.

SLEEP & BREATHING

Diagnosis and treatment of snoring in adults – S2k Guideline of the German Society of Otorhinolaryngology, Head and Neck Surgery
Reviewed by: Vik Veer
Vol 24 No 2
 

This article summarises the work done by the German Society of Otorhinolaryngology, who have developed guidelines for the management of snoring. ‘S2k’ is German nomenclature for a consensus based guideline, which (for those of you interested in such things), is one step above an informal consensus (S1), and two steps below a full evidence validated review (S3).  For a ‘S2k’ review, this is a remarkably comprehensive account of the present evidence related to snoring surgery. Evidence for each step in the patient journey is provided from presentation to aftercare. A reasonable algorithm protocol is outlined for ‘Diagnostic measures’ and a separate one for ‘Therapeutic principles’. A good section on history taking and minimal standards for examination of snoring patients is provided. In addition the evidence for the more peripheral, esoteric aspects of snoring management is presented, such as acoustic analysis, rhinoresistometry, nasal dilators etc. Predictably the level of evidence for much of this protocol is rather lower than what one would like when judged against modern levels of scrutiny, but as a current state of the evidence, it is an impressive work. My impression however of the level of enthusiasm for some of the measures in the protocol was slightly too high. It felt too positive in the description of some of these measures, when really little evidence was presented. This may be due to a heightened cultural acceptance of snoring management in Germany, or perhaps secondary to the translation process from German to English. I would have liked a little more information about questionnaires used in snoring patients, but the brevity of this section may again be due to the lack of evidence for a more detailed account. The algorithms do seem to make a good attempt at avoiding sending everyone off for full polysomnography, but some of steps aren’t clearly defined. For example the step before PSG is ‘objective diagnostic measures’, but the evidence presented suggests that there aren’t any. The article seems to leave this to the discretion of the reader. Developing a protocol for snoring management was never going to be easy, particularly as we still don’t even have the basics such as a working definition! But I would recommend this article to anyone considering setting up a snoring practice / clinic, as it does provide a reasonable protocol and an overview of the state of our understanding (or lack of it) with regards snoring management.

Reference

Diagnosis and treatment of snoring in adults – S2k Guideline of the German Society of Otorhinolaryngology, Head and Neck Surgery.
Stuck B, Dreher A, Heiser C, et al.
SLEEP & BREATHING
2015;19:135-48.

THE HEARING JOURNAL

A future for unilateral deafness
Reviewed by: Linnea Cheung
Vol 24 No 2
 

Every year, we see several patients struggling with irreversible unilateral hearing loss that is non-responsive to sound amplification. This article emphasises that clinicians should not underestimate the functional and psychological impairment single-sided deafness can have on an individual, even though patients themselves may find it difficult to describe this impact, particularly when the hearing loss is mild. Usually the complaint is of poor discrimination of sounds in the presence of background noise, for instance, at a social gathering, but the problem can be more dangerous in situations where audio-spatial discrimination is required, such as when crossing a busy road. There are several devices available including various CROS-aids and bone-anchored hearing aids that may be useful in these patients, but this article highlights that some evidence shows cochlear implantation may also play a beneficial role. It is however too early to tell which patients exactly may benefit and clearly further studies are required to evaluate this potential, but for the meantime, cochlear implantation is not recommended by United States or British guidance authorities. Paediatric patients pose a further challenge since the brain’s ability to adapt is enhanced by early identification and intervention of unilateral deafness, and therefore further work is required in order to evaluate when and what intervention is appropriate in the management of this problem particularly in babies and infants. In general there has been an improvement in awareness of this condition but for now there is no perfect solution without further research. We should no longer be settling for just “one good ear”. We should strive to seek out more accurate evaluation studies for assessment of sound localisation and hearing ability and research further into the comparative efficacy of the devices currently available so that we are best able to inform and manage our patients for the future.

Reference

Single-sided deafness: causes, and solution, take many forms.
Weaver J.
THE HEARING JOURNAL
2015:68(3):20-4.

THYROID RESEARCH JOURNAL

Follicle stimulating hormone receptors; an aid for the pathologist?
Reviewed by: Adam Shakir
Vol 24 No 2
 

It is well known that Follicle Stimulating Hormone receptors (FSHRs) are found in extra-gonadal tumours such as those within thyroid tissue. This Polish study analysed 44 thyroid resection specimens to look for the presence of these receptors. No mention is made for the indications for surgery or pre-operative investigation results. Eight specimens were formally reported as benign (follicular adenomas) and the rest a mix of undifferentiated, papillary and follicular carcinomas. Specimens were analysed using an antibody immunostaining technique and evaluated using a subjective scoring system based on microscopic appearance and quantity of staining seen. FSHRs were not seen in normal thyroid tissue and also in the majority of follicular adenomas (six of eight). The majority of follicular and papillary carcinomas (28 of 32) and all four undifferentiated carcinomas displayed strong staining. The authors speculate that such laboratory testing may be a useful aid for pathologists with specimens that are difficult to interpret, particularly in differentiating follicular adenomas from follicular adenocarcinomas. The authors also rightly state that conclusions would be best derived from a bigger study.

Reference

Expression of follicle stimulating hormone receptors (FSHR) in thyroid tumours – a marker of malignancy?
Pawlikowski M, Fuss-Chmielewska J, Jaranowska M, et al.
THYROID RESEARCH
2015;8:1.

TRENDS IN HEARING

Hearing loss in the young and self-esteem
Reviewed by: Ameera Abdelrahim
Vol 24 No 2
 

How can those involved in the care of children with hearing loss identify those at risk of low self-esteem? This study provides some guidance. Overall differences from hearing peers in terms of communication skills, physical appearance and social maturity place this group at risk. The authors of the study explore the effect of generic and specific factors on self-esteem in children and adolescents with hearing loss. Fifty children with cochlear implants (38) or hearing aids (12) were assessed using interview questionnaires that included validated questionnaires on communication skills, social engagement, temperament and self esteem. The age range of the children was eight to 18 years (mean 12.88, SD=2.32) with an almost equal ratio M:F. Mean age for fitting of the device was 3.43 years (SD=2.28. Age 8m - 9yrs). Interestingly the findings in the study were that this particular group rated their self-esteem slightly but significantly more positively than typically developing children. Temperament and behaviour characteristics were the only factors that correlated with self esteem appraisal. Greater affiliation and attention had a positive effect whilst depressive mood had a negative effect. The authors highlight early implantation and device use as a factor that would potentially explain the positive result. A proportion of participants with cochlear implants were chosen from a cochlear implant summer camp which in itself would provide a positive environment and would include children who are well supported overall. The recommendation for professionals working with children with hearing loss is that they should pay attention not only to communication performance but also quality of life. A full assessment of factors affecting self-esteem would identify those at greater risk of lower self-esteem. This in turn would allow for earlier referrals to the required services and for appropriate support mechanisms to be accessed.

Reference

Self-esteem in children and adolescents with hearing loss.
Warner-Czyz A, Loy B, Evans C, et al.
TRENDS IN HEARING
2015;19:1–12.

AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY

Outcomes in rhinosinusitis
Reviewed by: Edward W Fisher
Vol 24 No 1
 

This review goes through the various different ways of assessing outcomes and describes the pros, cons and limitations of each. The different methods are described in the context of guidelines in diagnosis and management and compared with other conditions such as rheumatological conditions. This is a useful and compact update which is authoritative and includes discussion of: symptoms, examination, endoscopy, imaging, correlation symptoms-CT-endoscopy, olfaction, cultures, allergy tests, nasal airflow and the difficulties in putting it all together for the purpose of trials or clinical outcomes analysis. There are as many questions as answers but this is a useful summary of the current position.

Reference

Measuring outcomes in rhinosinusitis.
Benninger MS, Hopkins C, Tantilipikorn P.
AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY
2014:28(3):249-54.

AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY

Sarcoidosis and the nose
Reviewed by: Edward W Fisher
Vol 24 No 1
 

This retrospective case note review from Mount Sinai in New York looked at just 14 patients with sarcoidosis. Individual ENT units in the UK are likely to see relatively few of these patients, unless there is a major tertiary referral in the particular unit, so it is still interesting to view the experience of a group of patients of this size. The authors suggest a classification of the patients into four groups: atrophic / hypertrophic / destructive / nasal enlargement. This seems to me to be useful, as it reminds us of the wide variety of manifestations of sarcoidosis in the nose, with more than one pattern of behaviour. The authors emphasise that the vast majority of cases will be managed medically with relatively few requiring surgery.

Reference

Sinonasal sarcoidosis: a new system of classification acting as a guide to diagnosis and treatment.
Lawson W, Jiang N, Cheng J.
AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY
2014:28(4):317-22.

ANNALS OF THE ROYAL COLLEGE OF SURGEONS OF ENGLAND

Patient-reported outcome measures in septorhinoplasty
Reviewed by: Thomas Jacques
Vol 24 No 1
 

Patient-reported outcome measures (PROMs) are used increasingly in surgical research to quantify the efficacy of surgical interventions. This can help to fill an ‘evidence gap’ where healthcare rationing threatens particular treatments. Procedures aimed at improving quality of life, especially with a cosmetic element such as septorhinoplasty, are termed ‘procedures of limited clinical efficacy’ by many UK commissioning groups. The authors used the validated Rhinoplasty Outcomes Evaluation (ROE) questionnaire to assess patient satisfaction in 100 patients. The satisfaction score overall was 73.3%. In supplemental questions, 75% of patients were happy with the result of the procedure, and 83% would be happy to undergo the procedure again based on the final outcome. The ROE tool would ideally be used longitudinally to compare preoperative and postoperative scores, which was not performed in this study. Nevertheless the study provides good evidence of efficacy from a patient-centred perspective, an essential indicator in quality of life surgery. However, patient satisfaction alone may not necessarily be deemed sufficient justification for NHS funding for partly cosmetic interventions.

Reference

Patient reported outcome measures in septorhinoplasty surgery.
Biggs TC, Fraser LR, Ward MJ, et al.
ANNALS OF THE ROYAL COLLEGE OF SURGEONS OF ENGLAND
2015;97:63-5.

AUDIOLOGY NEUROTOLOGY

Aural fullness in Ménière’s disease
Reviewed by: Stephen James Broomfield
Vol 24 No 1
 

This survey of the Finnish Ménière’s Association aimed to examine the severity and consequences of aural fullness, the least reported cardinal symptom of Ménière’s disease. An initial pilot survey informed a second, restructured survey, giving a total of 726 respondents (response rate 53%). The survey included tools for measuring symptom severity, general quality of life and ability to cope. Overall, aural fullness was commoner in females and occurred in 493 (68%) at the time of the survey. Tinnitus and hyperacusis were strongly associated with aural fullness, which was described as moderate or severe by 30% and as a ‘major complaint’ by 4.4%. Severity of anxiety, low ability to cope and mood diseases were connected with more severe aural fullness, which was associated with reduced quality of life and social isolation. Relaxation was found to be the only statistically significant method for alleviating aural fullness. Whilst there are some methodological flaws in this study, it highlights the potential impact of aural fullness for patients with Ménière’s disease.

Reference

Aural fullness in Ménière’s disease.
Levo H, Kentala E, Rasku J, Pyykko I.
AUDIOLOGY NEUROTOLOGY
2014:19;395-99.

AUDIOLOGY NEUROTOLOGY

Clinical evaluation of an image-guided cochlear implant programming strategy
Reviewed by: Stephen James Broomfield
Vol 24 No 1
 

This study ingeniously combines two current areas of active research in cochlear implantation (CI), the first is the use of imaging to assess intra-cochlear electrode position. The second, is the optimisation of a programming strategy to prevent current spread between active electrodes resulting in loss of speech discrimination. In this study, pre- and postoperative CT imaging was used to assess the position of the implanted electrodes relative to the cochlear modiolus and spiral ganglion. Using the principle that electrodes will maximally stimulate the closest population of spiral ganglion cells, the authors predicted which frequencies each electrode would stimulate. Current spread was then reduced by switching off electrodes whose predicted regions of stimulation significantly overlapped (when two electrodes were found to stimulate the same frequency regions of the spiral ganglion, one of the electrodes was deactivated). This strategy was applied to 22 bilateral and 46 unilateral CI recipients with an average of 2.9 years of CI use and previously thought to have a stable and optimal CI map. Employing the programming strategy as described led to significantly improved speech recognition, spectral resolution and subjective hearing quality. As new imaging and programming techniques develop, it is likely that future research will increasingly examine techniques that allow for personalised programming strategies rather than a ‘one-size-fits-all’ approach.

Reference

Image-guided cochlear implantation programming.
Noble JH, Gifford RH, Hedley-Williams AJ, et al.
AUDIOLOGY NEUROTOLOGY
2014:19;400-11.

B-ENT

Cochlear implantation in Ménière’s disease
Reviewed by: Sunil Sharma
 

This was a Belgian retrospective study of seven patients with Ménière’s disease who underwent cochlear implantation. All patients had bilateral severe to profound hearing loss and all met AAO-HNS criteria for Ménière’s disease. Follow-up for patients ranged from six months to two years. In terms of hearing outcomes there was a statistically significant improvement in hearing post cochlear implantation and in speech recognition. The mean improvement in speech recognition in noise is reported as 47%. In terms of vestibular outcomes, the authors report that four out of the seven patients had no vertigo symptoms post-implantation, but of these four patients only one patient had vertigo symptoms pre-implantation. Indeed, one patient actually had new onset of vertigo post-implantation. The authors also used the Nijmegen Cochlear Implant Questionnaire (NCIQ) to measure quality of life in cochlear implantation patients (using six domains). The mean NCIQ score was 48.3% post-implantation, which is considered satisfactory, but it is not clear how far after implantation these scores were obtained. This is lower than NCIQ scores reported in other patients after implantation, and the authors postulate this may be due to the general negative effect that Ménière’s disease has on overall quality of life. Although there is proven improvement in hearing and quality of life post-cochlear implantation in Ménière’s disease, there does not seem to be any clear improvement in vertigo symptoms.

Reference

Is cochlear implantation an effective treatment for Ménière’s disease?
Vermeire K, Van Yper L, De Vel E, Dhooge I.
B-ENT
2014;10:93-8.

BMC EAR, NOSE AND THROAT DISORDERS

Cochlear Implantation in SSD?
Reviewed by: Gauri Mankekar
Vol 24 No 1
 

Contra lateral routing of signals (CROS) using hearing aids and bone conduction devices has been the conventionally accepted modality for the treatment of single sided hearing impairment. The CROS hearing aid has been found to improve speech understanding in noise, when the signal-to-noise ratio is more favourable at the impaired ear than the non-impaired ear. However, the indiscriminate routing of signals to a single ear has practical detrimental effects when interfering sounds are located on the side of the impaired ear. Recently several reports have suggested that cochlear implantation in single sided hearing impairment can restore access to the binaural cues which underpin the ability to localise sounds and segregate speech from other interfering sounds. The current article reports on a prospective trial which has started recruiting and is designed to assess the efficacy of cochlear implantation, compared to a CROS hearing aid in restoring binaural hearing in adults with acquired single-sided deafness. The patients will be assessed at baseline and after receiving a CROS hearing aid. A cochlear implant will be provided to those patients who do not receive sufficient benefit from the hearing aid. The outcome of this trial promises to be interesting and may provide an answer to whether cochlear implantation will replace CROS devices as the standard of care in single sided hearing impairment.

Reference

Comparison of the benefits of cochlear implantation versus contra-lateral routing of signal hearing aids in adult patients with single-sided deafness: study protocol for a prospective within-subject longitudinal trial.
Kitterick PT, O’Donoghue GM, Edmondson-Jones M, et al.
BMC EAR, NOSE AND THROAT DISORDERS
2014:14:7.

BMC EAR, NOSE AND THROAT DISORDERS

Incidental findings in paranasal sinus Magnetic Resonance Imaging (MRI) studies
Reviewed by: Gauri Mankekar
Vol 24 No 1
 

Incidental findings in the paranasal sinuses of mucosal thickening and polyps in MRI studies may  cause concerns for clinicians and patients. The authors studied MRIs of 982 participants with a mean age of 58.5 years who randomly and independent of their medical history underwent MRI of the head as part of a large public health survey in Norway. Incidental opacifications were found in 66% of the participants, mucosal thickenings in 49% and this most common in the maxillary antra (29%). Other opacifications occurred in the anterior ethmoid (23%), posterior ethmoid (21%), frontal sinus (9%), and sphenoid (8%). Polyps and retention cysts were also found mainly in the maxillary sinuses in 32%. Fluid was observed in 6% of the MRIs. Mucosal thickening was observed more frequently in men than in women. The authors conclude that knowledge of these incidental findings is important as it can influence clinical practice.  Overzealous radiological reporting may also cause anxiety for patients.

Reference

Incidental findings in MRI of the paranasal sinuses in adults: a population-based study (HUNT MRI).
Hansen AG, Helvik AS, Nordgård S, et al.
BMC EAR NOSE AND THROAT DISORDERS    
2014;14:13.

CURRENT OPINION IN OTOLARYNGOLOGY & HEAD AND NECK SURGERY

Current management of facial fractures in the preadolescent
Reviewed by: Susan A Douglas
Vol 24 No 1
 

This article reviews the trends in management of preadolescent facial fractures – a challenging population due to the need to consider growth, dynamic changes in dentition, and evolving fracture patterns. In summary, conservative management is preferred in all fractures in preadolescents whenever possible with the exception of significantly displaced fractures wherein the risks associated with open reduction and internal fixation outweigh the poor outcomes associated with inadequately aligned facial fractures. When necessary, brief periods of intermaxillary fixation are acceptable in the preadolescent. However, because of the primary or mixed dentition in this age group, alternatives to traditional tooth-anchored intermaxillary fixation may be required. Occasionally, a combination of techniques is useful. Consideration should be given to resorbable plating systems given the high growth potential of the facial skeleton in this age group and the need for metallic hardware removal. The article discusses the management of various facial fractures according to the anatomical location. This includes orbital and frontal skull base fractures, zygomatic and mid face fractures, mandibular fractures and nasal fractures. For nasal fractures, the authors recommend closed reduction but in the 7 to 12 year old group, recommend a ‘watch and wait’ philosophy for minimally displaced fractures. This is because of the need for general anaesthetic, the potential for further disruption of growth of the facial bones and the low likelihood of addressing septal deviation. They recommend formal septorhinoplasty after the age of 16 if necessary. As preadolescent fractures occur in a period of growth and evolving dentition in the facial skeleton, it is mandatory for the treating surgeon to have a thorough knowledge of standard and alternative treatment options to optimally manage these patients. This is a well written article with some useful images, which describes the current management of facial fractures in the preadolescent.

Reference

Current management of facial fractures in the preadolescent.
Alhumsi TR, Gilardino MS.
CURRENT OPINION IN OTOLARYNGOLOGY & HEAD AND NECK SURGERY
2014;22(4):336-41.

EUROPEAN REVIEW OF ENT

Facial reanimation
Reviewed by: Badr Eldin Mostafa
Vol 24 No 1
 

Non-conservative surgery in the parotid region results in a devastating complete facial paralysis (as with other causes of persistent facial palsy). Lengthening temporalis myoplasty is one of the available rehabilitating techniques. This is a series of 15 patients who had this procedure after a radical parotidectomy. Ninety-three percent had a good result at rest and 66.6% good result for smile. The authors recommend this type of surgery immediately after extirpation as it does not compromise the oncological field and improves the patient’s quality of life. It can be associated with additional measures to rehabilitate the upper face as well such as lengthening of the levator palpebris superioris or the implantation of a gold weight.

Reference

Lengthening temporalis myoplasty for facial palsy reanimation after parotid surgery.
Foirest C, Gatignol P, Bernat I, et al.
EUROPEAN REVIEW OF ENT
2013;134:259-65.

HEAD & FACE MEDICINE

Facial landmark localisation by curvature maps and profile analysis
Reviewed by: Bilal Gani Taib
Vol 24 No 1
 

The detection of three dimensional (3D) landmarks by scanning surfaces is a well established method in medical science. Anatomical landmarks are visually or palpably detectable and act as reference points for clinical measurements. When measuring these landmarks with a sliding calliper no 3D image is created. This shortcoming can be overcome with surface laser scanners or parallel white light projections. The measurements of 15 residents were performed with the FastSCAN™ laser-scanning system and their curvature maps were calculated. The Koenderink shape index maps identified several landmarks from which seven commonly used distances were calculated and compared to manual measurements by way of Lin’s concordance correlation coefficient. The study measured the intercanthal distance, mouth length, nasal width, outer eye corners distance, soft tissue nasion to subnasal point distance, subnasal point to mento labial point distance and the distance between subnasal point and soft tissue pogonion. In general, measurements obtained from the scanned faces were very similar to manual measurements based on the physical face with only a few major discrepancies, this may be due inadequate image quality exacerbated by head movement during the scanning process. This preliminary study is a first step towards an automatic and objective localisation method of the anatomical landmarks and pertaining distances in clinical facial analysis.

Reference

Facial Landmark localisation by curvature maps and profile analysis.
Carsten Lippold, Xiang Liu, Kim Wangdo, et al.
HEAD & FACE MEDICINE
2014;10:54.

HEAD AND NECK

Proliferative Verrucous Leukoplakia; which one is this one?
Reviewed by: Sunil Kumar Bhatia
Vol 24 No 1
 

Oral leukoplakia has the potential for malignant change and it may frequently require histological analysis and a period of regular clinical observation. The majority of oral leukoplakia remains constant but there is a subset that progress to carcinoma. The authors discuss Proliferative Verrucous Leukoplakia (PVL) that is unique in that it is progressive variant. It is suggested that identifying this form is by repetitive clinical and histological observation. The difficulty in early diagnosis is mainly due to the overlapping clinical and pathologic features with conventional leukoplakia with dysplasia. PVL is rare but aggressive and can present in any of its four clinical progressives states: early focal; geographic expansion; verrucous appearance; and malignant change. It also has no risk factors identified. This is a good paper that discusses the problem of oral leukoplakia and devotes a section to the differential diagnosis of leukoplakia that includes lichen planus.

Reference

Proliferative verrucous leukoplakia: recognition and differentiation from conventional leukoplakia and mimics.
Gillenwater AM, Vigneswaran N, Fatani H, et al
HEAD AND NECK
2014;36(11):1662-7.

HEAD AND NECK

The stigma of HPV in oral cancer
Reviewed by: Sunil Kumar Bhatia
Vol 24 No 1
 

The increase of oropharyngeal carcinoma (OPC) in the developed world seems to be largely caused by infection with the human papillomavirus (HPV). HPV is a group of 150 DNA viruses that are common and most people will be infected at some point. While less than 1% of infections cause cancer, it may account for 5% of all cancers and may be the second most significant human carcinogen after tobacco. HPV status is relevant as HPV-positive OPC has significantly better outcomes and lower regional failures, independent of the treatment methods. While knowledge of the HPV status should not affect the routine clinical management it is required to inform discussions about prognosis and trial eligibility. This excellent article summarises the key messages about HPV in OPC, which are that it is common and affects most people at some time in their lives, is transmitted by normal sexual activity and not a marker of promiscuity or abnormal sexual practices. Infection does not imply recent infidelity. This editorial is a well written informative and summative and a must read for all involved in head and neck cancer.

Reference

Sexual health in oral oncology: breaking the news to patients with human papillomavirus-positive oropharyngeal cancer.
Evans M, Powell NG.
HEAD AND NECK
2014;36(11):1529-33.

INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY

Cadaveric variation of nasolacrimal duct lateral nasal wall landmarks
Reviewed by: Laith Tapponi
Vol 24 No 1
 

Twenty mid-sagittal head sections of 10 fresh frozen cadavers were studied after removal of the nasal septum. This study showed that the most anterior projection of the middle turbinate head was noted to be anterior to the nasolacrimal duct in 70% of specimens. In positional relationship, the maxillary line was posterior to the nasolacrimal duct in 55%, whereas the bulla ethmoidalis and the free edge of uncinate process were uniformly posterior to the nasolacrimal duct in all the specimens. This study provides useful anatomic and positional relationships between the nasolacrimal duct and the major lateral wall landmarks. Although the maxillary line and the head of the middle turbinate are often considered useful guides to the position of the ipsilateral nasolacrimal duct, their spatial relationship to the duct is not consistent. These landmarks, therefore, cannot be solely relied upon during surgery to avoid injury to the nasolacrimal duct.

Reference

Anatomic relationship of nasolacrimal duct and major lateral wall landmarks: cadaveric study with surgical implications.
Ali MJ, Nayak JV, Vaezeafshar R, et al.
INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY
2014;4(8):684-8.

INTERNATIONAL JOURNAL OF AUDIOLOGY

Frequency Compression – is there a benefit?
Reviewed by: Richard Navarro
Vol 24 No 1
 

The goal of this study was to investigate whether frequency compression (FC) hearing aids provide more benefit than conventional hearing aids. Twelve experienced hearing aid users 65-84 years of age with moderate to severe high frequency hearing loss wore the same hearing aid for six weeks in two conditions- FC enabled and FC disabled. Data from speech recognition in quiet and noise and two questionnaires was gathered. The authors reported that FC results were significantly higher in all of the administered speech tests and high frequency phoneme perception improved over time with the FC; however, subjective perception of benefit from the questionnaires failed to show a significant change. This is an important study as many individuals have high frequency hearing loss with consequent difficulty understanding speech. This study, however, has multiple deficiencies that limited the applicability of the data. The small sample size is further complicated by the heterogeneity of hearing loss in the subjects. There was no mention of the ear coupler-earmold configuration and no testing to explore for cochlear dead regions. With this sample population, cognitive ability was another variable that was not tested. This report was interesting but presented too many methodological errors to be of benefit in addressing the real question regarding superior benefit from FC.

Reference

Benefit from, and acclimatisation to, frequency compression hearing aids in experienced adult hearing-aid users.
Ellis RJ, Munro KJ.
INTERNATIONAL JOURNAL OF AUDIOLOGY
2015;54:37-47

INTERNATIONAL JOURNAL OF AUDIOLOGY

Promotion of trust with adult hearing impairment in hearing healthcare
Reviewed by: Richard Navarro
Vol 24 No 1
 

The goal of this study was to assess how trust is promoted among adult hearing impaired patients seeking hearing healthcare. Previous interview transcript data collected from 29 adults across hearing health care centres in four countries was re-analysed thematically in an attempt to determine how adult subjects sought and pursued hearing healthcare services. A major conclusion of the study was that trust evolves over time from practising good communication, encouraging shared decision making in hearing aid sales, and providing a professional clinic setting. This is an important question as many consumers have developed a sense of mistrust or confusion regarding hearing aid sales due to many factors. This study is a good read for those planning a marketing plan or improving their clinical service. Unfortunately the sample size from each country was too small to draw specific conclusions or to do a comparative study across the sample countries. Some data was collected from facilities where the consumer did not pay for the hearing aids as hearing aids were provided at no charge. The lack of homogeneity across the population sample and the clinical / sales environment makes meaningful conclusions tenuous. The authors’ conclusions support common sense but the data analysis provides little new insight.

Reference

Perceptions of adults with hearing impairment regarding the promotion of trust in hearing healthcare service delivery.
Preminger JE, Oxenball M, Barnett MB, et al.
INTERNATIONAL JOURNAL OF AUDIOLOGY
2015;54:20-28.

JAMA FACIAL PLASTIC SURGERY

Use of angular vessels in head and neck free-tissue transfer – a comprehensive preclinical evaluation
Reviewed by: Bilal Gani Taib
Vol 24 No 1
 

Free tissue transfer (FTT) has transformed the capabilities in head and neck reconstruction. Rotational and pedicled flaps are limited by the pedicle length, the type of tissue required and the size of the defect. FTT helps lessen the impact of some of these issues although its main limitation is pedicle reach for the anastomosis to the inflow and outflow tract. The use of the terminal branch of the facial artery, the angular artery has been described extensively in facial plastic surgery literature. The angular vessels, owing to their high central location in the mid face and accessibility via a camouflaged nasolabial fold incision, may have value in midfacial and nasal reconstructions. This study used 13 cadaveric heads to derive 26 angular arteries and veins. It found that the angular vessels have a consistent anatomical location deep to the intersection point of the nasolabial fold and vertical line through the oral commissure. The vein consistently runs in a deeper plan than the artery 1.5cm superior to the artery along the lateral border of zygomaticus major / minor complex. The mean (SD) artery diameter was 2.34 (0.67)mm prior to dilation and 3.21 (0.87)mm after dilation. The diameters of the vein before and after dilation were 3.57 (0.53)mm and 6.40 (0.81)mm. This study shows that the angular vessels can be reliably dissected using known landmarks, that they have adequate calibre for microvascular anastomosis.

Reference

Use of angular vessels in head and neck free-tissue transfer- a comprehensive preclinical evaluation.
Timothy M. Haffey MD, Jennifer M, et al.
JAMA FACIAL PLASTIC SURGERY
2014;16(5):348-351.

JOURNAL OF INTERNATIONAL ADVANCED OTOLOGY

Full Vs tapered dose of oral prednisolone for sudden sensorineural hearing loss
Reviewed by: Emma Stapleton
Vol 24 No 1
 

I was drawn in by the title of this article, in the expectation that it might be a randomised controlled trial, but it was not. Sudden sensorineural hearing loss is an uncommon condition, which has a potentially disastrous outcome, so any new evidence could be valuable. The paper concludes that “Prescription of a tapering dose of prednisolone is highly recommended as routine management for patients with sudden sensorineural hearing loss. Compared with full-dose treatment, it has equivalent efficacy while reducing the risk of severe side-effects.” The study appears to suggest that there was no significant difference in outcome between the two groups (27 subjects in each) and that one patient in the full dose group developed acute closed-angle glaucoma. This is an interesting observation but it isn’t a sufficiently large or robust study to draw such a confident conclusion. Patients were not randomised to each of the treatment groups, but allocated ‘based on the specialist’s clinical experience’ and this was a retrospective study. There was no control group. The full dose group received seven days of 1mg/kg followed by seven days of a 1/3 dose, whilst the tapered dose group received three days of 1mg/kg, four days of 2/3 dose and seven days of 1/3 dose, so there was not a great deal of difference in dosing regimen between the two treatment groups. It was interesting to note that, in contrast to our practice in the UK, patients presenting to this department with sudden sensorineural hearing loss all underwent both ABR and MRI in order to exclude intracranial pathology, and that they all spent at least seven days as an inpatient. But overall, I don’t think we can learn a great deal about the treatment of sudden sensorineural hearing loss from this article.

Reference

The efficacy of varied oral steroid doses on the treatment of sudden sensorineural hearing loss.
Liu CL, Ho KY, Wang LF, et al.
JOURNAL OF INTERNATIONAL ADVANCED OTOLOGY
2014;10(2):113-7.

JOURNAL OF INTERNATIONAL ADVANCED OTOLOGY

The effect of sleep deprivation on auditory processing
Reviewed by: Emma Stapleton
Vol 24 No 1
 

This article caught my eye for personal and professional reasons. As a full time ENT trainee working 24-hour on-calls, I also have young children who have never slept through the night and don’t respect weekends or days off. My FRCS revision took place between midnight and 3am over a recent twelve-month period. Sleep deprivation is my normal state of existence, and I’m sure I’m not alone. But back to the paper… This study from India aimed to observe the effects of 24 hours of sleep deprivation on temporal processing and frequency resolution in 16 healthy adults. Local ethical approval was acquired, and a number of tests were carried out on the subjects. A paired T-test was used to demonstrate statistical significance of the results of all tests between the two conditions, with p<0.005. The authors acknowledge that the reduced scores may be due to the effects of sleep deprivation on working memory, arousal, attention, concentration etc, and recommend that clinicians should take proper care in diagnosing a patient if sleep deprivation is a factor. This was a very small but neat study, which could lead onto some interesting further research. In the meantime though, I’ll keep in mind that sleep deprivation – my patients’ and mine – can have a serious effect on cognitive function. Goodnight

Reference

The effect of acute sleep deprivation on temporal processing and frequency resolution in normal healthy adults.
Arora A, Bhat JS, Raj D, et al.
JOURNAL OF INTERNATIONAL ADVANCED OTOLOGY
2014;10(2):134-7.

JOURNAL OF LARYNGOLOGY & OTOLOGY

Association of sinonasal symptoms with ear disease
Reviewed by: Madhup K Chaurasia
Vol 24 No 1
 

The study explores the possible association of sinonasal symptoms with ear disease. The subjects were patients with ear problems which were categorised as group A – patients with external ear problems (15%), group B1 – patients with middle ear mucosal disease, (30%), B2 – patients with squamous disease and group C – patients with inner ear disease. Assessment of sinonasal symptoms was via the Dundee Rhinogram. The mean sinonasal symptom scores for groups A, B1,B2 and C were 0.8, 5.94, 0.72 and 1.65 respectively. The association between middle ear mucosal disease and sinonasal symptoms was statistically significant. Some previous studies have shown association between septal deviation, nasal polyposis and eustachean tube dysfunction. One interesting aspect of this study was lack of association between squamous middle ear disease and sinonasal symptoms and it is believed that the link with acquired cholesteatoma may be indirect. The study has its limitations and only sinonasal symptomatology is considered.

Reference

Sinonasal symptoms in adults with ear disease.
Yin B-S, Miah MS, Hussain SSM.
THE JOURNAL OF LARYNGOLOGY & OTOLOGY
2014;128(5):438-41.

JOURNAL OF LARYNGOLOGY & OTOLOGY

Chronic facial pain: types and long-term treatment
Reviewed by: Madhup K Chaurasia
Vol 24 No 1
 

This publication discusses the details and differences between chronic tension type headache and migraine and followed a cohort of 240 patients over 36 months. The authors applied strict criteria to distinguish between chronic tension headache and migraine, these essentially being that in the former, the pain lasted for hours not days, the pain was bilateral and photophobia, nausea and vomiting were much less prevalent than in migraine. It was noted that patients suffering from facial pain had no difference in BMI but were better educated and in more professional occupations. Strict inclusion and exclusion criteria were applied. Patients who had past sinus surgery, baro-trauma, trauma, TMJ dysfunction, were pregnant, had a history of drug usage for depression or use of solvents and alcohol were excluded. Patients with positive sinus CT findings were also excluded. In the three-year follow-up, it was observed that 45.5% of patients with chronic tension headache who received regular amitriptyline for eight weeks reported resolution (less than one episode per month) whereas only 23% of those with migraine, treated with 10mg amitriptyline or propanolol, achieved the same. Patients on regular medication did better than ones taking NSAID for chronic tension headache and triptans for migraine as and when required. Interestingly, pain was reported as bilateral in 48% of patients with migraine, in contrast to the general belief that it is unilateral. The incidence of rhinitis, positive skin tests, cigarette smoke and exposure to systemic illnesses was similar in patients with mid-facial pain and migraine in comparison with the general Maltese population; this is in contrast to a previous Norwegian study. This is an elaborate study that highlights symptomatology and presentation of facial pain common to otolaryngology clinics.

Reference

Prospective three-year follow-up of a cohort study of 240 patients with chronic facial pain.
Agius AM, Jones NS, Muscat R.
THE JOURNAL OF LARYNGOLOGY & OTOLOGY
2014;128(6):518-26.

JOURNAL OF MEDICAL CASE REPORTS

Head and neck myxofibrosarcoma: a case report and review of the literature
Reviewed by: Bilal Gani Taib
Vol 24 No 1
 

Myxofibrosarcoma is the most common soft tissue sarcoma that occurs in late adult life, peaking in the seventh decade, and it is mainly encountered in the lower extremities. Cases within the head and neck region are extremely rare and to date only 19 cases have been described so far. The case report described here is of 35-year-old caucasian man who presented with a complaint of facial asymmetry for a mass in his right midcheek area, which had increased in size over four months. An intraoral examination revealed an expansion of his upper right gums and the vestibular portion and his teeth were movable with the presence of a widespread periodontitis. Computed tomography revealed a hyperdense mass 83mm x55mm in the pterygopalantine fossa. An open biopsy sample was obtained and this was consistent with a myxofibrosarcoma. A total right maxillectomy was performed using a Weber-Ferguson approach preserving the orbital floor. The tumour was detached and the excised portion was reconstructed with a free rectus abdominis myocutaneous flap. Postoperative radiotherapy was given to the area. The authors having reviewed the literature recommend a complete tumour resection with adequate resection margins, followed by adjuvant radiotherapy with possible re-excision of recurrent lesions. Aggressive follow-up is required to monitor any possibility of metastases.

Reference

Head and neck myxofibrosarcoma: a case report and review of the literature.
Dell G, Orabona A, Laconetta G, et al.
JOURNAL OF MEDICAL CASE REPORTS
2014;8:468.

JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY

Multiple free flaps for head and neck cancer
Reviewed by: Sunil Kumar Bhatia
Vol 24 No 1
 

Most patients with advanced head and neck cancers now undergo microvascular free flap reconstruction. This is mainly as flaps facilitate complete tumour and margin removal by providing reliable wound coverage and better restoration of form and function. However despite this, loco regional recurrence remains the dominant form of treatment failure. Furthermore these patients are at risk for developing a second primary malignancy 55-30% and complications of multimodality treatment include osteoradionecrosis, strictures and fistulae. The optimal treatment for these might involve further microvascular free flap reconstruction. There is understandable hesitation in performing sequential head and neck free flaps, mainly for fear of lack of suitable vessels and other post operative complications. In this retrospective study the authors analysed patients that underwent one or more sequential flap reconstructions between 2000 and 2012. A total of 278 flaps were performed on 117 patients and 23 patients had two or three simultaneous flaps, one patient a total of five free flaps. This is an impressive series including a wide variety of flaps, receipt vessels and veins. Complications for subsequent free flaps 22.2-43.1% are reported and were not significantly different from those of primary flap surgery. Also survival and good function was demonstrated. The authors demonstrate that in selected patient cohort with the possibility of good long-term quality life it is worth considering sequential flap reconstruction. This is an impressive series of flaps for reconstruction in a difficult set of patients and gives the surgeon confidence to think about sequential free flaps.

Reference

Success of sequential free flaps in head and neck reconstruction.
Hanasono MM, Corbitt CA, Yu P, Skoracki J.
JOURNAL OF PLASTIC, RECONSTRUCTIVE AND AESTHETIC SURGERY
2014;67:1186-93.

JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY

Postauricular advancement flap for partial helix defect repair
Reviewed by: Sunil Kumar Bhatia
Vol 24 No 1
 

Ear defects can be the result of trauma, burns or ablative surgery. The three dimensional structure of the pinna presents a difficult reconstructive challenge as successful ear reconstruction requires both similar tissue cover and a supporting framework. Partial ear reconstruction can be achieved with a number of options and the postauricular advancement flap is a well-recognised technique to repair this defect. The authors present a novel method for helix repair with the use of the postauricular advancement flap and free ipsilateral conchal cartilage graft. The authors report on 10 cases, between May 2010 and October 2012, of unilateral partial ear defects repaired with this technique. A random pattern postauricular flap was raised and ipsilateral conchal cartilage harvested. Vaseline impregnated gauze was used to shape the neo-scapha and helix, and free cartilage and flap reconstructed the ear. This is a useful technique to be aware of, it is an elegant solution to quite a difficult reconstructive issue but it does require a secondary procedure. Advantages include single donor site, reduced trauma surgical simplicity and good colour match of the flap.

Reference

Partial helix defect repair by use of postauricular advancement flap combined with ipsilateral conchal cartilage graft.
Hu J, Zhang Q, Zhang Y, et al.
JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY
2014;67(8):1045-9.

JOURNAL OF VESTIBULAR RESEARCH

Alcohol and the vestibulo-ocular reflex (VOR)
Reviewed by: Fiona Barker
Vol 24 No 1
 

I was drawn to this paper initially for slightly unscientific reasons but in fact it proved a worthwhile read. It describes the effect of alcohol consumption on the VOR of eight healthy subjects as measured using video head impulse testing and the dynamic visual acuity test. It nicely measures what those of us fond of the odd glass of wine already know: that things get blurry after one too many glasses. However it also shows how relatively subtle changes in the VOR can be measured using these tests. This has implications for those who might want to use them to track compensation or treatment effect. In addition it also implies that these tests might have a higher association or correlation with subjective report of symptoms than our existing test battery has been shown to have.

Reference

Ethanol consumption impairs vestibulo-ocular reflex function measured by the video head impulse test and dynamic visual acuity.
Rotha TN, Weberb KP, Wettsteina VG, et al.
JOURNAL OF VESTIBULAR RESEARCH
2014;24(4):289-95.

JOURNAL OF VESTIBULAR RESEARCH

Visual vertigo and optokinetic response
Reviewed by: Fiona Barker
Vol 24 No 1
 

This study measured differences in optokinetic responses (sitting, standing, with and without a static visual target) in three groups of people: those classified as having unilateral vestibular loss (n=10), unilateral loss with visual vertigo (n=8) and a control group (n=10). In the abstract the authors have highlighted the differences between the visual vertigo group and the control group and used this to argue that visual dependency should be considered in vestibular rehabilitation. While I concur with this broad conclusion, further reading of the paper reveals little difference between the two groups with vestibular loss. They both differ from the control group on some of the test measures. It is therefore less clear what this paper is saying about visual vertigo as a separate ‘special case’ in addition to unilateral vestibular loss. The way the results are reported in the abstract represents potential reporting bias on the part of the authors and not a dispassionate presentation of the test findings. The title perhaps conveys the content more accurately than the abstract.

Reference

The influence of visual vertigo and vestibulopathy on oculomotor responses.
Zura O, Dickstein R, Dannenbaum E, et al.
JOURNAL OF VESTIBULAR RESEARCH
2014;24(4):305-11.

NEUROSURGERY

Long-term outcomes after endoscopic pituitary macroadenomas resection
Reviewed by: Ms Gauri Mankekar
Vol 24 No 1
 

In this retrospective study the authors attempted to find out long-term outcomes after pituitary macroadenoma resection via the endonasal endoscopic transsphenoidal route. Eighty of the 162 patients operated on met the study criteria of clinical and radiological follow-up for at least five years after resection. Seven patients who had grossly complete resection were found to have recurrences with a mean time to recurrence of 53 months. The authors found that patients with Knosp grade 0-2 tumours and tumour volumes <10 cm3 were significantly more likely to have received a grossly complete resection compared to patients with Knosp grade 3 to 4 tumours or tumours with volumes >10 cm3. Of the 23 patients who had sub-total resection, 11 progressed radiographically and three were found to have symptomatic progression. Recurrent or residual tumours were treated with either repeat surgery or gamma knife radiosurgery. The authors found that the rates of grossly complete resection, incidence of new hypopituitarism, and postoperative complications were similar to those in published literature on endoscopic and microscopic pituitary adenoma resection. The article however does not provide the author’s outcome results following microscopic versus endonasal endoscopic resection.

Reference

Long-term results of endonasal endoscopic transsphenoidal resection of nonfunctioning pituitary macroadenomas.
Dallapiazza RF, Grober Y, Starke RM, et al.
NEUROSURGERY
2015:76:42-53.

NEUROSURGERY

Outcomes after facial nerve preservation surgery for large vestibular schwannomas
Reviewed by: Gauri Mankekar
Vol 24 No 1
 

Large vestibular schwannomas (Koos grade three or four) are traditionally treated by surgical resection. Gross total resection of such large tumours often results in facial nerve dysfunction. Hence facial nerve preservation surgery was introduced in which maximal surgical resection is attempted with a potential residual tumour capsule or nodules left behind in an effort to maintain facial nerve function. The authors of this paper retrospectively studied the outcomes of this technique in 52 patients. Their findings support facial nerve preservation surgery as the new standard for acoustic neuroma treatment. They suggest that maximising resection with close postoperative radiographic follow-up enables early identification of tumours that will progress to radiosurgical treatment. This sequential approach can lead to combined optimal facial nerve function and effective tumour control rates. Facial nerve preservation surgery seems to definitely reduce the morbidity following vestibular schwannoma resection.

Reference

Facial nerve preservation surgery for koos grade 3 and 4 vestibular schwannomas.
Anaizi AN, Gantwerker EA, Pensak ML, Theodosopoulos PV.
NEUROSURGERY    
2014:75:671–7.

OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY

Cochlear implantation techniques
Reviewed by: Suzanne Jervis
Vol 24 No 1
 

This issue concentrates on the advancement in techniques within the field of implant otology starting with cochlear implantation. Here it is sub-divided into indications, candidacy (including full pre-operative testing and investigations), surgical technique and outcomes for both adults and children. The surgical section is further divided into the relevant surgical steps one progresses through. Of particular note, the authors explain the positioning of the ideal incision and the considerations with regard to avoiding post-operative wound complications. The merits of cochleostomy and insertion via the round window are discussed in detail but the extended round window technique is also described as a third option for electrode access. The article clearly has a central theme with regard to hearing preservation and the techniques adopted to optimise this. In particular, ‘soft surgery’ principles to minimise trauma and prevent contamination into the cochlear to preserve residual hearing are explained. The speed of electrode insertion with relevance to hearing preservation was also discussed. Issues regarding securing the device (especially in children where bony wells are less feasible) and the various techniques used were described. Complications that have been encountered in drilling the well down to the dura (CSF leaks and subdural haematomas) have been identified within the literature such that this technique is no longer favoured. Finally, the need for Pneumococcal vaccinations is emphasised to prevent meningitis in implant patients. These topics were all supported by current available evidence, which in the most part pertained to case series and cohorts rather than randomised trials. They also drew on their own experience at the Johns Hopkins School of Medicine, Baltimore. The reader is therefore reminded that the techniques described are based on personal preference with at best level IIb supporting evidence in some situations. However, a useful overview of the differing options in insertion techniques.

Reference

Techniques in cochlear implantation.
Weinreich HM, Francis HW, Niparko JK, Chien WW.
OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY
2014:25(4);312-320.

OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA

A higher aspiration for fine needles
Reviewed by: Charlie Giddings
Vol 24 No 1
 

Fine needle aspiration biopsy (FNAB) has aided in the diagnosis and management of thyroid nodules for decades. Now a rapid evolution is hoped to benefit an increasing cohort of patients with small nodules and non-diagnostic investigations. This review discusses the well-documented limitations of FNAB and the diagnostic utility of testing for somatic mutations and rearrangements found in thyroid cancer. Fine needle aspiration (FNA) with molecular alteration testing has high specificity and positive predictive value. FNA with gene expression has high sensitivity and negative predictive value and hopes to reduce the number of diagnostic thyroid lobectomies. Patients whose results are either follicular lesion of unknown significance or atypia of unknown significance may be the biggest beneficiaries as they frequently undergo diagnostic lobectomy that may be unnecessary, with associated healthcare costs and morbidity. Several mutations within the mitogen-activated protein kinase pathway have been documented in the development of papillary thyroid carcinoma, including RAS and BRAFV600E mutations and RET/PTC rearrangements. In follicular thyroid carcinoma and follicular adenoma, genetic mutations in the PI3K-AKT pathway are common. Well-differentiated thyroid cancer exhibits indolent behaviour but occasionally may behave in a very aggressive fashion. Prognostication using biomarkers may be a useful tool to guide the extent of initial surgery as BRAFV600E has been identified as an independent risk factor for the recurrence of papillary thyroid cancer and also death.

Reference

Clinical application of molecular testing of fine-needle aspiration specimens in thyroid nodules.
Yip L, Ferris RL.
OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA
2014;47(4):557-71.

OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA

Childhood bony facial tumours
Reviewed by: Charlie Giddings
Vol 24 No 1
 

This review article covering maxillary and mandibular tumours is from an edition of the Clinics covering paediatric head and neck masses from frequently encountered congenital malformations to the rarities. There is a wide differential diagnosis for childhood mandibular or maxillary masses and many have non-specific radiological findings making open biopsy essential. The conditions covered in this chapter are divided into odontogenic causes and non-odontogenic. Fibrous dysplasia (FD) is caused by a sporadic mutation in the GNAS1 gene on chromosome 20, causing replacement of normal bone with fibrous connective tissue with a slow clinical progression. FD is not a neoplastic disease, is characterised by ground glass appearances on CT and is divided into monosteotic, the majority of cases, and polyosteotic. Polyosetotic disease involves two or more bones and in combination with café au lait spots and endocrinopathies suggests McCune-Albright syndrome. Treatment is symptom driven, and also depends on sites involved and maturity of the skeleton. Bone pain may be aided with bisphosphonates and for those who require treatment, it is usually surgical. A comprehensive review article of lesions arising in the facial skeleton from simple cysts to histiocytosis.

Reference

Pediatric maxillary and mandibular tumours.
Trosman SJ, Krakovitz PR.
OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA
2015;48:101-19.

OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA

Thyroid nodules in children
Reviewed by: Charlie Giddings
Vol 24 No 1
 

Whilst 5% of nodules in adults may harbour malignancy it is reported in this review that about a quarter of nodules may do so in children. Malignancies in this group are almost always well-differentiated subtypes of papillary, follicular and medullary carcinoma. Radiation has been implicated with the risk increasing with increasing exposure, and the well-established genetics of multiple endocrine neoplasia (MEN) is described. Aside from MEN there is an increased risk in other syndromes including Cowden, Gardner, Peutz-Jeghrs and familial adenomatous polyposis, most of which are autosomal dominant. All solid thyroid nodules greater than 1cm in size should undergo a needle aspiration for cytology, smaller nodules only in the presence of other suspicious features. Once identified, nodules should undergo surveillance if a conservative course is followed. A useful algorithm for nodules in the paediatric population is presented along with unusual presentations either ectopic or in congenital cysts. A helpful description of methodology to monitor the recurrent laryngeal nerves is also described, in particular alternatives given the smallest endotracheal tube with monitoring electrodes is likely too big for almost all children. It should be noted in this review that quoted articles include ages up to 21.

Reference

Pediatric thyroid nodules and malignancy.
Jatana KR, Zimmerman D.
OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA
2015;48:47-58.

OTOLOGY & NEUROTOLOGY

BAHA loading two weeks after implant insertion
Reviewed by: Anand Kasbekar
Vol 24 No 1
 

The time thought necessary for sufficient osseointegration to occur  to enable use of a BAHA has reduced from months to a few weeks. This paper further reduces this timescale to two weeks in patients with healthy bone and soft tissue (excluding diabetes, radiotherapy etc). The implant tested was a Cochlear BIA300 with a 4mm implant and 9mm abutment. Forty-nine patients (mean age 61 years), were randomised to either dermatome and soft tissue reduction technique, or the newer linear incision with no soft tissue reduction. The implant stability quotient (ISQ) was measured every few days up to a month and then at various points up to one year. The results revealed no difference in ISQ between the surgical methods of implantation. Early loading of the implant at two weeks did not lead to any implant losses or any significant change in ISQ. It is important to note that this study only provides safety data on the particular implant used on patients with healthy bone.

Reference

Successful loading of a bone-anchored hearing implant at two weeks after surgery: randomised trial of two surgical methods and detailed stability measurements.
Høgsbro M, Agger A, Johansen LV.
OTOLOGY AND NEUROTOLOGY
2015;36(2):e51-7.

OTOLOGY & NEUROTOLOGY

Canal wall down with obliteration of cavity for paediatric cholesteatoma
Reviewed by: Anand Kasbekar
Vol 24 No 1
 

The authors present evidence that canal wall down (CWD) surgery with primary obliteration is an effective way to treat paediatric cholesteatoma. Fifty-eight ears were operated on and follow-up was for five years on average. Residual cholesteatoma rate was 9.9% with no recurrences. Otorrhoea rate at one year was 0%. Reoperation risk was 17% at five years which included reasons such as hearing improvement (ossiculoplasty), planned second look and abnormality on the post-op CT scan at one year.
The points to note are that firstly all children routinely require a CT scan post-op if they are compliant. This does not feel right, in view of the not so insignificant added risk of second malignancy in children exposed to CT scans. Perhaps this will change as the author’s institution has started diffusion weighted MR imaging. When performing this surgery, one has to be sure (as can be), that all cholesteatoma has been removed and all mastoid air cells are exenterated. The cavity is obliterated using cartilage plates and hydroxyapatite granules or glass-ceramic crystals. Follow-up for longer than 10 years may find extrusion of the exogenous material, although at the present time it is an attractive material to use. Good hearing results are also presented. Overall, the technique achieves with good probability the goal of leaving a trouble free, water-proof ear in children with often aggressive cholesteatoma and significantly reduces the need for automatic second-look surgery as in canal wall up surgery.

Reference

Paediatric cholesteatoma surgery using a single-staged canal wall down approach: results of a 5-year longitudinal study.
Trinidade A, Skingsley A, Yung MW.
OTOLOGY AND NEUROTOLOGY
2015;36(1):82-5.

OTOLOGY & NEUROTOLOGY

Nasal decongestants don’t improve Eustachian tube function
Reviewed by: Anand Kasbekar
Vol 24 No 1
 

Prescribing nasal steroids and decongestants. It’s something most of us do routinely, in an effort to reduce chronic middle ear effusion in an adult by trying to improve eustachian tube (ET) patency. This study used clever devices (tube manometry and the pressure equalization test) to measure opening pressures of the ET before and after (15 mins) instillation of xylometazoline (Otrivine). Adult subjects had intact ear drums (44 ears), non-infected perforated ear drums (43 ears) and six patients had upper airway infection. Decongestant was also instilled into the ear in some patients with perforated ear drums in an effort to get the medication into the ET. Overall, nasal decongestants did not improve ET patency and in some cases even led to reduced ET ventilation! If we think about it, how should solution in the nose work its way up the ET against the beating cilia. The environment of the nasal mucosa and the ET is also different and the vasoconstriction effect of the nasal mucosa will be much more than on the ET mucosa. Measurements made much longer than 15 mins after nasal decongestant instillation in other studies have not shown a beneficial effect either. This study was not geared towards proving any effect on patients with acute otitis media related to an upper airway infection which is a future area of research.

Reference

Can nasal decongestants improve eustachian tube function?
Ovari A, Buhr A, Warkentin M, et al.
OTOLOGY AND NEUROTOLOGY
2015;36(1):65-9.

OTOLOGY & NEUROTOLOGY

Revision stapedectomy with bone cement works well!
Reviewed by: Anand Kasbekar
Vol 24 No 1
 

Revision stapes surgery is notoriously difficult and results are worse than in primary surgery. This group in Utah have described the use of hydroxyapatite bone cement to stabilise the nitinol prosthesis they use in revision surgery due to incus necrosis related failure. It is worth a read for stapes surgeons as the word limit here is too short to describe the technique in full, and in stapes surgery, it’s all in the detail! There is also a video attached on-line. The results: 27 patients with average follow-up of only seven months. Postoperative closure of the air-bone gap to within 10dB was established in 78%, and closure within 20dB was achieved in 96%. These are excellent results by any standards and better than previous reports on revision stapes surgery. Their excellent results may be due to the rest of their technique rather than the bone cement use and it would have been so useful to have had a comparison group.

Reference

Revision stapedectomy with bone cement: are results comparable to those of standard techniques?
Hudson SK, Gurgel RK, Shelton C.
OTOLOGY & NEUROTOLOGY
2014;35(9):1501-3.

OTOLOGY & NEUROTOLOGY

Vascular loops found on MRI IAM for tinnitus
Reviewed by: Anand Kasbekar
Vol 24 No 1
 

This group from the Netherlands looks at the finding of vascular loops found on MRI IAMs requested for tinnitus. It is a common finding for all who request such imaging. This work adds to the body of evidence that such vascular loops should be regarded as an incidental finding. It occurred in 23% of patients scanned (321 patients). There was a 41% rate of abnormalities on MRI, which were not the cause of tinnitus. This is a familiar situation I face on a regular basis and deciding what requires further evaluation and what can be left alone safely without causing undue anxiety to the patient. Interestingly, their protocol scans for bilateral tinnitus (51% of patients), which in a cash strapped NHS is difficult to justify. Not unsurprisingly, unilateral tinnitus had a significantly higher chance of finding pathology that may account for the tinnitus (p=0.044). Two acoustic neuromas were found (1.7%) and both cases had hearing loss in addition. A discussion regarding whether unilateral tinnitus on its own merits an MRI is presented. It depends on your point of view but in my opinion it does not, and further clinical / audiometric signs are usually present. Rarely would I expect to find significant pathology (e.g. a large acoustic neuroma) warranting treatment, with symptoms of unilateral tinnitus, symmetrical hearing and no other clinical signs. Definitely worth a read and discussing with your radiology department to come up with your own guidelines for MRI IAM requests.

Reference

Diagnostic yield of a routine magnetic resonance imaging in tinnitus and clinical relevance of the anterior inferior cerebellar artery loops.
Hoekstra CE, Prijs VF, van Zanten GA.
OTOLOGY AND NEUROTOLOGY
2015;36(2):359-65.

SAUDI JOURNAL OF OTO-RHINO-LARYNGOLOGY HEAD & NECK SURGEY

Role of fine needle aspiration cytology in the management of thyroid neoplasm
Reviewed by: B Viswanatha
Vol 24 No 1
 

Fine needle aspiration cytology (FNAC) is a useful procedure in the assessment of thyroid swellings. This retrospective study was done at King Abdul-Aziz University hospital, King Saud University, Riyadh. The objectives of this study were: to determine the cytological pattern of thyroid lesions; to determine the diagnostic accuracy of FNAC of thyroid lesions; to compare the results with data published in literature; and to stress on the importance of using standardised cytological reporting system for thyroid FNAC. This retrospective study period was from January 2010 to December 2012. During this period 81 patients with thyroid lesions underwent FNAC. Results of the FNAC were grouped according to Bethesda system for reporting thyroid cytopathology. The results were as follows:
I)     1.2% patient’s results were not satisfactory
II)    59% patients had benign lumps
III)   14.8% patients had follicular lesion of undetermined significance
IV)    7.4% patients had follicular neoplasm
V)     2.4% patients had results suspicious for malignancy
VI)    14.8% patients had malignancy.
In this study FNAC findings, in relation to histopathological diagnosis, showed accuracy rate of 95% with a sensitivity rate of 80% and specificity of 100%. Authors state that the implementation of a standardised cytological reporting system with defined diagnostic categories will result in improved understanding of FNAC results and this will help in the management of thyroid neoplasm.

Reference

Thyroid gland fine needle aspiration cytology, a retrospective review in a tertiary hospital.
Al-Jabar I, Al-Aahmari M, Al-Qahtani K.
SAUDI JOURNAL OF OTO-RHINO-LARYNGOLOGY HEAD & NECK SURGEY
2014:16(1):11-14.

THE HEARING JOURNAL

Audiology in palliative care
Reviewed by: Linnea Cheung
Vol 24 No 1
 

The goal of palliation is to provide services that are centred on understanding the salient needs for the patient, maintaining quality of life and addressing any functional and supportive needs of the patient and those caring for them. The audiologist plays an important role in raising awareness of hearing impairment, teaching others to recognise behaviours indicative of hearing impairment, and outlining effective strategies and techniques by which to improve communication. Shifting focus to the promotion of good communication can help enhance shared decision making, thus enhancing patient autonomy, dignity and quality of life. Good communication certainly has an important role in all forms of decision making with regards to healthcare, but perhaps its role in the palliative setting has been previously overlooked. Expanding the palliative multidisciplinary team by involving of audiologists certainly seems like a wise idea, but as with many changes in healthcare, would inevitably require additional resources in both hospital and community settings.

Reference

Palliative care: defining the role of the audiologist.
Weinstein B.
THE HEARING JOURNAL
2015;68(1):23-4.

THE HEARING JOURNAL

Auditory brainstem response patterns are neural signatures
Reviewed by: Linnea Cheung
Vol 24 No 1
 

Through examples, this article describes how particular aspects of auditory brainstem responses can portray certain kinds of language or communication impairments – a characteristic pattern or ‘neural signature’. A reduction in processing of the fundamental frequency is seen commonly in dyslexia, impaired pitch tracking ability is seen in the context of autistic spectrum disorder and pervasive delays across all measures are observed in older subjects with an otherwise clinically normal audiogram. In addition, there are neural signatures that are characteristic for those subjects with hearing expertise, such as musicians and bilingual language speakers who have enhanced response consistency and earlier peak timing. An individual’s neural signature takes into account lifetime experiences therefore, such variation in auditory brainstem responses as mentioned above may be superimposed upon each other giving a unique picture for that individual, for example, a dyslexic bilingual subject. Whilst neural signatures may enhance the broad interpretation of auditory brainstem responses as recognisable patterns, ultimately, detailed analyses will still rely on interpretation of pure threshold values.

Reference

Identifying neural signatures of auditory function.
Kraus N, Anderson S.
THE HEARING JOURNAL
2015;68(1):38-40.

THE HEARING JOURNAL

Earplugs fit for purpose
Reviewed by: Linnea Cheung
Vol 24 No 1
 

The aim of occupational audiology is to prevent hearing loss caused by occupational sound exposure which can exacerbate the long-term effects of central presbyacusis as employees age. To provide the best noise protection over time, research suggests that best practice should be to attempt to limit sounds at the eardrum to 75-80dBA. Attenuation of sound by 10-15dB through earplugs should be sufficient to achieve this. Practical fit testing and counselling is required in order to obtain optimum hearing protection because although earplug manufacturers give noise reduction ratings for their products, this does not correlate the actual protection delivered when in use. The other benefit of proper fit testing is that it can be used to identify unusual configurations of ear canal anatomy which may result in incompatibility with certain earplugs. Low tone attenuation of >20dB must also be tested for separately to detect slit leak venting, as well as interaural performance difference. Three quarters of the earplug length should fit snugly and deeply into the ear canal with a deep seal, without significant slit leak and should not move outwards with temporomandibular joint movement, nor be able to be removed easily. Sound protection must be optimised for each individual employee as best possible in order to prevent hearing loss and to promote better lifelong hearing for all.

Reference

Fit for hearing protection with earplug testing.
Colucci D.
THE HEARING JOURNAL
2014;67(12):40

AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY

The stubborn polyp cases are ‘different’
Reviewed by: Edward W Fisher
Vol 23 No 6
 

The widely different behaviour of nasal polyp disease between patients is a major feature of rhinology practice and makes counselling of patients difficult when approaching their first operative intervention. Setting aside aspirin sensitivity (Samter’s triad), which is known to be indicative of a patient being in the ‘stubborn’ group of recalcitrant polyps, are there any other indicators? This study looked specifically at the immune mediators and immune profile in 21 cases of ‘first’ polypectomy and 15 cases where previous surgery had been undertaken. They found that some mediators or antibodies were higher in the recurrent polyp group. These included: specific IgE to Staph. Aureus enterotoxin, Eosinophil Cationic Protein (ECP) and interleukin 5 (IL-5) were raised in this group. This indicated a predominant Th2 type of inflammation in the recurrent polyp group. Another study in this issue of the journal showed that tissue eosinophilia and high levels of eosinophilic mucin was associated with recurrence. While this might help us to counsel patients, since medical therapy is likely to be tailored to the individual patient, I am not sure that knowing this helps us in management at this stage.

Reference

Differences in initial immunoprofiles between recurrent and nonrecurrent chronic rhinosinusitis with nasal polyps.
Van Zele T, Holtappels G, Gevaert P, Bachert C.
AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY
2014:28(3):192-8.

AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY

Waiting for smell to recover after post-viral hyposmia
Reviewed by: Edward W Fisher
Vol 23 No 6
 

The patient with post-viral anosmia will always want to know how long they must wait to reach a plateau. This study from South Korea of a comparatively small group (20 controls and 63 patients) tells us that favourable prognostic indicators were female sex and long follow-up. This was a retrospective case note study, which detracts somewhat from the conclusions, although many patients had threshold testing and the setting was a dedicated smell and taste clinic. Over 80% showed some recovery (subjectively) after a year. The occasions where a scientific article makes me laugh out loud (for good rather than bad reasons) are few and far between, but when this occurs it is a pleasant change from the weeping that is often the appropriate emotional response. On this occasion, the authors had a theory as to why female gender was a favourable prognostic factor (and the theory could be true, from what we know about the human capacity for olfactory training and regeneration): ‘most female participants in our study were housewives and continuous olfactory stimulation during cooking might have accelerated regeneration of olfactory neurons.’ I would not be brave enough to advocate support for this theory at the British Rhinological Society meeting (even if I think it is correct)!

Reference

Prognosis of postviral olfactory loss: follow-up for longer than one year.
Lee DY, Lee WH, Wee JH, Kim J-W.
AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY
2014;28(5):419-22.

ANNALS OF THE ROYAL COLLEGE OF SURGEONS OF ENGLAND

Variability in the management of differentiated thyroid cancer (DTC)
Reviewed by: Thomas Jacques
Vol 23 No 6
 

his retrospective study analyses for the first time the management planning of thyroid surgeons across the specialties. A questionnaire was sent to members of ENT-UK, the British Association of Endocrine and Thyroid Surgeons, Association of Surgeons of Great Britain and Ireland, and the Association of Breast Surgery. Six clinical vignettes were given, describing DTC patients with differing levels of risk, with several options in terms of subsequent management. The available options were denoted either risk-stratified (RS) or non-risk-stratified (NRS) choices, as determined by expert consensus based on current evidence. NRS choices indicated under- or over-treatment of the patient. Data regarding the experience and practice of the surgeons was also collected. The study revealed considerable variability in practice, particularly in patients of intermediate risk (e.g. older patients with incidental, low-risk disease). The authors attribute this in part to a lack of consensus at guideline level. ENT surgeons had a tendency to perform more aggressive nodal dissection; this was conjectured to be due to the influence of their experience of squamous head and neck tumours. However, in common with specialised endocrine surgeons, they exhibited more RS preference overall when compared with other surgeons. Surgeons who perform a higher volume of thyroidectomies (>25/year), those who participated in an MDT, and those in the early and middle years of their consultant careers, were more likely to make appropriate RS choices. This is in keeping with previously-published literature. Overall the study provides useful insight into concerning levels of variation in the management of DTC, and makes a case for more concentrated, multi-disciplinary thyroid surgery practice.

Reference

A cross-specialty survey to assess the application of risk stratified surgery for differentiated thyroid cancer in the UK.
Craig WL, Ramsay CR, Fielding S, Krukowski ZH.
ANNALS OF THE ROYAL COLLEGE OF SURGEONS OF ENGLAND
2014;96(6):466-74.

Auris Nasus Larynx

What’s the risk of regrowth with partial (intracapsular) tonsillectomy
Reviewed by: Ravi Thevasagayam
Vol 23 No 6
 

Partial (intracapsular) tonsillectomy is enjoying somewhat of a revival offering the potential for less postoperative pain and bleeding whilst relieving the obstructive element. The authors look at 303 patients, 82 of whom had partial tonsillectomy using coblation. They measured pre and post immunoglobulin levels in both groups and found no significant levels pre and post surgery or between the two groups. Partial tonsillectomy appeared to be quicker and most interestingly there were no postoperative bleeds in this group. Five patients in the partial group had tonsillar regrowth (6.1%) of which two went on to total tonsillectomy. All five had tonsillitis following the partial tonsillectomy. This small study seems to support data emerging that partial intracapsular tonsillectomy effectively deals with obstructive symptoms while potentially offering dramatic reductions in postoperative haemorrhage. The down side remains the potential for regrowth, tonsillitis and further surgery. More developments to follow I’m sure!

Reference

Long term outcome of tonsillar regrowth after partial tonsillectomy in children with obstructive sleep apnea.
Zhang Q, Li D, Wang H.
AURIS NASUS LARYNX
2014:41(3):299-302.

B-ENT

Deep neck infections
Reviewed by: Sunil Sharma
Vol 23 No 6
 

This study from Shanghai is a retrospective review of 142 patients presenting to an ENT hospital with deep neck infections (DNIs). The findings of the study are comparable to many of the previous studies, however the authors found tonsillitis and foreign bodies to be the most common cause for DNIs, as opposed to dental infections. This may well be due to the fact that this study took place in a specialist ENT hospital with no oral and maxillofacial surgery cover. The most common causative organism was found to be streptococci, which is comparable to the literature. The literature reports Klebsiella pneumonia as the most common causative organism in diabetic patients but the authors here describe that out of 30 patients with diabetes only one patient grew K. pneumoniae. The most common subsite for infections was the parapharyngeal space which is probably due to the high rate of tonsillitis patients in this study. There is a significantly lower rate of prophylactic tracheostomy for these patients that the authors postulate may be due to their use of intravenous steroids routinely in patients with pharyngeal infections. The authors have discussed the limitations in this study including the small numbers, retrospective data collection and the follow-up by telephone. The most important message that the authors make is regarding the significant possibility (46%) of underlying congenital lesions, such as a branchial cyst, in patients who have recurrent infections and the importance of thorough imaging in this subset.

Reference

Deep neck infections: a retrospective study of 142 patients.
Jin L, Zhang T.
B-ENT
2014;10:127-32.

B-ENT

ENT emergencies
Reviewed by: Sunil Sharma
Vol 23 No 6
 

This Belgian paper reports the epidemiology of 1296 patients attending the emergency department with ENT problems over a five-year period. As expected the most common presentation was epistaxis, but interestingly vertigo seemed to be the second most common presentation to the emergency department during most years. This is in contrast to many British hospitals where vertigo would more commonly present to the outpatient clinic. Indeed the authors don’t seem to give a clear reason for this high proportion of vertigo patients. They hypothesise the reason for a high rate of epistaxis is due to the perception that epistaxis is a severe ENT problem requiring urgent attention by an ENT specialist. The authors compare their results to a similar German paper, which has a higher rate of less urgent problems such as earplugs, etc. They hypothesise this may be because in the Belgian institute they have daily clinic slots available for (semi-) urgent cases compared to the German paper where there are longer waiting lists for outpatients, so patients are more likely to attend the emergency department rather than wait for an outpatient appointment. The authors also report a low rate of re-attendance and of admission (8%) compared to the literature. The low admission rate may be due to patients with nasal packs not being routinely admitted, which is at odds with UK practice. This paper gives an interesting insight into the epidemiology of ENT emergencies in Belgium across a large patient group, and highlights some important differences in service arrangements compared to the UK.

Reference

Epidemiology of ENT emergencies.
Lammens F, Lemkens N, Laureyns G, et al.
B-ENT
2014;10:87-92

BMC EAR, NOSE AND THROAT DISORDERS

Laryngopharyngeal reflux (LPR) in posterior laryngitis
Reviewed by: Gauri Mankekar
Vol 23 No 6
 

The authors of this study investigated the prevalence of acid reflux in the proximal oesophagus and functional gastrointestinal symptoms in patients with posterior laryngitis. They analysed plasma motilin as well as health-related quality of life (HRQOL) questionnaires before and after treatment in 46 patients. Oesophago-gastro-duodenoscopy, 24-h pH monitoring, Plasma motilin analysis and a 36-item short-form questionnaire were completed at inclusion and at follow-up 43±14 months later. Forty percent of patients showed distal acid reflux while 34% showed proximal acid reflux. Only 17% of the 94% patients who received acid reducing treatment showed relief of symptoms. Patients with reflux symptoms had lower plasma motilin levels compared to patients without reflux symptoms. The study concluded that only a minority of patients with posterior laryngitis had LPR and were cured by acid-reducing therapy. However, abnormal plasma motilin levels and functional gastrointestinal symptoms were found in patients with posterior laryngitis and the impaired HRQOL improves over time.

Reference

Posterior laryngitis: a disease with different aetiologies affecting health-related quality of life: a prospective case-control study.
Pendleton H, Ahlner-Elmqvist M, Olsson R, et al.
BMC EAR, NOSE AND THROAT DISORDERS
2013:13:11.

EUROPEAN REVIEW OF ENT

Day care or admission for aesthetic nasal surgery?
Reviewed by: Badr Eldin Mostafa
Vol 23 No 6
 

Day-care surgery is gaining in popularity throughout the surgical specialities due to economical constraints and patient convenience. However this is not without risk and a careful procedure by procedure evaluation should be performed to prove the suitability of this type of surgery for day surgery. The authors studied 424 patients admitted for septoplasty and / or septorhinoplasty and reviewed various pre- and postoperative variables to evaluate the risk / benefit ratio for daycare aesthetic nasal surgery. Between 17 and 40% of patients were eligible for day surgery especially those living <1 hour from the point of care. Given proper selection criteria, it is possible to offer patients undergoing aesthetic nasal surgery the option of a day care hospitalisation with all its benefits and without any additional risks.

Reference

Feasibility study of septoplasties and septorhinoplasties in ambulatory surgery.
Lechot A, De Gabory L.
EUROPEAN REVIEW OF ENT
2013;134:191-7.

EUROPEAN REVIEW OF ENT

The septum, outside!
Reviewed by: Badr E Mostafa
Vol 23 No 6
 

Extracorporeal sculpturing of the septum during septorhinoplasty (SRP) is a well-established technique. However, the extent of manipulations of the septum varies amongst authors. In a series of 630 patients undergoing SRP, the authors used a complex extracorporeal septal three dimensional structural composite graft in 63 patients. This technique allows a more precise fashioning of the graft and insertion under vision with proper positioning. The authors used 11 criteria to evaluate their results with a (rather short) mean follow-up period of 19 weeks. They had an 85% improvement in the dorsal axis, an 82% improvement in the tip projection and nasolabial angle. However they noted a 71% reduced stability and broadening in 28% of cases.

Reference

Post-operative evaluation of 63 cases of rhinoseptoplasty by nasal frameworks.
Hardy C, Goga D, Disant F.
EUROPEAN REVIEW OF ENT
2013;134:175-8.

INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY

Comparing patient and surgeon concerns in sinus surgery
Reviewed by: Laith Tapponi
Vol 23 No 6
 

This prospective observational study had a total of 180 patients undergoing endoscopic sinus surgery for chronic rhinosinusitis with or without polyposis. Data was analysed using descriptive statistics and analysis of variance. Subjects felt the greatest level of concern regarding potential need for revision surgery as well as the wait time for surgery. Patients were least concerned about psychological factors. No differences with respect to age or gender were identified. Patients’ areas of greatest concern may not align with those perceived by surgeons. This study provides insight into patient concerns prior to undergoing elective sinus surgery and emphasises the importance of the patient-centred approach to care. Patient-centred care is recognised as being fundamental to successful medical practice.

Reference

Preoperative concerns of patients undergoing endoscopic sinus surgery.
Yeung JC, Brandt MG, Franklin JH, et al.
INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY
2014;4(8):658-62.

INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY

The effect of cocaine or adrenaline dressing during endoscopic sinus surgery
Reviewed by: Laith Tapponi
Vol 23 No 6
 

A randomised controlled study of 37 patients took place that underwent endoscopic sinus surgery for chronic rhinosinusitis and received adrenaline or cocaine-soaked patties. The study showed no difference in the mean surgical field scores between adrenaline and cocaine sides. Adequate surgical field visualisation is among the most important factors in preventing complications in functional endoscopic sinus surgery, but this study was small and limited.

Reference

Topical cocaine vs adrenaline in endoscopic sinus surgery: a blinded randomized controlled study.
Valdes CJ, Bogado M, Rammal A, et al.
INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY
2014;4(8):646-50.

INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY

What are the best minimal surgical techniques used for concha bullosa?
Reviewed by: Laith Tapponi
Vol 23 No 6
 

This prospective endoscopic and radiologic evaluation studied 42 patients who underwent concha bullosa surgery, amounting to a total of 55 conchae surgeries. The patients were allocated consecutively to either of the two groups. The presurgical and one year postsurgical endoscopic nasal cavity images and computed tomography (CT) scans of all patients were recorded. Preoperative and postoperative measurements were compared using a paired t-test and student t-test. Crushing with intrinsic stripping is an effective and easy technique, when compared to crushing alone, and provides significantly more decrease in middle concha volumes as demonstrated both by the CT and by endoscopic evaluations.

Reference

A comparison of the long-term results of crushing and crushing with intrinsic stripping techniques in concha bullosa surgery.
Eren SB, Kocak I, Dogan R, et al.
INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY
2014;4(9):753-8.

INTERNATIONAL JOURNAL OF AUDIOLOGY

Diet quality, noise, and hearing
Reviewed by: Richard Navarro
Vol 23 No 6
 

This is an important article for all audiologists to better understand the relationship between dietary habits and hearing loss. It reports poor dietary habits plus noise exposure may lead to increased high frequency hearing loss. The literature review lays the groundwork for understanding that the ear is a part of a complex mechanism (the body) and should, therefore, not be viewed in isolation. The implication of this understanding is that audiologists must consider all aspects of the body, particularly metabolism, in trying to decipher causes, prevention, and treatment of hearing loss, tinnitus, and dizziness. The authors retrospectively reviewed data from the National Health and Nutrition Examination Survey, 1999-2002, using the Healthy Eating Index, correlated this data with low and high frequency tonal thresholds after controlling for age, sex, race / ethnicity, education, diabetes, hypertension, and smoking. From the population of 10,000 subjects, 2176 were included in the study. Significant differences were found between dietary habits and high frequency hearing loss. The major limitation of the study was that it was a cross sectional analysis; however, the size of the data pool is sufficient for useful conclusions. The conclusions are not entirely supported by histological evidence presented by Schuknecht that posited a flat audiogram as representative of a metabolic hearing loss. The literature review did not include research from the early 1980s that demonstrated audiometric improvements from nutritional supplementation for Meniere’s patients. Regardless of the weaknesses in the article, it should invite the audiologist to be proactive in learning how the ear is impacted by dietary habits so that more effective prevention and treatment options are developed. Effective hearing conservation is more than noise reduction or ear plugs and should include the entire spectrum of hearing health.

Reference

Associations between dietary quality, noise, and hearing: Date from the National Health and Nutrition Examination survey, 1999-2002.
Spankovich C, Le Prell CG.
INTERNATIONAL JOURNAL OF AUDIOLOGY
2014;Early Online: Posted online on June 30, 2014:1-14.

JAMA OTOLARYNGOLOGY – HEAD & NECK SURGERY

Patients with advanced oral cavity carcinoma are not candidates for the ‘organ preservation’ approach
Reviewed by: Shabbir Akhtar
Vol 23 No 6
 

The authors of this study, from the University of Michigan, evaluated the role of induction chemotherapy for patients with stages III and IV resectable oral squamous cell carcinoma. Nineteen patients were initially enrolled in the induction chemotherapy cohort. Patients with clinical or radiographic evidence of bone involvement were excluded. Patients with a response of at least 50% underwent concurrent chemoradiotherapy; those with a response of less than 50% underwent surgical treatment and postoperative radiotherapy. A comparison was made with cohort of patients treated with primary surgery. No difference was noted in age, sex, pretreatment AJCC stage, T and N classifications, smoking status, alcohol consumption, or tumour subsite between induction chemotherapy and surgical cohorts. Median follow-up was 9.4 years in the induction chemotherapy group and 7.1 years in the surgical cohort. The overall survival at five years was 32% in the induction chemotherapy group and 65% in the surgical group. The disease-specific survival was 46% in the induction chemotherapy group and 75% in the surgical group. The locoregional control was 26% in the induction chemotherapy group and 72% in the surgical cohort. Multivariable analysis demonstrated significantly better overall and disease-specific survival and locoregional control outcomes (P = .03, P = .001, and P < .001, respectively) in the surgical cohort. These findings support surgery as the principal treatment for oral squamous cell carcinoma.

Reference

Efficacy of induction selection chemotherapy vs primary surgery for patients with advanced oral cavity carcinoma.
Chinn SB, Spector ME, Bellile EL, et al.
JAMA OTOLARYNGOLOGY - HEAD & NECK SURGERY
2014;140(2):134-42.

JOURNAL OF LARYNGOLOGY & OTOLOGY

Anatomic guidelines to endolymphatic sac in transmastoid approach – a cadaveric study
Reviewed by: Madhup K Chaurasia
Vol 23 No 6
 

This study involved cadaveric dissection using transmastoid approach in cadaveric embalmed five half heads and posterior fossa approach in fourteen. The sac was identified by electron microscopy. The relatively consistent measurements were the relationship of the operculum to the internal auditory meatus (10mm) and the width of the operculum varied only slightly more. Marked variations were noted in the distance from superior petrosal sinus to the operculum (6-14mm), width of the sac (7-16mm), length of sac borders- lateral (5-15mm), medial (4-17mm) and the distance from the operculum to the sigmoid sinus – lateral (7-17mm), medial (8-15mm). In eight cases the endolymphatic sac extended beyond the medial margin of the sigmoid sinus. No appreciable lumen was identified in two. The most consistent finding was dural thickening in the region of the endolymphatic sac. Results are compared with previous studies and appear largely similar. Emphasis is laid on adequate removal of bone from superior petrosal sinus to the jugular bulb and from a point medial to the posterior semicircular canal to the sigmoid sinus, remembering that the sac can extend a bit further and decompression of this sinus may be required. A previously described method of measuring from the short process of the incus to the lower limit of the posterior semicircular canal in transmastoid approach is considered unreliable as it pertains to the intradural part of the sac where it is most variable.

Reference

Endolymphatic sac surgical anatomy and transmastoid decompression of the sac for the management of Ménière’s disease.
Locke RR, Shaw-Dunn J, O’Reilly BF.
THE JOURNAL OF LARYNGOLOGY & OTOLOGY
2014;128(6):488-93.

JOURNAL OF LARYNGOLOGY & OTOLOGY

Possibility of noise induced hearing loss during middle ear suction for secretory otitis media
Reviewed by: Madhup K Chaurasia
Vol 23 No 6
 

Emission of high intensity sound is dangerous to the cochlea and can result in noise induced hearing loss (NIHL). Removal of middle ear fluid is common in everyday practice and the possibility of inducing NIHL is seldom considered and not much is known about immission levels. In this study the authors measured sound intensity levels delivered to the ear in the use of suction to remove middle ear fluid. The subjects of the study were children of age six months to six years and sound intensity was measured with a microphone probe attached to the suction tip. The maximum peak intensity ranged from 84 to 157 dB SPL. Half the number of ears were exposed to greater than 140 dB of which 80% were exposed for more than 0.2msec. This is above pain threshold and considered detrimental in terms of NIHL. Higher intensities and duration of suction were recorded for evacuation of mucoid fluid. Suction of serous fluid and empty middle ear caused much less noise exposure in terms of duration and intensity. Interesting literature is discussed examining a direct correlation between the contributions of calibre of the suction tube and lack of finger closure. Most studies recorded lower intensities which can be attributed to less efficient technology in the past and possibly less awareness of this phenomenon. One study demonstrated temporary threshold shift of 15dB or greater. This however, has not been measured in this study but the authors are aware of its significance. This interesting study should be further explored and perhaps mentioned in any consent.

Reference

Measurement of sound intensity during suction of middle-ear fluid following myringotomy.
Wang, JC, Allen SJ, Rodriguez AI, et al.
THE JOURNAL OF LARYNGOLOGY & OTOLOGY
2014;128(7):604-11.

JOURNAL OF LARYNGOLOGY & OTOLOGY

Use of tranexamic acid in ENT surgery
Reviewed by: Madhup K Chaurasia
Vol 23 No 6
 

Postoperative bleeding in otolaryngologic procedures causes delayed discharge, requires re-admission and adds considerably to the cost of patient care. Whether the anti-fibrinolytic activity of tranexamic acid should be used routinely to prevent haemorrhagic complications after ENT operations is speculation but the author has given several examples of this practice being prevalent in other specialities and describes a number of studies supporting its role in reducing blood loss without causing thromboembolic complications. Tranexamic acid has been used in cleft palate and cardiac surgery, knee replacements, management of trauma patients and post-partum haemorrhage. Transfusion of blood has several risks in itself and this may be avoided with use of tranexamic acid. Use of tranexamic acid in tonsillectomy has been shown to reduce operative and immediate postoperative blood loss thus facilitating same day discharge but it does not prevent secondary haemorrhage. Irrigation of the nasopharynx with tranexamic acid after adenoidectomy reduced blood loss in one study. In a randomised controlled trial a single intravenous injection of tranexamic acid proved more effective than anterior nasal packing and similar encouraging results have been seen in functional endoscopic sinus surgery. The cost effectiveness of using tranexamic acid has been suggested by estimating savings achieved by avoiding post tonsillectomy haemorrhage. The author believes that in tonsillectomy haemorrhage, expenditure could be reduced from £8 million to £0.23 million. Side-effects of tranexamic acid are discussed, mainly thromoembolic phenomenon and gastrointestinal upsets, but the incidence of these is low.

Reference

Tranexamic acid – a useful drug in ENT surgery?
Robb PJ.
THE JOURNAL OF LARYNGOLOGY & OTOLOGY
2014;128(7):574-9.

JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY

Lipofilling for scar improvement
Reviewed by: Sunil Kumar Bhatia
Vol 23 No 6
 

Since Coleman et al. in 1991 reported on lipofilling, numerous applications have been reported; these include but are not limited to contour restoration, lip augmentation, and wrinkle therapy. There has also been some one off reported improvements in scars following autologous lipofilling. This paper is a prospective clinical evaluation of 26 patients with 35 scars on the face treated with autologous lipofilling between 2008 and 2012. The most common cause of the scars was trauma and surgical excision of nevus and acne. Scars caused by resection of malignant tumours were excluded. Standardised preoperative and postoperative assessments were used to assess success, patient and observer scar (POSAS), photographs and laser Doppler spectrometry of oxygen saturation (to assess the micro circulation). Postoperatively patients were followed up at one, three, six, and 12 months. Scar quality was improved in all cases with a high patient satisfaction. There was also an increase in the postoperative haemoglobin levels in the scar area. While this is a limited number of cases and the authors concede further studies are necessary this is a valuable method to add to facial surgeons’ armamentarium. Any technique to improve facial scars is always welcome in the facial surgeon’s practice.

Reference

Improvement of facial scar appearance and microcirculation by autologous lipofilling.
Pallua N, Baroncini A, Alharbi Z, Stromps JP.
JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY
2014;67(8):1033-7.

JOURNAL OF VESTIBULAR RESEARCH

Vitamin C, a possible remedy for seasickness?
Reviewed by: Victor Y Osei-Lah
Vol 23 No 6
 

The internet is full of devices and medicines vying for superiority over which one is the best for preventing seasickness. This study was based on the following observations: elevated histamine levels trigger seasickness; blockade on histidine decarboxylase prevents seasickness while elevating vitamin C levels in animal models; low concentration of vitamin C are seen in mastocytosis and nausea reduces after taking vitamin C. The aim of the double-blind placebo-controlled cross-over study was to investigate whether vitamin C suppresses nausea in people exposed to motion at sea. The authors recruited 70 volunteers aged between 19 years and 60 years, divided into two groups. They were exposed to one-metre waves in an inflatable raft in an indoor pool for 20 minutes on two separate days. Group VP received 2g of oral vitamin C one hour before exposure on day one and placebo before exposure on day two. The reverse was done in the other Group PV. Blood levels for histamine, diamine oxidase (DAO, degrades histamine), tryptase and vitamin C were determined one hour before exposure and immediately after the 20 minute exposure. Participants rated their symptoms on 10-point visual analogue scale (VAS) immediately after leaving the raft and at a 30-minute intervals for three hours. Twenty-two, 42 and six subjects reported slight, moderate and strong sensitivity to seasickness respectively. However, seven subjects (two females, five males) had no symptoms on either day. In both groups, the majority of subjects felt better and had fewer symptoms on the days they took vitamin C. In females, vitamin C was significantly associated with less symptoms than placebo. Twenty-three subjects left the raft before the 20 minute test duration but even so, those on vitamin C stayed significantly longer than those on the placebo. Histamine levels increased during exposure but DAO levels increased following intake of vitamin C. On the whole, vitamin C suppressed symptoms of seasickness but the effect was more pronounced for females than in males except in men younger than 27 years. The authors concluded that in women and in men under 27 years of age, vitamin C could effectively suppress seasickness while emphasising the quick onset of action and absence of significant side-effects in comparison to other motion sickness medication.

Reference

Impact of oral vitamin C on histamine levels and seasickness.
Jarisch R, Weyer D, Ehlert E, et al.
JOURNAL OF VESTIBULAR RESEARCH
2014;24(4):281-8.

NEUROSURGERY

Stereotactic radiosurgery for pituitary adenomas
Reviewed by: Showkat Mirza
Vol 23 No 6
 

Residual and recurrent functioning pituitary adenomas can be difficult to delineate on postoperative MRI scans, making them difficult targets for stereotactic radio surgery. In such cases radiation delivery to the entire sellar has been utilised as a radio surgical equivalent of a total hypophysectomy. This paper evaluated the outcomes of 64 patients over about 20 years who underwent stereotactic radiosurgery to the whole sellar region. The median endocrine follow-up was 41 months. Sixty-nine per cent of patients with acromegaly, 71% of patients with Cushing’s disease and 50% of patients with a prolactinoma achieved endocrine remission. One patient developed a new visual field deficit, two patients had an oculomotor nerve palsy and one developed an abducens nerve palsy. A new onset hypopituitarism developed in 43.5% of patients. Therefore whole sellar stereotactic radio surgery for image negative or venous sinus invasive adenomas following failed resection, can offer reasonable rates of endocrine remission with hypopituatrism being the most common complication.

Reference

Whole-sellar stereotactic radiosurgery for functioning pituitary adenomas.
Lee CC, Cheng CJ, Yen CP, et al.
NEUROSURGERY
2014;75(3):227-37.

NEUROSURGERY CLINICS OF NORTH AMERICA

Preoperative tumour embolisation
Reviewed by: Gentle Wong
Vol 23 No 6
 

This review article analyses the role of preoperative endovascular tumour embolisation in the treatment of a variety of hypervascular head and neck lesions including juvenile nasal angiofibroma, glomus tumour, carotid body tumours, and meningioma. Although the concept of tumour embolisation dates back several decades, this article provides a refreshing reminder and updates us with current improvements in catheter design, enhanced angiographic imaging capabilities, as well as novel embolic agents; all of these making endovascular intervention safer and easier. Despite its advances, the pertinent question to ask is not whether embolisation is feasible, but whether it is necessary. It is important to understand tumour hypervascularlity alone is not a good reason to subject the patient to the added risk of embolisation, especially if the tumour is small, and the major blood supply to the tumour is readily accessible early at surgery. On the other hand, if embolisation may decrease total operative time (and anaesthetic risk to the patient), or deal with surgically inaccessible arterial feeders, and improve visualisation at surgery thus facilitating tumour resection, then the appeal becomes apparent. In conclusion, as technology advances and more studies are conducted, embolisation will evolve to further complement (or substitute in some cases!) surgery.

Reference

Preoperative tumour embolisation.
Ashour R, Aziz-Sultan A.
NEUROSURGERY CLINICS OF NORTH AMERICA
2014;25(3):607-17.

ORL

Effects of nasal sprays on ciliary function
Reviewed by: Zi Wei Liu
Vol 23 No 6
 

What do topical nasal sprays do to the nasal mucosa in the long term? This study reports the effect of corticosteroids, antihistamines and common preservatives in nasal sprays, benzalkonium chloride (BKC) and potassium sorbate (PS), on an in-vitro model of human nasal mucosa. Fluticasone and azelastine were both shown to cause a remarkable rapid and irreversible decrease in ciliary beating frequency when applied undiluted or at 50% concentration. BKC, a common preservative in nasal steroid sprays including fluticasone proprionate and azelastine hydrochloride, induced ciliary stasis at half the concentration found in commercial preparations. Budesonide and potassium sorbate both had reversible or minor effects on ciliary motility. The long-term effect of topical nasal preparations on mucosa is controversial, and the results of this study must be interpreted with caution. There is little evidence to support the idea that fluticasone or azelastine have irreversible ciliotoxic effects from clinical observation, and indeed the authors of the study state that although their findings are in line with several other cell culture studies, these adverse effects cannot be replicated in vivo. This is likely to be due to the dilutional effect of nasal secretions and protective mechanisms which are not present in the in vitro model. Until further studies are done in vivo, this remains a cautionary tale that laboratory findings do not translate easily in complex biological systems.

Reference

The effect of topical corticosteroids, topical antihistamines, and preservatives on human ciliary beat frequency.
Jiao J, Meng N, Zhang L.
ORL
2014;76(3):127-36.

OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA

Thyroid cancer: to dissect the neck or not?
Reviewed by: Charlie Giddings
Vol 23 No 6
 

This is a good review of the much-debated management of the neck in thyroid cancer. It discusses oncological goals that must be achieved whilst maintaining voice, swallowing and parathyroid function. A clear description is made of the common nodal basins involved in metastatic disease, their boundaries and frequency of involvement. Therapeutic neck dissection for differentiated thyroid cancer is widely supported by the literature. The evidence for prophylactic neck dissection is less clear with a small but significant reduction in locoregional recurrence reported in some series. It is summarised that prophylactic dissection of level VI should be considered in tumours greater than 4cm in size or for those with extrathyroidal extension. Non-infiltrative types of follicular-variant of papillary thyroid cancer may however be an exception, with lower rates of reported nodal disease. Judicious dissection of level VI is also supported by the recently published British Thyroid Association guidelines that estimate approximately 20-30 patients would have to undergo prophylactic level VI dissection to convey benefit to one individual. Surgical technique is described and in particular the anatomical differences between the left and right sides along with optimum technique for the preservation of the parathyroid glands. Postoperative management of calcium is addressed, importantly the need to empirically start replacement with level VI dissection.

Reference

Management of the neck in thyroid cancer.
OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA
Schoppy DW, Holsinger FC.
2014;47(4):545-56.

OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA

Thyroid nodule update
Reviewed by: Charlie Giddings
Vol 23 No 6
 

This excellent article summarises the current diagnostic difficulties with an endocrine gland that frequently produces nodules, some of which may harbour malignancy. At 50 years of age and over there is about a 50% chance of having a nodule; at 90 years it is almost a certainty. Clinically insignificant thyroid cancers discovered incidentally at autopsy have been estimated to occur in up to 36%, and with better diagnostic imaging they are found easily. A good diagnostic algorithm is presented for the evaluation of a thyroid nodule with an up to date detailed risk factors assessment that might stimulate further investigation. Large one-off radiation exposure occurring after 20 years of age has not been proven to increase thyroid malignancy incidence. However radiation in childhood, even from CT and PET imaging, should be enquired about in any taken history. The commonest useful characteristics on ultrasound for the detection of malignancy are still microcalcifications, size greater than 2cms and entirely solid composition. Molecular markers are explored in more detail in another paper that is reviewed below. When considering intervention, attention is rightly drawn to the competing risk of death from other co-morbidities, given that the 20-year survival for papillary cancer (tumours of any size confined to the gland) is 99%.

Reference

Evidence-based evaluation of the thyroid nodule.
OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA
Davies L, Randolph G.
2014;47(4):461-74.

OTOLOGY & NEUROTOLOGY

Cochlear implants in Ménière’s disease
Reviewed by: Anand Kasbekar
Vol 23 No 6
 

This retrospective review firstly reminds us that a cochlear implant (CI) is possible with Ménière’s disease (MD) and provides a good account of what can be expected with a CI in patients with MD. Twenty MD patients who underwent cochlear implantation were matched (as well as could be expected) with controls having had similar types of CI. The results demonstrated equivalent hearing performance at one year post implant. Tinnitus was significantly reduced in MD patients. Unfortunately, ongoing dizziness in the MD group affected the overall quality of life (QoL) outcome (SF-36 questionnaire), but was nonetheless significantly improved from preoperatively. We are reminded that vertigo is the most disabling of symptoms for most of our otology patients. Control patients had a greater QoL outcome. MD patients must be warned of the risk of oscillopsia if the ear with the only remaining vestibular function is to be implanted; however it is very infrequent and should not be a contraindication state the authors. This is debatable in my view.

Reference

Cochlear implantation in patients with advanced Ménière’s disease.
Mick P, Amoodi H, Arnoldner C, et al.
OTOLOGY & NEUROTOLOGY
2014;35(7):1172-8.

OTOLOGY & NEUROTOLOGY

Endolymphatic sac surgery for Ménière’s disease
Reviewed by: Anand Kasbekar
Vol 23 No 6
 

This is a very useful meta-analysis for those that perform surgery for Ménière’s disease. It specifically looked at differences in various forms of endolymphatic sac surgery (ESS). A total of 36 papers were included. The results: ESS controls vertigo in the short-term (>1 year) in 75% of cases who haven’t had trial of intratympanic treatment. Long-term control drops to 63% (6.5 years follow-up). There is no difference between sac decompression (removing bone over the sac) and mastoid shunting (also inserting silastic into the sac to allow drainage), procedures for vertigo, however there is probable 6dB worsening of hearing with shunting procedures rather than just decompression. Interestingly, in shunting procedures, there is a greater chance of maintaining hearing if no silastic is used. The recommendation is to open the sac and not to leave in silastic as a stent. It is postulated that silastic causes an immunological reaction within the sac.

Reference

Endolymphatic sac surgery for Ménière’s disease: a systematic review and meta-analysisreconstruction in cholesteatoma surgery.
Sood AJ, Lambert PR, Nguyen SA, Meyer TA.
OTOLOGY & NEUROTOLOGY
2014;35(6):1033-45.

RHINOLOGY

Nasal peak inspiratory flow (NPIF) as a diagnostic tool for differentiating decongestable from structural nasal obstruction
Reviewed by: Lakhbinder Pabla
Vol 23 No 6
 

Identification of the cause of nasal obstruction is critical before surgical intervention such as septoplasty. This study assesses changes in nasal peak inspiratory flow (NPIF) as a tool for discriminating decongestable versus structural obstruction. A cross-sectional study of 52 patients (24 with decongestable, 28 with structural obstruction) undergoing nasal airflow assessment was performed. Rhinomanometry, nasal obstruction visual analogue score (VAS) and NPIF were performed pre- and post-decongestion. Population groups were defined with decongestable or structural obstruction by relative post-decongestion changes in airways resistance and symptoms. Pre- and post-decongestion NPIF were similar between groups. Absolute and percentage NPIF changes were larger with decongestable versus structural obstruction. Sensitivity and specificity for predicting decongestable obstruction were 75.0% and 60.7% for NPIF increase >20L/min; 75.0% and 64.3% for NPIF increase >20%. The respective positive predictive values were 62.1% and 64.3%. The study concluded that the NPIF increase after decongestion is larger with decongestable than structural obstruction but NPIF alone cannot discriminate the two conditions and does not replace more formal assessment.

Reference

Nasal peak inspiratory flow (NPIF) as a diagnostic tool for differentiating decongestable from structural nasal obstruction.
Chin D, Marcells G, Malek J, et al.
RHINOLOGY
2014;52(2):116-21.

SLEEP AND BREATHING

Postoperative complications in OSA patients
Reviewed by: Vik Veer
Vol 23 No 6
 

This well researched meta-analysis describes the various complications obstructive sleep apnoea (OSA) patients may acquire after surgery. These American reviewers found that OSA patients after non-upper airway operations, were more like to suffer (compared to non-OSA patients), from the following complications: respiratory complications were significantly more likely to occur in OSA patients (overall OR=2.77 – 95%CI 1.73–4.43). Specifically hypoxemia and the need for prolonged oxygen therapy postoperatively; cardiac complications including dysrhythmias, abnormal heart rate, myocardial infarction and ischemia, hypotension, and congestive heart failure had a OR=1.76 (95%CI 1.16–2.67); neurological complications including delirium, agitation, confusion, and excessive drowsiness had an OR=2.65 (95%CI 1.43–4.92); and the risk of an unplanned ITU admission was OR=2.97 (95%CI 1.90–4.64). The discussion concludes that patients at high risk of OSA need to be screened before undergoing an operation. This will hopefully reduce these stormy postoperative spells, and result in better outcomes for patients, and less sleepless nights for surgeons. Now all we need is a good screening tool! Currently all we have is clinical vigilance with preoperative polysomnography.

Reference

Post-operative outcomes in adult obstructive sleep apnea patients undergoing non-upper airway surgery: a systematic review and meta-analysis.
Gaddam S, Gunukula SK, Mador MJ.
SLEEP & BREATHING
2014;18(3):615-33.

THE HEARING JOURNAL

Earplug use in clubbers
Reviewed by: Linnea Cheung
Vol 23 No 6
 

Past studies show that there is a low frequency of use of earplugs at music events. In this research article produced by the National Acoustic Laboratories, Australia, a group of 51 regular attendees at music events were recruited and given music earplugs. An initial survey clarified their exposure regularity to music venues, and presence of any pre-existing hearing problems. They were followed up by surveys after four and 16 weeks of issue via e-mail, to explore their experiences of comfort, music enjoyment, ease of communication and overall attitude towards their use. Only 37 subjects completed all three surveys for comparative results. There was significant increase in reported comfort, ease of insertion and music enjoyment over time. The overall attitude towards the effect of earplugs on communication was unchanged at around half of all participants. Over 80% retained a positive attitude towards their use to prevent noise induced hearing loss at such events after the second survey. A small proportion of patients found difficulty with insertion, and an unsatisfactory level of music enjoyment from use. This study only evaluated the use of one particular type of earplug marketed specifically for exposure to loud music. It would be interesting to see parallel results using types of earplug for comparison. Clearly to achieve benefit from earplugs in the presence of loud music requires a positive attitude, perseverance, and a period of trial and error of the different products available by the user.

Reference

Clubbers’ attitude toward earplugs: better with use.
Nielsen LB, Beach E, Gilliver M.
THE HEARING JOURNAL
2014;67(4):6-11.

TRENDS IN HEARING

Controlling tinnitus
Reviewed by: Ameera Abdelrahim
Vol 23 No 6
 

The absence of sufficient evidence for the use of integrated sound generators for the management of tinnitus led the authors to conduct a randomised blind clinical trial in which they compared the use of a conventional hearing aid with a hearing device that contained an integrated sound generator. The study included 49 novice patients with mild to moderate bilateral symmetrical sensorineural hearing loss, at least six months of tinnitus and a Tinnitus Handicap Inventory (THI) > 20. The sound generator setting was started at the minimum setting and increased until the patient reported relief from their tinnitus. The minimum recommended treatment was use of the device for at least eight hours per day and the evaluation was conducted at three months. Both groups received counselling. The evaluator was blinded to the device provided. Measures included psychoacoustic measures of tinnitus, numeric scale and the THI. In total 47 patients completed the study. Both groups showed an improvement in symptoms when comparing the pre- and post-intervention scores. Of patients in the combined fitting group 62.5% had a reduction of 20 points or more in the THI. In the amplification group this rose to 78%. However, there was no statistical significance between outcomes for the two groups and levels of discomfort reduced for both from moderate to mild. Therefore this small study does not provide evidence for superiority of the combined device and finds both devices to be equally effective.

Reference

The influence of sound generator associated with conventional amplification for tinnitus control: randomized blind clinical trial.
Santos G, Bento R, Medeiros I, et al.
TRENDS IN HEARING
2014;18:1-9.

AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY

Passive smoking and rhinosinusitis
Reviewed by: Edward W Fisher
Vol 23 No 4
 

One would expect that subjects exposed to more passive smoke would have a significantly increased level of rhinosinusitis. This study looked at a reasonable number of sinusitis and control subjects (404 and 165) using hair nicotine as an assessment of the amount of exposure to cigarette smoke. Surprisingly, the nicotine levels were similar in the two groups and had not changed over time (one would perhaps expect the sinusitis group to actively avoid smoke after diagnosis). The prevalence of evidence of passive smoke exposure was higher in children, and had not reduced overall in the subjects over time despite many public health measures intended to reduce it. While this does not pretend to be a definitive study, the result is surprising and suggests to me that passive smoking is not a major aetiological factor in the pathophysiology of rhinosinusitis.

Reference

Passive smoke exposure in chronic rhinosinusitis as assessed by hair nicotine.
Wentzel JL, Mulligan JK, Soler ZM, et al.
AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY
2014:28(4):297-301.

ANNALS OF THE ROYAL COLLEGE OF SURGEONS OF ENGLAND

Primary ossicular chain reconstruction in open-cavity mastoidectomy
Reviewed by: Thomas Jacques
Vol 23 No 4
 

The authors performed a retrospective analysis of 21 patients who had undergone primary reconstruction of the ossicular chain during canal-wall-down mastoidectomy. The ossiculoplasty technique used consisted of removal of the malleus head and division of tensor tympani, and rotation of the malleus remnant to lie on the stapes superstructure. The procedure was deemed to have failed in three of 21 cases due to presumed non-adherence of the stapes to the malleus neck. Subgroup analysis of the 18 successful procedures showed a mean post-operative air-bone gap of 15dBHL, 19dBHL, 8dBHL and 26dBHL at 0.5, 1, 2 and 4 kHz respectively. The patients’ pre- and post-operative sensorineural thresholds were not reported, so the practical benefit of the good conductive results cannot be ascertained; however no patients suffered a ‘dead ear’. The conductive gap outcomes compared favourably with modified radical mastoidectomy alone, although no direct comparisons were drawn by the authors with other patients undergoing other forms of reconstruction. They note that further work to compare the quality-of-life outcomes of such a reconstruction with other techniques would be useful. Patients had no recurrence of cholesteatoma during the follow-up period. The paper presents a suitable technique for single-stage ossicular chain reconstruction in canal-wall-down surgery, albeit in selected cases, as the procedure relies upon the presence of an intact stapes.

Reference

Hearing outcomes following primary malleostapedial rotation ossiculoplasty in patients undergoing modified radical mastoidectomy.
Kanegaonkar RG, Whittaker M, Najuko-Mafemera A.
ANNALS OF THE ROYAL COLLEGE OF SURGEONS OF ENGLAND
2014;96(6):458-61.

Auris Nasus Larynx

A new septoplasty technique
Reviewed by: Ravi Thevasagayam
Vol 23 No 4
 

This article describes a novel septoplasty technique to correct a cartilaginous deflection. Although it took a while to understand it as the operative photographs were not very helpful it is an interesting concept. The author excises an inferior strip and performs a posterior chondrotomy. Then a slit is made in the quadrilateral cartilage anterior to the posterior chondrotomy. A small cartilaginous or bony strut (or ‘wedge’) is created and placed to run from the vomer to the slit via the convex side. This acts as a lever to pull the deflected septum to the midline. Whilst it's difficult to appreciate without the aid of the diagram in the article the concept seems very interesting. The paper describes a series of 17 consecutive patients and demonstrates both subjective and some objective measures of improvement although the acoustic rhinometry data is incomplete. My main concern would be thickening of the septum at the level of the strut, which the author concedes does happen but as this is well behind the nasal valve area this doesn't seem to be problematic. Limited numbers and data but an interesting concept and potentially a worthwhile addition to the array of techniques to try and correct the difficult cartilaginous septal deformity.

Reference

A novel wedge technique to correct the curved deviation of the cartilaginous nasal septum.
Ji-Eun L, Hahn JJ, Munyoung C, Hong RJ.
AURIS NASUS LARYNX
2014:41(2):190-94.

Auris Nasus Larynx

Risk factors for post tonsillectomy bleeds
Reviewed by: Ravi Thevasagayam
Vol 23 No 4
 

This paper reviews post-tonsillectomy bleeding in 692 patients and attempts to tease out risk factors. The overall bleed rate of 11.6% seems very high. The return to theatre rate was 2.6%. The paper identifies male patients and adult patients as risk factors. It also suggests that junior surgeons have increased bleed rates. The paper is most remarkable because patients at this institute remain inpatients for eight days and have their tonsillar fossae examined every day and hence the high bleed rate includes any blood staining during the prolonged inpatient stay. It is interesting that more than 10% of post-tonsillectomy patients have some degree of bleeding that is probably not seen in an environment where patients are discharged as day cases or overnight stays. The paper is most fascinating because it highlights the spectacular variations in worldwide practice with patients being admitted for over a week post-tonsillectomy.

Reference

Risk factors for post tonsillectomy hemorrhage.
Ryo Ikoma Sayake Sakane, et al.
AURIS NASUS LARYNX
2014:41(4):376-9.

B-ENT

Management of necrotising otitis externa
Reviewed by: Sunil Sharma
Vol 23 No 5
 

Although uncommon, necrotising (previously malignant) otitis externa (nOE) can be very aggressive, particularly if not managed appropriately. In this study the authors perform a retrospective review of 25 patients admitted with nOE over a four year period at a tertiary referral centre. They have also described a treatment algorithm for the management of nOE, having identified a lack of consistency in management within their department. Only 92% of patients had CT scanning, so two patients had no form of imaging. Almost 60% of cases were associated with pseudomonas aeruginosa, and the authors postulate that the increased use of quinolones in managing otitis externa has led to the increased finding of nOE associated with other bacterial strains. The issue of whether to biopsy these patients is a controversial one, and in this paper just over half of patients had a biopsy of granulation tissue. In 28% of cases, the biopsy sample aided the isolation of the causative organism in cases where canal swabs were negative, thus the authors recommend biopsy in resistant cases. In cases of resistant disease repeat CT was also suggested. However no mention is made of MRI scanning, which is suggested in other departments for evaluation of the extent of soft tissue involvement. In line with most UK departments, the authors’ department organises for patients to have extended course of intravenous antibiotics in the community, but the authors recognise that this can be fraught with difficulties in terms of organisation. This paper provides a useful initial management protocol for nOE but some departments may have existing protocols agreed with their local microbiology service.

Reference

Lessons learnt from the diagnosis and antimicrobial management of necrotising (malignant) otitis externa: our experience in a tertiary referral centre.
Williams SP, Curnow TL, Almeyda R.
B-ENT
2014;10:99-104.

BMC EAR, NOSE AND THROAT DISORDERS

Treatment of olfactory dysfunction
Reviewed by: Gauri Mankekar
Vol 23 No 4
 

The sense of smell is crucial to our being able to relish food and experience our environment. Olfactory dysfunction has been trivialised or ignored previously, but the negative consequences of the loss of sense of smell are being increasingly highlighted. For this study, the authors reviewed the experiences of a thousand patients with olfactory dysfunction. The patients answered 43 questions on the consequences of their problem. Although the patients did not experience any practical problems such as those associated with visual or auditory impairments, they did report their olfactory dysfunction as a debilitating condition. Loss of smell induced social isolation and motivational anhedonia having a severe detrimental effect on the quality of life of these individuals. The authors conclude that although educating the patients, the public, and medical professionals about disorders of olfaction would improve the quality of life for affected patients by reducing their practical and social problems, research into an effective treatment alone will provide the best solution to consequences of olfactory dysfunction.

Reference

Hidden consequences of olfactory dysfunction – a patient report series.
Keller A, Malaspina D.
BMC EAR, NOSE AND THROAT DISORDERS
2013:13:8.

CLINICAL OTOLARYNGOLOGY

Assessment in ENT: Intra-operative videos
Reviewed by: Andy Hall
Vol 23 No 5
 

An article examining the reliability and validity of remote scoring; a video assessment of myringotomy and grommet insertion. The primary outcome measures were to determine construct validity (differentiating between different grades of surgeons) and reliability of video scoring. Unfortunately, the study was underpowered with 10 procedures in each group (core trainee / specialist registrar and consultant) and therefore could not discern a statistical significance for construct validity on this occasion. The methodology shows promise and shouldn’t detract from further developments. There was a strong correlation between scores by the blinded raters and quite rightly this allows assessor bias to be avoided in the assessment. In the present climate it would appear video assessment is likely to become a useful adjunct for both the trainee and trainer.

Reference

A validation study on the use of intra-operative video recording as an objective assessment tool for core ENT surgery.
Bowles PF, Harries M, Young P, et al.
CLINICAL OTOLARYNGOLOGY
2014;39(2):102-7.

CLINICAL OTOLARYNGOLOGY

Emerging antimicrobial resistance in ENT outpatients
Reviewed by: Andy Hall
Vol 23 No 5
 

Given the recent statement from the UK Prime Minister on this issue, it would appear timely to assess the ‘time bomb’ of antibiotic resistance in otology. Comparison of ear swabs over twelve months from 2007 and 2012 demonstrates an increasing level of resistance: 6.5% gentamycin resistance amongst staphylococcus in 2012 (in comparison to 0% in 2007) while a similar increase in resistant pseudomonas was also demonstrated. The authors sensibly question the use of antibiotic alternatives (such as aluminium hydroxide) as an alternative. Given that it has been twenty-five years since the last ‘new’ topical antibiotic for the ear, it is wise we work closely with microbiology colleagues to ensure adequate treatment of the discharging ear.

Reference

An analysis of emerging antimicrobial resistance in an ENT outpatient department: a comparison of three hundred and forty-nine swabs taken in 2007 with five hundred and seventy-four swabs in 2012.
Prowse SJ, Marsh P, Raine CH.
CLINICAL OTOLARYNGOLOGY
2014;39(1)63-66.

CLINICAL OTOLARYNGOLOGY

Transnasal oesophagoscopy: prospective cohort review
Reviewed by: Andy Hall
Vol 23 No 5
 

This paper looked at 257 patients undergoing the procedure in a tertiary otolaryngology department. In light of the morbidity of upper GI endoscopy associated with the sedation required, the safety profile of transnasal oesophagoscopy is a clear advantage. This cohort demonstrated a 97% success rate with poor view preventing diagnosis in only 1% of cases. Most common indications were unexplained throat symptoms and dysphagia. Following transnasal oesophagoscopy 56% patients had no detectable abnormality, allowing discharge to primary care or referring specialty. Positive findings were most commonly of GI pathology including hiatus hernia, Barretts oesophagus and dysmotility. This procedure appears likely to significantly evolve patient care over the coming years and appears in trained hands a safe and diagnostically sensitive tool.

Reference

Transnasal oesophagoscopy: diagnostic and management outcomes in a prospective cohort of 257 consecutive cases and practice implications.
Abou-Nader L, Wilson JA, Paleri V.
CLINICAL OTOLARYNGOLOGY
2014;39(2):108-13.

CURRENT OPINION IN OTOLARYNGOLOGY & HEAD AND NECK SURGERY

Fungal rhinosinusitis
Reviewed by: Susan A Douglas
Vol 23 No 5
 

Allergic fungal rhinosinusitis (AFRS) has been defined by the following characteristics: presence of nasal discharge, nasal obstruction, decreased sense of smell or facial pressure for 12 weeks, mucin within the sinus cavity containing fungal hyphae and degranulating eosinophils, endoscopic evidence of nasal polyps within the sinus cavity, computed tomography (CT) or MRI findings consistent with chronic impaction of eosinophilic mucin within diseased sinuses, evidence of fungal-specific IgE by skin prick or serum IgE testing, and no evidence of invasive fungal disease. Fungal culture is variably sensitive, therefore the histologic appearance of fungal elements within eosinophilic mucin remains the more reliable indicator of AFRS. This is a well written review of the pathophysiology of allergic fungal rhinosinusitis (AFRS), which is not fully understood and is in constant evolution. Although initial theories favoured an immunoglobulin E-mediated immune response to fungal antigens as having a primary role in the immunopathologic process of AFRS, the purpose of this review was to highlight recent studies that suggest a more complex, epithelial cell-driven immune response being central to the pathophysiology. Recent studies demonstrate a central role of cytokines derived from respiratory epithelial cells, including interleukin (IL)-25, IL-33, and thymic stromal lymphopoietin, in the orchestration of both innate and adaptive T helper 2 (Th2) immune responses that are important components of the immunopathology of chronic rhinosinusitis with nasal polyposis and AFRS. In addition, the robust Th2 adaptive response may be mediated by both fungal antigens and Staphylococcus aureus superantigens. Given the evolving understanding of AFRS pathophysiology, management continues to focus on minimising the burden of the inflammatory trigger(s) and suppressing the inflammatory cascade. This is primarily accomplished through surgery and corticosteroid therapy. Immunotherapy, antimicrobial therapy and other immunomodulatory medications may help mediate the disease process as well.

Reference

Current understanding of allergic fungal rhinosinusitis and treatment implications.
Plonk DP, Luong A.
CURRENT OPINION IN OTOLARYNGOLOGY & HEAD AND NECK SURGERY
2014;22(3):221-6.

CURRENT OPINION IN OTOLARYNGOLOGY & HEAD AND NECK SURGERY

Tracheostomy safety project
Reviewed by: Susan A Douglas
Vol 23 No 5
 

Tracheostomy care is evolving, with the majority of procedures now performed percutaneously to facilitate weaning from mechanical ventilation in the critically ill. Traditional surgical indications remain, but surgical tracheostomies are increasingly performed in more complex patients. This brings unique challenges for the multidisciplinary team (MDT) in which speech and language therapists (SLTs) have a key role. Comprehensive tracheostomy care is a truly multidisciplinary process, and the roles of medical, nursing and allied health staff in safely managing and rehabilitating all patients with tracheostomies has been reinforced in the UK by the National Tracheostomy Safety Project (NTSP). Reviews of tracheostomy-related critical incidents have identified recurrent themes associated with adverse outcomes for this high-risk population. The vast majority of adverse incidents occur more than one week after initial tracheostomy tube insertion and many of these events are due to factors that are amenable to prospective system improvement strategies. Recent research has highlighted the impact of tracheostomy on communication and swallowing, along with the contribution of SLTs to the MDT, prompting new guidance for SLTs. The UK NTSP has developed educational and practical resources that have been shown to improve care. Similar approaches from around the world led to the newly formed Global Tracheostomy Collaborative. SLT-specific expertise in assessing and managing communication and swallowing needs is a vital part of this process.

Reference

The UK National Tracheostomy Safety Project and the role of speech and language therapists.
McGratha BA, Wallace S.
CURRENT OPINION IN OTOLARYNGOLOGY & HEAD AND NECK SURGERY
2014;22(3):181-7.

EUROPEAN ARCHIVES OF OTO-RHINO-LARYNGOLOGY

Swallowing outcomes following partial laryngectomy: objective assessment and pre-operative predictive factors
Reviewed by: George Garas
Vol 23 No 5
 

Partial laryngectomy constitutes one of the treatments for early stage glottic carcinoma (i.e. T1N0 and T2N0) in specialised centres. Over the years, several partial laryngectomy and reconstruction techniques have been described in the literature. The choice of technique depends on disease location and extension, as well as the individual surgeon’s preference. The most widely practised operations are vertical partial laryngectomy and horizontal supracricoid laryngectomy. Partial frontolateral laryngectomy with epiglottic reconstruction (PFLER) has been shown to produce functional and oncological results analogous to supracricoid partial laryngectomy (cricohyoidoepiglottopexy) for T1b and T2 glottic carcinomas. The purpose of this study was to evaluate swallowing following PFLER using reproducible and objective tests and also identify preoperative factors that could influence swallowing outcomes. Twenty four patients that underwent PFLER in the period 2008-2012 were retrospectively evaluated. Locoregional control was achieved in all cases, but one after a median follow-up of 16.7 months. Swallowing was evaluated within 15 days (early score) and at two months (late score) post-operatively. In this series, 83% of patients had achieved at least partial oral feeding at time of hospital discharge (mean 18 days, range 10-39 days) and 87.5% achieved exclusive oral feeding at two months postoperatively. An objective swallowing assessment by videofluoroscopy showed that 50% had a good or excellent early score, 4.2% had an average early score and 41.8% had a poor early score. Regarding late scores, 63% were classified as good or excellent, 29% were classified as ‘middle result’ because their time to recover was longer (i.e. between one and two months postoperatively), and only two patients had a poor late score. Finally, only one patient was partially fed by gastrostomy (180 days after surgery). All patients tolerated decannulation and none experienced chronic pulmonary problems. With regards to pre-operative factors, T stage was the only factor shown to influence early swallowing outcomes (but not late outcomes), probably a direct result of the extent of surgical resection. The study’s main limitation relates to the small number of patients (n=24). This knowledge may prove of particular significance to head and neck surgeons when selecting and consenting patients for partial laryngeal surgery.

Reference

Analysis of swallowing after partial frontolateral laryngectomy with epiglottic reconstruction for glottic cancer.
Fakhry N, Michel J, Giorgi R, et al.
EUROPEAN ARCHIVES OF OTO-RHINO-LARYNGOLOGY
2014;271(7):2013-20.

EUROPEAN ARCHIVES OF OTO-RHINO-LARYNGOLOGY

The anatomy and actual number of branches of the sphenopalatine artery: surgical implications
Reviewed by: George Garas
Vol 23 No 5
 

Endoscopic sphenopalatine artery ligation or cauterisation is nowadays the main treatment for epistaxis unresponsive to medical therapy. However, on review of the literature, there appears to be confusion relating to the anatomical nomenclature of the sphenopalatine artery branches and more importantly to their actual number. Many authors have described numerous branches (up to 10) arising from the sphenopalatine foramen but this is rarely the case in clinical practice. The idea of this study was to use a mixed cohort of live epistaxis patients and cadavers to investigate the actual number of branches at the level of the sphenopalatine foramen, the incidence of an accessory foramen and finally describe their surgical outcomes with sphenopalatine artery ligation. Of the 107 nasal cavities that the authors explored (combined live epistaxis and cadaveric cohorts), the sphenopalatine artery consisted of a single branch in 68 cases (63%), divided into two branches in 34 cases (32%) and three branches in five cases (5%). No more than three branches were identified. The presence of an accessory foramen was observed in 7% of cases. In each of these cases only one branch was found to traverse the accessory foramen. Their reported success rate with sphenopalatine artery ligation was 88% (15/17). Following analysis of the two failed cases, the authors found that this was due to one case where the vascular clip had been displaced following application and another where the bleeding point did not arise from a branch of the sphenopalatine artery, but from the anterior ethmoidal artery instead. This study provides useful information that has significant implications in clinical practice: 1. In most cases there will be one or two branches arising from the sphenopalatine foramen. 2. Coagulation is probably more effective than clipping as the vascular clips may not sit properly on the vessel and as a result become displaced leading to re-bleeding. 3. During endoscopic dissection it is advisable that the surgeon extends the subperiosteal flap inferiorly due to the possibility of discovering an accessory foramen through which one additional branch traverses.

Reference

Anatomical and surgical study of the sphenopalatine artery branches.
Gras-Cabrerizo JR, Ademá-Alcover JM, Gras-Albert JR, et al.
EUROPEAN ARCHIVES OF OTO-RHINO-LARYNGOLOGY
2014;271(7):1947-51.

EUROPEAN REVIEW OF ENT

CIs and the elderly
Reviewed by: Badr Eldin Mostafa
Vol 23 No 5
 

Although cochlear implantation (CI) is thought to be a predominantly paediatric procedure, more and more adults are candidates for cochlear implants. This retrospective study was performed on 80 adults aged above 50 who were implanted for at least nine months. Results showed an improved speech perception and quality of life throughout all studied age groups. It is well recognised that CI surgery is a low risk surgery and can be safely offered to adults of all age groups. Hearing rehabilitation is important and allows adults to regain an active role and to avoid social isolation and depression especially in the older patient.

Reference

Cochlear implantation in older patients: outcomes and comparisons.
Rafferty A, Tapper L, Strachan D, Raine C.
EUROPEAN REVIEW OF ENT
2013:134(3):119-24.

EUROPEAN REVIEW OF ENT

The unknown primary again
Reviewed by: Badr Eldin Mostafa
Vol 23 No 5
 

In this retrospective study of 35 patients, the authors followed a systematic protocol for the detection and management of malignant cervical lymph nodes without an apparent primary lesion. Although their one, three and five year survival results are consistent with the international literature, the study has some flaws. They did not submit their patients to a PET-scan, although it is in the recommendations of the French ENT society, they did not biopsy the nasopharynx (only a tonsillar biopsy in 25 cases), and a fine needle aspiration cytology was only performed in 19 cases whereas all cases underwent a preliminary open biopsy and frozen section examination during the presumptive definitive surgery. Although it confirms the dire prognosis of this cohort of patients, the group was rather heterogeneous as were the treatment protocols.

Reference

Treatment of head and neck squamous cell carcinoma of an unknown primary (HNCCUP): oncologic analysis of 35 cases.
Berta E, Atallah I, Quesada JL, et al.
EUROPEAN REVIEW OF ENT
2013;134(3):131-8.

FACIAL PLASTIC SURGERY

Freestyle facial artery perforator flaps for nasal reconstruction
Reviewed by: Sunil Kumar Bhatia
Vol 23 No 5
 

This is an update from the authors that originally described the freestyle facial artery perforator flap for one stage nasal reconstruction in 2009. They now update with their 10-year experience of freestyle facial artery perforator flaps, accumulating a series of 21 patients (out of 86 nasal alar reconstructions) since 2004. Only one flap had minor congestion leading to flap tip necrosis. There is a good overview of the technique with an insight into its evolution and discussion of the relevant anatomy. Crucially they describe planning methodology and contraindications with the technique illustrated clearly with excellent photographs. They conclude that near total alar subunit or lateral alar defects are well served with this freestyle facial artery perforator flap reconstruction. This is good read for all surgeons interested in nasal reconstruction.

Reference

Reconstruction of nasal alar defects with freestyle facial artery perforator flaps.
D’Arpa S, Pirrello R, Toia F, et al.
FACIAL PLASTIC SURGERY
2014;30(3)277-86.

FACIAL PLASTIC SURGERY

One stage nasal reconstruction with local flaps
Reviewed by: Sunil Kumar Bhatia
Vol 23 No 5
 

This is an excellent and authoritative review of an often difficult and controversial (as there are so many options or so few) clinical subject. Better education and earlier diagnosis of skin tumours allows defects with limited size and depth to present in clinical practice; achieving good reconstruction, however, is often challenging. The authors have put together an excellent article with schematic diagrams and case studies accompanied by photographs. The main themes are the supratip area, dorsum and side wall subunits, and their experience with local rotation or advancement flaps. It is obvious that the authors have a wealth of experience and the article discusses the planning, selection and use of local flaps. This is an excellent review for nasal tip / lateral wall cutaneous reconstruction and is worth reading as both a technical review and reminder of the options.

Reference

One stage nasal soft tissue reconstruction with local flaps.
Helml G, von Gregory HF, Amr A, et al.
FACIAL PLASTIC SURGERY
2014;30(3):260-7.

FACIAL PLASTIC SURGERY CLINICS OF NORTH AMERICA

May 2014 issue: Neck Rejuvenation
Reviewed by: Mrinal Supriya
Vol 23 No 5
 

The May issue of this popular facial plastic journal is dedicated to detailed discussion of surgical and non-surgical procedures for rejuvenation of the neck. Following descriptions of relevant neck and face anatomy, techniques are discussed for neck and face rejuvenation. In addition to commonly employed interventions such as botulinum toxin, chemical peels, dermabrasion and carbon dioxide laser, relatively uncommon means such as intensity focused ultrasound, plasma skin regeneration and micropulsed 1444-nm Nd:YAG interstitial fibre laser are mentioned in detail. Adjunctive procedures including implants and treatment of the ptotic submandibular gland has been given in a separate chapter. Equally useful are the chapters dedicated to careful and detailed description of various surgical procedures used for neck and face lifts such as classical superficial musculoaponeurotic system (SMAS), extended SMAS approach, deep plane lifts and vertical neck lifts. The final chapter is dedicated to discussion of complications and sequel of surgical procedures. There are exceptional pre- and post-procedure photographs, which are given in ample number throughout the journal. This edition is essential for any budding facial cosmetic surgeon as well as a useful one for the veterans.

Reference

FACIAL PLASTIC SURGERY CLINICS OF NORTH AMERICA
Edited: Thomas JR, Hamilton MM, Beaty MM.
2014;22(2):161-336.

INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY

The impact of rhino-sinusitis treatment on olfaction
Reviewed by: Laith Tapponi
Vol 23 No 5
 

This study included 28 adults prospectively enrolled between March 2011 and May 2013 into a non-randomised, multi-institutional cohort. Adults electing endoscopic sinus surgery experienced gains in olfaction comparable to adults electing continued medical management. The evidence in this study comparing the impact of medical and surgical management of chronic rhinosinusitis on olfactory function is limited. Further study with larger sample size and more sensitive measures of olfaction are needed to determine differences between treatment groups.

Reference

Comparative effectiveness of medical and surgical therapy on olfaction in chronic rhino sinusitis: a prospective, multi-institutional study.
DeConde AS, Mace JC, Alt JA, et al.
INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY
2014;4(9):725-33.

INTERNATIONAL JOURNAL OF LANGUAGE & COMMUNICATION DISORDERS

Ideal terminology for unexplained paediatric language problems
Reviewed by: Gauri Mankekar
Vol 23 No 5
 

This paper aims to open a discussion about the different labels being used to refer to children’s unexplained language impairments. A wide range of terminology has been applied creating confusion, impeding progress of research and access to appropriate services. For example, the terms ‘dyslexia’, ‘attention deficit hyperactivity disorder’ and ‘autistic spectrum disorder’ are used for difficulties with reading, attention or social cognition respectively. But there is no definitive label for children with unexplained language problems. In DSM-5, the term ‘language disorder’ is problematic as it identifies too wide a range of conditions on an internet search. The author of this paper suggests retaining ‘specific language impairment’ with the understanding that ‘specific’ means ‘idiopathic’ rather than implying there are no other problems beyond language. The author has also suggested several other diagnostic terms and their advantages and disadvantages for evaluation.

Reference

Ten questions about terminology for children with unexplained language problems.
Bishop DVM.
INTERNATIONAL JOURNAL OF LANGUAGE & COMMUNICATION DISORDERS
2014;49(4):381-415.

INTERNATIONAL JOURNAL OF PEDIATRIC OTORHINOLARYNGOLOGY

Cochlear implants with an absent or hypoplastic cochlear nerve?
Reviewed by: Patrick Spielmann
Vol 23 No 5
 

The cornerstone of successful cochlear implantation has been the presence of a population of cochlear nerve endings which are able to mount a neural response to electrical stimulation. The authors of this paper present their experience of five children with absent or hypoplastic cochlear nerves who received cochlear implants. All children used their implants daily and had some improvement in perception of sound but only one achieved intelligible speech, in common with other similar series. There were no pre-operative imaging or auditory factors that predicted good performance. It appears that a small number of children with apparent cochlear nerve dysplasia may benefit from cochlear implantation, but it is currently impossible to predict which. Further, more sophisticated imaging or physiological tests will probably tell us in the future.

Reference

Cochlear implantation in children with cochlear nerve deficiency.
Vincenti V, Ormitti F, Ventura E, et al.
INTERNATIONAL JOURNAL OF PEDIATRIC
OTORHINOLARYNGOLOGY
2014;78(6):912-17.

INTERNATIONAL JOURNAL OF PEDIATRIC OTORHINOLARYNGOLOGY

Do we need to intervene after complications of acute sinusitis in children?
Reviewed by: Patrick Spielmann
Vol 23 No 5
 

Complications of acute sinusitis in children are not uncommon and some are managed surgically. The authors of this paper reviewed their experience of subsequent chronic rhinosinusitis (CRS). Nine of 86 patients required surgery in the 12 months after their initial presentation for symptoms and signs of CRS. There was no difference between the initially surgically or medically managed groups but they were young (mean and median age <5 years). The authors, not unreasonably, suggest reviewing patients up to 12 months following an orbital or intracranial complication of sinusitis as a significant percentage (10% here) may require further intervention.

Reference

Do you need to operate following recovery from complications of pediatric acute sinusitis?
Patel RG, Daramola OO, Linn D, et al.
INTERNATIONAL JOURNAL OF PEDIATRIC
OTORHINOLARYNGOLOGY
2014;78(6):923-5.

INTERNATIONAL JOURNAL OF PEDIATRIC OTORHINOLARYNGOLOGY

Friendly bacteria in the ear nose and throat to combat the bad…
Reviewed by: Patrick Spielmann
Vol 23 No 5
 

The author presents a thorough review of bacterial interference and the studies that have been conducted in common ENT conditions. The simple concept is that a strong population of normal flora will interfere with colonisation and subsequent infection by pathogenic strains. By replacing or preserving this flora, the recurrence of infections can be reduced: alpha haemolytic streptococci have been successfully inoculated into the naso / oropharynx of children to reduce the recurrence of with Group A beta haemolytic streptococcal tonsillitis. Several randomised double-blind, placebo-controlled trials are presented to support this as an effective therapy. The role of selecting antibiotics to preserve normal flora (such as first or second generation cephalosporins) is presented, again with compelling evidence that a change in antibiotic prescribing away from penicillin might be a good thing. Bacterial interference appears to provide us with a new way to reduce the swelling tide of antibiotic resistance and is clearly worthy of further study.

Reference

The effects of antimicrobials and exposure to smoking on bacterial interference in the upper respiratory tract of children
Brook I.
INTERNATIONAL JOURNAL OF PEDIATRIC
OTORHINOLARYNGOLOGY
2014;78(2):179-85.  

JAMA OTOLARYNGOLOGY – HEAD & NECK SURGERY

Extent of central neck dissection in the patients with thyroid carcinoma
Reviewed by: Shabbir Akhtar
Vol 23 No 5
 

The first level of lymphatic spread in well-differentiated thyroid carcinoma is to the central compartment of the neck, namely, the paratracheal, prelaryngeal and pretracheal lymph nodes. Central neck dissection may carry an increased morbidity, namely, hypoparathyroidism and recurrent laryngeal nerve injury. The limits of central neck dissection are bordered by the hyoid bone superiorly, the suprasternal notch inferiorly (including the upper mediastinal lymph nodes), the common carotid artery laterally, and the trachea medially. Central nerve dissection refers to removal of the unilateral or bilateral paratracheal regions. The upper part of central neck lies between hyoid bone superiorly and cricoid cartilage inferiorly. The hypothesis of authors was that the upper part of central neck is devoid of lymphatic structures and need not be dissected as part of a routine central neck dissection. A total of 31 paratracheal neck dissections were performed. The surgical specimens were divided into upper and lower paratracheal regions, corresponding to the level of the cricoid. A median of 8 nodes were retrieved (range, 2-21). All metastatic lymph nodes were detected in the lower paratracheal region, and similarly all lymphatic structures were also located in the lower central neck dissection specimen. The upper specimens were devoid of lymphatic tissue or cancer-bearing lymph nodes and consisted of fibrofatty connective tissue only. This series challenges the need to dissect this area routinely as a part of central neck dissection for patients with well-differentiated thyroid cancer.

Reference

The upper limits of central neck dissection.
Holostenco V, Khafif A.
JAMA OTOLARYNGOLOGY – HEAD & NECK SURGERY
2014;140(8):731-5.

JOURNAL OF CRANIO-MAXILLO-FACIAL SURGERY

An analysis of 60 treated cystic lesions in children
Reviewed by: Sunil Kumar Bhatia
Vol 23 No 5
 

This is a retrospective single-centre study of 60 consecutive cases in children. Children aged four months to 14-years-old underwent intervention under general anaesthetic from 2000 to 2012. As one might expect, most of these cysts were mucoceles and ranulas. Of this group, 49 patients had an intraoral approach and 11 required an external. There is a good discussion of each of the common cysts, namely mucoceles, ranulas, plunging ranulas, dermoid and epidermoid cysts, cystic hygromas, branchial cleft cysts and thyroglossal cysts. The paper is worth reading just to get an overview of the incidence and treatment of the commonest types of these lesions. There are good photographs and some illustrations. It is also good to get a perspective on these fairly common and some uncommon lesions that may present unexpectedly.

Reference

Surgical treatment of oral and facial soft tissue cystic lesions in children. A retrospective analysis of 60 consecutive cases with literature review.
Kolomvos N, Theologie-Lygidakis N, Tzerbos F, et al.
JOURNAL OF CRANIO-MAXILLO-FACIAL SURGERY
2014;42(5):392-6.

JOURNAL OF CRANIO-MAXILLO-FACIAL SURGERY

Free flap reconstruction in stage three bisphosphonate-related osteonecrosis
Reviewed by: Sunil Kumar Bhatia
Vol 23 No 5
 

There is no widely accepted gold standard for the treatment of bisphosphonate-related osteonecrosis of the jaw (BRONJ). Early BRONJ is managed conservatively but there is controversy regarding the treatment of the later stages. Stage three is defined as exposed bone with pain and or infection, in the presence of at least one of the following: pathological fracture, extra-oral fistula or osteolysis extending to the inferior border. The authors present a systematic review of the literature and discuss their own series. Twenty-seven papers were analysed and eight papers fulfilled the inclusion criteria of academic publications, clinically and histologically confirmed diagnosis, reconstruction with vascularised free osseous transfer and minimum follow-up of 12 months. This paper goes some way to promoting free flap vascular transfer and suggests good results. It is a small dataset, and by the authors’ own admission, additional studies from larger case series or case controlled series are necessary.

Reference

Outcomes of osseous free flap reconstruction in stage III bisphosphonate-related osteonecrosis of the jaws: Systematic review and a new case series.
Vercruysse H,Backer T, Mommaerts MY.
JOURNAL OF CRANIO-MAXILLO-FACIAL SURGERY
2014;42(5):377-86.

JOURNAL OF CRANIOFACIAL SURGERY

A conservative approach to treat ameloblastoma
Reviewed by: Sunil Kumar Bhatia
Vol 23 No 5
 

Ameloblastoma is an odontogenic tumour that is benign but locally aggressive and is associated with local recurrence. They are rare, accounting for 1% of oral tumours, and occur almost exclusively in the jaws. It is more common in the mandible and occurs most frequently at the angle. It has traditionally been treated aggressively with wide local excision, marginal or sectional resections. The authors discuss the management of this lesion using a 19-year-old female patient as an example. This patient presented with a large cyst that on orthopantomogram (OPG) appeared radiolucent, centred around the third molar and ascending ramus of the mandible. Initial treatment with decompression and daily irrigation was followed by a further enucleation procedure and application of Carnoy’s solution. Three years post-operatively the patient is well with no recurrence. This does confirm that a less radical approach in the treatment is possible at least for some types of unicystic ameloblastomas. This is a well written and succinct paper quite pertinent for surgeons that operate in the maxillofacial region.

Reference

Conservative approach: using decompression procedure for management of a large unicystic ameloblastoma of the mandible.
Xavier SP, Mello-Filho FV, Rodrigues WC, et al.
JOURNAL OF CRANIOFACIAL SURGERY
2014;25(3)1012-1014.

JOURNAL OF CRANIOFACIAL SURGERY

Reconstruction after parotid surgery
Reviewed by: Sunil Kumar Bhatia
Vol 23 No 5
 

This is a retrospective study from Naples, Italy. The authors compare patients with benign parotid disease that were reconstructed with three different techniques. In total 224 patients between February 2002 and March 2009 were included; these patients had either formal superficial parotidectomy or extra capsular dissection and were reconstructed by superficial musculoaponeurotic system (SMAS) flap, sternocleidomastoid (SCM) muscle flap or a temporoparietal fascia (TPF) flap. The surgical approach was a modified facelift and only patients with pleomorphic adenoma or Warthin tumours were included. The authors conclude all three reconstructive techniques drastically reduce post-parotidectomy Frey’s syndrome. There is some discussion of the raising of the three flaps but it is limited. They advise the SMAS flap to reconstruct in middle aged patients, the SCM in patients with recurring neoplastic disease and the TPF flap in other patients. It would be interesting to check a similar number of patients with no reconstruction and compare their outcomes, especially quality of life. Similarly it would be interesting to gather data on the numbers of surgeons that perform immediate reconstruction and if it is indicated.

Reference

Reconstructive techniques of the parotid region.
Orabona GD, Salzano G, Petrocelli M, et al.
JOURNAL OF CRANIOFACIAL SURGERY
2014;25(3)998-1002.

JOURNAL OF LARYNGOLOGY & OTOLOGY

Application of paper patching in patulous eustachian tube
Reviewed by: Madhup K Chaurasia
Vol 23 No 5
 

The condition of patulous eustachian tube, as opposed to dysfunctional eustachian tube, is less frequently diagnosed. Symptoms related to this, such as autophony, aural fullness, ‘being under water’, ‘hearing their own breathing’, and hearing sensitivity (varying in either direction) can occur in other conditions such as eustachian tube dysfunction and canal dehiscence. In this interesting study, the authors diagnosed this problem on the basis of symptoms and tried paper patching to see if this resolved symptoms instantly or in the long term. Twenty-one patients were selected and paper patching was done under the microscope, with rectangular pieces of cigarette paper applied to the superior part of the tympanic membrane. Observations were made from a casual query after the procedure as to whether or not the symptoms disappeared. In 76.2% of patients the symptoms disappeared immediately. In some cases the symptoms disappeared only partly and therefore more paper patches were applied. In the long term the symptoms reappeared in half the number of ‘cured’ patients and this was because the paper patches were dislodged. Some patients experienced slight discomfort but there were no adverse effects. The authors explain the improvement on the basis that a lax tympanic membrane, which can be a feature of a patulous eustachian tube, allows a higher admittance for lower frequencies; stiffening by paper patching reduces this and relieves the symptoms. The presence of retraction pockets tensing up the tympanic membrane or a cholesteatoma may circumvent this phenomenon. High admittance of lower and mid-frequencies is related to the upper and lower parts of the tympanic membrane respectively. Other studies in literature have been described, one of which used clay to stiffen the tympanic membrane. The method described by the authors is simple, non-invasive and can be conveniently undertaken in a clinic setting and therefore, if successful, conforms to cost effectiveness.

Reference

Paper patching of the tympanic membrane as a symptomatic treatment for a patulous eustachian tube syndrome.
Boedts M.
THE JOURNAL OF LARYNGOLOGY & OTOLOGY
2014;128(3):228-35.

JOURNAL OF LARYNGOLOGY & OTOLOGY

Factors affecting the occurrence of salivary fistula after total laryngectomy
Reviewed by: Madhup K Chaurasia
Vol 23 No 5
 

It is generally believed that patients should be fed by nasogastric tube for 7-10 days after undergoing total laryngectomy or laryngopharyngectomy to avoid the occurrence of post-operative salivary fistula. This study challenges this belief and looks into various factors that cause occurrence of salivary fistula, predominantly the timing of resumption of oral feeding. Eighty-nine patients were divided into an ‘early feeding’ group in which oral feeding started 24 hours after surgery and a ‘late feeding’ group in which oral feeding began seven days later. The exact protocols for feeding were observed in the two groups in terms of starting with clear fluids and going on to semi-solids. Various other factors possibly causing the occurrence of post-operative salivary fistula were also assessed. Variables such as gender, pre-operative tracheotomy, presence of chronic co-morbidities, pre- and post-operative haemoglobin levels, nutritional status, tumour location (glottic, supraglottic, transglottic or hypopharyngeal), primary tumour surgery type, duration of surgery and size of the remnant pharynx did not exhibit any statistically significant difference in the development of salivary fistula. The same was the case with the type of neck dissection carried out, jugular vein ligation and blood transfusion requirement. It is interesting that the nutritional status of patients was also insignificant in determining the occurrence of salivary fistula. The only variable which was associated with the development of post-operative salivary fistula was the histopatholgical cancer involvement of the surgical margins. This did not matter if it was carcinoma in situ but the tumour invasion of the surgical margin significantly affected the development of salivary fistula. The results of this study are in agreement with earlier studies quoted from the literature that did not demonstrate that early feeding increases the risk of salivary fistula. The authors contend that early feeding does not add any risks to this complication. Early feeding is therefore recommended as it restores normal physiology, is possibly more hygienic and is, after all, no different from ingesting saliva. It would also encourage early discharge and therefore reduce the cost of the treatment.

Reference

Does early oral feeding increase the likelihood of salivary fistula after total laryngectomy?
Sousa AA, Porcaro-Salles JM, Soares JMA, et al.
THE JOURNAL OF LARYNGOLOGY & OTOLOGY
2014;128(4):372-8.

JOURNAL OF LARYNGOLOGY & OTOLOGY

Lower respiratory involvement in allergic rhinitis and chronic sinusitis
Reviewed by: Madhup K Chaurasia
Vol 23 No 5
 

The recent ARIA (Allergic Rhinitis and its Impact on Asthma) project has generated interest in simultaneous involvement of the lower respiratory airway in cases of chronic rhinosinusitis and allergic rhinitis. This study takes into account the extent of pulmonary function involvement in these patients. Relevant indicators of pulmonary function were assessed in 203 patients with chronic rhinosinusitis who were scheduled to undergo FESS because of failed medical treatment. These were divided into two groups, with and without nasal polyps. Another 89 patients with allergic rhinitis participated in this study. In all these patients there was no obvious or diagnosed lower respiratory involvement such as asthma or chronic obstructive pulmonary disease (COPD). Prior to FESS an extensive range of pulmonary function tests were performed along with rhinomanometry, and the radiographic severity of chronic sinusitis was assessed by the Lund-Mackay CT staging system. IgE levels were measured along with inflammatory mediators and exhaled nitric oxide concentration. The results showed that pulmonary function was significantly affected in chronic rhinosinusitis patients compared with normal controls but the presence or absence of polyps did not matter. Pulmonary function parameters did not seem impaired in patients with allergic rhinitis as compared with controls, and the same was the case regarding nasal obstruction between patients with chronic rhinosinusitis and controls. In patients with chronic rhinusinusitis, variations in CT scores according to the Lund-Mackay scoring system and IgE levels did not relate to the presence of nasal polyps. However, a higher level of IL-5 significantly correlated with reduced pulmonary function. The authors claim that this study has shown for the first time that patients with chronic sinusitis have latent obstruction of the small airways, as detected by pulmonary airflow testing, even though these patients may not be diagnosed as having obstructive lung function changes and tend to be asymptomatic. It has been suggested that cytokines and chemokines present in the post-nasal discharge are important factors causing asthma and COPD. The study is well controlled and subjected to statistical analysis. It adds an important dimension to the concept of ARIA.

Reference

Pulmonary function in patients with chronic rhinosinusitis and allergic rhinitis.
Kariya S, Okano M, Oto T, et al.
THE JOURNAL OF LARYNGOLOGY AND OTOLOGY
2014;128(3):255-62.

JOURNAL OF LARYNGOLOGY & OTOLOGY

Supplementing intranasal cortical steroids with montelukast: does it help
Reviewed by: Madhup K Chaurasia
Vol 23 No 5
 

Intranasal steroids are widely used in the treatment of allergic rhinitis. Whether or not the addition of montelukast helps was assessed in this study. This was a single centre prospective randomised double-blind placebo-controlled trial of two groups of patients, one receiving intranasal steroids with a placebo and the other intranasal steroids with montelukast. Symptom scores and quality of life questionnaires were obtained in the first visit when the treatment was started. All patients had moderate to severe allergic rhinitis and therefore sleep disturbance was also taken into account. Identical recordings were taken at four and eight weeks after starting the treatment. Patient compliance was studied and results were subjected to statistical analysis. At the end of one month the mean scores for daytime nasal and nocturnal symptoms, but not daytime eye symptoms, were significantly lower in the montelukast group compared to the placebo group. All symptom scores improved significantly at two months, but the improvement was significantly greater in the montelukast group. The quality of life score was improved in the montelukast group and the difference compared with the placebo group was statistically significant. A record was also made of breakthrough symptoms and requirement of loratidine; this was much lower in the montelukast group. The authors are aware that this study is limited due to lack of objective measures such as rhinomanometry. The results of this study quite convincingly suggest that addition of montelukast in patients with moderate to severe allergic rhinitis is helpful in reducing symptoms and improving quality of life. The study is well structured and suggests a simple method to improve the management of allergic rhinitis.

Reference

Quality of life assessment in patients with moderate to severe allergic rhinitis treated with montelukast and/or intranasal steroids: a randomised, double-blind, placebo-controlled study
Goh BS, Ismail MIM, Husain S.
THE JOURNAL OF LARYNGOLOGY & OTOLOGY
2014;128(3):242-248.

JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY

Coupler microvascular anastomoses: how good?
Reviewed by: Sunil Kumar Bhatia
Vol 23 No 5
 

This paper is written by a group of reconstructive surgeons and a school of computing. The study used computational fluid dynamics to model blood flow through idealised sutured and coupled vessels, to investigate if differing anastomotic techniques affect intravascular blood flow. A computer-aided three-dimensional interactive application (CATIA), computer-aided design (CAD) and a microvascular anastomotic coupling (MAC) device were employed to obtain results of simulated anastomoses. They demonstrated how the flow patterns in the two different anastomoses vary to produce different physical properties at the anastomotic site. Based purely on the simulated data gathered, it appears clot formation may be more likely using the sutured technique. It would suggest the coupled anastomosis has less thrombogenic potential.

Reference

Blood flow through sutured and coupled microvascular anastomoses: A comparative computational study.
Wain RAJ, Whitty JPM , Dalal MD, et al.
Journal of Plastic, Reconstructive & Aesthetic surgery
2014;67(7)951-59.

JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY

Harvesting the flexor hallucis longus: what is the increased morbidity?
Reviewed by: Sunil Kumar Bhatia
Vol 23 No 5
 

The free fibula flap is now widely used in clinical applications for microvascular reconstruction and occasionally, to add bulk, the flexor hallucis longus (FHL) muscle is harvested along with the fibula. The post-operative morbidity is usually described as mild and temporary, however a reduction of hallux flexion is expected when muscle is harvested. This retrospective study assessed 32 patients, all of whom had undergone mandibular reconstruction with a free fibula flap between 1995 and 2009. All patients were assessed by a blinded observer using an average of three measurements of the range of motion of the metatarsophalangeal joint, the interphalangeal joint and the combined strength of the hallux flexors. It was found that the donor leg had a significant decrease in strength of hallux flexion independent of FHL muscle harvest. It is suggested that following the harvest of the fibula and its peroneal vessels, the muscle is possibly left devascularised and denervated. While the morbidity is small, it appears that no benefit is conveyed by FHL preservation.

Reference

The effect of flexor hallucis longus harvest on hallux function: A retrospective cross-sectional cohort study.
Van den Heuvel SCM, van der Veen FJC, Winters HAH.
JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY
2014;67:986-91.

JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY

Nasolabial flap to reconstruct periorbital defects
Reviewed by: Sunil Kumar Bhatia
Vol 23 No 5
 

The authors present a series of 25, mainly geriatric patients that had ablative surgery with complex defects in the paranasal and orbital regions. The paranasal and periorbital regions are extremely important for facial aesthetics and quality of life. The authors describe a contralateral cranial based nasolabial flap for complex full thickness defects. The advantages of the flap are a thin and pliable flap, good aesthetic matching, minimal donor site morbidity, reliability and resilience of the flap and single stage closure of the defect. There are very good colour photographs that show the various stages. The surgical technique is very sparingly described and will require further reading prior to attempting this flap. In older patients this would be a very useful alternative to free flap reconstruction.

Reference

The cranially based contralateral nasolabial flap for reconstruction of paranasal and periorbital surgical defects.
Kerem H, Bali U, Sönmez E, et al.
JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY
2014;67(5):655-61.

JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY

The many uses of human amnion
Reviewed by: Sunil Kumar Bhatia
Vol 23 No 5
 

Human amnion has historically been the focus of much myth and superstition. To be born with the ‘caul’ intact was considered lucky and the caul was often manufactured into clothing. In 1910 foetal membranes were first used in skin transplantation and since then have been used with great success in almost all sites of the body by most surgical specialties. The authors have written an excellent paper discussing the various uses. They initially outline the anatomy and physiology and go on to discuss the mechanism of its therapeutic effects. This tissue provides an incredible versatile, economical and widely available substrate and is easy to store. This paper is definitely worth reading to appreciate this amazing material and its applications.

Reference

The clinician applications of human amnion in plastic surgery.
Fairbairn NG, Randolph MA, Redmond RW
Journal of Plastic, Reconstructive & Aesthetic surgery
2014;67(5):662-75.

JOURNAL OF VESTIBULAR RESEARCH

Be sober to stay on your feet
Reviewed by: Victor Y Osei-Lah
Vol 23 No 4
 

Readers would either have had a personal experience or observed the inelegant gait of the inebriated. Re-aligning the body during postural perturbations involves changes in head position, shoulders, and hip, knee and ankle joints. The main hypothesis of this study was that alcohol intoxication would cause misalignment of the head and other body segments in upright stance. A secondary aim was to investigate whether alcohol intoxication affects the ability for the body to adapt and maintain accurate body alignment during balance perturbations. Twenty-five adult subjects with no neurological / neuro-otological disease were recruited. The subjects consumed an unspecified amount of 70% ethanol diluted in elderflower juice. The balance tests required subjects to stand on a platform in quiet stance without perturbations and in upright posture with perturbations using calf muscle vibration, with eyes open and eyes closed. To measure the changes in posture in the antero-posterior and lateral directions, sensors were attached to five areas: head, shoulder, hip, knee and ankle. The tests were performed once a week for three weeks at three blood alcohol levels (BAC): 0.00%, 0.06% and 0.10%. In the absence of alcohol intoxication (BAC 0.00%), head position was more anterior when the eyes were closed. This head position increased further when perturbations were introduced; the position of the knee in quiet stance became more posterior, that is rigid, at higher BAC, made worse by both perturbations and eye closure. There was a significantly greater lateral displacement of the head, and antero-posterior displacement of the shoulders at high BACs. The displacements were worse during perturbations. An interesting finding was that the rigid alignment of the body when intoxicated was worse when the eyes were open than when closed, indicating that visual stabilisation is inadequate in compensating for alcohol-induced ataxia. Vertical alignment of the head was affected by alcohol intoxication most likely due to impairment in the perception of true vertical. The authors conclude that the changes in body alignment and the poor compensatory mechanisms probably contribute to the risk of falling in the inebriated.

Reference

Acute alcohol intoxication impairs segmental body alignment in upright standing.
Hafstrom A, Patel M, Modig F, et al.
JOURNAL OF VESTIBULAR RESEARCH
2014;24(4):297-304.

JOURNAL OF VESTIBULAR RESEARCH

Is auditory neuropathy spectrum disorder a disorder of the whole eighth cranial nerve?
Reviewed by: Victor Y Osei-Lah
Vol 23 No 5
 

Auditory neuropathy spectrum disorder (ANSD) is now well recognised in audiological circles. Vestibular nerve function has not been extensively studied in ANSD. The authors used cervical vestibular evoked myogenic potential (cVEMP) and caloric tests to assess the integrity of the inferior and superior vestibular nerves respectively in 26 ANSD subjects. There were 16 females and 10 males with ages ranging between 13 years and 42 years (mean 21.8 years). Vestibular complaints were reported by 15 subjects (57.6%) although I would not consider blackouts and loss of consciousness, vestibular in origin. A control group of 26 subjects were recruited. The results in the ANSD group were as follows: in 96.15% subjects (50 ears), cVEMPs were absent. In a further one ear, the amplitude was abnormal. Normal cVEMP was elicited in one ear. Caloric results were classified as hypoactive (86.53%), hyperactive (5.76%) or normal (7.69%). When the cVEMP and caloric abnormalities were combined, bilateral vestibular hypofunction was identified in 76.92%. Asymmetric dysfunction was seen in five subjects (19.23%) whereas in four subjects (15.38%), hypofunction was unilateral. Vestibular dysfunction did not correlate with the pattern and degree of hearing loss. This is an excellent study overall, that shows further evidence that ANSD is more than an ‘auditory’ nerve abnormality and vestibular function tests should perhaps be done in all such patients. The formula used by the authors to determine caloric abnormality was unconventional and it would have been interesting to know if the aetiology of the ANSD had any bearing on the type of caloric abnormality. Should ANSD, with its many synonyms, be renamed? That is a discussion for another time.

Reference

Cervical vestibular evoked myogenic potentials and caloric test results in individuals with auditory neuropathy spectrum disorders.
Sujeet KS, Niraj KS, Animesh B, et al.
JOURNAL OF VESTIBULAR RESEARCH
2014;24(4):313-23.

LARYNGOSCOPE

Paediatric pain control post-tonsillectomy
Reviewed by: Mark Puvanendran
Vol 23 No 5
 

The use of codeine in the paediatric population is widely debated since the American Food and Drug Administration (FDA) published warnings regarding overdose and death following the usage of codeine. Codeine is metabolised by the polymorphic cytochrome PY4502D6 (CYP2D6) in the liver. The variations of CYP2D6 lead to four phenotypes for the metabolism of codeine; ultra-rapid, extensive, intermediate and poor metabolisers. The paper highlights the frequencies of these phenotypes in Caucasians, Asians and Africans. The authors consist of a paediatric otolaryngologist, anaesthetist, paediatrician and pharmacist. Their literature review search strategy is not clearly described, the levels of evidence of the studies is summarised at the end but this information is not provided for individual study. The use of paracetamol, ibuprofen and dexamethasone are briefly discussed. Guidelines from the American Academy of Otolaryngology- Head and Neck Surgeons in 2011 are described. This is an important subject and clear guidelines derived from a solid evidence base are required. This paper is a nice summary of the problem but fails to provide adequate guidance on the next step in analgesia following paracetamol and ibuprofen. The consensus statement of the Royal Colleges of Anaesthetics, Paediatrics and Child Health and two groups of pharmacists in the UK provide additional guidance.

Reference

What Is the best non-codeine postadenotonsillectomy pain management for children?
Yellon RF, Kenna MA, Cladis FP, et al.
LARYNGOSCOPE
2014;124(8):1737-8.

NEUROSURGERY

Malignant craniopharyngiomas
Reviewed by: Showkat Mirza
Vol 23 No 5
 

Craniopharyngiomas are successfully managed with surgery and / or adjuvant chemoradiotherapy. The transnasal endoscopic route has become increasingly utilised in the management of these challenging tumours. This paper reviews 23 cases from the literature of the rarely reported malignant transformation. Histologically the most common tumour type was a squamous cell carcinoma. Twenty-two percent of the cases were diagnosed as malignant craniopharyngioma at first biopsy. Of the rest the median time from initial benign diagnosis to malignant transformation was 8.5 years (range 3-55 years). The median overall survival after malignant transformation was six months. Malignant craniopharyngiomas are therefore rare and associated with a poor prognosis. Malignant transformation tends to occur years after the initial benign craniopharyngioma diagnosis and is associated with multiple benign craniopharyngioma recurrences. Their analysis shows that contrary to wide spread belief there seems to be a poor colouration between radiotherapy and subsequent malignant transformation.

Reference

Malignant transformation in craniopharyngioma.
Sofela AA, Hettig ES, Curran O, Bassi S.
NEUROSURGERY
2014;75(3):306-14.

NEUROSURGERY CLINICS OF NORTH AMERICA

Endovascular management of cavernous and paraclinoid aneurysms
Reviewed by: Gentle Wong
Vol 23 No 5
 

This review discusses management of aneurysms arising from the internal carotid artery from the entrance into the cavernous sinus until just before the take off of the posterior communicating artery. Whilst paraclinoid aneurysms do not tend to have ENT presentations, cavernous ones may rarely present with epistaxis, and retro-orbital pain. Focusing on cavernous aneurysms, treatment depends upon whether they are ruptured / unruptured, and if they are symptomatic or not. Endovascular management is preferred over open surgical intervention because of the latter’s high morbidity and mortality. For unruptured, asymptomatic aneurysms (i.e. detected incidentally), treatment is not recommended if <13mm; and for those >13mm, the decision is made on a case-by-case basis. For the unruptured, symptomatic, and ruptured aneurysms, generally coil embolisation is well tolerated. Flow diversion is a newer technology and complements coiling well with higher occlusion rates

Reference

Endovascular management of cavernous and paraclinoid aneurysms.
Brown B, Hanel RA.
NEUROSURGERY CLINICS OF NORTH AMERICA
2014;25(3):415-24.

ORAL AND MAXILLOFACIAL SURGERY CLINICS OF NORTH AMERICA

Resection margins in head and neck surgery
Reviewed by: Deepak Chandrasekharan
Vol 23 No 5
 

Although an increasing proportion of head and neck malignancies are treated with non-surgical modalities, when surgery is undertaken an incomplete clearance results in significantly worse prognosis. However, the intraoperative assessment of an adequate margin is difficult. The personal practice of the authors in this review is to attempt margins of 1cm or greater of visible mucosa and 1cm of palpable deep margins. The review goes on to comprehensively explore the various factors influencing adherence to, or deviation from, this decision and the success of resection. As well as covering concepts such as anatomical and histological margins, it discusses the importance of meeting with the histopathologist to review the specimen, particularly in fragmented and poorly oriented tumours as is the case with minimally invasive approaches. Specimen tissue shrinkage may also affect margin analysis, and whilst electrosurgical instruments reduce shrinkage as compared with a steel scalpel (possibly due to thermal injury to tissues) the latter is associated with less tissue distortion of the margin which may affect subsequent analysis. Finally the review discusses the potential future role of molecular analysis of margins. The techniques of epigenetic analysis of tumour markers such as p16 and DAPK as well as using optical techniques of autofluorescence or topical fluorescent agents with high resolution micro-endoscopes may one day help intraoperative delineation of the dysplastic margin at a molecular level. Overall this is a useful and engaging review with appeal to both the generalist and specialist in head and neck surgery.

Reference

Pitfalls in determining head and neck surgical margins.
Weinstock Y, Alava I, Dierks E.
ORAL AND MAXILLOFACIAL SURGERY CLINICS OF NORTH AMERICA
2014;26(2):151-62.

ORL

Hyoid bone interposition graft in treatment of laryngotracheal stenosis
Reviewed by: Zi Wei Liu
Vol 23 No 5
 

Laryngotracheal stenosis remains a challenging condition to manage, with treatment options plagued by either high rates of recurrence or excessive morbidity. The authors describe two cases of adult laryngotracheal stenosis treated by a hyoid interposition composite graft. A two-step procedure is described in this study. The first patient had tracheal stenosis at rings 3-4 secondary to prolonged intubation, and the second had laryngeal stenosis due to lymphangiomatosis. In both cases an anterior split is performed through either the trachea or the larynx, and a mucosa lined 'trough' created. As a second stage procedure, the central portion of the hyoid bone is mobilised with thyrohyoid muscles on either side acting as pedicles, and reflected downwards into the trough. A covering tracheostomy is sited inferiorly and the patient is decannulated at a later date. The two patients had two- and ten-year follow-ups with satisfactory airway and swallow. Compared to primary laryngotracheal resection with end-to-end anastomosis, this procedure has the disadvantage of being a two-stage procedure. However, injury to the recurrent laryngeal nerves remains a notable risk in primary resection, and this technique may be a useful option depending on patient and surgeon preference.

Reference

Composite hyoid bone graft interposition for the treatment of laryngotracheal stenosis.
Mizokami D, Araki K, Tomifuji M, et al.
ORL
2014;76(3):147-52.

OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA

In the future there will be robots
Reviewed by: Charlie Giddings
Vol 23 No 5
 

This edition of review articles encompasses the emerging techniques of robotic surgery, written by international experts from centres that are increasing their repertoire of procedures. The treatment of oropharyngeal cancer is challenging irrespective of modality, as oncological and functional outcomes have great impact on quality of life. This article focuses on transoral robotic resections of oropharyngeal cancers for which acceptable oncological outcomes have been reported. The rationale behind this technique is to improve functional outcomes, avoid the morbidity of traditional open approaches, reduce length of stay, decrease tracheostomy and gastrostomy tube rates and de-escalate or obviate the need for chemoradiotherapy. Disease must be surgically resectable with negative margins and the technique is therefore most appropriate to small tumours. The procedures are described in detail, from setting up the equipment to the surgical procedures, and include many useful tips likely gained by personal experience. There is an accompanying set of four videos demonstrating the procedure from the initial incision to the dissection of the pharyngeal musculature. This is an excellent guide for robotic lateral oropharyngectomy for which robust outcome data is awaited.

Reference

Robotic approaches to the pharynx: tonsil cancer.
Brickman D, Gross ND.
OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA
2014;47(3):359-72.

OTOLOGY & NEUROTOLOGY

Mastoid obliteration for canal wall down surgery
Reviewed by: Anand Kasbekar
Vol 23 No 5
 

Surgery for acquired cholesteatoma is varied amongst surgeons with some only performing combined approach tympanoplasty. The change in lifestyle for patients with canal wall down surgery is significant and hence this group in Japan looked at 118 adult patients with acquired cholesteatoma who underwent canal wall down tympanomastoidectomy with reconstruction of the cavity and ear canal wall. They did this for cholesteatoma that only went up to the mastoid antrum and not into the cavity. The cavity was filled with autologous bone dust / pate (less chance of extrusion as autologous), fibrin glue and a bone pate plate to recreate the canal wall without gaps. The attic was also obliterated and no cartilage was used. The attic reconstruction is vital to stop re-retraction! Hearing results were not provided. Follow-up was at one and five years with a CT scan and otoscopy. There was a 2.5% postoperative otorrhoea. Ninety-six percent had an almost normal looking ear at five years. No residual / recurrent cholesteatoma was observed in the obliterated cavity (but there was none to begin with). Residual cholesteatoma in the tympanic cavity however was seen in 8% and is fairly low compared to other published series. This I believe was with a CT scan as details are not provided and is something we wouldn’t routinely perform without symptoms or signs. Overall, I like their technique of mastoid reconstruction, but it usually takes 10 years or longer to tell whether the reconstruction will hold. Using autologous bone for their ossiculoplasty and reconstruction is ideal in my view and likely to last. This paper however highlights the importance of trying to keep the canal wall or reconstruct it whenever one can to allow patients a normal quality of life and prevent those smelly discharging cavities

Reference

Long-term follow-up results of canal wall down tympanoplasty with mastoid obliteration using the bone pate plate for canal wall reconstruction in cholesteatoma surgery.
Yamamoto Y, Takahashi K, Morita Y, et al.
OTOLOGY & NEUROTOLOGY
2014;35(6):961-5.

RHINOLOGY

Importance of nasal septal cartilage perichondrium for septum strength mechanics: a cadaveric study
Reviewed by: Lakhbinder Pabla (Bal)
Vol 23 No 5
 

This experimental cadaver study aimed to investigate the biomechanical qualities of the perichondrium and cartilage, and to determine the strength of the septal cartilage against bending forces. The nasal septal cartilages of 14 fresh cadavers (eight hours post-mortem) without nasal septal deviation or any history of nasal trauma were excised. Each one was cut into two strips: one with the perichondrium (group A) and one without the perichondrium (group B). A three-point bending test was performed on the strips. The deflection of group A strips was larger than the deflection of group B. Flexural strength was also larger in group A compared to group B strips. The average modulus of elasticity was 122% higher in group A compared to group B and all conducted tests revealed statistically significant differences between the groups. This study objectively shows that the perichondrium provides the cartilage with a 25% bending strength and highlights the importance of the perichondrium, particularly its role in supporting the cartilage. However, the study is limited by the small sample size included. It is also important to remember that the septal cartilage does not exist in isolation but is fixed by the surrounding bone, cartilages and other soft tissues. Therefore, it may not be appropriate to extrapolate from small pieces of individual cartilage to real-life physiological and pathological situations.

Reference

Importance of nasal septal cartilage perichondrium for septum strength mechanics: a cadaveric study.
Tekke NS, Alkan Z, Yigit O, et al.
RHINOLOGY
2014;52(2):167-71.

SEMINARS IN SPEECH AND LANGUAGE

Postconcussion syndrome: weighing up the options on balance
Reviewed by: Roganie Govender
Vol 23 No 5
 

Balance problems, dizziness, headaches, nausea, vomiting and sensitivity to light and sound, are a few of the symptoms which may be associated with post concussion syndrome (PCS), concussion symptoms which persist longer than 21 days. This article presents a physical therapy perspective on managing dizziness experienced by athletes with PCS. It provides an overview of conditions that may contribute to dizziness: this may include benign paroxysmal positional vertigo (BPPV), poor gaze stabilisation, visual motion sensitivity, postural instability and cervicogenic dizziness. Goals of physical therapy targeted at the identified cause are explained. This article is set within the context of a journal edition devoted to raising awareness of concussion or mild traumatic brain injury (mTBI) particularly as it relates to the variety of sporting activities (both amateur and professional) that may put an individual at risk for concussion. A useful read for any practitioner involved in differential diagnosis of balance disorders.

Reference

Management of athletes with postconcussion syndrome.
Diaz DS.
SEMINARS IN SPEECH AND LANGUAGE
2014; 35:204-10.

SLEEP AND BREATHING

European position paper on drug induced sedation endoscopy (DISE)
Reviewed by: Vik Veer
Vol 23 No 5
 

DISE is a controversial topic but a practice that is largely accepted in the UK. There has been much variation about the technique, and how to interpret the results. For this reason, a collection of European DISE bigwigs aimed for consensus of opinion with a position paper. In summary this group decided that standard practice for DISE should include: avoidance of local anaesthesia, or decongestants or indeed any drugs at all that may influence the examination of the upper airway; assess supine, with and without gentle jaw thrust to simulate a mandibular advancement splint; sedation may be induced by propofol, midazolam or a combination. The advantages and disadvantages, and differing infusion techniques of each are appraised in the paper. Although not implicitly stated, a combination of the two seems to be favoured; and depending on the drugs used for sedation, two or more cycles of airway collapse need to be allowed before beginning the examination. The major stumbling block was on how to describe what is found. Seven common classification systems were examined, and no consensus was found indicating that they are probably all flawed. There is a long way to go before we have a standardised DISE technique, and this is mainly because of lack of research in the field. The exponential growth in DISE related research in recent years should help this European group reach a more satisfactory conclusion next time they meet.

Reference

European position paper on drug-induced sedation endoscopy (DISE).
De Vito A, Carrasco Llatas M, Vanni A, et al.
SLEEP AND BREATHING
2014;18(3):453-65.

THE HEARING JOURNAL

Treatments for hyperacusis
Reviewed by: Linnea Cheung
Vol 23 No 5
 

Centred on a patient’s experience, this article provides a brief summary of the condition of hyperacusis as an introduction to the treatments that are currently available. It is enhanced by the fact that the individual mentioned is a musician by profession, whose journey of diagnosis and treatment had a significant impact on his quality of life. The article categorises hyperacusis into four different subtypes based upon the patient's emotional response to sound. References are made to research conducted within the last decade highlighting the overall prevalence of the condition and the potential role of increased tensor tympani muscle activity causing pain in response to sound. Various different forms of sound therapy are available for hyperacusis, such as continuous low level broadband noise, successive approximation of high level broadband noise with or without partial masking. The featured case found benefit from a ‘pink noise program’ using open air headphones where sound presentation was incrementally adjusted in a successive approximation fashion. The article reiterates the need for further studies in this condition to improve understanding, which in turn would hope to better the diagnostic pathways and highlight an aim for targeted therapy for affected cases.

Reference

Help for hyperacusis: treatments turn down discomfort.
Lindsey H.
THE HEARING JOURNAL
2014;67(8):22-8.

THE JOURNAL OF INTERNATIONAL ADVANCED OTOLOGY

Pomegranate juice as an otoprotective agent
Reviewed by: Emma Stapleton
Vol 23 No 5
 

Chemotherapeutic agents such as cisplatin, given alongside irradiation, offer a survival advantage in head and neck cancer. Some patients often complain bitterly about side-effects of their treatment, one of which is ototoxicity. In this paper, the authors propose the use of freshly squeezed pomegranate juice, allegedly known for its antioxidant properties, to prevent free-radical mediated damage to cochlear hair cells. The study used 56 albino rats, which were randomised to sham treatments, or various combinations of cisplatin, radiotherapy, and fresh pomegranate juice. Changes in hearing were measured using DPOAEs, and histopathological examination of the cochleas. The results appear to indicate that fresh pomegranate juice has the potential to eliminate damage to cochlear hair cells resulting from irradiation, cisplatin, and combined use of cisplatin and irradiation. These were small animal groups, and the study does not take into account more modern techniques that can reduce the dose delivered to radiation sensitive tissue. Nevertheless, in the current oncological environment, newer treatments are constantly being sought in order to cure cancer with minimal side-effects, and there is a vogue for ‘natural’ treatment options. If a freshly squeezed fruit juice has genuine potential for reducing the ototoxic effects of cancer treatment, this certainly seems to be a topic worth pursuing in human subjects. What’s the worst that could happen?

Reference

Does short term usage of fresh pomegranate juice (FPJ) protect cochlear hair cells after cisplatin-based chemo-irradiation?
Akdağ M, Daşdağ S, Alabalık U, et al.
THE JOURNAL OF INTERNATIONAL ADVANCED OTOLOGY
2014;10(2):128-33.

TRENDS IN HEARING

Viral induced hearing loss
Reviewed by: Ameera Abdelrahim
Vol 23 No 5
 

Viruses are a common cause of hearing loss both in children and adults. This article provides a good review of the viral causes of hearing loss and can be regarded as an essential read. The authors divide the viruses into three categories: those causing congenital hearing loss (cytomegalovirus, rubella and lymphocytic choriomeningitis virus); those causing both acquired and congenital hearing loss (human immunodeficiency virus and herpes simplex virus types 1 and 2); and lastly those causing acquired hearing loss (measles, varicella zoster virus, mumps and West Nile virus). Prevention and management are discussed for each of these. Sensorineural hearing loss is the commonest outcome and treatments discussed range from primary prevention by vaccination, antiviral therapy to treat the acute phase and reduce associated complications, and hearing aids or cochlear implants to treat the subsequent hearing loss. They highlight conductive hearing loss secondary to recurrent bacterial infections of the middle and outer ear in immuno-compromised individuals as a virus related hearing loss. Furthermore they advocate recommending vaccination against common viruses to patients and parents to protect against the risk of these devastating complications.

Reference

Viral causes of hearing loss: a review for hearing health professionals.
Cohen B, Durstenfeld A, Roehm P.
TRENDS IN HEARING
2014;18:1-17.

WORLD JOURNAL OF SURGICAL ONCOLOGY

CT and intraoperative nerve monitoring to identify non-recurrent laryngeal nerve during thyroid surgery
Reviewed by: Jonathan Hughes
Vol 23 No 5
 

A non-recurrent laryngeal nerve (NRLN) is a rare (incidence 0.3% to 1.3%) anatomical variant that results in a higher rate of vocal cord palsy following thyroid surgery. This team from China examined the utility of preoperative CT and intraoperative nerve monitoring in identifying these at risk patients. NRLN is associated with abnormalities of the aortic arch and brachiocephalic / subclavian arteries which are detectable by CT. Nine NRLN were detected on imaging out of 1574 patients undergoing thyroid surgery. Seven of these were identified preoperatively and two following a retrospective scan analysis. Intraoperative nerve testing required exposure of the vagus nerve at a proximal and distal level (inferior thyroid pole). A positive electromyography signal at the proximal vagus and negative signal at the distal vagus was diagnostic for NRLN; with positive signals at both levels suggestive of RLN. All nine NRLN were identified using nerve monitoring. This paper suggests that CT and intraoperative nerve monitoring may have a place in patients undergoing thyroid surgery. However the morbidity of the radiation exposure of CT and the additional dissection required when exposing the vagus nerve at two levels to identify a very rare anatomical variant makes it questionable whether this should be routine practice for all patients. There are also health economic factors to consider, as most patients currently will only have an ultrasound scan prior to thyroid surgery.

Reference

Increased prediction of right nonrecurrent laryngeal nerve in thyroid surgery using preoperative computed tomography with intraoperative neuromonitoring identification.
Gao E-L, Zou X, Zhou Y-H, et al.
WORLD JOURNAL OF SURGICAL ONCOLOGY
2014;12:262.

ACTA OTOLARYNGOLOGICA

Head injury and prolonged bed rest, but not inner ear disease, predict poorer outcome after Epley manoeuvre in posterior semicircular canal benign paroxysmal positional vertgo (P-BPPV)
Reviewed by: Victoria Possamai
September/October 2014 (Vol 23 No 4)
 

This Japanese study included 197 patients with P-BPPV treated over a two and a half year period. The vast majority had idiopathic BPPV (n=157). The remaining 40 had secondary BPPV, eight following head trauma, 14 due to prolonged bed rest and 18 related to inner ear disease, including sudden sensorineural deafness, Ménière’s disease and vestibular neuritis. A single Epley manoeuvre was performed by the same therapist in all patients, and patients were followed up weekly with repeat Epley manoeuvre to assess response. Comparing response at seven days, there was 73% resolution in the idiopathic group, 56% in the inner ear group (no significant difference), 25% in the head trauma group and 36% in the bed rest group (both statistically significant). The study then assessed resolution over the longer term with helpful Kaplan Meier curves to demonstrate that again there was no significant difference in resolution rates between the idiopathic and inner ear groups at one and three months post Epley manoeuvre, but significantly lower rates of resolution at these intervals in the head trauma and bed rest groups. In all groups the majority of patients had resolution by three months. This was poorest in the head trauma group with 25% of patients still unresolved, whereas for the three other groups this was less than 10%. One must bear in mind the small numbers of patients in each of the secondary BPPV groups when considering the strength of the conclusions, however this study certainly adds weight to the notion that idiopathic P-BPPV has a better outcome than that secondary to a separate pathology. The authors hypothesise regarding the possible mechanism of deposition of otoconial debris to explain their observations.

Reference

Risk factors for poor outcome of a single Epley maneuver and residual positional vertigo in patients with benign paroxysmal positional vertigo.
Sato G, Sekine K, Matsuda K, Tadeka N.
ACTA OTOLARYNGOLOGICA
2013;133(11):1124-27.

ALLERGY

Is there a cause-and-effect relationship between allergic rhinitis and chronic rhinosinusitis?
Reviewed by: Evangelia Tsakiropoulou
September/October 2014 (Vol 23 No 4)
 

This review examines the possible causative relationship between allergic rhinitis (AR) and chronic rhinosinusitis (CRS) that has long been proposed. Many observational and experimental studies exist, however no clear and definitive connection has been established. This is mainly due to great diversity in study methodology. For this reason, the authors applied the revised Bradford-Hill guidelines to relevant studies, aiming to answer the question “is AR a predisposing factor for CRS?”. Despite the ‘unified airway’ concept, multiple pathophysiologic mechanisms seem to be involved that are not common in both clinical entities. This review identifies that there is a lack of consistency in the terms used to define AR and CRS, which undermines the strength of the association. The authors conclude that no clear and definitive causal relationship can be established, especially in children. It is also suggested that any CRS patient with uncontrolled symptoms should be evaluated for underlying allergies. The authors appropriately reinforce this principle, also supported by the Joint Task Force on Practice Parameters (JTFPP) document, Clinical Practice Guideline: Adult Sinusitis (CPG:AS), The British Society for Allergy & Clinical Immunology (BSACI) and European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS) guidelines.

Reference

Is chronic rhinosinusitis related to allergic rhinitis in adults and children? Applying epidemiological guidelines for causation.
Georgalas C, Vlastos I, Picavet V, et al.
ALLERGY
2014;69(7):828-33.

AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY

Evidence and nasal polyp treatments
Reviewed by: Edward W Fisher
September/October 2014 (Vol 23 No 4)
 

The change in the routine management of nasal polyps in the past 2-3 decades has been fascinating and this review from Charleston covers the topics of systemic treatment, local treatment, perioperative treatment and immunotherapy and touches on the lower airway effects. Few would disagree with the statement ‘aggressive medical and surgical treatment of CRSwNPs (chronic rhinosinusitis with nasal polyps) improves asthma outcomes’, but it deserves repetition. Otolaryngologists would be particularly interested in topical steroid delivery methods such as bioresorbable materials and we are reminded that ‘topical antibiotic use for CRSwNPs is not currently supported by evidence. We are informed that ‘macrolides and doxycycline have anti-inflammatory effects and macrolides also have mucolytic and anti-biofilm properties. Thus it is difficult to attribute any benefit solely to antimicrobial characteristics.’ This is an article for all rhinologists to read. I would be surprised if something here is not new to a reader.

Reference

Evidence-based treatment of chronic rhinosinusitis with nasal polyps.
Schlosser RJ, Soler ZM.
AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY
2013;27(6):461-66.

AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY

Improving smell outcomes after sinus surgery: impregnated dressings?
Reviewed by: Edward W Fisher
September/October 2014 (Vol 23 No 4)
 

There is much we can do to improve the airway of patients with chronic sinus disease, especially those with polyps. However, the olfactory outcomes are usually disappointing and patients miss this important sensory modality, which has an effect on their quality of life. These authors report a study in which a gelatin dressing was placed high in the nose, as close as possible to the olfactory epithelium, at the conclusion of sinus surgery. The gelatin had been impregnated with triamcinolone. The 60 patients were divided into two groups, one of which did not receive the triamcinolone. The outcome for smell was good in the treated group, but follow-up was only 8 weeks. While this is gratifying, it is the long-term effect that is demoralising for this group of patients and I would be surprised if this short-term gain was translated into a superior long-term gain.

Reference

The effect of an absorbable gelatin dressing impregnated with triamcinolone within the olfactory cleft on polypoid
rhinosinusitis smell disorders.
Bardaranfar MH, Ranjbar Z, Dadgarnia MH, et al.
AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY
2013;28(2):172-75.

AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY

What do we put in our nasal douches? Anything?
Reviewed by: Edward W Fisher
September/October 2014 (Vol 23 No 4)
 

The rise of the popularity of saline nasal douches, with several commercial preparations available, may be a rediscovery of an age-old tradition, but it has been shown to benefit patients. The question then arises as to whether this can be improved by adding in various medications, especially in recalcitrant cases of chronic rhinosinusitis (CRS) in patients who perhaps have had several operations. This paper pulls together information on anti-infective additives (rather than corticosteroid or anti-inflammatory additives), which include topical antibiotics (e.g. mupirocin, gentamicin, tobramycin), topical antifungals and ‘additives’ which include surfactants, xylitol, manuka honey and N-Chlorotaurine (an antiseptic). The overall message is that such additives are not part of the routine management of standard CRS patients, but should be reserved for recalcitrant cases, but that research is weak on most of these categories (apart from antibiotics). The evidence on antifungals is particularly weak and these are not recommended. Clearly, there is a long way to go before we have enough evidence to recommend use of these categories of additives to douches with a good evidence base, except for antibiotics and, even in those cases, there are many unanswered questions (dose, risk-benefit balance, outcomes, case selection, etc).

Reference

Topical anti-infective sinonasal irrigations: update and
literature review.
Lee JT, Chiu AG.
AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY
2013;28(1):29-38.

ANNALS OF THE ROYAL COLLEGE OF SURGEONS OF ENGLAND

Consequences of tonsillectomy rationing?
Reviewed by: Thomas Jacques
September/October 2014 (Vol 23 No 4)
 

This article examines Hospital Episode Statistics and Office for National Statistics data to investigate the change in rates of tonsillectomy and admissions for tonsillitis and its complications, over a 20-year period. Between 1991 and 2011, 44% fewer tonsillectomies were performed. This was accompanied by a 310% increase in admissions for tonsillitis. Admissions for retropharyngeal and parapharyngeal abscesses rose by 39% between 1996 and 2011. The trends were most pronounced in paediatric patients. It was identified that ‘Procedures of Limited Clinical Effectiveness’ guidance varies regionally by clinical commissioning group (CCG), with some adhering to Scottish Intercollegiate Guidelines Network (SIGN) guidelines, and others being more stringent. The authors rightly state that these data cannot imply causation, and are subject to some limitations in terms of accuracy. However it is likely that they represent sobering evidence of the erroneous economic and clinical logic behind surgical rationing. Whilst the authors caution that a return to historical rates of tonsillectomy is not desirable, they conclude that deliberate disregard of the evidence for the efficacy of tonsillectomy, in the pursuit of monetary savings alone, may be endangering patients.

Reference

The rising rate of admissions for tonsillitis and neck space abscesses in England, 1991-2011.
Lau AS, Upile NS, Wilkie MD, et al.
ANNALS OF THE ROYAL COLLEGE OF SURGEONS OF ENGLAND
2014;96(4):307-10.

ANNALS OF THE ROYAL COLLEGE OF SURGEONS OF ENGLAND

Trends in parathyroidectomy
Reviewed by: Thomas Jacques
September/October 2014 (Vol 23 No 4)
 

he authors retrospectively analysed Hospital Episode Statistics data for parathyroidectomy between 2000 and 2010. Overall, parathyroidectomy rates nearly doubled from 3.3/100,000 population in 2000 to 5.8/100,000 in 2010, with particularly significant increases in elderly patients. The authors attribute this rise to the development of standardised endocrinological guidelines indicating surgery in asymptomatic hypercalcaemia, and an increasing life expectancy. Improvements in pre-operative localisation have also led to an increase in minimally-invasive parathyroidectomy, allowing shorter anaesthetic times, or even surgery under local anaesthesia. The data may not apply to surgery for secondary or tertiary hyperparathyroidism (HPT), but the authors point out that the most recent British Association of Endocrine and Thyroid Surgeons (BAETS) audit shows that around 90% of surgery is performed for primary HPT. The authors’ conclusions do rely on inference, but the reasoning is very plausible and an interesting insight. They reflect that the changes mirror a more general trend, whereby improvements in diagnostic and surgical technology tend to expand the indications for surgical procedures.

Reference

A decade of change in the uptake of parathyroidectomy in England and Wales.
Evans LM, Owens D, Scott-Coombes DM, Stechman MJ.
ANNALS OF THE ROYAL COLLEGE OF SURGEONS OF ENGLAND
2014;96(5):339-42.

BMC EAR, NOSE AND THROAT DISORDERS

3D ultrasonography for evaluation of muscles following facial palsy
Reviewed by: Gauri Mankekar
September/October 2014 (Vol 23 No 4)
 

Reconstructive surgery for facial nerve palsies is not recommended beyond two to three years after a degenerative facial nerve lesion. Since the time course of muscle atrophy is variable, this timeline is a rough guideline. The only assessment method currently used is needle electromyography (EMG). This paper describes a fast, non-invasive, and reliable method to evaluate the condition of the facial muscles and the degree of atrophy. The authors used a 3D ultrasonographic (US) acquisition system driven by a motorised linear mover combined with conventional US probe to acquire 3D data sets of several facial muscles on both sides of the face in a healthy subject and in seven patients with different types of unilateral degenerative facial nerve lesions. The US results were correlated to the duration of palsy and the EMG results. The facial muscles on the side of the paralysis, with the exception of the frontal muscle, were much smaller than on the healthy side in patients with severe facial nerve injuries. This new 3D ultrasonographic tool seems to be a promising innovation for the quantitative evaluation of facial muscles in patients considering reconstructive surgery or conservative treatment.

Reference

3D-Ultrasonography for evaluation of facial muscles in patients with chronic facial palsy or defective healing: a pilot study.
Volk GF, Pohlmann M, Finkensieper M, et al.
BMC EAR, NOSE AND THROAT DISORDERS
2014;14(4):2-8.

BMC NEUROLOGY

Head and neck radiation and the brain
Reviewed by: Badr Eldin Mostafa
September/October 2014 (Vol 23 No 4)
 

An increasing number of patients with head and neck squamous cell carcinoma and other lesions are treated with high dose radiotherapy. An increase in survival rates is being reported along with a younger patient demographic. The long-term effects of treatment on the carotid arteries and hence cerebral function are not well recognised. The authors followed 103 patients undergoing head and neck irradiation for a variety of lesions for more than five years. Baseline protocol (before radiotherapy) included screening for cerebrovascular risk factors and intima media thickness measurement of carotid arteries by ultrasonography. Follow-up assessment after radiotherapy included screening for cerebrovascular risk factors, cerebrovascular events, neurological examination with gait and balance tests, extensive neuropsychological examination, self-reported questionnaires, ultrasonography of the carotid arteries with measurement of intima media thickness and elastography, magnetic resonance imaging of the brain and magnetic resonance angiography of the carotid arteries. The final results are not yet published but the mere amount of data is likely to improve our understanding of the causes and consequences of long-term cerebral and vascular changes after radiotherapy of the neck. These data will be helpful to develop a protocol for accurate diagnosis and aid preventive strategies to avoid long-term neurological complications in patients undergoing radiotherapy treatment

Reference

Long term cerebral and vascular complications after irradiation of the neck in head and neck cancer patients: a prospective cohort study: study rationale and protocol.
Wilbers J, Kappelle AC, Kessels PCR, et al.
BMC NEUROLOGY
2014;14:132.

BRITISH JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY

Is it time for cone-beam CTs to replace the traditional orthopantomogram in the primary diagnosis of temporomandibular joint disorders?
Reviewed by: Sampath Chandra Prasad
September/October 2014 (Vol 23 No 4)
 

Cone-beam CT requires a lower dose of radiation compared to the multidetector CT and provides much more detailed information in 3D about the bony structures of the temporomandibular joint (TMJ) when compared to the traditional orthopantomogram (OPG). In this article the authors assess the value of cone-beam computed tomographic (CT) images in the primary diagnosis and management of 128 outpatients with disorders of the temporomandibular joint (TMJ). After clinical examination, an assessment of the cone-beam CT images was made and the oral and maxillofacial surgeon was allowed to revise the provisional primary diagnosis and management. The degree of certainty was rated by the clinician before and after the cone-beam CT had been assessed. The primary diagnosis was changed in 32 patients (25%), additional diagnostic procedures were changed in 57 (45%), and the treatment was changed in 15 (12%). In 4/15, the treatment was changed to a (minimally) invasive procedure. A total of 74 patients (58%) had their diagnosis and management changed after the cone-beam CT had been assessed. Changes in diagnosis and management were clinically relevant in 9/32 and 9/61 patients, respectively. The clinician’s certainty about the primary diagnosis increased after the cone-beam CT had been assessed in 57 patients. Logistic regression analysis showed that the odds in favour of changes in primary diagnosis and management increased when limited mandibular function was a primary symptom, the patient was taking medication for pain, and the articular eminence could not be assessed on OPG. Assessment of cone-beam CT led to changes in primary diagnosis and management in more than half the patients with disorders of the TMJ.

Reference

Value of cone-beam computed tomography in the process of diagnosis and management of disorders of the temporomandibular joint.
de Boer EW, Dijkstra PU, Stegenga B, et al.
BRITISH JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY
2014;52(3):241-6.

BRITISH JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY

Role of copper ions in drinking water in the pathogenesis of oral submucous fibrosis: the missing link in the aetiopathology?
Reviewed by: Sampath Chandra Prasad
September/October 2014 (Vol 23 No 4)
 

Often a breakthrough link in the understanding of the aetiopathogenesis of a hitherto common pathology that has been evading the medical community may not come from the hi-tech labs of the developed world, but from the intelligent investigations from a modest laboratory of a developing nation. Researchers from a far-flung district in Southern India have investigated the concentration of copper ions in drinking water and attempted to determine whether copper has a role in the pathogenesis of oral submucous fibrosis (OSMF). They studied 50 patients with clinically and histologically diagnosed OSMF from the Yadgir district of Karnataka in India. Fifty healthy people, matched for age and sex, were used as controls. In both groups concentrations of copper ions in serum, saliva, and home drinking water were measured using atomic absorption spectroscopy and intelligent nephelometry technology. Serum ceruloplasmin concentrations were also estimated in both groups. The studies showed that the mean (SD) concentration of copper in the home drinking water of patients with OSMF was significantly higher (764.3 (445.9)μmol/L) than in the controls (305.7 (318.5)μmol/L) (P<0.001). Patients with OSMF also had a significantly higher copper concentration in serum and saliva, and serum ceruloplasmin than controls (P<0.001). The authors claim that, for the first time, a positive association between copper concentrations in home drinking water and OSMF has been established. It raises the possibility that increased copper in drinking water contributes to the development of OSMF, and adds to that ingested when areca nut is chewed.

Reference

Evaluation of possible role of copper ions in drinking water in the pathogenesis of oral submucous fibrosis: a pilot study.
Arakeri G, Patil SG, Ramesh DN, et al.
BRITISH JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY
2014;52(1):24-28.

CLINICAL OTOLARYNGOLOGY

Balloon dilatation of the eustachian tube: An evidence based review
Reviewed by: Andy Hall
September/October 2014 (Vol 23 No 4)
 

Eustachian tube dysfunction has long provoked debate among otolaryngologists with wide-spread variation in management. Establishing a safe and effective surgical technique to bring about resolution would be of benefit to those affected, with an estimated incidence of 0.9% in the UK. This well-constructed article takes a pragmatic approach to evaluating the current evidence through a case series review of cartilaginous dilatation. Pre- and post-operative parameters of tympanometry, otoscopy findings, valsalva and subjective symptoms were used focusing on short term (<6 months) and long term (>6 months). The literature demonstrates balloon dilatation performed on 375 eustachian tubes from 235 patients with clear short-term benefits across the aforementioned outcome measures. A complication rate of 3% was observed, yet these were deemed minor and short-lived. Indeed, in the absence of bony dilatation the practice of a routine pre-operative CT scan is questioned by the authors. The stage appears set for the eventual evolution of its use in mainstream practice, although the authors sensibly emphasise the importance of formalised training and meticulous review of outcomes.

Reference

Balloon dilatation of the Eustachian tube: an evidence based review of case series for those considering its use.
Miller BJ, Elhassan HA.
CLINICAL OTOLARYNGOLOGY
2013;38(6):525-32.

CLINICAL OTOLARYNGOLOGY

Clinical coding: variability and error in otolaryngology
Reviewed by: Andy Hall
September/October 2014 (Vol 23 No 4)
 

The ever topical spectre of coding in otolaryngology is comprehensively evaluated in this article. It attempts to debunk the mystique of current coding practices and the challenge of health informatics in the modern NHS. A total of 3131 randomly selected otolaryngology patients initially coded in the standard manner were evaluated by a clinician-auditor multi-disciplinary team. This was substantially larger than the sample size used to audit coding accuracy in the entire NHS by the audit commission! Overall this led to a 13% rate of change in both the primary procedure and underlying diagnosis. Coding data informs resource allocation and has an influence on clinical prioritisation within the NHS. Attempts to decrease variability and drive excellence in coding should remain a priority for clinicians as well as managers yet achieving this continues to present difficulties.

Reference

An audit of the nature and impact of clinical coding subjectivity variability and error in otolaryngology.
Nouraei S, Hudovsky A, Virk J, et al.
CLINICAL OTOLARYNGOLOGY
2013;38(6):512-24.

CLINICAL OTOLARYNGOLOGY

Cost effectiveness and vestibular schwannoma surgery
Reviewed by: Andy Hall
September/October 2014 (Vol 23 No 4)
 

This is the first cost effectiveness modelling study looking at the three main treatment options for small to medium sized vestibular schwannomas. This study uses the widely accepted cost per quality adjusted life year (QALY) outcome measure to evaluate three hypothetical cohorts of adult patients receiving conservative, radiosurgery or surgical treatment. The model used finds initial conservative management to be the most cost effective treatment strategy available for small to medium sized vestibular schwannomas (extrameatal diameter less than 2cm). Slow growth allows two-thirds of these to never require aggressive treatment. Overall this strategy appears to offer more QALYs at a lower cost, yet overall quality of life data in this patient population continues to need evaluation.

Reference

Conservative management, surgery and radiosurgery for treatment of vestibular schwannomas: a model-based approach to cost-effectiveness.
Gait C, Frew EJ, Martin TPC, et al.
CLINICAL OTOLARYNGOLOGY
2014;39(1):22-31.

CLINICAL OTOLARYNGOLOGY

Management of metastatic neck disease
Reviewed by: Andy Hall
September/October 2014 (Vol 23 No 4)
 

This article publishes the findings of a recent expert-led evidence based management symposium in the UK with recommendations according to the SIGN level of evidence and grading. The article neatly summarises the key points, and its clarity despite the complexity of the topic should be recognised. Naturally any topic such as this will continue to involve areas in need of further research and discussion; one key point, however, is in the need for international agreement on the most appropriate neck dissection classification system. Consistency in terminology is vital in areas such as this. This article is a must for oncological surgeons looking for a neat review of the current understanding of the topic; anyone with examinations around the corner would also be wise to review.

Reference

Management of metastatic neck disease – summary of the 11th Evidence Based Management Day.
O'Hara J, Simo R, McQueen A, et al.
CLINICAL OTOLARYNGOLOGY
2014;39(1):3-5.

CLINICAL OTOLARYNGOLOGY

National analysis of outcome of head and neck cancer surgery
Reviewed by: Andy Hall
September/October 2014 (Vol 23 No 4)
 

Patient outcomes continue to become ever more visible in the NHS with ongoing drives to demonstrate transparency in our delivery of healthcare. This article reviews unit-level data publication using Hospital Episode Statistics data in all units undertaking head and neck cancer surgery in England. This includes 10,589 patients who underwent major head and neck cancer surgery between 2006 and 2011. Interestingly the authors used an in-hospital mortality measure in contrast to the commonly accepted 30-day mortality used elsewhere. Data such as an overall in-hospital mortality rate of 3.05% and myocardial infarction rate of 4% is provided. The important issue of variability between units is explored and the demonstration of distinction between units performing ‘intermediate’ numbers of major surgeries (16-25 a year) as opposed to high volumes is not unexpected given work in other areas (cardiothoracics and vascular). Summarising this paper is no mean feat owing to the breadth of issues discussed and illustrated; I urge you to read and consider for yourself how the future of head and neck cancer care is likely to develop and be monitored.

Reference

A national analysis of the outcome of major head and neck cancer surgery: implications for surgeon-level data publication.
Nouraei S, Middleton SE, Hudovsky A, et al.
CLINICAL OTOLARYNGOLOGY
2013;38(6):502-11.

CLINICAL OTOLARYNGOLOGY

Sham controlled trial: BPPV
Reviewed by: Andy Hall
September/October 2014 (Vol 23 No 4)
 

I was drawn to this study and it proved an enlightening read; it also is a good example of where recommendations of a Cochrane review for long-term evidence of benefit have been acted upon! The study looked at the efficiency of the Epley manoeuvre as a long-term therapeutic procedure for posterior canal benign paroxysmal positional vertigo (BPPV). A randomised, double blind sham-controlled trial involving two groups of 22 patients ensued. Following identification of BPPV, participants were treated with either an Epley or sham procedure and followed up for a year post treatment. Outcome measures of both conversion of a positive Dix Hallpike test to a negative Dix Hallpike test and Dizziness Handicap Inventory were used. Treatment success was found in 91% of patients after 12 months of follow-up in the Epley group as opposed to 46% in the sham group.

Reference

A randomised sham-controlled trial to assess the long-term effect of the Epley manoeuvre for treatment of posterior canal benign paroxysmal positional vertigo.
Bruintjes TD, Companjen J, van der Zaag-Loonen HJ, van Benthem PP.
CLINICAL OTOLARYNGOLOGY
2014;39(1):39-44.

COCHLEAR IMPLANTS INTERNATIONAL

Cochlear implantation in elderly candidates and effect on quality of life
Reviewed by: Thomas Nikolopoulos
September/October 2014 (Vol 23 No 4)
 

The authors aimed to assess the improvement in quality of life (QoL) of cochlear implant patients over 60 and its relation to audiometric benefits. An observational retrospective study was conducted on 26 individuals older than 60. The outcome was compared to the respective outcome in 10 implanted patients aged between 40 and 60. A full postoperative audiological evaluation was completed and the Glasgow Benefit Inventory test was used to assess QoL. The patients in both groups had similar preoperative speech recognition levels. Preoperative audiometric thresholds were significantly worse in patients from 40 to 60 years of age, although they scored better in speech recognition after implantation. Patients experienced significant improvement in their QoL in all areas, especially in general health, while they experienced a smaller improvement in social interaction. Age, duration of deafness, and years wearing the processor were statistically related to QoL, regardless of audiometric benefit. The authors concluded that cochlear implantation improves QoL of patients over 60 by the mere fact of having been implanted, regardless of poorer audiological benefits. Older patients, with long-term deafness experience a greater improvement in QoL after implantation. An interesting study with interesting results. However, a better study design with a larger number of patients would help in identifying the small differences between the two groups.

Reference

Cochlear implants in adults over 60: A study of communicative benefits and the impact on quality of life.
Ramos Á, Guerra-Jiménez G, Rodriguez C, et al.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(5):241-5.

COCHLEAR IMPLANTS INTERNATIONAL

How can we assess children with complex needs?
Reviewed by: Thomas Nikolopoulos
September/October 2014 (Vol 23 No 4)
 

In the early days of cochlear implantation, children with additional disorders were being excluded as poor candidates whereas today a large number of children with complex needs are being referred for cochlear implant assessment. However, the related problems include difficulties in the assessment to determine whether a particular child is suitable for cochlear implantation and post-implantation tuning of the device in order to obtain accurate threshold responses to acoustic or electrical stimuli. The behavioural and objective tests of hearing have weaknesses and this study outlines the pros and cons of these tests which should be taken into account when performing them on children with complex needs. The author reviewing all related problems concludes that just because a child has complex needs as well as deafness should not mean he / she is ruled out for consideration for cochlear implantation. However there are issues which need to be addressed with the family prior to a decision. The main problem is that there is a lack of preoperative candidature criteria and postoperative outcome measures specific to children with complex needs. A greater evidence base is needed to allow informed decisions to be made. It seems that cochlear implantation in children with additional disorders has made it more clear than ever that (re)habilitation of these children urgently needs appropriate and well designed outcome measures.

Reference

Audiological assessment of children with complex needs.
Midgley E.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(S3):s18-s19.

CURRENT OPINION IN OTOLARYNGOLOGY & HEAD AND NECK SURGERY

Sublingual immunotherapy
Reviewed by: Susan A Douglas
September/October 2014 (Vol 23 No 4)
 

This paper reviews the recent European studies on sublingual immunotherapy (SLIT). SLIT is currently widely used in Europe and is gaining popularity in the United States. It is known that longer treatment is needed with SLIT compared with subcutaneous immunotherapy (SCIT) to reduce the rhinitis symptoms in children with house dust mite (HDM) allergies. SLIT appears to be a well-tolerated and effective disease-modifying option for treating rhinitis and asthma in children and adults including the elderly. Studies on HDM, grass, and ragweed have demonstrated post-treatment efficacy in both monosensitised and polysensitised patients. The effects of treatment are lasting, providing clinical benefit even one year after SLIT is discontinued. With its roots in Europe, SLIT is now gaining attraction around the world as a viable alternative to SCIT. The advantages include an improved safety profile with no reported systemic effects, a more tolerable route of administration, and the potential to significantly improve compliance by allowing at-home self-administration. Recent studies shed light on the wider age range that may benefit from SLIT, the potential for treating a larger array of environmental allergies, and the sustained effects beyond the treatment period.

Reference

Sublingual immunotherapy: what we can learn from the European experience.
Linkov G, Toskala E.
CURRENT OPINION IN OTOLARYNGOLOGY & HEAD AND NECK SURGERY
2014;22(3):208-10.

EUROPEAN ARCHIVES OF OTO-RHINO-LARYNGOLOGY

Endoscopic myringoplasty: a promising alternative to microscopic surgery
Reviewed by: George Garas
September/October 2014 (Vol 23 No 4)
 

Endoscopes have revolutionised otitis media surgery in recent years and are increasingly used in the surgical management of cholesteatoma, sinus tympani pathology and facial nerve surgery. Despite this, the development of endoscopic myringoplasty and how this compares to its microscopic counterpart have received relatively little attention. This study aimed to assess exactly that, by directly comparing endoscopic with microscopic myringoplasty for similarly sized and positioned tympanic membrane perforations. Sixty patients were recruited and randomised between the two groups (30 endoscopic and 30 microscopic). Endoscopic myringoplasty was always performed transcanal with tympanomeatal flap elevation in all cases. On the other hand, microscopic myringoplasty was performed via a postaural approach. The use of an endoscope (0º or 30° 4mm rigid endoscope) proved to offer numerous advantages over microscope use. Firstly, no patient in the endoscopy group required canalplasty as adequate exposure of the margins of the perforation (even when very anterior) and visualisation of the incudostapedial joint complex were easily achieved with the endoscope and without the need for any posterosuperior canal wall curettage. This was despite four patients in the endoscopic group having significant canal overhangs. This was not the case in the microscopic myringoplasty group where all five patients with significant canal overhangs required canalplasty to obtain adequate exposure of the tympanic annulus and four also required curettage of the posterosuperior canal wall to obtain visualisation of the incudostapedial joint complex. Moreover, all patients in the endoscopy group (30/30) reported excellent cosmetic outcomes as the incision scar was well hidden in the hairline whereas the equivalent percentage in the microscopic group was 25/30 with the remaining five patients reporting it as only satisfactory due to the associated scar. No difference was observed in graft uptake rates which were 83.3% in both groups. The hearing outcomes were comparable between the two techniques and endoscopic myringoplasty was well received by the residents being trained in the technique. In summary, this study, albeit small, illustrates the promising role that endoscopic myringoplasty has to play as it achieved improved cosmesis, comparable tympanic membrane perforation and air-bone gap closure rates to microscopic surgery without the need for canalplasty and postaural incision even in the presence of major canal overhangs

Reference

Endoscopic vs microscopic myringoplasty: a different perspective.
Lade H, Choudhary SR, Vashishth A.
EUROPEAN ARCHIVES OF OTO-RHINO-LARYNGOLOGY
2014;271(7):1897-902.

EUROPEAN REVIEW OF ENT

The sentinel lymph nodes revisited
Reviewed by: Badr Eldin Mostafa
September/October 2014 (Vol 23 No 4)
 

The concept of sentinel lymph node sampling has been around for some time. However, its acceptability in routine head and neck practice has yet to be established. This article presents the authors’ experience in 10 patients with Merkel cell carcinoma [eight T1N0Mo, one T2N0M and one T3N0M0], which is an aggressive cutaneous neuroendocrine tumour. Lymphoscinti-graphy was performed after infiltrating the tumour surround with Tc-99m labeled NANOCIS. Sampling of the sentinel node was performed during the excision of the primary tumour and stained by HPS and immunostains. Scintigraphy-positive nodes were detected in 7/10 patients. Three patients underwent neck dissection, either because of absent marker detection during scintigraphy or the absence of a surgically detected sentinel node. All these nodes were negative for malignancy. One patient had systemic metastases, but no lymph node recurrence 12 months later. The remaining nine patients were disease-free after two years’ follow-up. The conclusion of the authors is that sentinel node sampling in such patients is useful to determine the need for simultaneous neck dissection during excision or, instead, just follow-up.

Reference

Prognostic value of sentinel lymph node in Merkell cell carcinoma of the head and neck.
Penicaud M, Cammilleri S, Giorgi R, et al.
EUROPEAN REVIEW OF ENT
2013;134(2):75-9.

FACIAL PLASTIC SURGERY

Polydioxanone in septal reconstruction
Reviewed by: Sunil Kumar Bhatia
September/October 2014 (Vol 23 No 4)
 

Septal reconstruction is a challenging problem and is undertaken for functional or cosmetic reasons, or a combination of both. Either autologous cartilage, commonly auricular, or other alloplastic material can be used. The authors describe the use of a Polydioxanone (PDS) plate for this purpose. The authors discuss extracorporeal septoplasty, indications and technique. Similarly they next discuss endonasal and then partial extracorporeal endonasal septoplasty. A very useful discussion on the indications and technique is provided. It is clear and succinct with excellent accompanying photographs. Similar sections are then provided on columellar struts, extension grafts and septal perforation repair. The final discussion is mainly on the useful applications of the PDS plate. There is some good background on the animal experiments that confirm the histoconductive effects. The authors conclude that the PDS plate is a valuable addition in difficult septal surgery. The article is of value for the seasoned nasal surgeon as well as others. This is a very well written and lucid paper, most surgeons will be able to pick some ‘tips’ and add a valuable technique to the armamentarium in correcting a difficult problem.

Reference

Use of Polydioxanone Plate in Septal Reconstruction.
Rimmer J, Saleh H.
FACIAL PLASTIC SURGERY
2013;29(6):464-72.

FACIAL PLASTIC SURGERY CLINICS OF NORTH AMERICA

Techniques in Facial Plastic Surgery: Discussion and Debate part 2
Reviewed by: Mrinal Supriya
September/October 2014 (Vol 23 No 4)
 

This edition of this popular journal is dedicated to ‘panel discussion’ on some of the most common controversies associated with ‘bread and butter’ facial aesthetic procedures. The procedures included are relevant and the aspects discussed are of practical importance to anyone involved in facial aesthetic procedures. The panel members are authorities in their field and they bring their experience to the discussion. I found the chapters well written and informative. I found the chapter discussing rhinoplasty and revision rhinoplasty particularly interesting as they discussed topics such as division of tip lobule, use of alloplast or options for dorsal augmentation, when there is no septal or auricular cartilage; these are relevant to all surgeons performing this procedure. It is heartening to see that even experienced surgeons can have divergent philosophy in tackling these tricky aesthetic and functional problems. Similar questions have been discussed for procedures such as blepharoplasty, mid face lift and chemical peel. In summary I think this issue will be beneficial to any surgeon who has a practice in facial aesthetics.

Reference

Techniques in Facial Plastic Surgery: Discussion and Debate part 2.
FACIAL PLASTIC SURGERY CLINICS OF NORTH AMERICA
2014;22(1):1-160.

HEARING, BALANCE AND COMMUNICATION

Auditory processing in children with unilateral hearing los
Reviewed by: Claudia Nogueira
September/October 2014 (Vol 23 No 4)
 

t is a common assumption that unilateral hearing loss (UHL) in children is of little consequence because appropriate development of speech and language can still occur with one normal hearing ear. Recent studies, however, suggest that there are significant differences in the cortical processing of sound between children with severe to profound unilateral hearing loss and normal hearing children. Central auditory processing was evaluated in children with UHL using the P300 component of event related potentials. Three groups of listeners participated in this prospective clinical study, listeners with UHL in the right (n=15) or left ear (n=15) and listeners with bilateral normal hearing (BNH) (n=20). Children with right UHL showed a significant reduction in P300 amplitudes in response to speech when compared to a tone stimulus. Comparing speech-evoked P300 response in the three groups revealed a significant delayed latency in the groups with UHL compared with children with bilateral normal hearing. These findings suggest that speech processing is affected in children with UHL whichever its side. The authors also suggested that a right UHL may have a greater impact on the central perception of processing of sound than a left UHL.

Reference

Auditory processing in children with unilateral hearing loss
Gabr TA.
HEARING, BALANCE AND COMMUNICATION
2014;12(2):99-104.

HEARING, BALANCE AND COMMUNICATION

Tinnitus in patients on therapy with PPI and in PPI non–users
Reviewed by: Claudia Nogueira
September/October 2014 (Vol 23 No 4)
 

Tinnitus is a chronic and debilitating condition and approximately 10% of the population is afflicted. A myriad of pharmacological treatments for tinnitus are available but only a few controlled studies have shown positive results. The relationship between proton pump inhibitors (PPI) and tinnitus is contradictory. The difficulty of a strict follow-up, due to the variable pattern of presentation of tinnitus symptoms, and the different methods of PPI application have made it difficult to draw definitive conclusions. In order to investigate the effect of PPI on tinnitus sufferers, a cohort of 120 consecutive patients aged 50-69 years were recruited in this study. Subjects were subdivided into two groups: PPI users and non-users. Each patient was instructed to complete an anonymous validated questionnaire on hearing problems. The results showed that in the age class 60-69 years, there was a significantly lower prevalence of generic tinnitus symptoms in patients on PPI maintenance therapy compared to those who did not take these drugs. The mechanism of action of PPIs in the relief of tinnitus is still unclear. Current research indicates a direct regulatory effect on inner ear homoeostasis through an action of PPIs on gastric-type proton pumps in the inner ear. The authors suggest that further longitudinal studies are required before claims can be made as to the beneficial effect of PPIs on tinnitus.

Reference

Tinnitus in patients on therapy with proton pump inhibitors (PPI) and in PPI non–users.
Piroda A, Raimondi MA, Cicero AFG, et al.
HEARING, BALANCE AND COMMUNICATION
2014;12(3):84-7.

INTERNATIONAL FORUM OF ALLERGY AND RHINOLOGY

Objective versus subjective – again!
Reviewed by: Christos Georgalas
September/October 2014 (Vol 23 No 4)
 

The use of objective measurements of nasal airflow has a long history; however, its clinical application remains, at most, patchy. The main reason for that has been the lack of convincing studies showing a good correlation between the findings of, for example, anterior rhinomanometry and nasal obstruction, as experienced by the patient. Having said that, an equally patchy relationship exists between chronic rhinosinusitis (CRS) symptoms and sinus opacification (Lund-McKay score), however no one would suggest abolishing sinus CT for the diagnosis and assessment of CRS. The key is interpretation; while the results of rhinomanometry may be insufficient to separate patients with obstruction from those with no obstruction; they appear to be useful to monitor the symptoms of individual patients over time. In this prospective study, the authors followed up 53 patients undergoing radiofrequency ablation for inferior turbinate hypertrophy with anterior rhinomanometry as well as VAS at one, three and six months. They found that objective improvement at one month correlated well with subjective improvement; however, this correlation disappeared after three months. It is very likely that other factors were also at play – with allergy and patient expectations being but two of them.

Reference

Prediction of outcome of radiofrequency ablation of the inferior turbinates.
Sahin-Yilmaz A, Oysu C, Devecioglu I, et al.
INTERNATIONAL FORUM OF ALLERGY AND RHINOLOGY
2014;4(6):470-4.

INTERNATIONAL JOURNAL OF AUDIOLOGY

Forward-going sound pressure wave with hearing thresholds
Reviewed by: Richard Navarro
September/October 2014 (Vol 23 No 4)
 

This article discusses an important and well-known point regarding the differences between coupler sound pressure measurements, used to calibrate earphones, and actual pressures delivered to the ear due to individual variances across patients. The study purports to suggest a new clinical tool; however, there is not sufficient definition of a number of key points, e.g. how is the ‘forward-going’ sound pressure wave defined? There are a number of methodological points that were not provided to help interpret the results in a meaningful way and the use of parametric statistical tests for non-parametric data raises some concern. While there may be some value to the use of a forward-going sound pressure wave, this article does not demonstrate the clinical utility with sufficient clarity to justify a wholesale change in the modus operandi for diagnostic or rehabilitative benefit. The article is worth reading as the introduction defines the issue well; however, the method needs considerable work before becoming a clinical tool.

Reference

The clinical utility of expressing hearing thresholds in terms of the forward-going sound pressure wave.
Withnell RH, Jeng PS, Parent P, Levitt H.
INTERNATIONAL JOURNAL OF AUDIOLOGY
2014;53(8):522-30.

INTERNATIONAL JOURNAL OF AUDIOLOGY

Inflammation associated with presbyacusis
Reviewed by: Richard Navarro
September/October 2014 (Vol 23 No 4)
 

Inflammaging and presbyacusis is a topic that few audiologists consider in their daily clinical routine due to lack of training in this area. Inflammaging is a chronic state of inflammation present throughout the body. The classic 1965 work by Rosen and Pikka laid the groundwork documenting the co-morbidity of hearing loss and cardio-vascular disease. The current work explores the relationship between a number of bio-markers, such as white blood count and homocysteine levels, and elevated hearing levels as measured by tonal audiometry in an aged population. They compared their results to a previous study. In both studies, they found a positive correlation with a number of biomarkers and concluded that both lifestyle and pharmacological treatment may provide prophylactic solutions to the development and progression of age-related hearing loss. This is an important paper for all audiologists because it clarifies that not all hearing loss is caused by intense noise, but that cochlear metabolism is one factor that should be considered in the treatment and prevention of hearing loss. The evolution of care provided by audiologists should be predicated on learning more about how metabolism affects hearing, balance, and tinnitus so that more effective prevention and treatment protocols may be developed. Similar studies might be improved if distortion product otoacoustic emissions were added to the research protocol as this may reveal cochlear hair cell inflammation prior to the development of permanent hearing loss.

Reference

Inflammation is associated with a worsening of presbyacusis: Evidence from the MRC national study of hearing.
Verschurr V, Agyemang-Prempeh A, Newman TA.
INTERNATIONAL JOURNAL OF AUDIOLOGY
2014;53(7):469-475.

INTERNATIONAL JOURNAL OF LANGUAGE & COMMUNICATION DISORDERS

Early habilitation for hearing impairment in children with Down syndrome
Reviewed by: Gauri Mankekar
September/October 2014 (Vol 23 No 4)
 

Approximately 40-80% of children with Down syndrome have hearing impairment in addition to speech and language impairment. The commonest cause of hearing impairment in young children is otitis media with effusion. This paper investigated the impact of early hearing loss on language outcomes in children with Down syndrome. They found that early hearing loss has a significant impact on the speech and language development of children with Down syndrome. The authors suggest that speech and language therapy should be provided when children are found to have ongoing hearing difficulties. In addition, joint audiology and speech and language therapy clinics could be considered for preschool children.

Reference

Early hearing loss and language abilities in children with Down syndrome.
Laws G, Hall A.
INTERNATIONAL JOURNAL OF LANGUAGE &
COMMUNICATION DISORDERS 2014:49(3):333-42.

INTERNATIONAL JOURNAL OF LANGUAGE & COMMUNICATION DISORDERS

Early intensive aphasia therapy in stroke patients
Reviewed by: Gauri Mankekar
September/October 2014 (Vol 23 No 4)
 

The impact of aphasia following stroke is devastating. Very early aphasia rehabilitation studies have been the subject of ongoing debate. This paper describes the comparison of a very early aphasia therapy regimen with a historical ‘usual care’ control group after therapy completion, at four to five weeks post stroke and again after six months. The authors found that an impairment-based aphasia therapy regimen, provided daily over 20 sessions (over four to five weeks) in very early stroke recovery, resulted in significantly greater communication gains in people with mild to severe aphasia. The study adds to the existing literature, suggesting that increased and intensive aphasia therapy in the very early recovery phases is important for improving the effects of spontaneous recovery.

Reference

A comparison of aphasia therapy outcomes before and after a very early rehabilitation programme following stroke.
Godecke E, Ciccone NA, Granger AS, et al.
INTERNATIONAL JOURNAL OF LANGUAGE &
COMMUNICATION DISORDERS
2014;49(2):149-61.

INTERNATIONAL JOURNAL OF LANGUAGE & COMMUNICATION DISORDERS

Early intensive aphasia therapy in stroke patients
Reviewed by: Gauri Mankekar
September/October 2014 (Vol 23 No 4)
 

The impact of aphasia following stroke is devastating. Very early aphasia rehabilitation studies have been the subject of ongoing debate. This paper describes the comparison of a very early aphasia therapy regimen with a historical ‘usual care’ control group after therapy completion, at four to five weeks post stroke and again after six months. The authors found that an impairment-based aphasia therapy regimen, provided daily over 20 sessions (over four to five weeks) in very early stroke recovery, resulted in significantly greater communication gains in people with mild to severe aphasia. The study adds to the existing literature, suggesting that increased and intensive aphasia therapy in the very early recovery phases is important for improving the effects of spontaneous recovery.

Reference

A comparison of aphasia therapy outcomes before and after a very early rehabilitation programme following stroke.
Godecke E, Ciccone NA, Granger AS, et al.
INTERNATIONAL JOURNAL OF LANGUAGE &
COMMUNICATION DISORDERS
2014;49(2):149-61.

INTERNATIONAL JOURNAL OF PEDIATRIC OTORHINOLARYNGOLOGY

Are biofilms present in deep neck abscesses?
Reviewed by: Patrick Spielmann
September/October 2014 (Vol 23 No 4)
 

Why are some cervical abscesses resistant to antibiotic treatment? The authors postulate that a biofilm develops to allow the bacteria to overcome normal host defences. They investigated the micro-environment of deep neck abscesses in a largely paediatric cohort. Biopsies of abscess walls were taken and processed for electron microscopy scanning. Twelve of 14 demonstrated cocci and rods embedded in a 3-dimensional matrix – all features of a biofilm. This may explain why so many abscesses, particularly large ones, are difficult to treat with antibiotics alone.

Reference

Potential role of biofilms in deep cervical abscess.
May JG, Shah P, Sachdeva L, et al.
INTERNATIONAL JOURNAL OF PEDIATRIC OTORHINOLARYNGOLOGY
2014;78:10-13.

INTERNATIONAL JOURNAL OF PEDIATRIC OTORHINOLARYNGOLOGY

BAHA stability measurement in children
Reviewed by: Patrick Spielmann
September/October 2014 (Vol 23 No 4)
 

This useful paper reports the experience of using resonance frequency analysis for single stage bone-conduction implants in a paediatric population. A smartpegTM is attached to the abutment and vibrated by a close quarters magnetic field. The amount of vibration is converted into an implant stability quotient (ISQ) score. The ISQ was produced for each implant at time of surgery and at follow-up intervals. The mean stability scores were good enough to accept loading on the day of surgery with marginal improvements thereafter (at four weeks and 16 weeks). This has encouraged the authors to accelerate the loading of paediatric patients to a median of six weeks (range 1-16 weeks). With improved implant design and better understanding of osseointegration the loading times are inevitably being reduced, which has to be a good thing…

Reference

Resonance frequency analysis of osseo-integrated implants for bone conduction in a pediatric population – a novel approach for assessing stability for early loading.
McLarnon C, Johnson I, Davison T, et al.
INTERNATIONAL JOURNAL OF PEDIATRIC OTORHINOLARYNGOLOGY
2014;78:641-44.

JOURNAL OF CRANIO-MAXILLOFACIAL SURGERY

Extranodal natural killer / T-cell lymphoma in the head and neck
Reviewed by: Sunil Kumar Bhatia
September/October 2014 (Vol 23 No 4)
 

The authors present a retrospective single institution review of patients with a very rare variant of non-Hodgkin lymphomas (NHL). They report on the occurrence, clinical course and outcomes of their patients with natural killer / T-cell lymphoma (NKTCL) nasal type. Sixty-three patients with NHL were treated between 2006 and 2011. Of these 11 had extranodal lymphoma with six in the head and neck; of these three had NKTCL nasal type group. They report three clinical cases leading to the diagnosis and treatment course of the disease and outcomes. Two of the three had aggressive disease resistant to chemotherapy. The authors discuss a tumour rarely found in Europeans, but highlight its aggressive nature, chemo resistance and poor clinical outcomes. Because this can present with features of upper respiratory tract infection, it could be seen by a maxillofacial or otolaryngology practitioner and authors do a good job of drawing attention to this disease.

Reference

Extranodal lymphomas of the head and neck with emphasis on NK/T-cell lymphoma, nasal type.
Coha B, Vucinic I,Mahovne I, Vukovic-Arar Z.
JOURNAL OF CRANIO-MAXILLOFACIAL SURGERY
2014;42,149-52.

JOURNAL OF CRANIOFACIAL SURGERY

Cheek reconstruction following melanoma excision
Reviewed by: Sunil Kumar Bhatia
September/October 2014 (Vol 23 No 4)
 

Malignant melanoma occurs most commonly on the cheek and thus is usually diagnosed early, and rarely needs large reconstructions for advanced disease. This is a retrospective study looking at 26 patients that had undergone treatment for cheek melanomas between 1996 and February 2012. Reconstruction was with skin grafts (split in nine and full in three cases), seven with local flaps and seven with free flaps. The authors quantify the size of the defects and methods of reconstruction. On average the skin defect was 41.4cm2 with skin grafts, 24.9cm2 with local flaps and 76.7cm2 with free flaps. The authors discuss the range of the size of the defects and suggest the dividing line between local or free flaps as 40cm2. Skin grafts meanwhile being so much more versatile can be used for defects up to as large as 78cm2. The other considerations were exposed structures, such as bone, that cannot be grafted and tumour thickness and hence resultant defect. They suggest three factors are important in selecting a reconstruction procedure, size and aesthetic considerations. stage of the melanoma and age of the patient. The study is limited because of the patient numbers but it provides a good mental algorithm to use in assessment and planning of reconstruction.

Reference

An analysis of cheek reconstruction after tumour excision in patients with melanoma.
Hayashi T, Furukawa H, Oyama A, et al.
JOURNAL OF CRANIOFACIAL SURGERY
2014;25: e98-101.

JOURNAL OF LARYNGOLOGY AND OTOLOGY

A diagnostic survey of dizziness
Reviewed by: Madhup K Chaurasia
September/October 2014 (Vol 23 No 4)
 

The prevalence of self-reported dizziness and that requiring medical consultation is remarkably high. Cardiac and neuropathic comorbidities, often associated with these patients confuse the diagnosis. In this multicentre study, the prevalence and characteristics of various diagnostic groups, for example, Benign paroxysmal positional vertigo (BPPV), Ménière’s and likewise were studied in 1034 consecutive patients presenting with dizziness. Various diagnostic categories relating to vestibular causes were defined and patients were placed in them. The study took into account the recurrence of dizziness which was highest in patients with BPPV and migraine associated vertigo. Imaging was carried out in 151 of the 1034 patients and 24 (15.8%) had abnormalities. Of the 150 patients with vertigo of central origin, 12 had abnormal imaging results. Of the 551 with BPPV 64 were scanned and three of them had abnormal findings of which only one could be related to vertigo. Patients with vestibular neuronitis required most sick leave and night time awakening was most frequent in patients with BPPV. The diagnostic certainty was highest for patients with BPPV. Patients with BPPV provided the largest diagnostic group. A number of interesting attributes have been mentioned for BPPV. In various studies published in the literature, the percentage of patients referred for dizziness who have vestibular causes is 14-72.9%. In one study, 52.5% of patients were diagnosed with BPPV. In this study the incidence of BPPV was highest in patients between 60-79 years of age and the author emphasised that this diagnosis should not be overlooked in elderly patients because they have an increased risk of falling. Of these patients 49% are aware of their dizziness and 85% reported that symptoms were triggered by turning over in bed. There is also evidence that awareness of BPPV is insufficient in clinicians and necessary tests are not performed. The study therefore illustrates that BPPV is the underlying cause in the majority of patients presenting with dizziness, it is easily diagnosed and treated and therefore should not be missed.

Reference

Prevalence and characteristics of diagnostic groups amongst 1034 patients seen in ENT practices for dizziness.
Luscher M, Theilgaard S, Edholm B.
JOURNAL OF LARYNGOLOGY AND OTOLOGY
2014;128:128-33.

JOURNAL OF LARYNGOLOGY AND OTOLOGY

Assessment of viral aetiology in the formation of nasal polyps
Reviewed by: Madhup K Chaurasia
September/October 2014 (Vol 23 No 4)
 

The exact aetiology of nasal polyposis is not yet established although it is believed that allergic, infectious, mechanical, immunological and biochemical factors may be involved. Using the technique of polymerase chain reaction, this study assesses the role of human adenovirus, metapneumovirus, coronavirus, parainfluenza virus types 1, 2 and 3, influenza A and B virus, respiratory syncytial virus A and B and rhinovirus A and B in the formation of nasal polyps. The authors used the method of polymerase chain reaction based on nucleic acid isolation, reverse transcription, polymerase chain reaction amplification of target DNA and DNA detection with agarose gel electrophoresis. There were 30 patients with nasal polyps, 22 men and eight women, and a control group of 20 healthy patients. Nasal polyposis was diagnosed histopathologically. Tissue examination by agarose gel electrophoresis identified human coronavirus and rhinovirus in one of the patients in the control group. Another patient in this group had human respiratory syncytial virus. Influenza B virus was identified in one of the nasal polyp patients along with human coronavirus in another in this group. There was no statistically significant relationship between nasal polyposis and respiratory viruses. The study therefore does not support viral aetiology in the formation of nasal polyps. References have been made to past studies which showed a high prevalence of EBV in normal nasal pharyngeal mucus but not in nasal polyps. Therefore its role in nasal polyposis is doubtful which agrees with this study. The aetiology of this common condition therefore still remains uncertain.

Reference

Investigation of the role of major respiratory viruses in the aetiology of nasal polyps using polymerase chain reaction technique.
Aksoy F, Yenigun A, Dogan R, et al.
THE JOURNAL OF LARYNGOLOGY & OTOLOGY
2014;128(4):356-9.

JOURNAL OF LARYNGOLOGY AND OTOLOGY

Can smaller cancer centres deliver high quality care for patients with laryngeal cancer?
Reviewed by: Madhup K Chaurasia
September/October 2014 (Vol 23 No 4)
 

There is a continuing conflict between treating patients as close to their homes as possible and centralising specialised services, taking into consideration the critical mass and the multi-disciplinary expertise available. This is a report of outcomes in the treatment of laryngeal cancer in a small cancer centre serving a population of only 330,000, just about a third of what is recommended by IOG guidelines (2005). The authors looked at the survival rates of 209 consecutive patients, who presented with laryngeal cancer, over a 15 year period. These patients were prospectively entered into a standardised database. The distribution of these patients was as follows: 86 had stage one disease, 43 had stage two, 33 had stage three and 47 presented with stage four disease. A five year disease specific survival rate is reported as 100% for stage one, 76% for stage two, 87% for stage three and 46% for stage four. Of the 46 patients treated non-surgically 36 had recurrence of disease (79%). Most of these patients were treated surgically, before or after radiotherapy. The authors compare their five year tumour related survival rate of 82% and a five year overall survival rate of 59% with relative survival figures for laryngeal cancer across Europe ranging from 44% to 86%. This suggests excellent outcomes in a small cancer centre. An interesting review of the literature addresses the more recent trend for non-surgical treatment of laryngeal cancer, resulting in a non-significant decrease in the overall survival at five and 10 years. The authors attribute their 87% five year survival for Stage three disease to favouring surgical management of such advanced disease. The problems associated with radiotherapy and chemotherapy are mentioned and the role of surgery for advanced disease is supported. Less radical radiotherapy regimes are favoured. The article lends credence to the belief that laryngeal cancer can be managed reasonably well in a small, remote head and neck cancer centre, bringing care nearer to the patients’ homes.

Reference

Laryngeal cancer management in a small, rural, multi-
disciplinary team setting: 15 year review.
Hamilton DW, McMeekin PJ, Dyson P, Robson AK.
JOURNAL OF LARYNGOLOGY AND OTOLOGY
2013;127:1203-7.

JOURNAL OF LARYNGOLOGY AND OTOLOGY

Clinical value of 3 T magnetic resonance imaging after intratympanic gadolinium injection in cases of delayed endolymphatic hydrops
Reviewed by: Madhup K Chaurasia
September/October 2014 (Vol 23 No 4)
 

Recurrent vertigo can continue after severe unilateral or bilateral hearing loss. This is a condition similar to Ménière’s disease, the diagnosis of which can be difficult. In this study intratympanic injection of gadolinium-diethylenetriamine penta-acetic acid dimeglumine was done in 25 patients and followed by inner ear 3-D fluid-attenuated inversion recovery MRI 24 hours later. The distribution of Gadolinium in the labyrinth was quantitatively scored in the regions of cochlear base, middle and apex, vestibule and the three semi-circular canals. The presence of endolymphatic hydrops was evaluated with an established formula and the diagnosis was thought confirmed if the score of the function reached an accepted numerical value. The authors claim that this method diagnosed 84% (21/25 patients) of endolymphatic hydrops and thus has a higher sensitivity rate. No complications resulted with this technique. At the same time the authors performed pure tone audiometry, electrocochleography, bithermal caloric testing and VEMP potential testing. They found this MRI method to be the most sensitive. Electrocochleography is not useful in cases of severe hearing loss. Bithermal caloric testing has 72% sensitivity but is not a normal physiological vestibular stimulus and often evokes a vestibule-autonomic reflex. VEMP is limited in that it evaluates only the saccular function. The authors claim that accurate identification of the clinical type of delayed endolymphatic hydrops helps determine surgical strategy for treating these patients. If there is delayed endolymphatic hydrops in one ear and hearing loss in the other, endolymphatic sac surgery in the affected ear can maintain hearing and eliminate dizzy spells. Despite limited numbers the study does seem promising in the management of vertigo where symptoms persist years after hearing loss.

Reference

Diagnostic value of 3 dimensional magnetic resonance imaging of inner ear after intratympanic gadolinium Injection, and clinical application of magnetic resonance imaging scoring system in patients with delayed endolymphatic hydrops.
Gu X, Fang ZM, Liu Y, et al.
JOURNAL OF LARYNGOLOGY AND OTOLOGY
2014;128:53-59.

JOURNAL OF LARYNGOLOGY AND OTOLOGY

Facial paralysis risk factors in benign parotid surgery
Reviewed by: Madhup K Chaurasia
September/October 2014 (Vol 23 No 4)
 

The literature shows that the risk of facial paralysis following benign parotid surgery can be as high as 57% for temporary weakness and 7% for permanent facial nerve damage. It is generally thought that the factors involved may be related to age, sex, types of benign tumours, indications for the procedure, histological diameter, tumour location and the extent of parotidectomy. In this retrospective study involving 150 patients over a 10 year period the authors have assessed these factors and compared their findings with other studies. Of these patients, 26.7% had temporary weakness and 2.6% had permanent weakness. The age of these patients ranged from 15-80 years but this factor did not influence this risk nor did their gender. Different types of benign tumours and their size did not add to the risk of facial paralysis and the same was the case with location of the tumour in the parotid gland. The study included 10 cases in whom parotidectomy was done for sialadenitis and this did not add to the risk of facial nerve paralysis. The grade of the surgeon performing the parotidectomies was also taken into account but this did not matter thus making the authors feel reassured of the training and supervision. The most interesting aspect of this study is that facial nerve monitoring was used in only 44% of cases and authors do not feel the lack of it affects the risk of facial nerve paralysis. This does appear reassuring but how it stands from the medico-legal point of view is another matter.

Reference

Stratifying the risk of facial nerve palsy after benign parotid surgery.
Sethi N, Tay PH, Scally A, Sood S.
JOURNAL OF LARYNGOLOGY AND OTOLOGY
2014;128:150-62.

JOURNAL OF LARYNGOLOGY AND OTOLOGY

Hearing loss in the contralateral ear after mastoid drilling
Reviewed by: Madhup K Chaurasia
September/October 2014 (Vol 23 No 4)
 

It is difficult to conceive that most of the noise generated by drilling the mastoid would not be conveyed to the contralateral cochlea, by direct transmission through the skull bone, where the attenuation factor is only 5-10 dB. Only a few studies have been conducted to ascertain this with minimal variables in terms of the duration of drilling, speed of the drill and the size and nature of the drills used – whether diamond or cutting. In this study the authors assessed 30 patients who underwent drilling of the mastoid for cholesteatoma and had normal hearing in the contralateral ear. The hearing was tested by DPOAE and TEOAE preoperatively, in the recovery and the first two consecutive days. Pure tone audiometry was used preoperatively and in the first and second consecutive postoperative days. The speeds of the drill were 60,000 and 35,000 rpm. There was no statistically significant difference observed in the pure tone audiometry assessed as average threshold for low and high frequencies in the pre and postoperative periods. However, there were statistically significant changes in the pre and postoperative TEOAEs over both low and high frequency ranges. The DPOAE changed only in the high frequencies. The follow-up period was only 72 hours, therefore it has not been established whether or not these changes were temporary or permanent. A few studies from the literature support these findings in contrast to one which does not, but the authors explain that in that particular study only a small diamond burr (1-4mm) was used. Diamond burrs produce less noise. There were also statistically significant correlations between the burr times and changes in DPOAEs at high frequencies and TEOAEs at both high and low frequencies for cutting burrs, and changes in high frequency DPOAE only for diamond burrs. The speed of drilling did not matter. Quite understandably, this study has used a number of variables but the sample size is rather small and the assessment is collective which excludes variables such as individual susceptibility. Studies with larger sample size and longer follow-ups are required.

Reference

The effect of mastoid drilling on hearing of the contralateral ear.
Goyal A, Singh PP, Vashishth A.
JOURNAL OF LARYNGOLOGY AND OTOLOGY
2013;127:952-56.

JOURNAL OF LARYNGOLOGY AND OTOLOGY

Medical information required with requests for CT scans of the temporal bones; a two cycle audit
Reviewed by: Madhup K Chaurasia
September/October 2014 (Vol 23 No 4)
 

It is a common experience that radiology reports on the CT scans of the temporal bones do not always reach a diagnosis. Various studies have produced differing results in that detailed information may not be necessary to help reach a diagnosis by the radiologist and there are no national guidelines to this effect. However, the general consensus is that comprehensive rather than scanty information is helpful. In this two cycle audit the authors assess the extent to which accurate diagnosis was made in relation to CT temporal bone requests, firstly with random clinical information and then in the second cycle of the audit, with regulated information which unfailingly included the site, the symptoms, past medical history, audiological results, specific clinical questions asked, any suspected complications and mention of differential diagnosis. It was noted that CT reports indicating a diagnosis or excluding an important complication increased from 52 to 94 and the need for further clinical information or repeat of the imaging dropped from 12 to two. The factors which played the most significant role in this were mention of a differential diagnosis in the request, the clinical questions, the audiological findings, duration of signs and symptoms and the patient’s history. The striking aspect of this audit is that the same three neuro-radiologists delivered the reports in both cycles of this audit and were not aware of the audit itself, thus removing the element of bias quite convincingly. The study therefore strongly illustrates that, regardless of some reports in the literature stating otherwise, detailed information including the factors mentioned helps arrive at a better diagnosis and save repeat imaging.

Reference

A two cycle prospective audit of temporal bones computed tomography scan request: improving the clinical applicability of radiology reports.
Qureishi A, Garas G, Shah J, Birchall J.
JOURNAL OF LARYNGOLOGY AND OTOLOGY
2014;128:49-52.

JOURNAL OF LARYNGOLOGY AND OTOLOGY

Noise induced hearing loss caused by nightclubs
Reviewed by: Madhup K Chaurasia
September/October 2014 (Vol 23 No 4)
 

Legislation on hearing loss and tinnitus, occurring due to noise exposure at work, has been well established in terms of protection and compensation, but the same damage resulting from noise in nightclubs remains an open issue. This study, based on a questionnaire answered by 325 university students of ages ranging from 18 to 30, explores in a subjective manner the damage caused by noise exposure in nightclubs and their awareness of this possibility. Of these subjects, 46.2% attended a nightclub at least once a week. More than half the participants experienced muffled hearing and tinnitus after exposure to noise in a nightclub and in a quarter this persisted till the following morning. 86.6% had never received information about noise induced hearing loss, although awareness of this was more prevalent in medical students. Interestingly enough, there was no statistically significant difference in the level of concern between medical and non-medical students. Only 26.8% of these subjects said that knowing the link between noise in a nightclub subsequent and hearing loss would affect their attendance. The subjects however agreed that the level of noise in nightclubs should be reduced to avoid hearing damage, so they can continue to attend. The study is limited as it is based on questionnaires and is therefore purely subjective, but it opens an important issue which is presently not governed by legislation, nor is there any warning for visitors to nightclubs that their hearing may be damaged due to noise exposure.

Reference

British university students. Attitudes towards noise-induced hearing loss caused by nightclub attendance.
Johnson O, Andrew B, Walker D, et al.
JOURNAL OF LARYNGOLOGY AND OTOLOGY
2014;128:29-34.

JOURNAL OF LARYNGOLOGY AND OTOLOGY

Post tonsillectomy recovery in thermal welding method compared with recovery in cold steel method
Reviewed by: Madhup K Chaurasia
September/October 2014 (Vol 23 No 4)
 

Many different methods for tonsillectomy have emerged but whether they provide an improvement over the traditional cold steel tonsillectomy is another matter. Thermal welding is a recent method of tonsillectomy in which the tissues are simultaneously coagulated and divided. In this study the authors have made a direct comparison between the two methods of tonsillectomy in the same patient. The study comprises 40 children ranging from four to 14 years. Postoperative morbidity was measured in terms of a visual analogue scale for pain, the presence or absence and sidedness of otalgia during swallowing, drinking and speaking, bleeding and comparison of postoperative healing on the two sides. Patients were assessed on the first, third, seventh and fourteenth postoperative days. It was noted that it took less time to do the thermal welding tonsillectomy, which also had less bleeding. However in cases undergoing cold dissection, tissue healing proved to be better and the throat pain scores were significantly lower on the seventh postoperative day. There was no primary or secondary bleeding in any of the cases. The authors are aware of the pain scores being confused because of the highly subjective nature of pain. The study has its merits in that the two different methods were used on the same subject by the same surgeon and statistical analysis has been applied. The study is in agreement with many comparative studies between cold dissection tonsillectomy and newer methods and rightly makes one conscious of introducing more expensive methods in a cost effective scenario.

Reference

Post tonsillectomy morbidities: randomised, prospective controlled clinical trial of cold dissection versus thermal welding tonsillectomy.
Aydin S, Taskin U, Altas B, et al.
JOURNAL OF LARYNGOLOGY AND OTOLOGY
2014;128:163-65.

JOURNAL OF LARYNGOLOGY AND OTOLOGY

Precautions to be taken in cosmetic facial surgery
Reviewed by: Madhup K Chaurasia
September/October 2014 (Vol 23 No 4)
 

In this comprehensive write-up on precautionary measures to be taken when doing cosmetic surgery on our patients, the authors begin by emphasising that facial plastic surgery is no longer limited to celebrities and the privileged. It has extended into everyday life situations involving people who in recent years have better means to undertake this surgery. The patient selection should be done with careful emphasis on patient motivation for surgery and expectation. They should not expect to obtain dramatic results such as saving of a marriage or secure employment. These patients can have variable personalities, ranging from perfectionist and narcissistic, excessively demanding, through to passive and unfocused who remain indecisive on both the need and result of the surgery. In this scenario various psychological disorders should also be considered. Some patients simply do not like their appearance, which results in altered personality traits and in extreme cases proves a continuous obsession. A note should be made of possible eating disorders and the difference between an unhappy patient and the one who is clinically depressed should be registered and psychiatric help sought. The legal aspect of an informed consent is elaborated. One can deliver relevant information (prudent patient test) based on the patient’s values and beliefs about operations and complement this with the desired level of information. The patient’s understanding of the consenting process does remain a problem and many available solutions are difficult to implement in the NHS. Documentation of the consenting process is by no means fool proof in the present legal system. A note should be made of the author’s particular statement that ‘a well prepared lawyer will manage to circumnavigate their (surgeon’s) defence’. Medical photography helps in documentation, that should not be limited to the best results of the surgeon. With image manipulation software the patient may consider the portrayed and agreed image as a guaranteed surgical result. Revision operations should be considered very carefully and only after allowing time for the healing process to complete. The patient’s family doctor should be copied into the correspondence, but sometimes patients may desire that family doctors do not know and this has to be handled very carefully. The conclusion that can be derived from this scenario is that the patient should know what to expect and the surgeon be aware of what can be done.

Reference

Pre-operative considerations in aesthetic facial surgery.
Veer V, Jackson L, Kara N, Hawthorne M.
JOURNAL OF LARYNGOLOGY AND OTOLOGY
2014;128:22-28.

JOURNAL OF LARYNGOLOGY AND OTOLOGY

The need for pre-operative overnight pulse oximetry in children undergoing surgery for obstructive sleep apnoea syndrome
Reviewed by: Madhup K Chaurasia
September/October 2014 (Vol 23 No 4)
 

Snoring is a common occurrence in children listed for adenotonsillectomy. This may be associated with obstructive sleep apnoea syndrome, in which case the post-operative recovery of these children needs to be closely monitored. This study undertakes to assess whether an overnight pre-operative pulse oximetry can determine the need for high dependency unit (HDU) observation of these children after their operation. It is a retrospective study identifying patients from the high dependency unit admissions register over a two-year period. It was noted in which of these patients a pre-operative pulse oximetry was actually done and how it related to the post-operative overnight pulse oximetry in terms of desaturation events. The study involved 82 patients who underwent elective adenotonsillectomy, adenoidectomy or tonsillectomy for obstructive sleep apnoea syndrome (OSAS). In 59% of these patients pre-operative overnight pulse oximetry was performed and 32 were considered high risk. Thirty patients showed oxygen desaturation events. It was observed that all children who showed desaturation events pre-operatively also exhibited this in the post-operative pulse oximetry monitoring. Other children, for whom HDU was arranged post-operatively on clinical grounds but who had not undergone pre-operative overnight pulse oximetry, also showed desaturation events in SaO2 monitoring in the post-operative phase. The authors therefore highly rate the value of pre-operative overnight pulse oximetry in predicting post-operative desaturation events and suggest that this simple investigation be carried out in all children in whom OSAS is suspected so that the need for HDU may be identified. This may be a useful predictor for HDU bed requirement allowing targeted referrals for an increased level of post of care.

Reference

Pre-operative overnight pulse oximetry to predict high dependency unit intervention in children undergoing adenotonsillectomy for obstructive sleep apnoea.
Lightbody KA, Kinshuck AJ, Donne AJ.
THE JOURNAL OF LARYNGOLOGY & OTOLOGY
2014;128(4):360-4.

JOURNAL OF LARYNGOLOGY AND OTOLOGY

‘Dead ear’ after mastoid surgery
Reviewed by: Madhup K Chaurasia
September/October 2014 (Vol 23 No 4)
 

The primary aim of surgery in the management of cholesteatoma is eradication of the disease which can potentially result in serious complications such as intracranial extension, facial nerve weakness and further hearing loss. A profound hearing loss resulting postoperatively considerably compromises the outcome but is sometimes unpredicted. In this series the authors looked at 617 middle ear operations performed by a single consultant in which there were six cases of ‘dead ear’. None of these followed 83 operations for otosclerosis or 62 paediatric mastoid operations. However in 187 adults undergoing exploration of the mastoid for cholesteatoma, five (2.7% of cases) ended up with ‘dead ears’. The author has described these six cases in which the pathology ranged from fistulae of the lateral semicircular canal, granulations over the footplate, cholesteatoma covering the footplate, cholesteatoma surrounding the ossicular chain and unanticipated extensive cholesteatoma. In two of these cases surgery went satisfactorily and ‘dead ear’ was not at all predictable, but in the other four further hearing loss appeared likely in the course of surgery. It appears that in one of these cases ‘dead ear’ was definitely avoidable, in two it was probably avoidable and in the other three total hearing loss was inevitable in the process of clearance of disease. All the cases had CT scans which helped to some extent to decide on the surgical approach, but did not reliably predict hearing outcome after surgery. In this series 2% of patients had a ‘dead ear’ due to cholesteatoma itself. Therefore, the risks involved with surgery can be weighed against the disease itself causing a ‘dead ear’. This requires careful thought on whether or not to operate and its timing. The incidence of 2.7% ‘dead ear’ following cholesteatoma surgery is rather high and this calls for informed consent with very clear explanation of surgery and the possible adverse outcomes.

Reference

An audit of ‘dead ear’ after ear surgery.
Prinsley P.
JOURNAL OF LARYNGOLOGY AND OTOLOGY
2013;127:1177-83.

JOURNAL OF PLASTIC, RECONSTRUCTIVE AND AESTHETIC SURGERY

Comparing gracilis free flap and pectoralis major after salvage laryngectomy
Reviewed by: Sunil Kumar Bhatia
September/October 2014 (Vol 23 No 4)
 

A pharyngocutaneous fistula (PCF) following total laryngectomy is the most common and challenging complication. Reported incidence varies widely 5-65% and there are multiple factors implicated, but their significance is still controversial. The current practice is of organ preservation with initial chemoradiation followed by salvage laryngectomy for recurrence. This practice increases the risk of a PCF by a factor of 2.6. Muscle flaps are often used in the prevention and treatment of PCF. Commonly pedicled flaps such as the pectoralis major or other free flaps are employed such as radial forearm free flap or the antero-lateral thigh free flap. The authors report their results with the gracilis muscle free flap, compared with the pedicled pectoralis major flap. They report 49 patients with post radiation recurrent laryngeal carcinoma over 10 years that underwent salvage laryngectomy, with 22 free gracilis free flaps and 27 patients with pectoralis major flaps. There were 12 complications in the pectoralis major group and eight in the gracilis group but fistula rates were similar. They discuss the advantages and disadvantages of both flaps and make a good case for immediate initial repair with a free flap and leaving the pectoralis major muscle for a future need. The authors present their experience clearly and suggest the gracilis free flap is a good alternative to the pedicled pectoralis major flap in the prophylaxis or treatment of PCF.

Reference

A comparison between the free gracilis muscle flap and pedicled pectorlis major flap reconstructions following salvage laryngectomy.
Jing SS, O’Neill O, Clibbon JJ.
JOURNAL OF PLASTIC, RECONSTRUCTIVE AND AESTHETIC SURGERY
2014;67:17-22.

JOURNAL OF PLASTIC, RECONSTRUCTIVE AND AESTHETIC SURGERY

The use of Integra™ to allow early cover wounds
Reviewed by: Sunil Kumar Bhatia
September/October 2014 (Vol 23 No 4)
 

The authors present the use of Integra™ in a unique cohort of patients. Seven patients ages 21-31 in a six month period treated in one hospital. These were a very fit group of patients that had injuries caused by improvised explosive devices and had limb and trunk injuries. With better medical evacuation and field services, more service personnel survive injuries that were fatal previously. Unfortunately, when first evacuated they have significant injuries apart from the massive soft tissue injuries. There is a relative lack of skin that can be used to close open wounds / amputation. These patients, whilst previously very fit, are now unable to undergo the complex surgery. This is in distinction to the more commonly encountered vascular patient with compromised physiology and motivation. The authors describe the use of Integra™ for early closure of the defects. Seven patients with 11 wounds were treated. Good take was noted in eight wounds and there was only one complete loss. Partial take was noted in two wounds. While this is a small number of patients, anything that helps in the treatment of this unique cohort of patients and these injuries in useful. There is also an introduction to this type of war injury and difficulty in treating it.

Reference

Integra™ permits early durable coverage of improvised explosive device (IED) amputation stumps.
Foong DPS, Evriviades D, Jeffery SLA.
JOURNAL OF PLASTIC, RECONSTRUCTIVE AND AESTHETIC SURGERY
2013;66:1717-24.

JOURNAL OF PLASTIC, RECONSTRUCTIVE AND AESTHETIC SURGERY

Use of atenolol to treat infantile haemangiomas and comparison with propranolol group
Reviewed by: Sunil Kumar Bhatia
September/October 2014 (Vol 23 No 4)
 

The authors present a prospective blinded series of 30 consecutive patients with infantile haemangioma (IH) treated with Atenolol, a selective beta-1 blocker. This is the first study comparing two different beta blockers. They achieved good results and they suggest this is because Atenolol is a more selective beta-1 blocker with fewer side-effects. All patients had significant IH. Prior to therapy all patients were screened for contraindications and an ECG was performed. Atenolol was administered to all patients with IH, orally. Patients were evaluated around two, eight and 20 weeks, weight, BP and heart rates as well as photographic records were noted. Side-effects were determined and documented. The data was compared with the propranolol group. The accepted treatment of IH is with beta-blockers. This study proposes fewer side-effects and significantly fewer serious side-effects, such as hypoglycaemia or bronchial hypersensitivity. While an interesting study, there still remains a number of questions. Although the authors do correct for age, the Atenolol group were treated at a younger age. It is a small group of patients with promising initial results and needs more investigation. This is echoed by the authors themselves.

Reference

Treatment of infantile haemangiomas with atenolol: comparison with a historical propranolol group.
de Graaf M, Raphael MF, Breugem CC, et al.
JOURNAL OF PLASTIC, RECONSTRUCTIVE AND AESTHETIC SURGERY
2013;66:1732-40.

JOURNAL OF PLASTIC, RECONSTRUCTIVE AND AESTHETIC SURGERY

Wide local excisions for dermatofibrosarcoma protuberance
Reviewed by: Sunil Kumar Bhatia
September/October 2014 (Vol 23 No 4)
 

The authors present a viable alternative treatment for Dermatofibrosarcoma protuberance (DFSP). They show that wide local excision for DFSP can achieve a good result, saving the patient multiple visits to undergo Mohs surgery. The accepted method of treatment is surgery, be it Mohs or wide local excision (WLE). Mohs surgery has been suggested as the standard of care. The advantage of WLE is the single procedure. The authors present a retrospective analysis of 10 years of all cases of DFSP treated with WLE by a single operator. Twenty patients were identified; all patients had excision and reconstruction as one procedure. There were no incomplete excisions and no recurrences were recorded. They do not report any post complications or recurrences over 5.6 years of follow-up. Apart from the excisions none of the patients had any other treatment. It is a sound study with a good discussion. The authors accept it being a small group and a very diverse one, as the sites include head, torso and limbs. One can identify with their statement, ‘WLE with immediate reconstruction offers complete excision of DFSP and allows safe, reliable excision of the tumour without the need for a two staged operation without compromising the long-term outcome.’

Reference

To Mohs or not to Mohs.
Kokkinos C, Sorkin T, Powell B.
JOURNAL OF PLASTIC, RECONSTRUCTIVE AND AESTHETIC SURGERY
2014:67 23-6.

JOURNAL OF ULTRASOUND IN MEDICINE

Ultrasound and MRI for NPC
Reviewed by: Badr E. Mostafa
September/October 2014 (Vol 23 No 4)
 

The traditional radiological evaluation of patients with suspected nasopharyngeal carcinoma (NPC) is CT and MRI. The authors compared MRI and ultrasonography of the nasopharynx of patients with biopsy proven disease. Both sonography and MRI had good diagnostic performance for nasopharyngeal carcinoma. There was no significant difference in the rate of tumor detection between sonography and MRI (p= 0.12); the specificities of sonography and MRI were also similar (p= 0.22). However, sonography is less expensive and easier to perform. The results of this study also suggest that nasopharyngeal sonography could be used for the initial investigation of primary nasopharyngeal carcinoma. This is a very attractive alternative to MRI but the main disadvantage of ultrasound remains: it is highly operator dependant.

Reference

Diagnostic Accuracy of Sonography Versus Magnetic Resonance Imaging for Primary Nasopharyngeal Carcinoma.
Gao Y, Zhu SY, Dai Y, et al.
JOURNAL OF ULTRASOUND IN MEDECINE
2014;33(5):827-34.

JOURNAL OF VESTIBULAR RESEARCH

Discussion of the dizziness handicap inventory
Reviewed by: Fiona Barker
September/October 2014 (Vol 23 No 4)
 

This paper purported to be a review of the dizziness handicap inventory. The authors start (and finish) by stating that the DHI is the most widely used self-report scale used to assess handicap in context of vestibular dysfunction. While this is probably the case this statement was not referenced or justified and, as this paper did not compare studies which used the DHI versus other measures, this review failed to add to the evidence in this regard. It was not clear whether this was meant to be a review of the validity, reliability and consistency of the DHI or whether it was attempting to review its effectiveness as an outcome measure. I’m afraid it did neither. The paper begins by stating that 227 articles met the inclusion criteria but only 74 were reviewed. The inclusion criteria for the review were rather ‘woolly’. It was not clear on what basis this selection of 74 studies was made. Not a great start! The main body of the paper appeared to be a list of studies using the DHI. There was no narrative or meta-analysis and no assessment of study quality despite the fact that some of the individual studies contradicted each other. In short, there was an absence of critical appraisal which is an essential element of a review of any body of evidence. This was a summary of evidence at best rather than a review. As a clinician, what I would like to know from a paper like this is whether the DHI measures what we think it measures and whether it is any good as an outcome. I’m afraid this paper did not answer either question for me.

Reference

Discussion of the dizziness handicap inventory.
Matlu B, Serbetcioglu B.
JOURNAL OF VESTIBULAR RESEARCH
2013;23:271-7.

JOURNAL OF VESTIBULAR RESEARCH

Using the international classification of functioning disability and health (ICF) in the context of vestibular rehabilitation
Reviewed by: Fiona Barker
September/October 2014 (Vol 23 No 4)
 

There should be something of interest in this paper for those interested in measuring outcome in vestibular rehabilitation. The paper introduces and describes the ICF and how it is being applied in this context. As the ICF is a global health classification system many of its categories do not apply in the context of vestibular work and the author describes how a relevant core set of classifications has been defined. This breaks the huge scope of the ICF into more manageable chunks that can be applied in clinical practice and to inform research. In particular the author suggests that this framework might be useful in the development of future outcome measures for vestibular rehabilitation that might more comprehensively capture the range of impairments, participation restrictions, activity limitations, barriers, facilitators and personal factors that impact on outcome. Using an agreed theoretical framework such as this to inform future research can only be a good thing and this paper presents a good introduction for those not familiar with the ICF.

Reference

Introduction to the international classification of functioning disability and health – ICF – in the context of vestibular rehabilitation.
Graziano M.
JOURNAL OF VESTIBULAR RESEARCH
2013;23:293-6.

LARYNGOSCOPE

Vascularised tissue in salvage total laryngectomy
Reviewed by: Mark Puvanendran
September/October 2014 (Vol 23 No 4)
 

Chemoradiation (CRT) has become the mainstay for locally advanced laryngeal cancer since the RTOG 91-11 trial. Unfortunately there is still a substantial demand for salvage laryngectomies, which have a higher complication rate, the most notable being pharyngocutaneous fistula (PCF). Several small studies have suggested that using vascularised tissue from outside the radiation field reduces the risk of PCF; this systematic review aims to identify evidence for this. The authors are a distinguished international group, who have carried out a vigorous systematic review. The search strategy is clearly described; inclusion criteria and excluded studies are clearly detailed. The outcome considered, the presence or absence of PCF, is not subject to bias. Ultimately seven articles (591 patients) made the grade and were included in the analysis. The PCF incidence was 31.2% in the primary closure group compared with 22.2% in the flap reconstruction group. PCF carries a significant morbidity, increases hospital stay and may lead to death. The reduction of the incidence by one-third is a significant finding; this paper is essential reading for all head and neck surgeons and should inform future practice in salvage total laryngectomy.

Reference

Vascularized tissue to reduce fistula following salvage total laryngectomy: A systematic review
Paleri V, Drinnan M, van den Brekel MW, et al.
THE LARYNGOSCOPE
2014;124(8):1848-53.

NEUROSURGERY

Caffeine consolidates memory?
Reviewed by: Gauri Mankekar
September/October 2014 (Vol 23 No 4)
 

Although caffeine has been touted as a cognitive enhancer, promoting vigilance, improving reaction times, and facilitating passive learning, the role of caffeine on short memory has been inconsistently described while studies on long-term memory are few. The authors of this paper conducted a randomised, double-blind, placebo-controlled trial at Johns Hopkins exploring memory consolidation in caffeine-naïve, healthy young volunteers. After performing an incidental encoding task involving visual images in an indoor-outdoor judgment paradigm, participants received either placebo or a dose equivalent to one short, eight-ounce cup of Pike Place Starbucks coffee. Baseline, 1-hour, and 3-hour saliva samples were obtained to measure caffeine metabolite levels. Participants returned to perform a second task to evaluate their recognition performance. The study showed that a one-time dose of caffeine administered after an incidental learning task enhanced a participant’s ability to differentiate similar images in a task 24 hours later, suggesting that caffeine intake improves long-term memory consolidation. The authors conclude that although further research is needed into the effects of caffeine on memory consolidation, the current evidence indicates that caffeine has benefits beyond prevention of neuronal loss.

Reference

Morning Joe or after-dinner espresso? Improved memory consolidation after caffeine administration.
Kelly KM, Mikell CB, McKhann GM
NEUROSURGERY
2014:74(6)N8-N11.

NEUROSURGERY

Flexible neuroendoscopic management of hydrocephalus
Reviewed by: Gauri Mankekar
September/October 2014 (Vol 23 No 4)
 

Neuroendoscopy has revolutionised the management of intracranial clinical conditions and its applications are continuously expanding. In this article, the authors have described their 17 year experience using a flexible neuroendoscope to manage fourth ventricle outflow obstruction in patients with hydrocephalus. Traditionally, patients with fourth ventricle outflow obstruction are managed with a ventriculoperitoneal shunt or endoscopic third ventriculostomy. The authors performed endoscopic transventricular transaqueductal Magendie and Luschka foraminoplasty in 30 patients. Of these, 26 patients had long-term follow-up; 17 (65.3%) of these had clinical improvement and did not require further procedures. Nine (34.7%) did not improve. Of these, eight required another procedure (seven shunts, and one endoscopic procedure) and one patient died. The authors describe the procedure as safe, feasible and with minimal risk of periaqueductal injury.

Reference

Endoscopic transventricular transaqueductal magendie and luschka foraminoplasty for hydrocephalus.
Torres-Corzo J, Sánchez-Rodrıguez J, Cervantes D, et al.
NEUROSURGERY
2014:74:426-36.

NEUROSURGERY CLINICS OF NORTH AMERICA

Occipital nerve modulation for chronic migraine
Reviewed by: Gauri Mankekar
September/October 2014 (Vol 23 No 4)
 

Chronic migraine is a source of significant disability, loss of productivity and impairment in health related quality of life. Pharmacotherapy of migraine includes preventive agents and abortive agents. Preventive agents include anticonvulsants, anti-depressants, beta-adrenergic blockers and serotonin antagonists. Abortive agents include non-steroidal anti-inflammatory agents, tryptans, opioids, ergot compounds and sedatives. This review article discusses the role of peripheral neuromodulation in the treatment of chronic migraine. Traditional neurosurgical procedures like dorsal root entry zone lesioning, dorsal root ganglionectomy, peripheral neurolysis and neurectomy have not gained any favour. On the other hand, occipital nerve stimulation is a non-destructive alternative. Although the mechanism of peripheral neuromodulation is unknown, two theories have been proposed for its mechanism of action – the first theory is similar to the pain gate theory implicated in the mechanism of spinal or peripheral nerve stimulation for somative neuropathic pain. The second theory is based on PET imaging which suggests that occipital nerve stimulation results in retrograde modulation of the brainstem nuclei involved in the trigeminal vascular system thus inhibiting migraine headaches.

Reference

Peripheral neuromodulation for treatment of chronic migraine headache.
Tavanaiepour D, Levy RM.
Neurosurgery Clinics of North America
2014:25(1):11-14.

NEUROSURGERY QUARTERLY

Artificial dura for sellar reconstruction
Reviewed by: Gauri Mankekar
September/October 2014 (Vol 23 No 4)
 

Transsphenoidal pituitary adenoma removal is often associated with large skull base defects and cerebrospinal fluid (CSF) leaks. This article adds to the existing literature on repair of the skull base defects to prevent CSF leaks. The authors used absorbable hemostatic cotton and gelatin sponge for intrasellar packing and a double layer of artificial dura mater and fibrin glue to manage CSF leaks. This obviated the need for tissue grafts. The authors suggest that over packing should be avoided to prevent compromise of the vascular supply, pituitary or optic chiasm function. The artificial dura used is water tight and is gradually absorbed to be replaced by connective tissue, thus forming a dura-like tissue to repair the sellar floor defect. The authors had an incidence of 1.3% CSF leaks postoperatively using this repair.

Reference

Sellar reconstruction using biomaterials after transsphenoid surgery in 449 cases of pituitary adenomas.
Du J, Qui B, Wang Y, et al.
NEUROSURGERY QUARTERLY
2014;24(1):22-6

NEUROSURGERY QUARTERLY

Familial glossopharyngeal neuralgia
Reviewed by: Gauri Mankekar
September/October 2014 (Vol 23 No 4)
 

The authors report the unusual occurrence of glossopharyngeal neuralgia in a 73-year-old male and his female sibling. The patients had bouts of sharp stabbing pain on the right side of the chin, ear, posterior tongue and pharynx lasting five to 10 seconds. The female sibling had syncopal attacks with paroxysmal pain. MRI scans showed a dolichoectatic vertebral artery compressing the glossopharyngeal nerve. 10 % lidocaine spray to the pharynx provided temporary relief. Pregabalin 150mg twice daily relieved the male patient’s symptoms and the female patient did not have any more syncopal attacks. This must be a one of the first reports of familial glossopharyngel neuralgia.

Reference

Glossopharyngeal neuralgia due to familial dolichoectatic vertebral artery.
Çöven Í, Çoban G, Horasanh B, Ílik MK.
NEUROSURGERY QUARTERLY
2014;24(1):44-6.

NEUROSURGERY QUARTERLY

Post-traumatic pseudoaneurysm causing near fatal epistaxis
Reviewed by: Gauri Mankekar
September/October 2014 (Vol 23 No 4)
 

This case report describes a rare case of near-fatal epistaxis with loss of consciousness in an 18-year-old boy, two months after head injury. The patient had repeated episodes of profuse epistaxis associated with loss of consciousness requiring blood transfusion. CT scan and MRI showed a destructive midline giant mass in the skull base lateralising to the left side, eroding the skull base, reaching the sphenoid sinus and posterior nasal boundaries. Initial CT angiography showed a giant aneurysm originating from the infraophthalmic segment (cavernous portion) of the left internal carotid artery. Carotid stenosis, unusual for an 18 year old, was noted at the origin of the pseudo aneurysm. The patient underwent transcervical ligation of the left carotid in the neck after angiography supported a good collateral circulation. Despite this procedure the epistaxis continued and a subsequent angiogram revealed small feeder vessels from the ophthalmic artery feeding the neck of the pseudoaneursym. The patient underwent a left carotid artery ligation (supraclinoidal) with exclusion of the ophthalmic artery via a left pterional craniotomy. Although traumatic carotid pseudoaneursyms are a rare cause for epistaxis, clinicians should be able to make early diagnosis, split second decisions and manage the situation promptly as the mortality rate can be as high as 50%.

Reference

Near-fatal epistaxis from traumatic giant carotid artery pseudoaneursym: a case report.
Rashad S, Hassan T, Eldawoody HF.
NEUROSURGERY QUARTERLY
2014;24(1):56-62.

ORL

TORS for OSA: outcomes and bench-marking
Reviewed by: Zi Wei Liu
September/October 2014 (Vol 23 No 4)
 

This is a large multicentre retrospective observational study of the outcomes of transoral robotic surgery (TORS) for obstructive sleep apnoea (OSA) in 243 cases. Tongue base and supraglottic level obstruction is the main indication for TORS in OSA patients. Postoperatively, patients experienced significant improvements in apnoea-hypopnoea index (AHI), Epworth sleepiness score (ESS) and lowest O2 saturation without a significant change in BMI. 53.8% of patients were no longer continuous positive airway pressure (CPAP) dependent (AHI <15 and ESS <10) and 66.9% had a significant reduction in daytime somnolence and cardiovascular risk factors (AHI <20, ESS <10). The most common complication is temporary mild hypogeusia. Forty-five percent of patients received a temporary tracheostomy as routine practice in some centres. In this series TORS was performed as part of a multi-level procedure in 86% and patients also received nasal surgery (59%), tonsillectomy (60%) and uvulopalatopharyngoplasty (UVPP) (60%). Follow-up time was short (minimum three months) and long-term efficacy of TORS cannot be determined from these data alone. The multifactorial nature of OSA is reflected in the need for multi-level procedures and accurate pre-operative assessment of key contributory factors to OSA is crucial to successful outcomes. However, it is difficult to establish the effects of TORS alone given most patients require multiple procedures. Long-term follow-up data is required on efficacy and rates of recurrence.

Reference

Clinical outcomes and complications associated with TORS for OSAHS: a benchmark for evaluating an emerging surgical technology in a targeted application for benign disease.
Vicini C, Montevecchi F, Campanini A, et al.
ORL
2014;76(2):63-9.

ORL

Which patients habituate to tinnitus? The role of trigger factors and success of tinnitus retraining therapy
Reviewed by: Zi Wei Liu
September/October 2014 (Vol 23 No 4)
 

Tinnitus arises from perception of electrical activity in the auditory system without external stimulus. Although a very common symptom, few patients are sufficiently troubled by tinnitus to seek medical attention. Those that do are said to associate tinnitus with negative emotional states through a learning process, generating a conditioned reflex. This study looked at the effectiveness of tinnitus retraining therapy (TRT) when related to severity of tinnitus, presence of hyper- and hypoacusis and identifiable trigger factors. A total of 294 patients who had experienced incapacitating tinnitus for at least six months were treated, followed up for a minimum of 18 months and had outcomes assessed using a visual analogue scale and Tinnitus Handicap Inventory (THI). Eighty percent of patients improved following treatment and all those with mild or recent onset of symptoms improved. Where the main symptom is tinnitus, 90% improve following treatment. With associated hyperacusis, 78% of patients improve. Where hearing loss is associated with tinnitus, only 59% of cases improve. The study group was able to identify factors which precipitated tinnitus onset in 66% of patients. They were able to show significantly better habituation where a trigger factor was identified (91% vs 56%). In patients with hypoacusis and absence of trigger factors, the outlook was worst (28% improvement). The authors suggest TRT should be adapted in patients without trigger factors correlating with tinnitus and that hearing aids should be used to complement therapy where necessary.

Reference

Impact of Identifying Factors Which Trigger Bothersome Tinnitus on the Treatment Outcome in Tinnitus Retraining Therapy.
Molini E, Faralli M, Calzolaro L, Ricci G.
ORL
2014;76(2):81-8.

OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA

“I’ve got sinus”
Reviewed by: Charlie Giddings
September/October 2014 (Vol 23 No 4)
 

This edition of the journal tackles headaches in otolaryngology, especially those thought to be rhinogenic in origin. For patients presenting with “sinus headache” symptoms a comprehensive history, detailed examination of the nose and correlation with imaging is essential. Meticulous investigation is as important as a close working relationship with a neurologist. International classifications of headache support acute rhinosinusitis as a cause of secondary headache if in conjunction with appropriate clinical findings. The literature is less clear with regard to chronic sinusitis, and this edition of the journal is a must read for any budding rhinologist. The review recognises conflicting literature as there is cross over between primary headache symptoms, and many studies lack strict diagnostic criteria and outcome measurements. Some studies have suggested that up to 90% of sinus headaches may be migraine, others studies reveal that migraine headache may not present in isolation. Much needed consistency in the management of this group of patients is needed and the article is a reiteration that surgery is far from the first choice treatment. Further quality literature would be welcome to define if headache attributed to disorders of the nasal mucosa, turbinates or septum, formerly “intranasal mucosal contact point headache”, is a remote justification for surgery.

Reference

What do we know about rhinogenic headache?
Mehle ME, Schreiber CP.
OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA
2014;47:255-68.

OTOLARYNGOLOGY-HEAD AND NECK SURGERY

Confirmation that Epley is more effective than watchful waiting for p-BPPV
Reviewed by: Hannah Blanchford
September/October 2014 (Vol 23 No 4)
 

This systematic review of eight papers posed the question ‘What is the effectiveness of watchful waiting compared to the Epley manoeuvre (EM) in patients diagnosed with posterior canal benign paroxysmal positional vertigo (BPPV) regarding symptom relief?’. Posterior semicircular canal BPPV (p-BPPV) is the most common form of BPPV, a disorder that has a significant impact on daily living. Up to 37% of patients cannot work and 18% avoid leaving their homes. This review of eight papers suggested that for ‘subjective symptom relief’ at one week, all studies showed a strong effect (varying from 20% to 59%) in favour of the EM. This effect was found to decrease over a longer follow-up period. The authors highlight the discrepancy in study protocols, with some advocating repeated cycles of the manoeuvre, which may account somewhat for the wide variation in efficacy. The authors conclude that, given the low cost and low risk of side-effects, the EM should be considered in every patient with p-BPPV and suggest increasing training for general practitioners to perform this procedure in the community.

Reference

Rapid systematic review of the Epley Maneuver for treating posterior canal benign paroxysmal positional vertigo.
Van Duijn JG, Isfordink LM, Nij Bijvank JA, et al.
OTOLARYNGOLOGY-HEAD AND NECK SURGERY
2014;150(6):925-32.

OTOLARYNGOLOGY-HEAD AND NECK SURGERY

How to make a quinsy simulator
Reviewed by: Hannah Blanchford
September/October 2014 (Vol 23 No 4)
 

This study evaluated the success of a peritonsillar abscess simulator for training residents in the skill of abscess drainage. Although not technically difficult, the authors concede that new residents may be intimidated by the prospect of having to perform this procedure during their first on-call. Simulators allow for safe repetition and a controlled environment to develop one’s confidence without having to manage patient anxiety and distress at one’s first attempt. A latex mould with indentations representing the tonsils and uvula was created over a clay cast. This was secured at the end of a 2.5 inch diameter pipe to simulate the limited space of the oropharynx. A small balloon filled with vanilla pudding and placed behind 3mm-thick polyurethane foam simulated the abscess lying behind mucosa and submucosal space. Lips were created from clay and the oral opening was 3cm high and 5cm wide. A rubber tongue taken from a mannequin was secured in the oral cavity. A flexible scope was mounted with video recording. The pilot study evaluated residents and medical students in performing abscess drainage and evaluated their responses. All participants felt that the simulator replicated the skills necessary to drain a quinsy. Ninety percent agreed that the simulator helped in learning how to anaesthetise the area and aspirate the abscess. Fifty percent felt it was a good anatomical representation. The authors claim an initial cost of 10 dollars, with disposable parts costing 25 cents, and demonstrate their simulator to be a low-cost tool for providing training whilst minimising risk to patients.

Reference

Novel peritonsillar abscess task simulator.
Taylor SR, Chang CWD
OTOLARYNGOLOGY-HEAD AND NECK SURGERY
2014;151(1):10-3.

OTOLARYNGOLOGY-HEAD AND NECK SURGERY

Sparse evidence for benefit of hearing aids for tinnitus
Reviewed by: Hannah Blanchford
September/October 2014 (Vol 23 No 4)
 

This section of the journal helpfully highlights a recent Cochrane review. It aims to help clinicians evaluate the effectiveness of interventions for tinnitus. The authors of the Cochrane review, for which only one randomised controlled trial met the inclusion criteria, concluded that current evidence for prescribing hearing aids for tinnitus is limited. This RCT of 91 patients with hearing loss above 2kHz compared hearing aids with sound generators and found no difference in outcomes (measured by the Tinnitus Handicap Inventory). As only one paper was eligible for inclusion, the authors highlight the deficit of robust evidence in this field. The commentators suggest the authors should have concluded that patients with tinnitus and mild hearing loss who receive tinnitus retraining therapy (TRT) and either a sound generator or an open hearing aid find an improvement in their tinnitus over time, but that current research does not allow us to define whether this is due to the sound generators, hearing aids, TRT or none of these. Also, if part of the improvement is due to sound generators or hearing aids, there is no evidence to suggest that one is better than the other. The authors suggest that, despite the absence of evidence in favour of hearing aids for tinnitus, where the only significant downside of hearing aids is cost, and the patient accepts this, it may still be reasonable to offer a trial of hearing aids.

Reference

Cochrane corner: amplification with hearing aids for patients with tinnitus and co-existing hearing loss.
Schilder AGM, Burton MJ, Eby TL, Rosenfeld RM.
OTOLARYNGOLOGY - HEAD AND NECK SURGERY
2014;150(6):915-18.

Otology & Neurotology

Fine tuning!
Reviewed by: Anand Kasbekar
September/October 2014 (Vol 23 No 4)
 

This neat little study provides us with evidence to quote when we are asked to find that elusive tuning fork on the postoperative ward round after tympanomastoid surgery. Essentially the authors, from Wolverhampton, UK, compared the Weber test with the scratch test in 56 major tympanomastoid operations and found that the scratch test is better! Overall, Weber's test had a sensitivity of 73.2% and specificity of 100% compared with a sensitivity of 89.3% and specificity of 100% for the scratch test. Bear in mind that a head bandage needs to be present and the ‘scratch’ should be performed over the centre of the forehead on the bandage.

Reference

How reliable is the "scratch test" versus the Weber test after tympanomastoid surgery?
Iacovidou A, Giblett N, Doshi J, Jindal M.
OTOLOGY & NEUROTOLOGY
2014;35(5):762-3.

Otology & Neurotology

Myringoplasty in children with cleft palate
Reviewed by: Anand Kasbekar
September/October 2014 (Vol 23 No 4)
 

Although we know that cleft palate (CP) patients generally have poor eustachian tube function, little is known on how these patients fare after myringoplasty when compared to the general population. Do they really perform worse? Previously published literature has mixed views. This well-conducted French retrospective study compares the results of underlay cartilage myringoplasty in children with and without CP. Both groups had an average age of 10.5 years at operation. Thirty-two CP patients had 32 matched non-CP controls and the closure rate of the perforation was the same in both groups (84%), helped by the cartilage support I suspect. The authors state that the matching process selected control patients with greater otologic disease hence the closure rate was the same and not better than in CP patients. Hearing results were however significantly worse in the CP group, but they were worse to begin with. Overall the message seems to be that if cartilage is used, the anatomical closure rate should be the same. Hearing outcome is likely to be worse in CP patients whichever method of grafting one uses.

Reference

Results of myringoplasty in children with cleft palate: a patient-matched study.
Harterink E, Leboulanger N, Kotti S, et al.
OTOLOGY & NEUROTOLOGY
2014;35(5):838-43.

PEDIATRIC ALLERGY AND IMMUNOLOGY

Is there a link between rhinitis and depression?
Reviewed by: Evangelia Tsakiropoulou
September/October 2014 (Vol 23 No 4)
 

Rhinitis and asthma are global health problems, increasingly common in childhood. There is a growing interest on the impact of respiratory allergies on quality of life, however, the association between allergic rhinitis and psychologic characteristics in children remains poorly understood. This study from Italy explored if there was a connection between rhinitis and depression in 1283 subjects aged 10-13 years old. Depressive and anxious mood states were assessed using the Depression and Anxiety in Youth Scale, along with spirometry and skin prick tests. Anxiety (16%) and depression (13.6%) rates were higher than comparable literature when rhinitis was present. Additionally, female gender was directly linked to anxiety but not with depression.. The authors state that female gender is an indirect risk factor for both depressive state and rhinitis. The authors recognise the self-reported data as a study limitation. Furthermore they did not explore any other psychological or environmental variables that could influence the relation between rhinitis and mood. The introduction of mood management in clinical care along with control of rhinitis could reduce disease burden.

Reference

Rhinitis as a risk factor for depressive mood in pre-adolescents: a new approach to this relationship
Audino P, La Grutta S, Cibella F, et al.
Pediatric Allergy and Immunology
2014:25(4):360-5.

RHINOLOGY

Bacterial biofilms in patients with chronic rhinosinusitis: a confocal scanning laser microscopy study
Reviewed by: Lakhbinder Pabla (Bal)
September/October 2014 (Vol 23 No 4)
 

Biofilms on sinonasal mucosa have been implicated in the development of chronic rhinosinusitis. Current methods to investigate biofilms on sinonasal mucosa include traditional light microscopy, electron microscopy and confocal microscopy. This study investigates the presence of biofilms in 61 patients with chronic rhinosinusitis and septal deviation undergoing primary functional endoscopic surgery, and 25 controls (no chronic rhinosinusitis but septal deviation present), using confocal scanning laser microscopy. Bacterial biofilms were detected in 90% of patients with chronic rhinosinusitis, significantly more than in controls, in which 56% were biofilm positive. The point prevalence of biofilms in the control group was found to be relatively high compared to other similar studies. A possible explanation for this was that patients undergoing septoplasty were used as the controls in this study whereas in other studies reporting low prevalence of biofilms in the control group were completely free of nasal complaints (undergoing skull base surgery). This may point to a role for biofilms in the pathogenesis of patients with nasal obstruction without chronic rhinosinusitis. However, further studies are required.

Reference

Bacterial biofilms in patients with chronic rhinosinusitis: a confocal scanning laser microscopy study.
Danielsen KA, Eskeland O, Fridrich-Aas K, et al.
RHINOLOGY
2014;52(2):150-5.

RHINOLOGY

External nasal valve collapse: validation of a novel outcome measurement tool
Reviewed by: Lakhbinder Pabla (Bal)
September/October 2014 (Vol 23 No 4)
 

In this study, the authors devised a grading system that measures external nasal valve collapse in each nostril both at rest and on deep inspiration. This is based on a subjective measurement score ranging from 0-4. This grading system was then validated by firstly assessing reliability (inter-rater agreement and test-retest repeatability) using sixteen rhinologists scoring clinical photographs separately on two occasions one year apart. Secondly, its clinical relevance in patients undergoing septorhinoplasty for external nasal valve collapse was evaluated with a prospective observational case series of twenty-six patients who were scored pre- and post-operatively. The devised scoring system was found to be reliable with substantial agreement between 16 surgeons which were reproducible over time. All patients in the prospective series showed significant improvement in their external valve score. The quality of life measured by the SNOT-22 tool also showed significant improvement after surgery. This is the first study to propose a scoring system for external nasal valve collapse and to validate it

Reference

External nasal valve collapse: validation of novel outcome measurement tool.
Poirrier Al, Ahluwalia S, Kwame I, et al.
RHINOLOGY
2014;52(2):127-32.

RHINOLOGY

Patient comfort following FESS and Nasopore® packing: a double blind, prospective, randomised trial
Reviewed by: Lakhbinder Pabla (Bal)
September/October 2014 (Vol 23 No 4)
 

This study aimed to determine patient comfort associated with nasal packing (a self-dissolving polyurethane foam pack) and the parameters of post-operative bleeding, nasal breathing, a feeling of pressure, headache, and general well-being and sleep disturbance, compared to no packing. One side was packed with Nasopore® after bilateral FESS whilst the opposite was not packed, thus acting as the control. A total of 57 patients were included across two centres and the observation period included the days of the inpatient stay. There were no significant differences between sides for post-operative bleeding and nasal breathing. The feeling of pressure was slightly less on the side packed with Nasopore® on post-operative days two and three. The authors suspect that this result was attributed to increased crusting in the absence of a pack. No trend could be observed regarding which side patients described as subjectively better. The main strength of this study is its methodology, in that it is a double-blind, prospective, randomised trial. Overall, this study concluded few differences between the side packed with Nasopore®, and the unpacked side, and suggests further studies to evaluate this.

Reference

Patient comfort following FESS and Nasopore® packing, a double blind, prospective, randomized trial.
Kastl KG, Reichert M, Scheithauer MO, et al.
RHINOLOGY
2014;52(1):60-5.

SAUDI JOURNAL OTO-RHINO-LARYNGOLOGY & HEAD & NECK SURGERY

The role of budesonide saline solution for nasal irrigation in the management of allergic fungal rhinosinusitis: a prospective study
Reviewed by: B Viswanatha
September/October 2014 (Vol 23 No 4)
 

Allergic fungal rhinosinusitis is a non-invasive form of rhinosinusitis that often recurs despite aggressive treatment. This prospective trial was conducted from February to August 2009 and included seventeen patients. The study employed budesonide saline solution as nasal irrigation on a twice-daily protocol for three weeks. All patients underwent pre- and post-endoscopic assessment using the Kupferberg staging system, and patient questionnaires (the Modified Arabic Sinonasal Outcome Test (MA-SNOT)). The important findings were: budesonide saline irrigation improved the overall well-being of all the patients both objectively and subjectively; endoscopic staging showed significant improvement when this treatment protocol was utilised; endoscopic examination revealed a decrease in allergic mucin; patient symptom scores, assessed by the MA-SNOT, improved significantly for all categories; and an improved sense of smell and decreased rhinorrhoea was observed in many patients. The authors state that this is the first study reported in the literature on the treatment of allergic fungal rhinosinusitis using budesonide saline solution, and conclude that it is a useful tool in the management of allergic fungal rhinosinusitis.

Reference

The efficacy of budesonide on management of allergic fungal rhinosinusitis.
Osma M, Amen A ,Tariq AF, et al.
Saudi Journal Oto-Rhino-Latyngology & Head & Neck Surgery
2014:16(1):20-23

SLEEP AND BREATHING

Positional therapy and surgery for OSA
Reviewed by: Vik Veer
September/October 2014 (Vol 23 No 4)
 

Every woman instinctively seems to know that if you roll a male sleeping companion on their side, they tend to sound less like a hog. The medical literature is finally catching up; an ever increasing catalogue of articles now describe this manoeuvre as ‘positional therapy’ (PT). An Amsterdam centre performed a retrospective analysis of its surgical outcome data on obstructive sleep apnoea (OSA) patients. The authors then performed a subgroup analysis based on whether the OSA severity was dependant on sleeping position or not. 48.9% of the 139 study population had positional OSA, but all patients were treated with a form of palatoplasty with or without radiofrequency ablation to the tongue base. It seems that surgery in patients with non-positional OSA resulted in a more pronounced reduction in the apnea-hypopnea index (AHI) than in patients with positional-type OSA. In positional OSA patients, the use of PT in some cases ‘cured’ patients bringing the AHI to below five. PT also greatly augmented the benefit gained from surgery in this patient group. The authors illustrated their case rather imaginatively by creating a theoretical flowchart for patients in their retrospective study. They exposed the fact that by having prior knowledge of positional OSA status, patients were able to effectively cure themselves with PT, thereby avoiding any surgery. Patients with non-positional OSA treated with surgery could also be converted to positional OSA patients post-operatively, allowing them the option of PT and further improving their results. The final message is clear; look carefully at the AHI results in different sleeping positions, and consider PT a valid treatment option in OSA patients.

Reference

Theoretical approach towards increasing effectiveness of palatal surgery in obstructive sleep apnea: role for concomitant positional therapy?
van Maanen JP, Witte BI, de Vries N.
SLEEP AND BREATHING
2014;18(2):341-9.

SLEEP AND BREATHING

Tonsillectomy for OSA
Reviewed by: Vik Veer
September/October 2014 (Vol 23 No 4)
 

This study describes the outcome of tonsillectomy in 34 adult obstructive sleep apnoea (OSA) patients who had grade three or four tonsils. The idea was to quantify the benefit of tonsillectomy in OSA patients compared to tonsillectomy in conjunction with more traditional OSA operations such as palatoplasty. In short, the results were very good when compared to most OSA surgery outcomes. A surgical response rate (defined as a 50% or greater reduction in the apnoea-hypopnoea index (AHI)) was seen in 71.4% of severe OSA patients, 77.7% of moderate OSA patients and 75% of mild OSA patients. Similar results were seen when analysing the respiratory disturbance index (a measure of events that disturb the sleep of the patient). The classic Freidman case series described the results of tonsillectomy with palatal surgery, which achieved roughly an 80% surgical response rate. One would wonder then how clinically beneficial palatal surgery is in these patients? The authors did attempt some subgroup analysis; however the numbers become rather small and difficult to comment on. Ideally the polysomnography results in each category would have been available (including for grade 1 and 2 tonsils), or enough power to do a subgroup analysis with a palatal surgery cohort followed by a crossover arm. These and other ideas, however, would make a modern ethics panel baulk in protest. In conclusion, I think most people know that removing big tonsils helps people breathe. This study is another step towards defining that with greater precision.

Reference

Effects of tonsillectomy on sleep study parameters in adult patients with obstructive sleep apnea - a prospective study.
Tan LT, Tan AK, Hsu PP, et al.
SLEEP AND BREATHING
2014;18(2):265-8.

THE HEARING JOURNAL

Potential hearing advantages in bilingual individuals
Reviewed by: Linnea Cheung
September/October 2014 (Vol 23 No 4)
 

In this short article by two American professors of neuroscience, the potential benefits of the bilingual brain over that of the monolingual in neural speech encoding are explored. They go on to review the work carried out by a group from the Northwestern University Institute of Neuroscience (one member of whom is also the author of this article) on this very topic in brief detail. This research of auditory neural responses to one syllable shows that a group of bilingual adolescents demonstrate better subcortical encoding of speech when compared with IQ and socioeconomically matched monolingual adolescents, both in quiet and in noise conditions, with a more marked effect in noise. Follow-up results illustrated greater consistent brainstem and cortical responses in the bilingual group compared to the monolingual group. There was positive correlation between response to signal with language proficiency as well as with selective attention in the bilingual group. Logical suggestions to explain these relationships include the presence of competing languages when subjects are trying to accurately perceive the speech signal in the presence of noise, and that the activation and suppression of different languages in the bilingual brain might strengthen efferent connections between the frontal cortex and brainstem. The research raises further questions regarding whether the effect of ageing and hearing loss may have an impact on speech-in-noise performance between bilinguals and monolinguals given that we already know speech-in-noise performance declines with age. It would be interesting to see how multilingual brains (i.e. more than two languages) compare even to bilingual individuals' performance, and with testing a variety of syllables, before we can decide whether it is truly advantageous to speak more than one language.

Reference

Bilingualism enhances neural speech encoding.
Kraus N, Anderson S.
THE HEARING JOURNAL
2014;67(7):40.

THE LANCET RESPIRATORY MEDICINE

The mighty allergy
Reviewed by: Badr Eldin Mostafa
September/October 2014 (Vol 23 No 4)
 

The coexistence of eczema, rhinitis and asthma was studied in a prospective cohort of children aged four and eight years in 12 European countries. The diseases were documented by a questionnaire and serum specific IgE to six allergens. The aim of the study was to determine whether the coexistence of these diseases was IgE related or a chance finding. The absolute excess of any comorbidity was 1·6% for children aged four years and 2·2% for children aged eight years; 44% of the observed comorbidity at age four years and 50·0% at age eight years was not a result of chance. Children with comorbidities at four years had an increased risk of having comorbidity at eight years. The final conclusion was the coexistence of all three diseases in children is more than expected by chance alone and that IgE hypersensitisation is not the dominant causal mechanism of comorbidity. Other factors seem at play and these should be studied as well.

Reference

Comorbidity of eczema, rhinitis, and asthma in IgE-sensitised and non-IgE-sensitised children in MeDALL: a population-based cohort study.
Pinart M, Benet M, Anesi-Maesano I et al.
THE LANCET RESPIRATORY MEDICINE
2014;2(2):131-40.

ACTA OTOLARYNGOLOGICA

Day case stapes surgery under local anaesthetic in Finland
Reviewed by: Victoria Possamai
July/August 2014 (Vol 23 No 3)
 

The authors start by stating that the common occurrence of postoperative vestibular disturbance may preclude day case stapes surgery. They carried out a prospective study of 20 patients undergoing stapedotomy under local anaesthetic and measured postoperative symptoms and recorded nystagmus with video-oculography, 30 minutes postoperatively. The nystagmus and vestibular symptoms showed no correlation. Nine patients had spontaneous horizontal nystagmus without gaze fixation (seven of nine showing an irritative pattern). Seven patients described nausea, though only one vomited. Nine experienced vestibular symptoms immediately postoperatively (vertigo in five, floating sensation in two and unspecific dizziness in two). All but one described this as mild-moderate. In five of these patients this had fully resolved within the first 50 minutes, however the duration of symptoms in the remaining four patients is not stated, and is highly relevant to the validity of the conclusion reached; that day case stapes surgery is a feasible approach.

Reference

Immediate postoperative nystagmus and vestibular symptoms after stapes surgery.
Hirvonen TP, Aalto H.
ACTA OTOLARYNGOLOGICA
2013;133:842-5.

AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY

Topical steroid sprays: importance of physical and chemical characteristics
Reviewed by: Edward W Fisher
July/August 2014 (Vol 23 No 3)
 

Topical nasal corticosteroids are so widely prescribed that perhaps the otolaryngologist’s thoughts are dominated more by efficacy than the differences between formulations and delivery method. We should take more interest in this subject. This paper from Memphis reviews the subject of side-effects, formulations and the volume of the agents. I would recommend this article, as I learned much that I perhaps should already have known. Subjects such as the reported incidence of adverse effects in all sprays (5-10%), candidiasis, the (doubtful) link with septal perforations, the effects of alcohol or thixotropic agents, potassium sorbate and the adherence of sprays (and its importance) are all covered. The aqueous versus aerosol difference seems to have been overplayed in the past, with little evidence that one causes more epistaxis than the other.

Reference

Intranasal corticosteroids topical characteristics: side effects, formulation and volume.
Petty DA, Blaiss MS.
AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY
2013;27(6):510-13.

AUDIOLOGY NEUROTOLOGY

Alternative middle ear implant fixation
Reviewed by: Stephen James Broomfield
July/August 2014 (Vol 23 No 3)
 

This cadaveric temporal bone study examined the function of a Vibrant Soundbridge device, when the floating mass transducer (FMT) was attached to the short process of the incus rather than the long process. Fixation of the FMT to the short process of the incus confers the advantage of avoiding a posterior tympanotomy, whilst also reducing the risk of facial nerve and chorda tympani damage. Laser doppler vibrometry was used to measure movement of the stapes footplate and round window membrane, reflecting the input to the cochlea and intracochlear fluid dynamics, respectively. No significant difference was found in the velocity responses of the stapes or the round window, up to 6KHz. The authors conclude that short process FMT fixation may be an efficient and safe alternative surgical approach, though further work is required to achieve an optimal technique that will guarantee firm and reliable fixation in the long term.

Reference

Alternative Fixation of an Active Middle Ear Implant at the Short Process Incus.
Schraven SP, Dalhoff E, Wildenstein D, et al.
AUDIOLOGY NEUROTOLOGY
2014;19:1-11.

AUDIOLOGY NEUROTOLOGY

BAHA in single sided deafness
Reviewed by: Stephen James Broomfield
July/August 2014 (Vol 23 No 3)
 

The authors of this paper sensibly start off by stressing the disability and impaired quality of life associated with single sided deafness (SSD). They highlight the potential for a bone anchored hearing aid (BAHA) to rehabilitate this group of patients, whilst acknowledging that it will not be taken up by all. There follows a retrospective review of patients presenting with SSD, aiming to identify the reasons why patients do not proceed to surgery and, ultimately, to optimise the rehabilitation of future patients. The authors reviewed 102 patients who had undergone a BAHA assessment, analysing the results of audiometry during a BAHA trial (tests of speech recognition in nose, multi-directional gain, and sound localisation), a Glasgow Health Status Inventory (GHSI) survey, and, for those who had refused BAHA, a questionnaire assessing their reasons. Overall, 29% of patients with SSD opted to receive BAHA. Interestingly, duration of deafness did not impact on the decision to proceed to BAHA surgery, perhaps due to the self-selected nature of this group. There was no statistically significant difference between the scores of the implanted and non-implanted groups in any domain of the GHSI. There were two reasons, on average, why patients refused BAHA, including absence of benefit during testing (59%), the need for surgery (35%), aesthetic concerns (41%) and the cost of the prosthesis (44%). The authors recommend a minimum improvement of 20% in understanding of speech-in-noise or a 4dB improvement in aided thresholds with a BAHA on a headband, before considering surgery.

Reference

Baha-Mediated Rehabilitation of Patients with Unilateral Deafness: Selection Criteria.
Saroul N, Akkari M, Pavier Y, et al.
AUDIOLOGY NEUROTOLOGY
2014;19:85-90.

AUDIOLOGY NEUROTOLOGY

Cone beam and micro- CT to assess minimally invasive cochlear implantation
Reviewed by: Stephen James Broomfield
July/August 2014 (Vol 23 No 3)
 

This study reports the use of cone beam computed tomography (CT), to assess electrode position, and micro-CT, to assess the extent of intra-cochlear trauma, following cochlear implantation using a direct cochlear access approach in eight cadaveric temporal bones. This approach utilises an image-guided robot to drill a 1.8mm tunnel from the mastoid surface to the inner ear, followed by a manual electrode insertion. The aim of this technique is to provide a more optimal angle of electrode insertion than might be available with other minimally invasive techniques, e.g. the suprameatal approach. The authors concede some of the disadvantages of this approach, including the need for a tympanomeatal flap, cost and the routine use of ionising radiation. Just 3/8 procedures resulted in an atraumatic insertion into the scala tympani, with the rest demonstrating disruption of the basilar membrane or incorrect positioning of the electrode in the scala media or vestibuli. Five out of the eight procedures required the use of traditional surgical instruments to position or advance the electrode array via the tympanomeatal flap and tympanotomy. At an estimated surgical time of two hours, it is a little difficult to see the benefit of this technique over the standard facial recess approach (other than avoiding what the authors describe as a ‘substantial’ mastoidectomy). Nonetheless, this is early work and it will be interesting to see how robotic techniques develop in cochlear implantation in the future.

Reference

Cone Beam and Micro-Computed Tomography Validation of Manual Array Insertion for Minimally Invasive Cochlear Implantation.
Wimmer W, Bell B, Huth ME, et al.
AUDIOLOGY NEUROTOLOGY
2014;19:22-30.

AUDIOLOGY NEUROTOLOGY

Simulation of middle ear surgery
Reviewed by: Stephen James Broomfield
July/August 2014 (Vol 23 No 3)
 

The authors of this paper describe the development of a computer model for simulating middle ear surgery. The need for such a model is clear, and otologists, young and old, struggle with the difficulty of balancing the need to train new surgeons with the need to protect patients from iatrogenic harm. Whilst temporal bone training remains the gold standard, the authors highlight some of its limitations; inability to reproduce disease, unrealistic environment (e.g. no mucosal bleeding), no measure of functional results. The authors used micro-magnetic resonance imaging to build a finite-element model of the ossicular chain. Anatomical measurements and middle ear mechanical parameters from published temporal bone studies were incorporated. The model was analysed by assessing the middle ear transfer function. Surgeons were then able to manipulate the simulated ossicles, whilst receiving haptic feedback, real-time measures of ossicular displacement and functional results of surgery. Undoubtedly this type of simulation will form a part of otological training in the future, in addition to its use in researching middle ear mechanics and the development of ossicular prostheses.

Reference

Validation Method of a Middle Ear Mechanical Model to Develop a Surgical Simulator.
Kazmitcheff G, Miroir M, Nguyen Y, et al.
AUDIOLOGY NEUROTOLOGY
2014;19:73-84.

BRITISH JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY

Changing trends in the management of osteoradionecrosis
Reviewed by: Sampath Chandra Prasad
July/August 2014 (Vol 23 No 3)
 

In the wake of new drugs that have been introduced for ORN like pentoxifylline, tocopherol, clodronate etc, traditional ‘conservative’ management of osteoradionecrosis (ORN) including minimal surgical debridement and hyperbaric oxygen therapy (HBOT) is under review. This study is a retrospective review of treatment outcomes of ORN of the mandible with specific reference to the evolving role of medical management with pentoxifylline (400mg twice daily), tocopherol (1000 IU/mg/day) and doxycycline (100 mg daily). The authors reviewed the presentation and management of 71 patients treated for ORN of the mandible at the regional head and neck unit during a 15-year period, and categorised them into three grades using the Notani classification: grade I (n=28), grade II (n=16), and grade III (n=27). Twelve patients with grade I ORN, three with grade II, and 10 with grade III, were prescribed medical treatment. Of these, three with grade I, and two with grade II ORN were cured, and progression of the disease had halted and there was satisfactory control of symptoms in eight with grade I and four with grade III disease. Patients who failed to respond to conservative treatment were further analysed for the need for free flap reconstruction. Medical management was introduced as a standard treatment after January 2006. Of the 39 patients diagnosed before this, 20 (51%) required resection and free flap reconstruction compared with only 8/32 (25%) after it had been introduced.

Reference

Changing trends and the role of medical management on the outcome of patients treated for osteoradionecrosis of the mandible: experience from a regional head and neck unit.
D’Souza J, Lowe D, Rogers SN.
BRITISH JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY
2014;52(4):356-62.

COCHLEAR IMPLANTS INTERNATIONAL

A special signal processing algorithm developed to improve speech recognition in noise
Reviewed by: Thomas Nikolopoulos
July/August 2014 (Vol 23 No 3)
 

ClearVoice is a special signal processing algorithm developed by one of the cochlear implant companies with the aim to improve speech recognition and listening comfort in noise. The study's objectives were to evaluate speech recognition in multiple listening conditions using several noise types with HiRes 120 and ClearVoice (Low, Medium, High) and to determine which ClearVoice program was most beneficial for everyday use. The authors assessed 15 postlingually deafened adults who attended four sessions; speech recognition was assessed at sessions one and three with HiRes 120 and at sessions two and four with all ClearVoice programs. Test measures included sentences presented in restaurant noise (R-SPACETM), in speech-spectrum noise, in four- and eight-talker babble, and connected discourse presented in 12-talker babble. Participants completed a questionnaire comparing ClearVoice programs. The results revealed that significant group differences in performance between HiRes 120 and ClearVoice were present only in the R-SPACETM; performance was better with ClearVoice High than HiRes 120. Among ClearVoice programs, no significant group differences were present for any measure. Individual results revealed most participants performed better in the R-SPACETM with ClearVoice than HiRes 120. For other measures, significant individual differences between HiRes 120 and ClearVoice were not prevalent. Individual results among ClearVoice programs differed and overall preferences varied. Questionnaire data indicated increased understanding with High and Medium in certain environments. It seems that, although there are several improvements, cochlear implants are still far for optimising speech recognition in noise.

Reference

Postlingual adult performance in noise with HiRes 120 and ClearVoice Low, Medium, and High.
Holden LK, Brenner C, Reeder RM, Firszt JB.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(5):276-86.

COCHLEAR IMPLANTS INTERNATIONAL

Acute mastoiditis in children with cochlear implants: can we save the device?
Reviewed by: Thomas Nikolopoulos
July/August 2014 (Vol 23 No 3)
 

Acute otitis media and its complications (including acute mastoiditis) are device-threatening conditions, along with the associated morbidity in implanted children. Despite the significant risks associated with mastoiditis, including compromise of the implant, there are no specific guidelines on the management of this population. The authors aimed to develop a treatment algorithm based on their experience. A retrospective chart review included eight patients, who experienced mastoiditis, in the context of cochlear implantation, during a period in which 806 implants had been performed. The median age at which mastoiditis occurred was 37 months, and the mean time from implantation to mastoiditis was 9.5 months. All patients underwent drainage of the middle ear in conjunction with intravenous antibiotics, and two additionally underwent post-auricular incision and drainage. All devices were saved and no explantation was performed. The authors propose an algorithm that involves rapid initiation of aggressive antibiotic therapy and a low threshold for conservative operative intervention, resulting in effective resolution of infection, while allowing preservation of the implant. A national or international multi-centre study with large numbers of patients would help us establish a valid treatment algorithm for each complication of cochlear implant patients.

Reference

The management of acute mastoiditis in children with cochlear implants: Saving the device.
Osborn HA, Cushing SL, Gordon KA, et al.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(5):252-6.

COCHLEAR IMPLANTS INTERNATIONAL

Electrode differentiation. How useful is it in device tuning?
Reviewed by: Thomas Nikolopoulos
July/August 2014 (Vol 23 No 3)
 

Device tuning is very important in cochlear implantation and fine details are usually underestimated. The authors assessed the effect of deactivating indiscriminable cochlear implant (CI) electrodes for unilaterally implanted adults using the BKB (Bamford-Kowal-Bench) sentence test in quiet and in pink noise (signal-to-noise ratio of +10dBA) and the adaptive Coordinate Response Measure (CRM). Each CI recipient who failed electrode differentiation (ED) in at least one electrode-pair, based on results of a pure-tone pitch-ranking task received two research programmes to try out in a cross-over study. Research programmes (RP) either employed discriminable electrodes only or the most discriminable two-thirds of the electrodes in the electrode array for CI recipients failing ED for more than a third of the electrodes. The participants were also asked to subjectively report improvement of or decline in sound quality in everyday listening situations. There was significant improvement in CRM speech reception thresholds, BKB sentence scores in quiet, and also in pink noise after deactivating indiscriminable electrodes. Very interesting study. However, identification of the appropriate electrodes for de-activation may be challenging.

Reference

Clinical use of electrode differentiation to enhance programming of cochlear implants.
Saleh SM, Saeed SR, Meerton L, et al.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(Suppl. 4):S16-8.

COCHLEAR IMPLANTS INTERNATIONAL

Bilateral cochlear implantation in Friedreich's ataxia
Reviewed by: Thomas Nikolopoulos
July/August 2014 (Vol 23 No 3)
 

Although Friedreich's ataxia patients may have normal or near normal sound detection thresholds, it is not rare for many individuals to show abnormal neural conduction along their central auditory pathways. Electrophysiological testing can show abnormal or absent cochlear nerve and auditory brainstem recordings, in the presence of normal pre-neural cochlear function (otoacoustic emissions or cochlear microphonics). This pattern of normal pre-neural cochlear function and disrupted neural conduction lies within the spectrum of auditory neuropathy (ANSD). The authors highlight the fact that the majority of the literature on ANSD treatment has focused on paediatric patients with the ‘dyssynchrony’ type of ANSD, rather than the true neuropathy type underlying the hearing loss in Friedreich's ataxia patients. The authors report a very interesting case of a patient with Friedreich's ataxia, who had bilateral moderate hearing loss with poor speech discrimination, that improved significantly with bilateral cochlear implantation. An interesting study that contributes to our knowledge on auditory neuropathy and its management.

Reference

Bilateral cochlear implantation in Friedreich's ataxia: A case study.
Frewin B, Chung M, Donnelly N.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(5):287-90.

COCHLEAR IMPLANTS INTERNATIONAL

Cochlear implantation in a ski-slope high-frequency hearing loss and chronic external ear pathology, using a slim straight electrode array
Reviewed by: Thomas Nikolopoulos
July/August 2014 (Vol 23 No 3)
 

The authors describe a case of cochlear implantation (using a straight slim electrode array) in a patient with ski-slope high-frequency hearing loss and chronic external ear canal infections. The recurrent infections precluded the consistent use of hearing aids with moulds. His speech discrimination in quiet and in noise was poor and his hearing loss was interfering with his ability to work. After years of frustration, this patient decided to risk losing his low-frequency residual hearing and was implanted with a slim straight electrode array. Hearing preservation was achieved and he gained a remarkable improvement in his hearing performance. The authors concluded that the good outcomes were the result of the combination of hearing presentation surgery, electrode design, and intensive auditory training. Finally, they suggest that this case report reinforces the statement that patients who do not fulfil the standard criteria for CI should be carefully considered on an individual basis. This is very reasonable. However, the particular case had a very short follow-up (only five months) in order to see if hearing preservation remains through time. Moreover, other alternative solutions (such as hybrid electrode arrays or other implants / aids) should be considered in such cases (although this particular patient refused them).

Reference

The use of Nucleus® CI422 in a ski-slope high-frequency hearing loss and chronic external ear pathology: A case study.
Távora-Vieira D, Rodrigues S.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(5):291-4.

COCHLEAR IMPLANTS INTERNATIONAL

Cochlear implantation in children when one ear is out of the criteria
Reviewed by: Thomas Nikolopoulos
July/August 2014 (Vol 23 No 3)
 

Cochlear implantation, in a child with one ear within the criteria for cochlear implantation and the other out of the criteria, is a relatively new issue for discussion. Of course there is a wide range of asymmetrical hearing loss: single-sided deafness is at one end of the spectrum. Amplification in asymmetrical hearing loss is usually difficult, it is often not possible to adequately aid the poorer ear; therefore patients often experience compromised hearing with adequate aiding of their better ear only. The impact of hearing with one ear on speech development, education, and employment may be considerable. The authors reported in this study eight paediatric cases of cochlear implantation who had the contralateral ear out of the criteria for cochlear implantation. The authors concluded that in all eight children cochlear implant provided benefit. However, the small number of participants and the lack of long-term robust assessments weaken these claims.

Reference

Cochlear implantation in asymmetrical hearing loss for children: Our experience.
Tzifa K, Hanvey K.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(Suppl.4):S56-61.

COCHLEAR IMPLANTS INTERNATIONAL

Cochlear nerve deficiency: a very challenging situation
Reviewed by: Thomas Nikolopoulos
July/August 2014 (Vol 23 No 3)
 

In this study the authors review the issue of cochlear nerve deficiency (CND) which is a very challenging situation in young profoundly deaf children, as the decision to proceed with cochlear or brainstem implantation (ABI) is often very difficult. Of course the assessment process is critical and magnetic resonance imaging (MRI), using very detailed submillimetric sequences, is mandatory for all profoundly deaf children to diagnose CND. Audiologic confirmation (behavioural or electrophysiological), especially using electric auditory brainstem response (EABR), testing may allow some quantification of auditory neural tissue and help decide whether a cochlear implant will be beneficial. According to the authors, age and cognitive development are other critical factors in determining ABI benefit. However, hearing outcomes from both cochlear implants and ABIs are variable and likely to be limited in children with CND. A proportion of children will get no benefit. Usually the implants would be expected to provide recognition of environmental sounds and understanding of simple phonetics. Most children will not develop normal speech and they will often need to learn to communicate with sign language. The ABI involves a major neurosurgical procedure and, at present, the long-term outcomes are unknown. The authors concluded that it is essential that parents who are considering this intervention have plenty of time to consider all aspects and the opportunity for in depth discussion. The last statement is very true. However, we have to develop more accurate measures and explore predictors, in order to inform parents in this very difficult situation.

Reference

The management of cochlear nerve deficiency.
Freeman SR, Stivaros SM, Ramsden RT, et al.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(Suppl.4):S27-31.

COCHLEAR IMPLANTS INTERNATIONAL

Poor use of sequential bilateral cochlear implantation
Reviewed by: Thomas Nikolopoulos
July/August 2014 (Vol 23 No 3)
 

The investigation of factors contributing to poor or no use of sequential bilateral cochlear implantation is very important, as it may substantially improve cost-effectiveness. The authors assessed six cases of poor sequential bilateral cochlear implant use (partial and complete non-use) using a semi-structured interview, as part of a service evaluation and development audit to improve the quality of a paediatric implant service, for sequential users. The issues explored were related to appearance, expectations of both the benefits and the challenges of adjustment, personal motivation for the implant and for engagement in rehabilitation, and dislike of the sound. The results revealed that appearance, unrealistic expectations, dislike and difficulty adjusting to the sound of the second implant, and motivation were very important determinants of poor use. Although the number of participants is very small, some useful conclusions can be drawn from this study, in order to limit poor use of sequential bilateral cochlear implantation.

Reference

Factors associated with poor use of sequential bilateral cochlear implants in young people: A preliminary audit of poor users.
Emond A, Moore M, Tjornby C, et al.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(Suppl.4):S40-3.

COCHLEAR IMPLANTS INTERNATIONAL

Psychosocial development in cochlear implant children
Reviewed by: Thomas Nikolopoulos
July/August 2014 (Vol 23 No 3)
 

This study assessed self-reported quality of life (QoL) of children with a cochlear implant (CI), comparing results with two published reports from the past decade. The authors assessed 33 children with cochlear implants with a mean age of 10 years, mean implantation age of 1.3 years, and mean CI experience of six years. Children in all three studies completed a self-report QoL questionnaire that included seven benefit and six problem items, rated on a 5-point Likert scale. The outcomes revealed agreement across studies in overall benefit and problem ratings. Environmental awareness and frustration reduction were the most and least positively rated outcomes, respectively. Items contributing to overall ratings differed across studies. Current CI recipients rated speech production, making new friends, and understanding speech more positively and taking extra care of the device more negatively than previous generations of paediatric CI users. Overall, benefits outweighed problems of the device, according to children using CI. Differences in issues motivating self-report ratings reflect changes in CI candidacy, technology, and social participation over the past decade. The authors concluded that their outcomes emphasise the need for clinicians to address not only communication needs, but also QoL issues in order to optimise outcomes in children using CI. It is expected that implanted children’s needs change through the years and as cochlear implantation evolves, not only due to the scientific developments but also due to the changes of the children themselves (expectations, social differences, etc.).

Reference

A comparative study of psychosocial development in children who receive cochlear implants.
Warner-Czyz AD, Loy B, Roland P, Tobey EA.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(5):266-75.

COCHLEAR IMPLANTS INTERNATIONAL

Sequential bilateral cochlear implantation. Factors that affect the use of the second implant
Reviewed by: Thomas Nikolopoulos
July/August 2014 (Vol 23 No 3)
 

The authors aimed to explore the demographic or performance variables associated with inconsistent use of a second implant in paediatric recipients of sequential bilateral cochlear implants. A retrospective chart review was conducted on paediatric recipients of sequential bilateral cochlear implantation. Children were divided into two age groups, 5-9 and 10-17 years of age. For each group, the authors examined whether inconsistent use of the second implant (CI-2) was associated with a variety of demographic variables, or speech-perception scores. The results revealed that in children aged 5-9 years, inconsistent use of CI-2 was not significantly associated with any demographic variable, but was related to both the word-recognition score with CI-2, and the difference in word-recognition scores between the first implant (CI-1) and CI-2. In children aged 10-17 years, these relationships were not significant and the authors attributed it to the small number of subjects. Finally, CI-2 word-recognition scores across all children were significantly correlated with the age of implantation for both CI-1 and CI-2, and the time between CI-1 and CI-2 surgeries. The factors associated with the everyday use of the second implant in sequential bilateral implantation are very important, as they are closely associated with the cost-effectiveness of the procedure and should be thoroughly investigated in all cochlear implant centres.

Reference

Factors influencing consistent device use in paediatric recipients of bilateral cochlear implants.
Fitzgerald MB, Green JE, Fang Y, Waltzman SB.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(5):257-65.

COCHLEAR IMPLANTS INTERNATIONAL

What about a hearing aid at the contralateral side?
Reviewed by: Thomas Nikolopoulos
July/August 2014 (Vol 23 No 3)
 

This study explored if the low frequency information from a hearing aid improved the perception of stress and intonation by English-speaking children with cochlear implants (CI). In addition, the authors investigated if users rely more on the cues of duration and amplitude to perceive stress and intonation. Nine children with bimodal stimulation (cochlear implant and hearing aid) participated in two experiments. The first measured the just audible change in F 0 (pitch) and amplitude for a speech-like word ‘baba’. The second experiment examined the children's ability to identify focus in natural and manipulated sentences. Overall, group results did not show a bimodal advantage in perceiving stress and intonation. However, the children were significantly better at perceiving focus in sentences with natural speech compared with manipulated speech in both the CI and bimodal conditions. The authors suggested that in the absence of pitch cues, amplitude and duration cues are used to perceive stress and intonation. However, the majority of children only perceived amplitude changes greater than the changes typically found in speech, implying duration cues were the most valuable. Finally the authors concluded that, in children with cochlear implants, cues to F 0 may not be essential for prosody perception and in the absence of cues to F 0 and amplitude, duration may offer an alternative cue. The small number of participants (a bimodal advantage was not found in all subjects) and the limited measures used weaken any outcomes (positive or negative) on the contralateral use of a hearing aid. Therefore, appropriate tuning and a trial are still the only ways to explore if a contralateral hearing aid would provide benefit in a particular implantee.

Reference

The perception of stress and intonation in children with a cochlear implant and a hearing aid.
Hegarty L, Faulkner A.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(Suppl.4):S35-9.

Ear and Hearing

Mild and Unilateral hearing loss in childhood
Reviewed by: Dr Vinaya KC Manchaiah
July/August 2014 (Vol 23 No 3)
 

The presence of even mild degrees of hearing loss and unilateral loss in early childhood can negatively affect typical development, although they are hard to identify and diagnose early. The main aims of the current study were to: (1) document the proportion of children identified with mild bilateral or unilateral hearing loss (MBUHL) before and after the implementation of a universal newborn hearing screening program (UNHS); and (2) to examine the clinical characteristics and audiologic management of this population of children. This population-based study involved an analysis of data on children with hearing loss which had been collected prospectively over a 20-year period from 1990 to 2010 in Canada. The proportion of all children with hearing loss identified with MBUHL before and after implementation of UNHS and their clinical profiles were documented. Also, the factors affecting amplification decisions and amplification use were examined. A total of 381 of 823 children (46.3%) aged 0 to 18 years who were identified with permanent non-acquired hearing loss presented with MBUHL. The proportions identified were similar in the pre- and post-UNHS periods. However, before UNHS children were identified at a median age of 5.0 years compared with a median of 0.8 years, post-UNHS. Progression of hearing loss was documented for 22% of all children, and for the group identified since UNHS, 32.4% experienced deterioration in hearing thresholds. Although 87.2% of children received recommendations for amplification, more than 50% experienced considerable delay from identification to amplification. Age at identification and severity of hearing loss in the better ear were associated with amplification decisions for bilateral but not unilateral loss. UNHS has lowered age of confirmation of MBUHL by four to five years, although delay to amplification suggests uncertainty of the benefit of intervening early for these losses.

Reference

Mild bilateral and unilateral hearing loss in childhood: A 20-year view of hearing characteristics, and audiologic practices before and after newborn hearing screening.
Fitzpatrick EM, Whittingham J, Durieux-Smith A.
EAR AND HEARING
2014;35(1):10-8.

European Review of ENT

Cordectomies and the voice
Reviewed by: Dr Badr Eldin Mostafa
July/August 2014 (Vol 23 No 3)
 

Although laryngeal malignancy is a devastating disease, treatment can be deleterious to function as well. This article discusses the effect of type II and III cordectomies on the sound intensity of the voice. Intensity depends on subglottic pressure, size of the sound conduit and on the power of adduction of the vocal folds. Comparing sound intensities for isolated vowels and vowels in context, the authors did not find any statistical difference between patients and controls. The anatomo-physiological changes to the vocal folds after surgery result in abnormal glottic closure and leaks. The authors conclude that patients adopt compensatory strategies at the level of the supraglottis and an increase in the subglottic pressures in order to achieve intelligibly powerful vowels.

Reference

The sound intensity after cordectomy of type II-III.
Wallet L.
EUROPEAN REVIEW OF ENT
2013;134(1):43-7.

European Review of ENT

Does your voice affect your career?
Reviewed by: Dr Badr Eldin Mostafa
July/August 2014 (Vol 23 No 3)
 

Twenty naïve evaluators listened to 30 dysphonic voice samples and evaluated them in a four item questionnaire. They were asked to imagine the speaker according to five categories: health appearance, character, lifestyle and competence. One hundred and twenty-seven attributes were used. The authors retained 18 which were presented with their antonyms as a bipolar visual scale (from 0 to 10). The average scores for normal voices was 7.2, for mild dysphonia 5.7 and for severe dysphonia 4.7. It seems that the social image of dysphonic subjects is negative regardless of the degree of dysphonia. Dysphonic subjects are considered to be less healthy, uglier, less elegant, less social, less optimistic, less energetic, less intelligent and less reliable and last, unsurprisingly, more likely to be users of tobacco. Such a study emphasises the strong effect of voice on the mental image we form of a person. As professionals dealing with the larynx, we should be aware that we can deeply influence the whole persona of our patients and this should be included in our discussion, prior to any intervention which may affect the voice of the patient.

Reference

Social consequence of a dysphonic voice, design and validation of a questionnaire and first results.
Revis J, Robieux C, Ghio A, Giovanni A.
EUROPEAN REVIEW OF ENT
2013;134(1):35-41.

European Review of ENT

The facial nerve and speech
Reviewed by: Dr Badr Eldin Mostafa
July/August 2014 (Vol 23 No 3)
 

The effect of facial paralysis on speech is an interesting subject. The authors evaluated the speech spectrogram of patients with facial paralysis using the Praat software. They found a real impact on the suprasegmental level. Repeated voluntary swallowing of the saliva significantly affected prosody with modifications of rhythmic structures. This was most pronounced during unguided reading, when the patient could not predict pauses and thus synchronise swallowing. Although the effects were not significant, we should be aware of this side-effect of facial paralysis and guide our patients to synchronise their speech with swallowing to avoid dysfluencies in speech which may increase their social handicaps.

Reference

Prosodic analysis of speech of patient affected by peripheral facial paralysis.
Robert M, Mauclair J, Lannadere E, et al.
EUROPEAN REVIEW OF ENT
2013;134:13-9.

FACIAL PLASTIC SURGERY

Conchal cartilage to reconstruct nasal septum
Reviewed by: Sunil Kumar Bhatia
July/August 2014 (Vol 23 No 3)
 

The authors discuss a problem frequently encountered, septal perforation. Unfortunately the most common cause is iatrogenic and previous surgery. The loss of the nasal septum is frequently also seen in repeated trauma and effective reconstruction using auricular cartilage is effective. However the use of this cartilage involves making this ‘bowl’ cartilage straight and imparting it with strength to support the nose, to allow for adequate nasal functioning. This paper, from authors in Italy, discusses the aetiopathogenesis of the loss of nasal cartilage and then patient analysis. Both these sections are well covered and the use of excellent colour photographs enhances the sections. They describe their technique of converting a curved flexible cartilage into a straight one, and increasing the structural strength, using partial thickness incisions and figure of eight sutures. There is an extensive review and discussion with good clinical photographs. Various donor sites are discussed as are the pros and cons. The importance of the effective support, in the form of the cartilaginous septum, as a prerequisite is again discussed.

Reference

Subtotal septal reconstruction by using conchal graft.
Boccieri A, Marianetti T.
FACIAL PLASTIC SURGERY
2013;29(6):479-86.

International Archives of Otorhinolaryngology

The temporomandibular joint and vertigo
Reviewed by: Dr Badr Eldin Mostafa
July/August 2014 (Vol 23 No 3)
 

Dysfunction of the temporomandibular joint (TMJ) has been implicated in several otologic disorders, especially pain, tinnitus and conductive hearing loss. The authors explore the relation between TMJ disorders and vertigo in a geriatric population. The joint was assessed by digital pressure and recording tenderness and muscle spasm. Vertigo was assessed by a Katz questionnaire. This study showed that there is a significant association between TMD and vertigo. Moreover, the studied elderly people with TM dysfunction showed 17.61% more chance of presenting with vertigo than those without TMD. Although interesting, a cause-effect could not be convincingly presented. Both are common disorders in this studied population and both are multifactorial. However their association may be due to a third common factor rather than a causal relationship.

Reference

Probable Correlation between Temporomandibular Dysfunction and Vertigo in the Elderly.
de Moraes Marchiori LL, Oltramari-Navarro PV, Meneses-Barrivieira CL, et al.
INTERNATIONAL ARCHIVES OF
OTORHINOLARYNGOLOGY
2014;18(01):49-53.

International Journal of Language and Communication Disorders

Adolescent stuttering therapy
Reviewed by: Gauri Mankekar
July/August 2014 (Vol 23 No 3)
 

Treatment of stuttering in adolescents is an under researched subject although the psychological, social, vocational and economic implications in this group are tremendous. The authors of this article outline an integrated programme for stuttering adolescents, incorporating speech restructuring, cognitive behaviour therapy and communication skills training. The article highlights some of the challenges faced in collecting long-term data with adolescent research participants but also mentions the effectiveness of therapy in stuttering teenagers and emphasises the importance of therapy resources being made available for this group of patients.

Reference

Effectiveness of intensive group therapy for teenagers who stutter.
Fry J, Millard S, Botterill W.
INTERNATIONAL JOURNAL OF LANGUAGE AND COMMUNICATION DISORDERS
2014;49(1):113-26.

International Journal of Language and Communication Disorders

Smart phone app in stuttering therapy!
Reviewed by: Gauri Mankekar
July/August 2014 (Vol 23 No 3)
 

This article discusses the efficacy of altered auditory feedback during scripted telephone conversations in stuttering therapy. The authors examined stuttering frequency under monaural auditory feedback with one combination (COMBO 2) of delayed auditory feedback (DAF) and frequency altered feedback (FAF) and two combinations (COMBO 4) of DAF and FAF during scripted telephone conversations. Stuttering was significantly reduced with both altered auditory feedback, although it was more significantly reduced with COMBO 4, probably indicating that second signals reduce stuttering along a continuum. The authors suggest that people who stutter can use specific software or smartphone apps that produce second speech signals to inhibit stuttering frequency effectively, during telephone conversations.

Reference

Stuttering inhibition via altered auditory feedback during scripted telephone conversations.
Hudock D, Kalinowski J.
INTERNATIONAL JOURNAL OF LANGUAGE AND COMMUNICATION DISORDERS
2014;49(1):139–47.

JAMA FACIAL PLASTIC SURGERY

Whisking recovery after automated mechanical stimulation during facial nerve regeneration
Reviewed by: Bilal Gani Taib
July/August 2014 (Vol 23 No 3)
 

Facial paralysis is a disorder with profound consequences, both functional and psychosocial. Functional recovery from facial nerve transection and surgical repair is typically poor in rats and humans. Therefore therapies applied to rats may translate to humans. This study used 61 rats that had undergone a left facial nerve transection with microsurgical connection via two to three epineural nylon sutures. The rats were randomised into eight groups. Six groups received 0.5, 1.5 and 8Hz frequencies delivered by a whisk assist (WA) system designed to move the whiskers horizontally beginning eight days postoperatively, five days per week for 15 weeks. Two groups received restraint without stimulation. The low frequency stimulations (0.5 and 1.5Hz) failed to enhance recovery. Further, the higher frequency stimulation (8.0Hz) was actually detrimental to recovery.

Reference

Whisking recovery after automated mechanical stimulation during facial nerve regeneration.
Kleiss IJ, Knox CJ, Malo JS, et al.
JAMA FACIAL PLASTIC SURGERY
2014;16(2):133-9.

JOURNAL OF CRANIO-MAXILLOFACIAL SURGERY

Immediate planned reconstruction following complex craniofacial reconstruction
Reviewed by: Sunil Kumar Bhatia
July/August 2014 (Vol 23 No 3)
 

The immediate reconstruction of 3-D cranio-facial defects is extremely difficult and can be more difficult than the ablation. Perfect shape and symmetry is required. In the past decade this has largely improved with CAD / CAM engineering. The authors report a one step technique that is fairly simple and allows for good results. They present a series of five patients that had complex orbito-frontal resections with immediate reconstruction. The resection was planned and an implant made preoperatively. Material used was Polyetheretherketone (PEEK), a material widely used in neurosurgery, and which shows good biocompatibility. This seems to be a reproducible and simpler method of reconstruction than using autologous bone or tissues. There is no donor site morbidity and excellent form and function. The equipment required and techniques are well accepted. CAD / CAM cranioplasty is well described and so is navigation. The resection is planned with virtual planning and allows an individualised accurate implant to be manufactured prior to surgery. This is an excellent technique and is of value to all facial surgeons. It does however require considerable back-up in the form of resources and equipment.

Reference

One-step primary reconstruction for complex craniofacial resection with PEEK custom-made implants.
Jalbert F, Boetto S, Nadon F, et al.
JOURNAL OF CRANIO-MAXILLOFACIAL SURGERY
2014;42:141-8.

JOURNAL OF CRANIOFACIAL SURGERY

Complications of plates in fibular free flaps
Reviewed by: Sunil Kumar Bhatia
July/August 2014 (Vol 23 No 3)
 

Good functional reconstruction of the mandible remains challenging for the maxillofacial surgeon. The fibula osteocutaneous flap is widely used as a method of mandibular reconstruction and it can withstand multiple osteotomies and requires hardware to adapt and hold the segments. There has also been significant improvement in the plate hardware. This is a single centre retrospective audit, looking at the plate-related complications following reconstructions of the mandible. They look at 41 reconstructions between 2004 and December 2012. Most common indication, in 30 cases, was resection for squamous cell carcinomas. Sixteen patients had postoperative adjuvant radiotherapy and one preoperative radiotherapy. Seven patients had chemotherapy, in addition to standard fractioned radiotherapy. The authors studied the complications of the plates used. Three types of plates were used; the mandible plates 2.0, locking plate 2.0 and locking plate 2.4. The commonest plates used the miniplates 86 with two complications, followed by 2.0 mandible plates two in 14 and then 2.0 locking plate one in 12 complications. Initially there were concerns that miniplates, with their smaller size had less strength and were predisposed to more complications. However, the newer miniplates, with their greater malleability and adaptability and lower profile, seem to have fewer complications. This study confirms that and the author’s first choice is the miniplate. A drawback is that with the use of multiple plates a period of intermaxillary fixation is required to maintain the occlusion. Also interesting is the fact that most complications occurred early within six months, and as expected the majority presented in patients that received radiotherapy. In patient numbers the study might be considered small but a total of 86 miniplates was used with only five ‘complications’, which is fairly conclusive.

Reference

Evaluation of plate-related complications and efficacy in fibula free flap mandibular reconstruction.
Zavattero E, Fasolis M, Garzino-Demo P, et al.
JOURNAL OF CRANIOFACIAL SURGERY
2014;25:397-9.

JOURNAL OF DERMATOLOGICAL TREATMENT

More tonsillectomy benefits
Reviewed by: Badr Eldin Mostafa
July/August 2014 (Vol 23 No 3)
 

Tonsillectomy has proven indications for obstructive sleep apnoea, recurrent infections and post-streptococcal sequels. For some time a deleterious effect on immunity was suggested in order to ban or limit tonsillectomies. In this work the aim of tonsillectomy was to reduce the production of autoreactive T cells, which may be implicated in psoriasis. The results highlight the benefit of tonsillectomy as a treatment for palmoplantar pustulosis and psoriasis. The findings of this study may not be limited to skin disorders but may be extended to other auto-immune disorders.

Reference

Tonsillectomy as a treatment for psoriasis: a review.
Wu W, Debbaneh M, Moslehi H, et al.
JOURNAL OF DERMATOLOGICAL TREATMENT
2014;24(6):482-6.

JOURNAL OF LARYNGOLOGY AND OTOLOGY

Consent for mastoidectomy
Reviewed by: Madhup K Chaurasia
July/August 2014 (Vol 23 No 3)
 

Mastoidectomy is a complex operation and often ill understood by patients. The risks involved are many, in terms of damaging vital structures inside the petrous temporal bones, resulting in major disability for the patient. In this publication the author has presented very detailed information offered to patients when obtaining consent for mastoidectomy extending to four A4 pages. The consent information comprises the actual operation, anaesthesia, possible damage to the facial nerve and other complications such as increased hearing loss, dizziness, tinnitus, taste disturbance, wound infection and numbness of the ear. The information also includes possible problems with a resulting mastoid cavity and the care protocol followed after the operation. For each item there is a tick box and space for questions from patients. The information leaflet was subjected to comments from patients in terms of understanding the text, any disagreements or grammatical mistakes and whether it was reasonable to offer all this information to patients in the form of a leaflet. The responses were very favourable. The text is simple and conforms to a reading age of 13-15 years, as determined by the text readability consensus calculator. The process involves the patient reading all this in the clinic, ticking boxes and then possibly responding with questions. The forms were brought by the patient in the preoperative appointment and only at this time the official hospital consent form was signed. At the outset, all this appears to be rather lengthy and tedious but serious complications can arise in a mastoid operation and patients may often not realise the gravity of the situation which exposed them to the risk involved in this surgery

Reference

Patient information leaflet on mastoid surgery risks: assessment of readability and patient understanding.
Pringall MB, Latesh BJ, Konieczny KM.
JOURNAL OF LARYNGOLOGY AND OTOLOGY
2013;127:1078-83.

JOURNAL OF LARYNGOLOGY AND OTOLOGY

Cost effectiveness of on-site cytologists in the neck lump clinic
Reviewed by: Madhup K Chaurasia
July/August 2014 (Vol 23 No 3)
 

The purpose of one-stop neck lump clinics is quick diagnosis and compliance with the cancer pathway. The two hurdles which come in the way of diagnosis by fine needle aspiration (FNA) are the accuracy of the site of aspiration and adequacy of material to make a cytological diagnosis. The first hurdle can be overcome by the presence of an interventional radiologist but whether the presence of the cytologist in these clinics would overcome the second hurdle and be cost effective is questionable. In this study authors made a hypothetical estimate of cost effectiveness if an on-site cytologist was introduced to the one-stop neck lump clinic, in which they already had an interventional radiologist. In an analysis of 307 ultrasound guided fine needle aspiration cytology procedures performed over six months, cytological diagnosis was not obtained in 22% of these cases. On repeating the FNA and subsequent appointments, only 5% of these produced a firm diagnosis. It was then speculated what would be the savings if there was an on-site cytological assessment. Hypothetical calculations showed a maximum theoretical saving of about £3k over six months. Furthermore, the authors contend that not every non diagnostic FNA will be detected by on site cytological assessment. The literature suggests that reduction in non-diagnostic FNAs through on-site cytological assessment ranges from 70% to no difference at all. These facts suggest that introduction of an on-site cytologist will result in costs which may outweigh the benefits. The study is hypothetical and the actual answer can only be obtained by a direct comparison of a one stop clinic with an on-site cytologist, with one that does not have this facility. Furthermore, discrete use of clinical guidance can reduce the necessity for repeat FNAs in seemingly benign cases and suggest more alternative methods such as core biopsy or surgical excisional biopsy in others.

Reference

Clinics; is on site assessment of fine needle aspirate diagnostic adequacy cost effective?
Burgess C, Dias L, Maughan E, Moorthy R.
JOURNAL OF LARYNGOLOGY AND OTOLOGY
2013;127:1122-26.

JOURNAL OF LARYNGOLOGY AND OTOLOGY

Is female nasal trauma increasing?
Reviewed by: Madhup K Chaurasia
July/August 2014 (Vol 23 No 3)
 

It is apparent that more and more women are attending with fracture of the nasal bones in general and especially due to non-domestic violence. The speculation is whether this is due to a changing culture and if this is related to what is described as ‘ladette’ attitudes of teenage females. In this study the authors observed an 825% rise in the treatment of women with nasal fractures in the five year period from 2004 to 2009. Accidental injury was the most common cause of fracture. Another common cause was sports-related injury. However, a quarter of these women had nasal injury as a result of non-domestic violence. The authors attribute this to the ‘ladette’ culture. ‘Ladette’ culture is characterised by women who behave in a boisterous, assertive or rude manner and engage in heavy drinking sessions, the expected outcome of which is fights resulting in nasal trauma. The increased incidence of nasal fractures in these girls and young women (13-20 years) is seemingly related to high consumption of alcohol which is facilitated by availability of cheaper drinks, longer public house hours and free entry for women. The higher incidence of nasal fractures in this age group was particularly confined to British white women. The authors support their views with data obtained from the Home Office’s British Crime Survey Episode Statistics. This rather disturbing finding calls for further research on alcohol consumption and its relation to nasal fractures and the need to guide Public Health policies.

Reference

Is there a change in epidemiology of nasal fractures in females in the UK?
Trinidade A, Buchanan M A, Farboud A, et al.
JOURNAL OF LARYNGOLOGY AND OTOLOGY
2013;127:1084-87.

JOURNAL OF LARYNGOLOGY AND OTOLOGY

Surgery for failed CPAP therapy
Reviewed by: Madhup K Chaurasia
July/August 2014 (Vol 23 No 3)
 

Recent evidence supports an ever widening spectrum of morbidities associated with Obstructive Sleep Apnoea Syndrome, ranging from hypertension to the more recently recognised encouragement of tumour genesis due to hypoxia. Continuous positive airway pressure (CPAP) remains the mainstay of treatment, especially with patients with a BMI of over 35 where surgery is generally considered unsuitable. The problem lies in the poor compliance with CPAP therapy which ranges from 46-83% and this dwindles with the number of years these patients have been on this therapy. In this study, the authors picked up 17 patients who failed CPAP treatment. They were considered unsuitable for a localised operation and therefore underwent multilevel surgery for improvement of airway. These patients underwent a full assessment with BMI index, Epworth Sleepiness Scores and polysomnographic recordings. An assessment was also made with CT scans to measure various cephalometric parameters. The surgery offered was more extensive than modified uvulopalatopharyngoplasty. Some patients underwent coblation channelling of the tongue with or without midline glossectomy. Some also had lingual tonsil reduction and CobLAMO or submucosal lingualoplasty. The patients showed a significant clinical improvement measured in terms of apnoea–hypopnea index (AHI) and Epworth Sleepiness Scores before and after surgery. The standard criteria of AHI less than 20 and more than 50% reduction in AHI was met in 12 and five of them were ‘cured’ with an AHI of less than five. Interestingly enough, the BMI remained stable after surgery, indicating that the surgical outcome was unrelated to weight loss. The study is limited by small size and lacks a control group. However it provides useful information and possible avenues to deal with the highly prevalent problem of failure or lack of compliance with CPAP therapy.

Reference

Beyond Uvulopalatopharyngoplasty for Obstructive Sleep Apnoea; Single Surgeon Case Series of contemporary airway reconstruction.
Mackay SG, Jefferson NN, Mashall MS.
JOURNAL OF LARYNGOLOGY AND OTOLOGY
2013;127:1184-89.

JOURNAL OF VESTIBULAR RESEARCH

Mal de debarquement and motion sickness: is there a link?
Reviewed by: Victor Osei-Lah
July/August 2014 (Vol 23 No 3)
 

Mal de Debarquement Syndrome (MdDS) is usually short-lived but in some patients, it can persist for months to years. The pathophysiology is not clearly understood. The association of this disorder with motion sickness has been reported. The purpose of this study was two-fold: to determine whether severity of motion sickness correlates with the severity and duration of MdDS and can an artificial horizon (AH) during motion prevent the development of MdDS (AH has been found to alleviate motion sickness). Twenty male students aged between 18 and 25 years were recruited. The experiment was conducted in a ship motion simulator (SMS) equivalent to a 1,200 tonne ship in moderate sea condition of 150cm waves. Over a 120-minute voyage, subjects were exposed to three earth-referenced scenes (AH) projected inside the closed SMS cabin (AH 0% when scene was parallel to SMS cabin wall; AH 35% and 75% when projections were scaled down to 35% and 75% of full movement). Two questionnaires were used to assess outcome: motion sickness susceptibility and Mal de Debarquement questionnaire. Subjects rated the severity and duration of MdDS symptoms after the three AH conditions. In 50%-67% of subjects, MdDS symptoms did not resolve immediately after the various AH exposures, persisting longer than 15 minutes in 27-35% of subjects (few after six hours). Most symptoms were mild but in 27% subjects, the symptoms were rated moderate. The most common MdDS symptoms were ‘rocking’ (38%) and ‘swaying’ (34%). Motion sickness scores were significantly less at AH 75%, due to a reduction in sensory conflict. There was a significant correlation between motion sickness during SMS runs and the severity and duration of MdD symptoms, leading the authors to conclude that both conditions might result from a failure of adaptation to new motion conditions. However AH did not prevent the development of MdD which may suggest the persistence of an abnormal cognitive reaction to motion, leading to a ‘phantom perception of motion’ - MdDS.

Reference

Mal de debarquement, motion sickness and the effect of an artificial horizon.
Tala D, Wiener G, Shupak A.
JOURNAL OF VESTIBULAR RESEARCH
2014;24:17-23.

JOURNAL OF VESTIBULAR RESEARCH

Promethazine or lorazepam, which is superior for treatment of acute vertigo?
Reviewed by: Victor Osei-Lah
July/August 2014 (Vol 23 No 3)
 

If you are involved in the treatment of acute vertigo in the emergency setting, this double-blind study will be of interest. One hundred and eighty-four patients, aged between 19 and 63 years, presenting with acute peripheral vertigo were randomised to receive either 25mg IV promethazine (group 1) or 2mg IV lorazepam (group 2). On visual analog scales (VAS) of 100mm, subjects rated the severity of pre-treatment vertigo and nausea and post-treatment vertigo and nausea after two hours. Other secondary outcomes were the need for a second dose and adverse side-effects (AE). Statistically, there were no differences between baseline vertigo and nausea in the two groups. The mean reduction in the intensity of vertigo at two hours post-treatment was greater in the promethazine than the lorazepam group (46.5mm vs 25.7mm; p <0.001). This difference was statistically significant. A similar finding was noticed with nausea. Twenty-seven patients in group 2 required a second dose compared with nine in group 1. The most common AEs were lethargy and drowsiness, both short-lasting, resolving before patients were discharged from the emergency room. Statistically, there were no differences in AEs between the two groups. The authors conclude that IV promethazine is superior to lorazepam in reducing vertigo and nausea. They discussed limitations of the study including the arbitrary 2-hour vertigo severity assessment, the lack of a placebo arm, the limited dosage regimes and alternative medications. What struck me was that the majority of their patients had Benign paroxysmal positional vertigo (BPPV) (158) compared with 15 and 11 for vestibular neuritis and Menière’s respectively. Interestingly, the BPPV patients were not treated with repositioning manoeuvres, until after the final outcome measurement. Their symptoms may therefore have resolved simply because they avoided positional triggers and not because of the medications. I think this is a major flaw in the study and it seems a bit excessive in my opinion to administer IV medication for BPPV.

Reference

Intravenous promethazine versus lorazepam for the treatment of peripheral vertigo in the emergency department: A double blind, randomized clinical trial of efficacy and safety.
Amini A, Heidari K, Asadollahi S, et al.
JOURNAL OF VESTIBULAR RESEARCH
2014;24:39-47.

JOURNAL OF VESTIBULAR RESEARCH

Testing for otolith function
Reviewed by: Victor Osei-Lah
July/August 2014 (Vol 23 No 3)
 

Due to recent developments in vestibular science, it is now possible to assess all five vestibular receptors independently in each ear. Testing for otolith function has been more challenging than that for semicircular canal function. Off-axis (eccentric) rotation and the subjective visual vertical (SVV) tests have been used to test otolith function. The authors conducted this study using a much simpler technique to assess otolith function in 12 healthy adult volunteers. Subjects were seated securely and blindfolded in a rotatory chair so that both head and body were on the same axis. Instead of eccentric rotation, the head was tilted 30⁰ to the right (+30⁰) and to the left (-30⁰) as the chair was rotated to a peak velocity of 360⁰/s. The subjects used a rod to indicate their sense of verticality (SVV) while stationary (head upright: 0⁰, 30⁰ tilt to right and then left) and during rotation (head upright: 0⁰, 30⁰ tilt to right and then left). The angle of deviation of the SVV was determined in all test positions. The authors found that in the 0⁰ position the SVV shifted more to one side. After applying a correction factor, they showed that head tilt enhanced the SVV – greater angle of verticality. The average SVV during head tilt and rotation was 5.3⁰ more than in the stationary position. This effect was dependent on rotation rather than direction of head tilt. The authors concluded this simple method could be used clinically to assess otolith dysfunction. Although simple, it’s not necessarily cheap or accessible as a rotatory chair is required.

Reference

Unilateral otolith centrifugation by head tilt.
Winters SM, Bos JE, Klis SFL.
JOURNAL OF VESTIBULAR RESEARCH
2014;24:9-15.

JOURNAL OF VESTIBULAR RESEARCH

The optimum rise and fall time for tone burst cervical VEMP
Reviewed by: Victor Osei-Lah
July/August 2014 (Vol 23 No 3)
 

Vestibular evoked myogenic potential (VEMP) testing, using short tone bursts, is now commonplace in many vestibular labs. However, the parameters of the stimulus have not been uniform. To determine the effect of the rise/fall time of the 500Hz short tone burst, the authors recruited 30 healthy adult volunteers aged between 18 years and 35 years. Cervical VEMPs were elicited with eight different rise/fall times (1ms to 8ms) at a common plateau time of 0ms. The stimulus intensity was 95dBnHL. Latencies (absolute and inter-peak) and amplitudes of the responses were analysed. As the rise and fall time increased, so were the mean absolute and inter-peak p13/n23 latencies (p <0.01). Further statistical analysis showed that a minimum difference of 2ms rise/fall time was required to produce a statistically significant difference in p13-n23 peak intervals. Larger amplitudes were observed at 2ms and 3ms but the variability in the standard deviation at these times was large. Although the amplitude at 1ms was slightly less than at 2ms and 3ms (but larger than all the rest), the variability of the standard deviation was much less, leading the authors to pick 1ms (plateau of 0ms) as the optimum rise / fall time. There is also the added advantage of saving time.

Reference

The effect of rise/fall time of 500Hz short tone bursts on cervical vestibular evoked myogenic potential.
Singh NK, Apeksha K.
JOURNAL OF VESTIBULAR RESEARCH
2014;24:25-31.

JOURNAL OF VESTIBULAR RESEARCH

Vestibular disorders activities of daily living scale (VADL)
Reviewed by: Victor Osei-Lah
July/August 2014 (Vol 23 No 3)
 

The 28-item Vestibular disorders Activities of Daily Living scale (VADL) was specifically developed to assess the functional limitations faced by patients with vestibular disorders. There are three domains (12 functional, nine ambulatory and seven instrumental/task-related activities) and 10 ratings of independence. In this brief review, the author highlights the differences between this scale and others that are in routine use in vestibular rehabilitation clinics, namely the Dizziness Handicap Inventory (DHI), the Vestibular Rehabilitation Benefit Questionnaire (VBRQ) and the UCLA Dizziness questionnaire (UCLA-DQ). An important strength of the VADL is that it is better at measuring the levels of functional difficulties in patients with vestibular disorders, irrespective of diagnosis, than the others. It does more than assess quality of life by assessing the independence in activities of daily living of patients. The 10-rating levels of independence makes it a better instrument at detecting subtleties in functional limitations compared to the DHI (three levels) and UCLA-DQ (five levels). Although the VADL does not discriminate between vestibular diagnoses, it can differentiate between asymptomatic, healthy controls and patients with chronic vestibular symptoms. Furthermore, it is very sensitive to change after treatment. It is easy to use and therefore if this is not used routinely in your rehabilitation clinic, you may wish to include the VADL as a useful outcome measure.

Reference

Use of the vestibular disorders activities of daily living scale to describe functional limitations in patients with vestibular disorders.
Cohen HS.
JOURNAL OF VESTIBULAR RESEARCH
2014;24:33-8

LARYNGOSCOPE

Inferior turbinate reduction
Reviewed by: Mark Puvanendran
July/August 2014 (Vol 23 No 3)
 

Inferior turbinate surgery is a common ENT procedure; there are a multitude of techniques in use. This paper attempts to provide some evidence-based clarity to the situation. The authors have conducted a literature review, unfortunately there is no detail provided on the search strategy and the findings. Five papers are discussed in detail but there is no explanation as to why they have been selected. All the papers discussed are randomised trials and constitute level 1 evidence, however the techniques analysed, and the follow-up time vary enormously, making it difficult to draw any meaningful conclusions. The authors have suggested that submucosal resection and lateral displacement is the most effective technique at decreasing nasal obstruction due to inferior turbinate hypertrophy. Whilst this may instinctively seem correct the evidence provided is insufficient to draw this conclusion. Evidence for the optimum technique of turbinate reduction remains elusive.

Reference

Which inferior turbinate reduction technique best decreases nasal obstruction?
Larrabee YC, Kacker A.
LARYNGOSCOPE
2014;124(4):814-15.

NEUROSURGERY

Can reducing the dose of stereotactic radiation preserve hearing in patients with vestibular schwannomas?
Reviewed by: Gauri Mankekar
July/August 2014 (Vol 23 No 3)
 

It has been a challenge to preserve hearing following stereotactic radiosurgery (SRS) of vestibular schwannomas (VS). This study evaluated the association between computed tomography-based volumetric cochlear dose and loss of serviceable hearing after SRS in 59 patients of VS who met the study criteria. Intraobserver and interobserver reliability were assessed when determining modiolar point dose with the use of magnetic resonance imaging and computed tomography. The authors found that tumour related factors beyond the cochlear dose were more significant than the cochlear dose alone in dictating hearing outcomes. They have explained with the example of patients with excellent pretreatment hearing, smaller tumours, or tumours with a greater distance from the fundus who are more likely to have good long-term hearing irrespective of whether they are managed with SRS, microsurgery, or just observed. Reducing the radiation dose to the cochlea may play some role in improving hearing outcomes after SRS, but may necessitate reducing the margin dose or intentionally under treating the lateral portion in many cases. According to the authors, both these strategies would theoretically run the risk of reducing long-term tumour control and therefore, they do not advocate those strategies.

Reference

Significance of cochlear dose in the radiosurgical treatment of vestibular schwannoma: controversies and unanswered questions.
Jeffrey T. Jacob JT, Carlson ML, et al.
NEUROSURGERY
2014:74:466-74.

OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA

Sphincter trouble?
Reviewed by: Charlie Giddings
July/August 2014 (Vol 23 No 3)
 

This comprehensive edition of clinical review articles focuses on dysphagia, from basic science to the rehabilitation and treatment of difficult clinical problems. It is acknowledged early in the edition that the presence of dysphagia is associated with a longer inpatient stay, a 13-fold increase in mortality in rehabilitation patients, a reduced quality of life and huge healthcare costs. This review article in particular will be pertinent for those who see a small number of patients every year who may have cricopharyngeal muscle (CPM) dysfunction and be symptomatic. The diagnosis of CPM dysfunction is challenging and requires clinical and endoscopic evaluation of swallowing, videofluoroscopy and manometry in an appropriate setting. The review reiterates the importance of patient selection with CPM dysfunction, as those who have intact laryngeal elevation and pharyngeal contraction make the best surgical candidates for interventions targeting the sphincter. For those with an interest in this area a quality prospective study, including quality of life outcomes and morbidity, is much needed to compare endoscopic laser division of the CPM to the open approach.

Reference

Management of cricopharyngeus muscle dysfunction.
Khun MA, Belafsky PC.
OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA
2013;46:1087-99.

OTOLARYNGOLOGY-HEAD AND NECK SURGERY

Acute otitis externa guidelines
Reviewed by: Hannah Blanchford
July/August 2014 (Vol 23 No 3)
 

Acute otitis externa is probably one of the first conditions one learns how to treat as a doctor in ENT. This succinct review article summarises eight key recommendations for this frequent complaint and the level of evidence each is based on. It includes a helpful table of some ‘frequently asked questions’ and a list of instructions for patients. One recommendation is that in known or suspected non-intact tympanic membranes, non-ototoxic topical preparations should be prescribed. Another explains the importance of patient education to ensure drug delivery is optimal. The authors state the level of confidence in the evidence is high for the efficacy of topical treatment as initial management, but low regarding the comparative benefits of different ototopical preparations. The strongest recommendations are those regarding the provision of adequate pain relief and the need to avoid systemic antibiotics as initial therapy for diffuse, uncomplicated, acute otitis externa (unless there is extension beyond the ear canal or specific host factors). I would recommend a copy for each ENT emergency clinic.

Reference

Clinical Practice Guideline: Acute Otitis Externa Executive Summary.
Rosenfeld RM, Schwartz SR, Cannon CR, et al.
OTOLARYNGOLOGY-HEAD AND NECK SURGERY
2014;150(2):161-8.

OTOLARYNGOLOGY-HEAD AND NECK SURGERY

How clean is your scope?
Reviewed by: Hannah Blanchford
July/August 2014 (Vol 23 No 3)
 

This small study swabbed ‘non-critical’ areas of their flexible fibreoptic laryngoscopes, immediately prior to use on patients. The investigators collected 17 samples from eye pieces, driver handles and light cables from flexible scopes that had undergone their department’s cleaning protocol (enzymatic sponge clean then immersion of the shaft in Cidex). Bacterial growth was found in 41% (n=7). The organisms found were of skin and oral flora origin. This paper highlights the wide variety of cleaning protocols in existence including the use of protective sheaths, which may also fail to address the problem of contamination of ‘non-critical’ areas of the scope. It adds to previous data showing contamination of scope handles. Importantly, the paper doesn’t address whether such contamination might lead to nosocomial infections or whether a bigger sample might have found pathogenic organisms. The authors suggest departments examine their cleaning protocols to ensure these ‘hidden sources of contamination’ are addressed.

Reference

Microbiological Sampling of the Forgotten Components of a Flexible Fiberoptic Laryngoscope: What Lessons Can We Learn?
Bhatt JM, Peterson EM, Verma SP.
OTOLARYNGOLOGY-HEAD AND NECK SURGERY
2013;150(2):235-6.

OTOLOGY & NEUROTOLOGY

A revised coronal illustration of the ear
Reviewed by: Rebecca Heywood
July/August 2014 (Vol 23 No 3)
 

John Hopkins medical artist Max Brödel drew a black and white pen and ink coronal representation of the ear in 1939. It has been faithfully reproduced ever since and most of us will have seen it at some stage in textbooks and published literature. Although it is a beautiful illustration, it is not anatomically correct. It may even have been a preliminary sketch drawn prior to Brödel’s detailed anatomic observations made through dissection, examining histologic sections and watching surgery. The authors have identified three types of anatomic inaccuracy. The carotid artery and tympanic segment of the facial nerve may have been intentionally left out to avoid an overly cluttered drawing. Several structures have been ‘enhanced’, possibly to make them more prominent in the drawing: the cochlea, lateral semicircular canal and entire inner ear are all either enlarged or lie in an altered plane and the whole incus has been rotated almost 180°, presumably because it would otherwise be almost completely hidden behind the head of the malleus. Other errors are probably inadvertent, for example, the scutum is missing. While the drawing was probably meant as an artistic interpretation of the ear, it has been reproduced for decades as an anatomic depiction. The authors have therefore used high resolution fine-cut CT images and 3D virtual models to study the relationships of temporal bone structures and revised Brödel’s drawing. The result is a more anatomically accurate schematic with colour to enhance certain structures and create the illusion of depth. They comment that eventually this will likely be surpassed by a computer simulated depiction of the ear with genuine 3D features.

Reference

Revisiting Max Brödel’s 1939 classic coronal illustration of the ear.
Jackler RK, Gralapp CL, Mudry A.
OTOLOGY & NEUROTOLOGY
2014;35(3):555-60.

OTOLOGY & NEUROTOLOGY

Cochlear implantation outcomes may be worse in Ménière’s disease
Reviewed by: Rebecca Heywood
July/August 2014 (Vol 23 No 3)
 

A proportion of patients with Ménière’s Disease (MD) will ultimately develop bilateral profound hearing loss and may become suitable candidates for cochlear implantation. This study looks at 21 patients implanted in an ear affected by MD and compares consonant nucleus consonant (CNC) scores to those of 178 implanted adult non-MD patients. Nineteen patients had bilateral MD and two patients had unilateral MD with idiopathic hearing loss in the contralateral ear. All patients included in the study had had their implant for at least six months. Subjective improvement in vertiginous symptoms was reported postoperatively by five of the six patients with active MD at the time of cochlear implantation (CI). Patients with a longer duration of MD symptoms achieved better word scores than those with a shorter duration but the difference was not statistically significant. MD patients as a group overall, and specifically those with inactive disease had significantly lower postoperative CNC scores than non-MD implanted patients, though the authors note that all of the scores of the MD group as a whole fell within the range of scores of the large non-MD sample. Those who had previously had surgical or vestibular ablative procedures for MD had significantly better outcomes than those who had only medical management; it is postulated that this may be due to arrest of an underlying irritative neural stimulus preventing further damage to neuronal conduction. The authors conclude that MD patients have generally worse outcomes after CI than the non-MD population but that CI in those with active disease may give similar outcomes to the non-MD population.

Reference

Cochlear implantation in Ménière’s disease patients.
McRacken TR, Gifford RH, Kahue CN, et al.
OTOLOGY & NEUROTOLOGY
2014;35(3):421-25.

PLASTIC AND RECONSTRUCTIVE SURGERY

Publish or perish
Reviewed by: Sunil Kumar Bhatia
July/August 2014 (Vol 23 No 3)
 

Most doctors have submitted papers and very rarely is the paper accepted outright. In fact the majority are not accepted initially. Not to worry, you are in good company. Only 9% of 6000 manuscripts submitted annually to the Journal of the American Medical Association are accepted. Nearly 85% of manuscripts submitted to ‘Plastic and Reconstructive Surgery’ are initially rejected. Even Stephen Hawkin’s paper on ‘black hole radiation’ was rejected initially. There are a number of articles on ‘how to get published’ and reasons why manuscripts are rejected. This article is different, as it also discusses how to approach the reviewer’s comments and advises on approaches to revision of the manuscript. The authors discuss the process of peer review and provide pointers on accepting rejection and tackling the revisions as well as guidance on peer review. There is a good flow chart that plots choices after manuscript rejections. Candid and well written, this is an easy paper to read and assimilate. It is also useful to learn how to do a good peer review of a manuscript.

Reference

Manuscript rejection: How to submit a revision and tips on being a good peer reviewer.
Kotis SV, Chung KC.
PLASTIC AND RECONSTRUCTIVE SURGERY
2014;133(4):958-64.

Acta Otolaryngologica

Day case stapes surgery under local anaesthetic in Finland
Reviewed by: Victoria Possamai
May / June 2014 (Vol 23 No 2)
 

The authors start by stating that the common occurrence of postoperative vestibular disturbance may preclude day case stapes surgery. They carried out a prospective study of 20 patients undergoing stapedotomy under local anaesthetic and measured postoperative symptoms and recorded nystagmus with video-oculography 30 minutes postoperatively. The nystagmus and vestibular symptoms showed no correlation. Nine patients had spontaneous horizontal nystagmus, without gaze fixation (seven of nine showing an irritative pattern). Seven patients described nausea, though only one vomited. Nine experienced vestibular symptoms immediately postoperatively (vertigo in five, floating sensation in two and unspecific dizziness in two). All but one described this as mild-moderate. In five of these patients this had fully resolved within the first 50 minutes, however the duration of symptoms in the remaining four patients is not stated, and is highly relevant to the validity of the conclusion reached that day case stapes surgery is a feasible approach.

Reference

Immediate postoperative nystagmus and vestibular symptoms after stapes surgery.
Hirvonen TP, Aalto H.
ACTA OTOLARYNGOLOGICA
2013;133:842-5.

AMERICAN JOURNAL OF RHINOLOGY & ALLERGY

How effective is balloon sinuplasty in uncomplicated chronic sinusitis
Reviewed by: Laith Tapponi
May/June 2014 (Vol 23 No 2)
 

This prospective randomised controlled study was conducted on 92 patients with chronic rhinosinusitis [50 balloon sinuplasty and 42 functional endoscopic sinus surgery (FESS)] for six months. Occurrence of postoperative nasal bleeding, duration of prescription of pain medication use, recovery time, postoperative nasal toilet and short-term symptom improvement were all significantly better for balloon sinuplasty versus FESS. Balloon sinuplasty is an effective treatment in patients with uncomplicated sinusitis, who meet the criteria for medically necessary FESS. Hoping in future further studies will be conducted for a longer duration of follow-up.

Reference

Standalone balloon dilation versus sinus surgery for chronic rhinosinusitis: a prospective, multicentre, randomized, controlled trial.
Cutler J, Bikhazi N, Light J, Truitt T, Schwartz M.
AMERICAN JOURNAL OF RHINOLOGY & ALLERGY
2013;27(5):416-22.

AMERICAN JOURNAL OF RHINOLOGY & ALLERGY

Lacking of medical / surgical strategies for cystic fibrosis chronic rhinosinusitis
Reviewed by: Laith Tapponi
May/June 2014 (Vol 23 No 2)
 

Chronic rhinosinusitis (CRS) is a life-long disease in cystic fibrosis (CF) patients that can lead to substantial morbidity and decreased quality of life. This review evaluates the available literature and provides an update concerning the patho-physiology, current treatment approaches and future pharmaceutical tactics in the management of CRS in patients with CF. Advances in the care of patients with CF have improved pulmonary outcomes and survival. In addition, rapid developments regarding the underlying genetic and molecular basis of the disease have led to numerous novel targets for treatment. However, clinical and basic scientific research, focusing on therapeutic strategies for CF-associated CRS, lags behind the evidence-based approaches currently used for pulmonary disease. A multidisciplinary approach will be necessary to develop consistent and evidence-based treatment paradigms.

Reference

Cystic fibrosis chronic rhinosinusitis: a comprehensive review.
Chaaban MR, Kejner A, Rowe SM, Woodworth BA.
AMERICAN JOURNAL OF RHINOLOGY & ALLERGY
2013;27(5):387-95.

AMERICAN JOURNAL OF RHINOLOGY & ALLERGY

Lidocaine and nasal packing after nasal surgery
Reviewed by: Laith Tapponi
May/June 2014 (Vol 23 No 2)
 

A prospective, randomised, double-blind controlled trial was conducted in 63 sinusitis patients undergoing functional endoscopic sinus surgery (FESS). At the conclusion of the operation, 2% lidocaine-soaked biodegradable synthetic polyurethane foam was used. Pain was evaluated using a visual analogue scale at postoperative 1, 4, 8, 16, 20 and 24 hours. In addition, the amount of gauze that cleaned the blood around the nose was counted. Heart rate, rhythm and blood pressure were checked preoperatively and postoperatively to evaluate the influence of lidocaine on vital signs. Postoperative pain was decreased in the lidocaine group at all the postoperative time periods. Lidocaine reduced postoperative bleeding at postoperative 8 and 24 hours. Changes of blood pressure from preoperative values in the lidocaine group were not different from those in the control group. Heart rate in the lidocaine group was more stable than that in the control group. Lidocaine-soaked packs significantly reduced postoperative pain without significant changes in vital sign. It is a useful method to reduce pain / nose discomfort during the early post FESS period.

Reference

Effect of lidocaine-soaked nasal packing on pain relief after endoscopic sinus surgery.
Mo MJ, Park Y, Chung Y.
AMERICAN JOURNAL OF RHINOLOGY & ALLERGY
2013;27(6):e174-e7.

AMERICAN JOURNAL OF RHINOLOGY & ALLERGY

Management of nasal polyposis with Montelukast
Reviewed by: Laith Tapponi
May/June 2014 (Vol 23 No 2)
 

The purpose of this study was to determine the impact of montelukast and leukotriene antagonists treatment alone and in conjunction with intranasal steroid on nasal symptoms, objective clinical outcomes and immune parameters in nasal polyposis. Twelve studies fulfilled eligibility: five randomised control trials and seven cases series. The montelukast group showed significant improvements in nasal polyposis symptoms over placebo; however, these randomised trials were unable to be combined via meta-analysis. Montelukast is an effective tool for treating nasal polyposis, with limited benefit as an adjunctive therapy. Additional study is required to determine the most beneficial strategy and patient population for their use.

Reference

Leukotreine antagonists in nasal polyposis: a meta-analysis and systemic review.
Wentzel JL, Soler ZM, DeYoung K, Nguyen SA, Lohia S, Schlosser RJ.
AMERICAN JOURNAL OF RHINOLOGY & ALLERGY
2013;27(6):482-9.

AMERICAN JOURNAL OF RHINOLOGY & ALLERGY

Nasal toilet and nasal surgery
Reviewed by: Laith Tapponi
May/June 2014 (Vol 23 No 2)
 

This is a good study. It is a prospective, controlled study, approved by the Institutional Review Board of Gachon University Gill Medical Center, of 30 patients for nine months. The aim was to evaluate the effect of maxillary sinus saline irrigation after surgery. Maxillary sinus saline irrigation is effective in the prevention of poor prognostic factors, such as the prevention of purulent rhinorrhoea, extensive granulation formation and polyp recurrence after endoscopic sinus surgery.

Reference

The effect of maxillary sinus irrigation on early prognostic factors after endoscopic sinus surgery: a preliminary study.
Kim ST, Sung UH, Jung JH, Paik JY, Woo JH, Cha HE, Kang IG.
AMERICAN JOURNAL OF RHINOLOGY & ALLERGY
2013;27(5):e158-e61.

AMERICAN JOURNAL OF RHINOLOGY & ALLERGY

Promote healing after endoscopic sinus surgery
Reviewed by: Laith Tapponi
May/June 2014 (Vol 23 No 2)
 

Steroid-infused absorbable nasal dressings after sinus surgery have been used to improve wound healing and to reduce the early recurrence of polyps . This study is small. Twenty patients, only, who underwent bilateral endoscopic sinus surgery (ESS) for chronic rhinosinusitis were recruited and randomised into two groups with / without triamcinolone, TA(20mg)-soaked bioabsorbable dressing in both nasal cavities. The purpose of this study was to evaluate the systemic effects and safety of steroid-impregnated absorbable nasal packing after ESS. Serum cortisol, 12-hour urine cortisol, serum adrenal-corticotrophichormone (ACTH) and serum osteocalcin were measured preoperatively and on postoperative days 2 and 10. The serum cortisol levels were significantly suppressed at postoperative days one and two in the TA group. However, their systemic effects changes are not statistically significant.

Reference

Systemic effects and safety of triamcinolone-impregnated absorbable nasal packing after endoscopic sinus surgery: a randomized, double-blinded, placebo-controlled study.
Hong SD, Kim JH, Dhong H-J, Kim HY, Chung S-K, Chang YS, Sohn JH.
AMERICAN JOURNAL OF RHINOLOGY & ALLERGY
2013;27(5):407-10.

AMERICAN JOURNAL OF RHINOLOGY & ALLERGY

The impact of patient education and treatment of allergic rhinitis
Reviewed by: Laith Tapponi
May/June 2014 (Vol 23 No 2)
 

Allergic rhinitis is associated with illness, disability, health care costs and comorbidities such as asthma. A series of patient surveys, between 2006 and 2011, was conducted. This article compares data regarding disease burden, treatment patterns and patient expectations in Middle Eastern countries with those from other regions. The survey highlighted the relatively low use of intranasal corticosteroids, the current ‘gold standard’ treatment for allergic rhinitis. Patient education must play a central role in treatment decision making, particularly in the Middle East, to achieve higher patient satisfaction. The health care practitioners in the Middle East should be more strongly encouraged to use intranasal steroidal sprays for their patients.

Reference

The impact and treatment of allergic rhinitis in the Middle East: a comparison with the landmark allergy surveys from other worldwide regions.
Hadi UH, Rahman HA.
AMERICAN JOURNAL OF RHINOLOGY & ALLERGY
2013;27(6):490-4.

AMERICAN JOURNAL OF RHINOLOGY & ALLERGY

The microdebrider versus the Blakesley forceps in FESS polypectomy
Reviewed by: Laith Tapponi
May/June 2014 (Vol 23 No 2)
 

Functional endoscopic sinus surgery (FESS) represents the ‘gold standard’ therapy when medical treatment fails. The availability of different tools raises the question of which one provides significant advances in technique and surgical outcome. This is a good prospective randomised single-blind study, designed to analyse 311 cases of bilateral nasal polyposis. Each patient served as his / her own control, meaning that one side was operated on using the Blakesley forceps and the opposite side using the micro debrider. The follow-up period was 12-14 months. Gender, age, allergy and eosinophilia did not affect the surgical prognosis. The Blakesley forceps caused a significantly lower nasal polyposis recurrence rate but yielded a higher rate of synechia formation than the microdebrider.

Reference

Surgical treatment of nasal polyposis: A comparison between cutting forceps and microdebrider.
Tirelli G, Gatto A, Spinato G, Tofanelli M.
AMERICAN JOURNAL OF RHINOLOGY & ALLERGY
2013;27(6):e202-e6.

BRITISH JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY

Minimal gap interpositional arthroplasty versus aggressive gap arthroplasty in temporomandibular joint ankylosis
Reviewed by: Sampath Chandra Prasad
May/June 2014 (Vol 23 No 2)
 

Arthroplasty in temporomandibular joint (TMJ) ankylosis is managed by three basic techniques; gap arthroplasty, interpositional arthroplasty and joint reconstruction. In this three-year, prospective, study of 15 patients, the authors evaluate whether or not aggressive gap arthroplasty is essential in the management of ankylosis of the TMJ. Of the 15 patients (17 joints), 12 had unilateral and three had bilateral involvement, with trauma being the most common cause. A minimal gap of 5-8 mm was created in all 15 patients and interpositional gap arthroplasty was achieved by insertion of temporalis fascia. Eleven patients had unilateral coronoidectomy and four had bilateral coronoidectomy based on Kaban's protocol. Preoperative assessment included recording of history, clinical and radiological examinations, personal variables, the aetiology of the ankylosis, the side affected, and any other relevant findings. Patients were assessed postoperatively by a surgeon unaware of the treatment given for a minimum of three years, which included measurement of the maximal incisal opening, presence of facial nerve paralysis, recurrence, and any other relevant findings. Preoperative maximal incisal opening was 0-2 mm in eight cases and 2-9 mm in nine. Postoperatively adequate mouth opening of 30-40 mm was achieved in all cases, with no recurrence or relevant malocclusion during three-year follow up. The authors conclude that aggressive gap arthroplasty is not essential in the management of ankylosis of the TMJ and that minimal gap interpositional arthroplasty with complete removal of the mediolateral ankylotic mass is a feasible and effective method of preventing recurrence.

Reference

Is aggressive gap arthroplasty essential in the management of temporomandibular joint ankylosis? – A prospective clinical study of 15 cases.
Babu L, Jain MK, Ramesh C, Vinayaka N.
BRITISH JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY
2013;51(6):473-8.

COCHLEAR IMPLANTS INTERNATIONAL

Another study investigating how patients and families choose their implants
Reviewed by: Thomas Nikolopoulos
May/June 2014 (Vol 23 No 2)
 

The authors describe the procedure followed by the Cochlear Implant Centre in involving the patients in their choice of device and tabulate the reasons given by patients for choosing a particular device. A retrospective service evaluation of 43 adults and 19 children was carried out and the data was analysed. The results revealed a wide range of reasons for choosing a particular device (fit and comfort, reputation of the company, look of the device and colour options, easiness to use,  smaller size of the processor, reliability, remote control, battery options, different programmes and extra features, direct repair management, future proof and local knowledge). However, it was interesting to find that the single most common reason for choosing a particular device was related to the aesthetics and comfort of the device. This is in contrast with the results reported by the other study in the same issue and shows that many factors may influence the related assessments (how many devices were available, type of interview, age of participants, etc.).

Reference

Patients' involvement in choosing a cochlear implant.
Chundu S, Stephens N.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(3):165-8.

COCHLEAR IMPLANTS INTERNATIONAL

Langerhans cell histiocytosis and bilateral cochlear implantation
Reviewed by: Thomas Nikolopoulos
May/June 2014 (Vol 23 No 2)
 

Otologic disorders associated with Langerhans cell histiocytosis (LCH) are rather frequent in this rare proliferative disease and can affect up to one third of patients. Treatment of local and systemic disease may include medical, surgical and radiation therapies. Involvement of the temporal bone can lead to conductive and, rarely, sensorineural hearing loss. The authors report a case of a 45-year-old female with known bilateral temporal bone LCH. Following bilateral partial labyrinthectomy, post-operative testing showed a Hearing in Noise Test (HINT) result in quiet of 17%. Left-sided cochlear implant followed by immunosuppressive therapy for persistent disease showed marked improvement with post-operative HINT in a quiet room of 80% and 63%, at one and two years. This decline in performance led the authors to decide on right side post-labyrinthectomy cochlear implantation. However, it is not clear why HINT deteriorated and how medical treatment affected it. Nevertheless, 55 months after left implantation, and 10 months after right cochlear implantation, binaural post-operative HINT in quiet was 81%. The authors concluded that surgical excision of LCH lesion remains a mainstay of treatment for temporal bone involvement and that bilateral cochlear implantation with adjuvant immunosuppression demonstrated both immediate and delayed improvement in auditory function after staged cochlear implantation in the setting of persistent disease. Although the results seem promising we should be very cautious in this particular disease and long-term follow-up is needed.

Reference

Bilateral cochlear implantation in bilateral Langerhans cell histiocytosis.
Segel JM, McKinnon BJ.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(3):178-80.

COCHLEAR IMPLANTS INTERNATIONAL

A case report showing how a teenager with progressive hearing loss and severe learning difficulties can be helped with a cochlear implant
Reviewed by: Thomas Nikolopoulos
May/June 2014 (Vol 23 No 2)
 

This paper describes the assessment and subsequent cochlear implantation of a teenager with progressive sensorineural hearing loss and severe learning difficulties. He had been diagnosed with trisomy 3P syndrome and severe additional disorders with global developmental delay. Imaging had demonstrated a primitive otocyst in one ear and Mondini dysplasia in the other ear. However, he eventually became a relatively good hearing-aid user. Unfortunately, his hearing deteriorated and this affected his behaviour, communication and quality of life. Finally, he did not want to use his hearing aid as it provided limited benefit. Although the assessment process was rather challenging, the decision for cochlear implantation had taken into account all the pros and cons. His mother and teacher helped to prepare him and the (re)habilitation and tuning sessions were modified in order to accommodate the related difficulties and his slow progress. However, the outcome of this particular deaf teenager with additional disorders indicates how flexible the assessment, the tuning and the (re)habilitation should be in order to provide the maximum benefit.

Reference

A difficult case: severe learning difficulties and patient selection.
Ford J, Bradley J.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(S3):s23-s5.

COCHLEAR IMPLANTS INTERNATIONAL

Assessing outcomes of bilateral implantation in the UK
Reviewed by: Thomas Nikolopoulos
May/June 2014 (Vol 23 No 2)
 

In 2009, the UK National Institute for Health and Care Excellence published guidance for cochlear implantation: all suitable children are eligible to have simultaneous bilateral cochlear implants or a sequential bilateral cochlear implant if they already had received one. Fifteen UK cochlear implant centres formed a consortium to carry out a multi-centre audit. The audit involves collecting data from simultaneously and sequentially implanted children at four intervals: before bilateral cochlear implants or before the sequential implant, one, two, and three years after bilateral implants. The measures include localisation, speech recognition in quiet and background noise, speech production, listening, vocabulary, parental perception, quality of life, and surgical data including complications (reported in another study). As the audit passed the two year point the authors reported data from 850 children. However, due to the short follow-up there were few results on sound localisation and speech recognition in noise. Auditory perception and speech intelligibility showed an improvement with time for simultaneously implanted children. With regard to the sequentially implanted children, there was a wide variation in the results. It seems that the two year interval is too early for any definite conclusions and this study gives us only a flavour of what we should expect.

Reference

United Kingdom National Paediatric Bilateral Cochlear Implant Audit: Preliminary results.
Cullington H, Bele D, Brinton J, Lutman M.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(Suppl.4):S22-6.

COCHLEAR IMPLANTS INTERNATIONAL

Can we perform cochlear implantation under local anaesthesia?
Reviewed by: Thomas Nikolopoulos
May/June 2014 (Vol 23 No 2)
 

The authors reviewed a patient series of 16 cochlear implantations performed under local anaesthetic, including a description of the centre's technique for this procedure. They also described the application of a method for calculation of the potential morbidity / mortality avoided by using this technique. The assessment included the 16 patients’ preoperative medical and anaesthetic notes and the calculation of predicted individual P-POSSUM scores (physiological and operative severity score for the enumeration of mortality and morbidity). The results revealed that all 16 patients were implanted successfully with no significant complications. Age range was 26-92 years, with an average of 68 years. The patients’ average predicted mortality score associated with a general anaesthetic was 8.6% and the respective morbidity score was 58%. The authors concluded that cochlear implantation under local anaesthesia seems to be a safe and effective procedure. It has the benefit of avoiding the operative mortality risk predicted by P-POSSUM scores. Therefore, a potential group of cochlear implant recipients considered ‘unfit’ or high risk for general anaesthesia may be operated under local anaesthesia. An interesting and useful study. However, a larger study assessing patients’ discomfort and surgeons’ related problems is needed.

Reference

How we do it: Local anaesthetic cochlear implantation.
Toner F, Jackson CP, Toner JG.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(4):232-5.

COCHLEAR IMPLANTS INTERNATIONAL

Comparison of implanted children with additional disorders with hearing controls
Reviewed by: Thomas Nikolopoulos
May/June 2014 (Vol 23 No 2)
 

The authors compared 14 deaf children with cochlear implants (CIs) and developmental disabilities with a hearing control group of seven children of similar ages and similar disabilities in a cross-sectional study of language and functional skills. Daily functional skills were measured using the Paediatric Evaluation of Disability Inventory (PEDI), which provides standard and scaled scores in self-care, mobility and social functioning domains. Language was assessed using the Preschool Language Scales which provide standard scores and age equivalents. Most children in this study (90.5%) had cognitive disabilities and 57% had motor disabilities. Compared with hearing controls, children with CIs were less likely to have functional independence in any PEDI domain. Children with CI had significantly lower median social functioning standard scores compared with controls. However, after controlling for nonverbal cognitive abilities and language level, the difference was no longer significant. Among children with CI, age at implant and duration with device were not associated with PEDI scores. The authors concluded that although children with CI and developmental disabilities were found to have similar functional skills as hearing children with similar disabilities regarding the PEDI domains of self-care and mobility, they had lower social function standard scores. This lower social functioning among children with implants was attributed to the possible lower language levels and possible language deficits seen in the CI group. However, several design problems of the study (e.g. small numbers, quite heterogeneous groups) weaken these very interesting outcomes.

Reference

Functional performance among children with cochlear implants and additional disabilities.
Meinzen-Derr J, Wiley S, Grether S, Choo DI.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(4):181-9.

COCHLEAR IMPLANTS INTERNATIONAL

Does aetiology of deafness affect cochlear implant outcome in deaf children?
Reviewed by: Thomas Nikolopoulos
May/June 2014 (Vol 23 No 2)
 

The authors retrospectively assessed 163 children implanted between 1996 and 2008 (0-18 years, mean 5 years). The mean follow-up was 65 months. Aetiology of deafness was found in 104 cases and 69 children (52%) suffered from hereditary hearing loss. All children showed improvement in their auditory performance. However the authors found that children with connexin-26 mutation performed significantly better and children with Usher and CHARGE-syndrome significantly worse. Post-meningitic and post-septic children were slower in progress but reached the same levels of performance later on. The authors concluded that the primary cause of deafness, among other factors, has a considerable impact on outcome of rehabilitation and this should be taken into account in designing aetiology-adjusted therapy modules. Again, mixing-up prelingual with postlingual deaf children with wide variation in ages and experience weakens the outcomes and suggest that future studies should control their comparisons for all confounding factors.

Reference

Influence of etiologic factors on speech perception of cochlear-implanted children.
Janeschik S, Teschendorf M, Bagus H, Arweiler-Harbeck D.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(4):190-9.

COCHLEAR IMPLANTS INTERNATIONAL

Does anaesthesia affect intraoperative monitoring of cochlear implant function in children?
Reviewed by: Thomas Nikolopoulos
May/June 2014 (Vol 23 No 2)
 

Intraoperative electrical impedance measurements, electrically evoked stapedial reflex threshold (ESRT) and evoked compound action potential (ECAP) are supposed to be very helpful in postoperative tuning of the device following implantation in young children. The authors’ aim was to evaluate the effects of intravenous anaesthesia on intraoperative monitoring of cochlear implant function in paediatric cochlear implantees. It was a prospective study of 29 children aged from 18 months to 11 years. All children had bilateral severe to profound sensorineural hearing loss. Patients were maintained on an infusion of Fentanyl at 0.3‐0.6  ugm / kg / hr and Propofol at 4‐8 mg / kg / hr intraoperatively. Intraoperative measurements were done after performing the train of four tests on the adductor pollicis muscle. The results revealed that ESRT was unaffected by intravenous anaesthesia. Electrical impedance and ECAP were not affected by any technique of anaesthesia. Therefore, the authors concluded that intravenous anaesthesia with the above mentioned protocol has little or no effect on the intraoperative auditory thresholds and is therefore recommended for determining these thresholds during cochlear implant surgery. A rather reassuring study, telling us to continue using these measurements under anaesthesia, with a standard protocol.

Reference

Effect of total intravenous anaesthesia on intraoperative monitoring of cochlear implant function in paediatric patients.
Jana JJ, Vaid N, Shanbhag J.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(3):169-73.

COCHLEAR IMPLANTS INTERNATIONAL

Does cochlear implantation surgery affect taste?
Reviewed by: Thomas Nikolopoulos
May/June 2014 (Vol 23 No 2)
 

The authors assessed the risk of taste disorders following the classical cochlear implantation surgery that involves mastoidectomy and posterior tympanotomy. Twenty-six patients underwent a taste test before, three days after and six weeks after cochlear implantation surgery. The taste sensations were evaluated. Patients’ self-ratings of taste function were also obtained. In addition, the surgeons provided information concerning the intraoperative status of the chorda tympani. The results revealed that 19% (5 of 26) of the patients had postoperative taste dysfunction, as measured either subjectively or objectively or both. One of these five individuals had taste disturbance as assessed by both subjective and objective measures; in another, it was merely reported subjectively. Three patients were subjectively asymptomatic but the postoperative taste test revealed a dysfunction. Sixteen percent of the patients in whom the chorda tympani was reported to be preserved intraoperatively had a postoperative taste dysfunction. Although the chorda tympani was rerouted in five patients, only two of them (40%) had transient taste disorder. In two of those patients with postoperative taste dysfunction, the chorda tympani was not intraoperatively exposed. However, these individuals experienced postoperative taste problems. The recovery rate was 100% at six weeks after surgery. The authors concluded that cochlear implantation entails only a minimal risk of taste dysfunction and that this is a rather transient problem. Although the results are interesting, it is already well known from stapes surgery that cutting off the chorda tympani does not cause significant problems in the majority of patients and that any related disturbance usually disappears with time. Moreover, the surgical reports are often inaccurate regarding chorda tympani and therefore the related studies ambiguous.

Reference

Taste sensation following cochlear implantation surgery.
Alzhrani F, Lenarz T, Teschner M.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(4):200-6.

COCHLEAR IMPLANTS INTERNATIONAL

Electrode array in the internal auditory canal of malformed ears. What do we do?
Reviewed by: Thomas Nikolopoulos
May/June 2014 (Vol 23 No 2)
 

The authors in this case report underline the importance of a radiological technique which allows 3D imaging of the cochlear implant electrode position postoperatively in cases of cochlear malformation, and show a technique to prevent a repeat of cochlear implant electrode insertion in the internal auditory canal (IAC). A one and a half-year-old patient with an incomplete partition (IP) III cochlear malformation was implanted and it was later discovered that the speech processor could not be tuned because the electrode array had been inserted into the IAC. The single plain postoperative X-ray was not sufficient to detect the incorrect insertion of the cochlear implant electrode array. However a three-dimensional radiology showed that the array was inserted in the IAC. During revision surgery, the original cochlear implant electrode was temporarily left in place under the assumption that it would block the entrance to the IAC and prevent IAC insertion of the replacement electrode. Indeed, the second array was correctly inserted as confirmed by three-dimensional radiology. The authors concluded that postoperative three-dimensional radiological assessment after cochlear implant surgery should be done in cases of malformation.  In addition, they suggest that leaving the original electrode in place can help to prevent a repeat incorrect insertion of the electrode. Although the whole case study is interesting and probably useful in malformed cochleas, the three-dimensional illustrations and the figures were of rather poor quality and difficult to interpret

Reference

Identification and revision of a displaced cochlear implant electrode in the internal auditory canal.
Todt I, Rademacher G, Ernst A.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(4):236-9.

COCHLEAR IMPLANTS INTERNATIONAL

Has hydroxyapatite bone cement any complications when used in cochlear implantation?
Reviewed by: Thomas Nikolopoulos
May/June 2014 (Vol 23 No 2)
 

The authors aimed to report the complications of using hydroxyapatite (HA) bone cement when implanting a cochlear implant (CI) device. A case series of three patients who had undergone cochlear implantation are presented in this study. A bony defect was seen in the external auditory meatal wall posteriorly in all three cases. This was intimately related to the site of HA bone cement, which had been used to anchor the electrode array at the time of the original implantation. Persistent otorrhoea was usually a feature at clinical presentation. The authors removed the HA bone cement and repaired the bony defect. This resulted in resolution of the otorrhoea in all cases. The authors concluded that the use of HA bone cement in cochlear implantation may cause dehiscence of the external auditory meatal wall. Taking into account that their current belief is that the electrode array does not need to be secured with cement, they recommend that HA cement should not be used to secure the electrode array in cochlear implantation surgery. I believe that a small number of centres still use it.

Reference

Complications of hydroxyapatite bone cement use in cochlear implantation?
Gaskin JA, Murphy J, Marshall AH.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(3):174-7.

COCHLEAR IMPLANTS INTERNATIONAL

Implanted children with cerebral palsy. The need for specific outcome measures
Reviewed by: Thomas Nikolopoulos
May/June 2014 (Vol 23 No 2)
 

The authors aimed to review the evidence for cochlear implantation in children with cerebral palsy and evaluate the current outcome measures in this group of patients. The evidence in the literature revealed that cognitive functioning appears to be the most important prognostic factor when considering cochlear implantation in children with cerebral palsy. On the other hand, physical impairment was not found to negatively impact the outcome of cochlear implantation. The authors highlight the lack of appropriate outcome measures and conclude that the current lack of a suitable set of outcome measures appropriate to this group of patients, should not lead clinicians to conclude that any impact upon quality of life is limited, or less significant when compared to children without complex needs. Although this is very clear and evident, the design and evaluation of such measures seems to be difficult as their continuous lack indicates.

Reference

The need for specific outcome measures when evaluating cochlear implantation in hearing impaired children with cerebral palsy.
Bruce IA, Markey A, Henderson L, Green KMJ.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(S3):s35-s7.

COCHLEAR IMPLANTS INTERNATIONAL

Ototoxicity and cochlear implantation
Reviewed by: Thomas Nikolopoulos
May/June 2014 (Vol 23 No 2)
 

The authors assessed the outcome of cochlear implantation in patients deafened by ototoxic drugs and compared it with the outcome of implantation in sudden sensorineural hearing loss (SSNHL) with a similar duration of deafness. Primary outcome measure was post-implantation Bamford-Kowal-Bench (BKB) score in quiet in both groups. Secondary outcome measure was any significant complications following implantation. The authors identified retrospectively 14 patients in the ototoxic group, who were matched with 13 patients in the SSNHL group. The postoperative BKB score in the ototoxic group ranged from 33 to 100% (median score 91%). One patient had bilateral CI. One patient required explantation following an infection. The postoperative BKB score in the SSNHL group ranged from 16 to 100% (median score 88%). One patient in this group could not be tested using this method as he / she did not have open set speech discrimination. Two patients in this group had bilateral CI. The authors found no statistically significant difference in the BKB scores in the two groups and concluded that patients with profound hearing loss due to ototoxic agents can be rehabilitated successfully with CI. The outcomes may be variable and may be dependent on the underlying pathology for which the ototoxic agents were prescribed. The last conclusion means that additional disorders or diseases may affect the outcome. This is reasonable and true for all implantees. The wide variation and the small numbers of patients do not help in the clarification of the issue studied.

Reference

Cochlear implantation in patients deafened by ototoxic drugs.
Nichani J, Bruce IA, Mawman D, Khwaja S, Ramsden R,
Green K.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(4):207-12.

COCHLEAR IMPLANTS INTERNATIONAL

Surgical safety and complications of bilateral paediatric cochlear implantation
Reviewed by: Thomas Nikolopoulos
May/June 2014 (Vol 23 No 2)
 

Bilateral paediatric cochlear implantation (CI) in the UK was approved in 2009 and a prospective multi-centre National Paediatric Cochlear Implant Audit was established in order to collect a large dataset of paediatric implantations. The aim of the surgical part of the audit, reported in this study, was to collect data on surgical practice, outcomes and complications. The data came from 14 surgical centres and was collected prospectively, including simultaneous and sequential bilateral as well as unilateral implantations. The data included several details such as age at implantation, aetiology of deafness, implant type, duration of surgery, the use of electrophysiological testing, and the use of pre- and postoperative imaging. Data of major and immediate minor complications were also collected. The results took into account 1397 CI procedures in 961 CI recipients; 436 bilateral simultaneous, 394 bilateral sequential, and 131 unilateral cochlear implantations. The overall major complication rate was 1.6% (0.9% excluding device failure) and was similar following bilateral CI compared to sequential and unilateral CI. The authors concluded that this prospective multi-centre audit provides evidence that bilateral paediatric CI is a safe procedure in the UK, thus endorsing its role as a major therapeutic intervention in childhood deafness. Although multi-centre studies have several weaknesses, large numbers are always helpful and give a rough estimate of the global picture of bilateral cochlear implantation with regard to surgical safety.

Reference

Results of a prospective surgical audit of bilateral paediatric cochlear implantation in the UK.
Broomfield SJ, Murphy J, Emmett S, et al.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(Suppl.4):S19-S21.

COCHLEAR IMPLANTS INTERNATIONAL

The incidence of auditory neuropathy as calculated from a newborn hearing screening programme in the UK
Reviewed by: Thomas Nikolopoulos
May/June 2014 (Vol 23 No 2)
 

The author aimed to estimate the prevalence and incidence of auditory neuropathy spectrum disease (ANSD) in the neonatal intensive care unit (NICU) population in Avon. Data was collected from the Newborn Hearing Screening Programme database to determine the number of babies with bilateral sensorineural hearing loss. Then, all available related data and audiological paper records were reviewed to determine the number of babies diagnosed with ANSD, their behavioural hearing thresholds and how the babies were managed. The average incidence of congenital bilateral sensorineural loss was 1.53 per 1000 births (range 1.03 to 1.94 per 1000 births); the average incidence of ANSD was 0.24 per 1000 births (range 0 to 0.52 per 1000 births). Over a period of eight years, 21 out of 134 (15.7%) children identified with abnormal air and bone conduction auditory brainstem response (ABR) thresholds were diagnosed with ANSD. The major shortcoming in this study is the fact that children with ANSD who were born in maternity units without being admitted to intensive care units were not diagnosed and taken into account. However, the follow-up audiological assessment was very interesting. It showed that the audiogram hearing thresholds cannot be predicted from the initial test results when ANSD is diagnosed, although the majority of children with no ABR will show at least a degree of hearing loss in the audiogram.

Reference

The prevalence of auditory neuropathy spectrum disorder in neonates referred from the Newborn Hearing Screening Programme in Avon (Greater Bristol Area).
Midgley E.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(S3):s15-s17.

COCHLEAR IMPLANTS INTERNATIONAL

The outcomes of implanted children with additional disorders or auditory neuropathy
Reviewed by: Thomas Nikolopoulos
May/June 2014 (Vol 23 No 2)
 

The authors assessed the benefit of cochlear implantation (CI) in (A) 70 children with complex needs (CD) and (B) 22 children with auditory neuropathy spectrum disease (ANSD). As outcome measures, a category scale score from 0 to 10 (0-100%) for speech perception and an alternative scale score from 0 (non-user) to 4 (great benefit) were used based on a broader view of benefit when speech tests were not applicable. The results revealed that children with CD had a mean alternative scale score of 3.0 (clear benefit). Forty-eight children with cognitive disabilities scored significantly worse than the 22 children with solely physical disorders, 2.6 vs. 3.8. The mean score for 29 children tested with standard speech tests was 7.7 (77%). Five out of six non-users had cognitive disabilities. The standard speech test battery was applicable in 19 / 22 children (86%) with solely physical disabilities, but only in 10 / 48 (21%) of children with cognitive disabilities. Thirteen out of 22 children with CI and ANSD were old enough to be evaluated by speech tests and had a mean speech category score of 8.3. For 20 children, improved language skills and better social interaction was reported. The two non-users were implanted late. The authors concluded that CI was beneficial to the vast majority of children with CD. Children with cognitive dysfunction had poorer speech and language development, but still benefited clearly from CI. Finally children with ANSD without cognitive difficulties had outcomes similar to those of implanted children without CD. A very interesting study, although children with ANSD might not be included in a study of children with CD.

Reference

The Oslo experience of cochlear implant in children with complex disorders and auditory neuropathy spectrum disorder.
Bunne M.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(S3):s31-s4.

COCHLEAR IMPLANTS INTERNATIONAL

The parents’ view on cochlear implantation of deaf children with additional disorders
Reviewed by: Thomas Nikolopoulos
May/June 2014 (Vol 23 No 2)
 

The authors assessed parents’ perspectives on their experiences of, access to, and outcomes from cochlear implantation for their child with complex needs. Purposive sampling was used to recruit 10 parents of children with varying additional disabilities. The age range of the children was between 2 and 11 years at the time. A semi-structured interview format was used to collect data and the interviews were audio recorded and transcribed for analysis. Thematic content analysis was used to explore the data. The results were analysed using the following pattern. Individual themes were clustered together to form four main themes describing parents’ perspectives and experience. The four main themes were: ‘Assessment process’, ‘Reported benefits of cochlear implantation’, ‘Wearing the processor’ and ‘Educational issues’. The outcomes were very interesting as parents described in detail their views that were sometimes surprising or unexpected. They appreciated changes in their child's communication and social changes where the child was included more in family life. Challenges relating to delays in the assessment process were reported. Similarly, the difficulties associated in accessing the technology were identified and perceived by some parents as discriminatory. One of the most interesting findings was the report from one parent that before implantation his child was diagnosed as having severe learning difficulties and the diagnosis following implantation was no learning difficulties. This highlights the ‘severe’ difficulties in diagnosis, assessment and (re)habilitation of these children.

Reference

Children with complex needs and cochlear implants: The parent's perspective.
Mulla I, Harrigan S, Gregory S, Archbold S.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(S3):s38-s41.

COCHLEAR IMPLANTS INTERNATIONAL

The protein pejvakin in human spiral ganglion cells
Reviewed by: Thomas Nikolopoulos
May/June 2014 (Vol 23 No 2)
 

Although cochlear implantation is one of the most successful methods of management for profound deafness, the exact aetiology and pathophysiology of deafness remain obscure. DFNB59 gene encodes the protein pejvakin (PJVK) and its mutations cause autosomal recessive auditory neuropathy as well as other forms of sensorineural hearing loss. The authors performed an immunohistochemical study and explored the distribution of PJVK protein in surgically obtained human cochleae. The human cochleae had normal hearing thresholds before the operation that was performed for brain tumours using a transcochlear approach. The expression of PJVK was located in the cell bodies of all spiral ganglion neurons rather than the nerve fibres that were labelled with Tuj 1 antibody. As Tuj 1 antibody stained the cytoplasm of type 1 cells, PJVK antibody labelled both type 1 and type 2 cells. The nuclei of the neurons were also PJVK-positive. No labelling was seen in the structures within the organ of Corti and the stria vascularis. The authors demonstrated for the first time the expression of PJVK in human spiral ganglion neurons. It remains to be seen how these advances in gene and protein research will lead to prevention or treatment of deafness

Reference

Distribution of pejvakin in human spiral ganglion: An immunohistochemical study.
Liu W, Kinnefors A, Boström M, Edin F, Rask-Andersen H.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(4):225-31.

CURRENT OPINION IN OTOLARYNGOLOGY HEAD AND NECK SURGERY

Vestibular migraine
Reviewed by: Susan A Douglas
May/June 2014 (Vol 23 No 2)
 

This is a review of the diagnosis and treatment of vestibular migraine. Migraine is a common illness and migraine - related dizziness occurs in up to 3% of the population. Many patients may go untreated because the diagnosis may be difficult and controversial. The categories of migraine accepted by the international headache society do not reflect the complex presentations of patients presenting with vestibular migraine. Clinical practice and research has begun to separate patients into ‘definite vestibular migraine’ and ‘probable vestibular migraine’. Vertigo may trigger migraine and therefore patients with vestibular migraine should be suspected of having vestibular end organ disease unless proven otherwise. Migraine associated vertigo may not present as the classic horizontal or torsional rotatory vertigo of peripheral vestibular disease. This may present as a horizontal-rotatory sensation or a ‘to-and-fro’ type sensation. Migraine is described by the International Headache Society in the International Classification of Headache Disorders, second edition (ICHD-II) as ‘migraine with prolonged aura’, ‘basilar migraine’, ‘migraine aura without headache’, ‘childhood periodic syndromes’, ‘benign paroxysmal vertigo (BPV) of childhood’, ‘migrainous infarction’. This system only recognises vertigo as a part of Basilar migraine or BPV of childhood. The most widely accepted classification of migraine related dizziness is the ‘Neuheuser criteria’, which defines ‘definite’ and ‘probable’ migraine. The best treatment strategy of patients suspected of vestibular migraine is dietary / lifestyle modification, anti nausea / anti emetics for acute attacks of vertigo and preventative medication for those with persistent disruptive symptoms. This is a well-written review examining the diagnosis and treatment of vestibular migraine. An article that is worthwhile reading for anyone with an interest in vertigo.

Reference

The challenge of vestibular migraine.
Sargent EW.
CURRENT OPINION IN OTOLARYNGOLOGY HEAD AND NECK SURGERY
2013;21:473-9.

HEAD & FACE MEDICINE

Variable expressivity of familial cherubism
Reviewed by: Bilal Gani Taib
May/June 2014 (Vol 23 No 2)
 

Cherubism is classified within the group of benign osteo-fibrous lesions. It is a rare (less than 1 in 10,000) genetic disease with a dominant autosomal inheritance pattern exhibiting variable penetrance and expressivity. It originates from a mutation of the SH3BP2 (SH3-domain binding protein 2), which is located at chromosome 4pl6.3. Phenotypically it manifests as abnormal growths of the facial bones, around the age of four, mainly affecting the jaw. Complications include sight loss due to optic neuropathy, obstruction of upper airways and abnormalities in the development and appearance of teeth. Diagnosis is made histologically with the presence of randomly assorted multi-nucleated giant cells in the vascular stroma of the fibrous connective tissue. The differential diagnosis includes fibrous dysplasia, odontogenic cyst, juvenile ossifying fibroma, giant cell granuloma, fibrous osteoma and osteosarcomae hyperparathyroidism. This case series describes a gentleman (patient 1), who first presented with the disease, his sister and her son (patient 2), who also has the disease. Patient 1 presented with multiple epidermal cysts with numerous malpositioned teeth, and a polypoid formation in the right maxillary sinus as well as orbital involvement. According to the Raposo-Amaral classification he is a grade VI. The female patient exhibited no signs whilst patient 2 (her son) presented with dental abnormalities, odontogenic cysts and non-specific headaches. According to the Raposo-Amaral classification he is a grade III. Diagnosis was confirmed with genetic analysis in which all three relatives were found to have SH3BP2 R415Q / normal genotype, in which the risk of transmission is 50%. This reports helps illustrate that when grouped by sex, expressivity amounts to nearly 100% in men and 50 to 75% in women. The paper suggests that an additional grade, grade 0, be added to the Raposo-Amaral classification for asymptomatic carriers.

Reference

Variable expressivity familial cherubism: woman transmitting cherubism without suffering the disease.
Pérez-Sayáns M, Barros-Angueira F, Suárez-Peñaranda JM, García-García A.
HEAD & FACE MEDICINE
2013;9:33.

INTERNATIONAL JOURNAL OF AUDIOLOGY

Optimum hearing aid prescription for tinnitus intervention
Reviewed by: Victor Osei-Lah
May/June 2014 (Vol 23 No 2)
 

For many years, the management of tinnitus has included the use of hearing aids. However, in many studies, the focus has been on hearing amplification rather than on the relief of tinnitus. The main goal of this study was to examine the effect of high frequency hearing aid amplification using the DSL(I/O) v5.0 prescriptive procedure on short-term tinnitus relief. The authors recruited 25 adults between the ages of 34 and 81 years who had experienced troublesome tinnitus from two years to 54 years. All participants had mild to moderate sensorineural hearing loss (SNHL) up to 8 kHz and moderate to severe between 9 and 16 kHz. None of them had used hearing aids prior to the study. Various tinnitus measures were obtained to quantify self-perception, loudness and pitch of the tinnitus. Thirteen speech files simulating the effect of change in DSL(I/O) v5.0 prescription in high frequency amplification were recorded. After being fitted with a master hearing aid according to their hearing loss, participants were instructed to listen to the speech files and select the level of amplification that makes their tinnitus least audible. The most preferred output was a 6 dB reduction at 2 kHz (26.4%) followed by a similar reduction at 4 kHz (14.7%) and a 3 dB reduction at 2 kHz by 11.76% of participants. The lower the pitch of the tinnitus, the lower the preferred DSL(I/O) v5.0 setting. The authors conclude that when fitting hearing aids for tinnitus relief, the DSL(I/O) v5.0 prescription and a reduction of 3 dB across the frequency when the pitch of tinnitus is ≤ 4 kHz are a good starting point, but the comfort and audibility of the tinnitus by the individual should not be ignored.

Reference

Prescription of hearing-aid output for tinnitus relief.
Shekhawat GS, Searchfield GD, Kobayashi K, Stinear CM.
INTERNATIONAL JOURNAL OF AUDIOLOGY
2013;52:617–25.

INTERNATIONAL JOURNAL OF AUDIOLOGY

Risks posed by the use of portable digital audio players
Reviewed by: Victor Osei-Lah
May/June 2014 (Vol 23 No 2)
 

Portable digital audio players (DAP) have virtually become fashion accessories nowadays. Some of them have estimated maximum sound output levels between 101 dBA and 107 dBA. However, many users are either ignorant about, or adopt a nonchalant attitude to the potential risk DAPs pose to hearing. The authors recruited 237 children aged between 10 years and 17 years from different schools (state and private) to study the relationship between DAP listening behaviours (duration / volume) and measured sound pressure levels, audiometric levels and self-reported symptoms of hearing loss. The students completed a 37-item questionnaire covering self-reported hearing health, frequency of recreational noise exposure, symptoms of hearing loss, frequency and usage of DAP in various situations, headphone / earphone fit, and use of hearing protection and knowledge of hearing loss prevention. Participants were asked to play a favourite song on their DAP at a typical self-identified maximum volume setting while the sound level pressure was measured. Objective evaluation of hearing was obtained with tympanometry and air-conduction pure tone audiometry. Parents of the participants completed a six-item questionnaire to determine the socioeconomic background. The daily personal noise exposure level – Lex (8 hr) was calculated, among others. The authors reported a positive correlation between the duration / loudness levels and the age of subjects: the older they were, the more likely they were to listen for longer periods of time at louder levels. Subjects who had listened to their DAPs for five years or more had higher average pure tone audiometry (PTA) thresholds at 4 and 8 kHz. The prevalence of tinnitus was 23.6% to 26.2% but in disagreement with other studies, the authors found no correlation with loudness levels in this study. However, in those who self-reported hearing loss, the high frequency PTA average was higher. Interestingly, but rather worryingly, the same people ‘believed doctors could restore their hearing’. It is obvious from this study that more education on hearing protection among the youth is needed!

Reference

Audiometric thresholds and portable digital audio player user listening habits.
Feder K, Marro L, Keith SE, Michaud DS.
INTERNATIONAL JOURNAL OF AUDIOLOGY
2013;52:606-16.

INTERNATIONAL JOURNAL OF LANGUAGE AND COMMUNICATION DISORDERS

Pragmatic skills essential to develop spoken language in children with cochlear implants
Reviewed by: Gauri Mankekar
May/June 2014 (Vol 23 No 2)
 

An increasing number of children are receiving cochlear implants (CIs) early in childhood. But CIs do not ensure that a child will develop spoken language easily. Pragmatic skills have proven to be essential in fine tuning spoken language. These skills and their relationship with spoken language in children with CIs under the age of three years was studied by these authors. They compared the linguistic and pragmatic skills of children undergoing cochlear implantation at 12 months old with those implanted between 13 and 26 months old. The authors found that CI does provide deaf children with a good opportunity to develop language skills but severe difficulties in early social experiences and interaction mediated by language still persist. They did not find any significant difference in vocabulary size or early grammar skills amongst children implanted prior to 12 months of age and those implanted after 12 months of age. They recommend that interventions taking into consideration the improvement of pragmatic skills should be undertaken even on very young children with CI.

Reference

Linguistic and pragmatic skills in toddles with cochlear implant.
Rinaldi P, Baruffaldi F, Burdo S, Cristina M.
INTERNATIONAL JOURNAL OF LANGUAGE AND
COMMUNICATION DISORDERS
2013;48(6):715-25.

JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY

A small series of superficial circumflex iliac artery perforator flap for intraoral reconstruction
Reviewed by: Sunil Kumar Bhatia
May/June 2014 (Vol 23 No 2)
 

Tissue loss in the head and neck region can be caused by a variety of mechanisms, most commonly following resection of malignant disease. These can lead to defects that are challenging, often requiring microvascular tissue transfer. The authors introduce a perforator flap based on the superficial circumflex iliac artery; it is a modification of the original groin flap. This has been used for lower limb reconstructions and the authors present an elegant article about this flap’s first use intraorally. While this is a small series, this is the first described use of this flap for intraoral reconstruction. There were four patients that had intraoral and one with pharyngeal resection and reconstruction. The authors describe excellent cosmetic and functional outcomes with flap.  The flap is reported to be very pliable and thus would work well for intraoral reconstruction.  The authors make an effort to compare the functional outcome of this flap, but are hampered by the small numbers. It would seem this flap is at least as good as the more conventional flaps used for intraoral reconstruction. One small difficulty might be the small calibre of the vessels. The article also discusses intraoral microvascular reconstruction in general and there is a succinct but valuable discussion of the various options.

Reference

The superficial circumflex iliac artery perforator in intra-oral reconstruction.
Green R, Rahman KMA, Owen S, Paleri V, Adams J, Ahmed OA, Ragbir M.
JOURNAL OF PLASTIC, RECONSTRUCTIVE AND AESTHETIC SURGERY
2013;66:1683-7.

JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY

Jejunal flap for pharyngolaryngectomy defect
Reviewed by: JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY
May/June 2014 (Vol 23 No 2)
 

This is a paper of 368 consecutive cases on 366 patients who had a hypopharyngeal defect reconstructed with a jejunal flap. Of these cases, 71% were for T3/T4 tumours. The average time to swallow was 12 days with a full oral diet achieved by 92% of patients. They had an 8% leak rate and 10% stricture rate. Abdominal complications occurred in 4%. The authors concluded that the jejunal flap consistently reproduces good functional results. They acknowledge an operator-dependent phenomenon associated with this operation.

Reference

Jejunal free flap reconstruction of the pharyngolaryngectomy defect: 368 consecutive cases.
Perez-Smith D, Wagels M, Theile DR.
JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY
2013;66:9-15.

JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY

Mandibular contouring
Reviewed by: Catherine Treacy
May/June 2014 (Vol 23 No 2)
 

This is a paper from China outlining mandibular contouring for correction of a square jaw as an aesthetics concern for East Asians. They describe, essentially, four types of contouring procedure including one involving a Medpore implant. Whilst it is uncommon that Western units will encounter this problem this is a useful guide to changing a square to an oval shaped face.

Reference

How to achieve a balanced and delicate lower third of the face in orientals by mandibular contouring.
Chen T, Khadka A, Hsu Y, Hu J, Wang D, Li J.
JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY
2013;66:47-56.

JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY

Nasolabial flap for lip reconstruction
Reviewed by: Catherine Treacy
May/June 2014 (Vol 23 No 2)
 

This paper suggests the use of a nasolabial flap for the reconstruction of intermediate to large lip defects. The authors advocate an algorithm for its use in defects, 30% of which are regarded as simple when the commissure is not intact. There were 21 cases and they suggest good functional and aesthetic results and a reliable flap. There were no cases of microstomia.

Reference

The nasolabial flap as a one-stage procedure for reconstruction of intermediate to large lip defects with functional and aesthetic assessments.
Tan N-C, Hsieh C-H, Riva FMG, Jeng S-F.
JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY
2013;66:352-57.

JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY

Prediction of leaking jejunal flaps
Reviewed by: Catherine Treacy
May/June 2014 (Vol 23 No 2)
 

This paper from Hong Kong reviews 96 patients, five of which had clinical leakage and 12 radiological leakage. The authors concluded that serum albumin and white cell count identify the presence of anastomotic leakage from the jejunal flap. Serum albumin was also an early predictor of leakage so early interventions could be employed. The albumin was relevant as early as three days following surgery; a higher white cell count became significant only after day seven. They suggest there is a strong benefit in monitoring postoperative serum albumin.

Reference

Early prediction of anastomotic leakage after free jejunal flap reconstruction of circumferential pharyngeal defects.
Chan JY, Liu LHL, Wei WI.
JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY
2013;66:376-81.

JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY

Sensate flap for oromandibular reconstruction
Reviewed by: Sunil Kumar Bhatia
May/June 2014 (Vol 23 No 2)
 

With the advent and now progress of microvascular techniques and expertise, the two frontiers are reducing morbidity and increasing functional outcomes. This is an excellent example of the latter. They initially dissected out on cadaveric specimens the nerve supply to the lateral lower leg and show it has a dual supply lateral sural cutaneous nerve and a previously unknown nerve they name recurrent superficial peroneal nerve. The innervated flap for intraoral reconstruction is vastly superior to the non-innervated one and may be critical in the maintenance of function and in enhancing remaining quality of life. The authors present a series of 31 patients that required composite mandibular reconstruction that were done with a sensate fibula. Intraoperatively the lateral sural cutaneous nerve or the recurrent superficial peroneal nerve was chosen as donor and anastamosed to the lingual or the greater auricular nerve. The outcomes were measured with the analysis of speech, type of food consumption and oral competence. At least six months later, on testing, 28 had some sensory return, including thermal and pinprick sensation. Better results were obtained in patients when the lingual nerve was used with end to end neurorrhaphies. Only three out of the five patients using the greater auricular nerve showed any sensory return. The authors define success by a return of sensation. The main advantage then is the detection of poorly fitting prostheses and limiting damage to the oral mucosa. They also report encouraging results, despite a small sample (3/31 end to end neurorrhaphy).  I think there is merit in their discussion, innervated flaps are superior to non-innervated ones and surgical skill plays a large part in functional outcomes. The functional outcomes should be assessed to determine the outcome.

Reference

The sensate fibular osteoneurocutaneous flap in  oromandibular reconstruction: clinical outcomes in 31 cases.
Boyd JB, Caton AM, Mulholland RS, Granzow JW.
JOURNAL OF PLASTIC, RECONSTRUCTIVE AND AESTHETIC SURGERY
2013;66:1695-701.

JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY

Subscapular flap for oro-facial defect
Reviewed by: Catherine Treacy
May/June 2014 (Vol 23 No 2)
 

This retrospective article from Montreal looks at 16 patients who underwent mandibular reconstruction with a latissimus dorsi flap. The flap comprised of one or two skin paddles and one bony component based on the angular branch of the thoracodorsal artery. Donor site complications were minimal. Fourteen patients were able to recommence oral nutrition. Diction returned to normal in all but one case. The authors propose that the single flap offers volumes of tissue with a reliable anatomy. The pedicle measured between 2.5 cm and 8 cm in length and it was thought this could reliably supply up to 20 cm of bone from both the medial and lateral scapula. They advocate it is a useful flap providing sufficient skin and oral lining, soft tissue bulk and bone stock.

Reference

Chiameric subscapular free flap for complex oro-facial defects.
L’Heureux-Lebeau B, Odobescu A, Harris PG, Guertin L, Danino AM.
JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY
2013;66:900-5.

JOURNAL OF VESTIBULAR RESEARCH

Could VEMPs be used to diagnose Ménière’s disease?
Reviewed by: Victor Osei-Lah
May/June 2014 (Vol 23 No 2)
 

Currently, the AAOHNS criteria are used to diagnose Ménière’s disease (MD). There is no specific diagnostic test. The aims of this study were two-fold: a) to determine the specificity and sensitivity of cervical vestibular evoked myogenic potentials (VEMPs) and caloric test and b) to compare these two tests with the American Academy of Otolaryngology-Head and Neck Surgery (AAOHNS) stages of MD. Retrospective data of patients attending a specialist vertigo clinic were analysed. There were 114 patients with a diagnosis of definite unilateral MD were included. A decreased or absent VEMP on the side of MD was classified as ‘appropriately identified with VEMP’. In addition to the latency and amplitudes, the percentage VEMP asymmetry was computed. Caloric test was done by irrigating the ears with 2ml of water at 4oC for 20 seconds and the degree of canal paresis (CP) was calculated (>20% was considered abnormal). Combining the results of both click and tone burst VEMPs, half of the patients (50%) were ‘appropriately identified’ and 50% were ‘inappropriately identified with VEMPs’. The specificity for VEMP was 48.9% when the MD subjects were compared with 1056 other dizzy patients. This major limitation of using non-MD patients to determine the specificity was addressed by the authors. The sensitivity and specificity of the caloric test in the MD patients were 37.7% and 51.5% respectively. The differences between VEMPs and caloric test results did not reach statistical significance. No firm conclusions could be made on the sensitivity of VEMPs versus stage of MD, however it was higher for stages I and II but not for III. We are a long way off finding a diagnostic test for MD. Until then, clinicians will continue to use the AAOHNS criteria.

Reference

The diagnostic value of vestibular evoked myogenic potentials in patients with Meniere’s disease.
Egamia N, Ushio M, Yamasoba T, Yamaguchi T, Murofushi T, Iwasaki S.
JOURNAL OF VESTIBULAR RESEARCH
2013;23:249-257.

JOURNAL OF VESTIBULAR RESEARCH

Effect of age, gender and anxiety on motion sickness
Reviewed by: Victor Osei-Lah
May/June 2014 (Vol 23 No 2)
 

It is known that children are more susceptible to motion sickness than teenagers, and females more than males. However motion sickness susceptibility (MSS) is not all that clear in older people. This study was designed to assess the effect of age, gender and the anxiety-trait on MSS in healthy subjects (167 adults) and dizzy patients (n = 94). Depending on vestibular tests, the dizzy patients were subdivided into those with vestibular loss (VL; unilateral or bilateral) and without vestibular loss (nVL; BPPV, migraine and Ménière’s). All subjects completed the short form of the MSS Questionnaire (MSSQ) and the Trait Anxiety Questionnaire (STAI – A and STAI – B). The MSSQ has two parts: symptoms in childhood (MSA) and after childhood (MSB). For the patients, a third section was added to attain a measure of MSS after onset of dizziness – MSV. For all three groups, MSA scores were significantly higher than MSB scores and were positively correlated (P<0.001). Mean MSV scores were lower for VL than for nVL patients. MSB and MSV scores were not significantly different (P>0.05). Posthoc analysis showed that MSSQ scores were significantly lower for VL patients than healthy subjects (P<0.01) which in turn were significantly lower than for nVL patients (P<0.001). These group differences were not affected by age, gender or anxiety-trait. However MSSQ scores declined with age for both females and males but across all age groups, female scores were higher, as supported by previous studies. The relationship between anxiety and MSS was small and limited to healthy subjects.

Reference

Motion sickness susceptibility in healthy subjects and vestibular patients: Effects of gender, age and trait-anxiety.
Paillard AC, Quarck G, Paolino F, Denise P, Paolino M, Golding JF, Ghulyan-Bedikian V.
JOURNAL OF VESTIBULAR RESEARCH
2013;23:203-10.

JOURNAL OF VESTIBULAR RESEARCH

Effects of ageing on dynamic visual acuity
Reviewed by: Victor Osei-Lah
May/June 2014 (Vol 23 No 2)
 

Dynamic visual acuity (DVA) enables the maintenance of visual acuity when the head is moving. This is primarily due to the vestibulo-ocular reflex (VOR). Whereas near distances rely more on linear VOR and far distances on angular VOR, there is some evidence that the cervico-ocular reflex (COR) makes a small contribution to DVA in general. This study was designed to assess the effect of ageing on DVA during locomotion, with specific emphasis on the distance of the visual target, walking velocity and neck receptor input. Thirty healthy subjects with no history of vestibular disorder, neck pathology, neuromuscular disease or falls were divided into three groups: Young (20-30 years), Older 1 (65-74 years) and Older 2 (75-85 years). There were 10 subjects in each group. The DVA was determined by positioning the visual target at 3m (far distance) and 0.5m (near distance) at walking speeds of 0.75m/s and 1.5m/s on a treadmill. For selected trials, COR was precluded by the use of a rigid cervical collar in order to assess the contribution of COR to DVA. A difference of P<0.05 was considered significant. Near DVA was significantly better in the Young than the two Older groups, worse when COR was restricted and at the faster walking speed. This finding was interpreted by the authors to indicate that COR augments linear VOR when the object is closer to the eyes. Far DVA was not affected by COR restriction in all age groups but it was significantly better at 0.75m/s than at 1.5m/s (p<0.001) but this was independent of age. Therefore in healthy older people, a decline in DVA at faster speeds places no limitations on daily activities. No extrapolations could be made for speeds greater than 1.5m/s or in older people with neck and vestibular pathology. A key limitation of the study, addressed by the authors, was the inability to assess the effect of the smooth pursuit system.

Reference

Dynamic visual acuity (DVA) during locomotion for targets at near and far distances: effects of aging, walking speed and head-trunk coupling.
Deshpande N, Tourtillott BM, Peters BC, Bloomberg JJ.
JOURNAL OF VESTIBULAR RESEARCH
2013;23:195-201.

JOURNAL OF VESTIBULAR RESEARCH

Is vestibular rehabilitation effective in posterior circulation stroke?
Reviewed by: Victor Osei-Lah
May/June 2014 (Vol 23 No 2)
 

Whereas the value of vestibular rehabilitation is well established for peripheral vestibular disorders, the same could not be said for central vestibular disorders. Twenty-five patients admitted with posterior circulation stroke were included. They all received instructions on routine balance and mobility exercises while on admission. On discharge from hospital, they were randomised into two groups: a) rehabilitation group (12 subjects) and b) home exercise group (13 subjects), who also served as controls. The rehabilitation group were further randomised into two: the first received standard supervised vestibular rehabilitation (VR) and the second, supervised visual feedback posturography training (VFPT). The home group continued with the balance and gait exercises they were taught, at home without supervision. Validated outcome measures used were the Berg Balance Scale (BBS), the ‘Time and Go’ (TUG), the Dynamic Gait Index (DGI), the Dizziness Handicap Inventory (DHI) and mCTSIB. Assessment was done at baseline and after a six-week exercise programme. Posttreatment outcomes were statistically significantly better in all treatment groups. However, it was surprising that there were no statistically significant differences between the posttreatment outcomes of the three groups – there was no advantage of a supervised over an unsupervised exercise regime! The authors suggest that the small sample sizes were likely to be responsible for this. As usual, larger studies are needed but the point was made that rehabilitating patients with central vestibular pathology can be worthwhile.

Reference

Vestibular rehabilitation in acute central vestibulopathy: a randomized controlled trial.
Balci BD, Akdal G, Yaka E, Angin S.
JOURNAL OF VESTIBULAR RESEARCH
2013;23:259-67.

OTOLARYNGOLOGY-HEAD AND NECK SURGERY

E-survey of transoral robotic surgery transoral robotic surgery experience
Reviewed by: Hannah Blanchford
May/June 2014 (Vol 23 No 2)
 

Since 2009, transoral robotic surgery (TORS) has been used as a minimally invasive approach to access pharyngeal tumours. Forty-five out of 300 TORS-trained surgeons in the United States responded to an electronic questionnaire. They reported a total of 2015 TORS procedures. A minority (10.6%) were performed in previously irradiated patients. Sixty-two percent of surgeons initiated feeding on day 0-1. Death was reported in 0.3% of cases. The complication rate was lower for surgeons who performed more than 50 cases. Only 6.7% of respondents reported performing a staged neck dissection before the TORS procedure. Eighty-four percent of respondents identified oropharyngeal carcinoma as the most common indication for TORS. One surgeon reported using TORS for T4 staged tumours. Local flap reconstruction was used in 12.6% of cases. Postoperative haemorrhage was the most common complication affecting 3.1%. For surgeons performing over 50 cases, the haemorrhage rate was 2.8% whereas for those performing fewer than 25, it was 4.5%. The survey was limited because two of the respondents accounted for nearly half of the cases. One of these surgeon’s haemorrhage rate was only 0.7%, which would have affected the average. It was also a retrospective survey and as such, was subject to recall bias and may represent estimations rather than exact incidence. Although this represents the largest series of TORS procedures to date, I look forward to future multi-centre prospective series. These will enable us to build a more robust picture of the true frequency of complication rates.

Reference

Surgeon experience and complications with transoral robotic surgery (TORS).
Chia SH, Gross ND, Richmon JD.
OTOLARYNGOLOGY-HEAD AND NECK SURGERY
2013;149(6):885-92.

Rhinology

Pilot study of submucosal radiofrequency for epistaxis in hereditary hemorrhagic telangiectasia
Reviewed by: Lakhbinder Pabla
May/June 2014 (Vol 23 No 2)
 

This prospective pilot study investigates the safety and efficacy of submucosal radiofrequency for hereditary haemorrhagic telangiectasia (HHT) patients with mild to moderate epistaxis. Sixteen consecutive patients underwent day case procedures under local anaesthetic where radiofrequency was applied to one or both sides of the nasal septum (50 joules per puncture). Overall, the procedure was well tolerated and the frequency of epistaxis per day and per month was significantly lower after radiofrequency. The duration of bleeding also decreased from over 10 minutes to less than five minutes in two thirds of patients. Thirteen of the 16 patients were satisfied with the technique and would request it for subsequent procedures to treat repeated bleeding. This minimally invasive, day case-based treatment under local anaesthetic presents an interesting option for patients with HHT with mild-moderate epistaxis. However, this study has a small sample size and a relatively short mean follow-up of 16 months, which may have had an impact on the results obtained and their statistical value. Therefore additional studies are required before any firm conclusions can be drawn on this procedure.

Reference

Pilot study of submucosal radiofrequency for epistaxis in hereditary hemorrhagic telangiectasia.
Mortuaire G, Boute O, Hatron PY, Chevalier D.
RHINOLOGY
2013;51(4):355-60.

THE JOURNAL OF LARYNGOLOGY AND OTOLOGY

Allergic fungal sinusitis or eosinophilic mucin rhinosinusitis?
Reviewed by: Madhup K Chaurasia
May/June 2014 (Vol 23 No 2)
 

Rhinosinusitis is a highly prevalent condition and its effective management depends on accurate diagnosis. Allergic fungal sinusitis and eosinophilic mucin rhinosinusitis are sub types of this condition and differentiation between them is important. In this article the authors have looked retrospectively at 34 patients and made an attempt to identify features to differentiate one from the other and also address the accompanying comorbidities such as asthma. This is a retrospective study and therefore only those investigations done in the past have been taken into account. Eosinophilic mucin rhinosinusitis has presence of eosinophils in the nasal secretions but the IgE levels are not raised and there are no fungi although they can be missed with inadequate staining. In the allergic fungal rhinosinusitis the fungi are visible and the IgE levels are raised in addition to the above features. The authors found 26 patients to have eosinophilic mucin rhinosinusitis and eight to have allergic fungal sinusitis. The former was associated with a higher incidence of asthma and the latter was prone to early orbital involvement. Surgical intervention was done more often in the eosinophilic mucin rhinosinusitis. The use of antifungal agents has not been highlighted here. The message conveyed is that both these conditions have identical clinical presentation but follow different clinical courses. A matter of concern that has been highlighted is that allergic fungal rhinosinusitis had more complications but fewer surgical interventions, this being a more aggressive clinical condition. There is therefore no doubt that further studies are required to establish definitive criteria and be able to diagnose one condition from the other.

Reference

Allergic fungal sinusitis and eosinophilic mucin rhinosinusitis: diagnostic criteria.
Uri N, Ronen O, Marshak T, Parpara O, Nashashibi M, Gruber M.
THE JOURNAL OF LARYNGOLOGY AND OTOLOGY
2013;127:867-71.

THE JOURNAL OF LARYNGOLOGY AND OTOLOGY

Cholesteatoma of external auditory canal
Reviewed by: Madhup K Chaurasia
May/June 2014 (Vol 23 No 2)
 

Cholesteatomas mainly present in the middle ear or the mastoid and established methods of treatment follow. However those presenting in the external auditory canal form a slightly unusual diagnosis and the treatment can be inadequate. A small series of eight patients with external auditory canal cholesteatoma is presented. Purulent otorrhoea and otalgia were the main complaints and some cases presented with sensorineural hearing loss affecting high tones. Axial and coronal computed tomography (CT) scans assessed the extent of the local involvement. The images showed bony erosion in all these cases. Biopsy was carried out to exclude squamous cell carcinoma and the authors were also aware of malignant otitis externa as possible diagnoses. The pathogenesis has been attributed to reduced migratory capacity of the canal epithelium but none of the cases in the series had recognisable aetiology. These cases were treated with a post-auricular surgical approach. The external auditory canal was drilled to remove the cholesteatoma and the defect repaired with tragal cartilage graft. Recurrence occurred in one of the eight patients. The principles of treatment were eradication of disease and also preservation of structure and function of the external auditory canal. None of these required skin grafting. Classification of external auditory canal cholesteatoma has been presented and the article provides helpful reading.

Reference

Operative management of external auditory canal cholesteatoma: case series and literature review.
Sayles M, Kamel HA, Fahmy FF.
THE JOURNAL OF LARYNGOLOGY AND OTOLOGY
2013;127:859-66.

THE JOURNAL OF LARYNGOLOGY AND OTOLOGY

Hormonal basis of rhinitis in pregnancy
Reviewed by: Madhup K Chaurasia
May/June 2014 (Vol 23 No 2)
 

Congestion of the nose is a common symptom in the final six weeks of pregnancy. This usually disappears completely about two weeks following child birth. In different questionnaire-based studies the prevalence of pregnancy rhinitis ranges from 11-32%. The present study included 30 pregnant Malaysian women. At the start of the study they were in their first trimester and did not have any preceding history of nasal allergy or sinusitis and had normal appearance of the ear, nose and the throat. A validated rhinitis questionnaire was given to complete and any local pathologies were excluded with a nasal examination. Blood samples were taken for oestrogen, progesterone, human growth hormone and insulin-like growth factor 1 (IGF-1) levels. This was repeated in the same patients in the second and third trimesters and results subjected to statistical analysis. Sixteen of the 30 patients (53.3%) developed symptoms of rhinitis. In those suffering from rhinitis, the level of oestrogen and IGF-1 increased in the third trimester but this was not statistically significant. The levels of growth hormone and progesterone did not increase in either group. Interestingly, 14 of the 16 rhinitic subjects gave birth to females compared with seven out of the 14 non-rhinitic subjects, and this difference was statistically significant. All four hormones have a role in increasing nasal congestion. Oestrogen has a direct cholinergic effect increasing local production of acetyl choline. Growth hormone stimulates IGF-1 which has been linked to the regenerative activity of the nasal mucosa and also to the formation of nasal polyps. Progesterone increases nasal congestion through increased blood volume and enhanced vasodilation. It should however be noted that all four hormones do not potentiate any allergic mechanism and pregnancy is associated only with increased congestion and reduced nasal patency. It is speculated that higher level of oestrogen associated with female births results in a higher incidence of rhinitis in expectant mothers. Relieving nasal congestion would certainly improve the quality of life in pregnant women but it is questionable if treating what is physiologic and lasts only a trimester is worth the risk of possibly inducing pathologic detriment in the babies born.

Reference

Hormonal changes causing rhinitis in pregnancy among Malaysian women.
Indirani B, Raman R, Omar SZ.
THE JOURNAL OF LARYNGOLOGY AND OTOLOGY
2013;127:876-81.

THE JOURNAL OF LARYNGOLOGY AND OTOLOGY

Role of antifungal drugs in indolent mucomycosis or paranasal sinuses
Reviewed by: Madhup K Chaurasia
May/June 2014 (Vol 23 No 2)
 

Antifungal drugs such as Amphotericin B are commonly used in treatment of fungal rhinosinusitis. Whether or not this treatment is required in immune-competent patients is the issue addressed in this article. The authors report four cases who had indolent mucomycosis involving the paranasal sinuses. All these patients presented with foul odour, postnasal drip and nasal stuffiness. The diagnosis was made with computed tomography (CT) scans which showed opacity of the maxillary sinus. None of these patients had invasion into the orbit or the anterior cranial fossa. The subjects were treated with functional endoscopic sinus surgery and followed up with postoperative CT scans three months after surgery. Apparently none of these patients had invasive mucormycosis. Apart from postoperative cephalosporin, no other drug treatment was given. Follow-up of these patients did not show any recurrence of the mucomycosis. The authors therefore contend that it is not necessary to use antifungal drugs in indolent mucomycosis which is noninvasive and occurs in immune-competent patients. They have of course emphasised the need to correct the cause of immune deficiency and do mention the need for antifungal treatment in invasive fungal sinusitis. Surgical debridement should also be carried out in these patients. Paranasal sinus mucomycosis is an extremely rare condition with life threatening possibilities particularly if it is invasive. However these authors have tried to offer reassurance that in noninvasive disease the use of antifungal drugs is unnecessary.

Reference

Indolent mucomycosis of paranasal sinus in immunocompetent patients: are antifungal drugs needed?
Jung H, Park SK.  
THE JOURNAL OF LARYNGOLOGY AND OTOLOGY
2013;127:872-5.

THE JOURNAL OF LARYNGOLOGY AND OTOLOGY

What causes secondary recurrence of pleomorphic adenoma?
Reviewed by: Madhup K Chaurasia
May/June 2014 (Vol 23 No 2)
 

Although pleomorphic adenoma is a benign tumour of the parotid it has a tendency to recur several years after its removal. Primary recurrence is in itself difficult to treat and secondary recurrence offers a much greater challenge for curing this disease. This is a retrospective review of 32 patients who had recurrence of pleomorphic adenoma. The recurrence was studied in terms of epidemiology, anatomical and pathological data, type of surgical treatment and adjuvant radiotherapy, if used. It was observed that younger patients, under 25 years had earlier recurrence. Treatment by parotidectomy or enucleation did not make any difference in the time of first recurrence. The time of subsequent recurrences decreased. The histopathological characteristics which seem to increase the risk of recurrence were deep lobe involvement, multi focality, hypocellarity, rupture of the capsule and maximal nodule size. It is emphasised that in younger patients the extent of necessary surgery should not be compromised. It was also observed that secondary recurrence occurs much quicker but is not related to the number of previous interventions and other factors usually associated with primary recurrence. However there is a greater risk of secondary recurrence in cases with multifocal tumour observed at first surgery. Facial paralysis is the main complication of pleomorphic adenoma surgery and the risk of this is higher with retrograde dissection. The risk of facial paralysis increases significantly in surgery for secondary recurrence. The criteria for adjuvant radiotherapy are specified. It is observed that radiotherapy may delay but will not prevent recurrence. The role of preoperative magnetic resonance imaging (MRI) in the treatment of recurrence is emphasised. This is particularly important if the tumours are multifocal. In these, the high secondary recurrence rate of 28% over six years seems to suggest that the clinician can only control the disease but not cure it.

Reference

Prognostic factors for secondary recurrence of pleomorphic adenoma: a 20 year retrospective study.
Mallard O, Wagner R, Joubert M, Belemazure A S, Rio E, Durand N, Espitalier F.
THE JOURNAL OF LARYNGOLOGY AND OTOLOGY
2013;127:902-07.

BRITISH JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY

Method of surgical resection affects reporting of margins of excision of tumours in the oral cavity
Reviewed by: Sampath Chandra Prasad
May/June 2014 (Vol 23 No 2)
 

It is important to obtain tumour-free resection margins in patients with oral cancer. Pathological processing is known to cause tissue to shrink, which affects the reported margins, and it is postulated that the method of resection also has an effect. In this interesting study the authors used a pig model to demonstrate that the method of resection influenced the surgical margin in oral cancers. They marked standardised simulated lesions on the tongues of 15 live anaesthetised pigs and divided each lesion into four equal sections. They were resected, each with a margin of 10 mm, using cutting diathermy, coagulative diathermy, harmonic scalpel and a conventional scalpel. After processing, the excision margins were measured. With cutting diathermy and coagulative diathermy, shrinkage of the soft tissues was minimal, relative to the margin of the simulated lesion compared with the harmonic scalpel (p=0.001) and conventional scalpel (p=0.001). Cutting diathermy and coagulative diathermy caused significant thermal damage (p=0.001). The authors stress that the method of resection affects the surgical margin and that diathermy resulted in thermal injury and denaturing of the underlying muscle. But there was less tissue contraction than when the harmonic scalpel and conventional scalpel were used. The authors go on to say that the method of resection may therefore affect the interpretation of the histological results, which in turn may have implications regarding adjuvant treatment.

Reference

Does the method of resection affect the margins of tumours in the oral cavity? Prospective controlled study in pigs.
George KS, Hyde NC, Wilson P, Smith GI.
BRITISH JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY
2013;51(7):600-3.

RHINOLOGY

Long-term results of functional endoscopic sinus surgery in children with chronic rhinosinusitis with nasal polyps
Reviewed by: Lakhbinder Pabla
May/June 2014 (Vol 23 No 2)
 

Chronic rhinosinusitis with nasal polyps (CRSwNP) has a major impact upon the quality of life of paediatric patients and their families. The aim of this study was to assess long-term results of functional endoscopic sinus surgery (FESS) in children with CRSwNP and to determine outcomes, symptoms, quality of life and complications. A combined prospective and retrospective study was based on a quality of life questionnaire sent to all children with CRSwNP who received FESS between 2000-2010. Fourty-four children underwent FESS – nine had cystic fibrosis and 10 had asthma. The mean follow-up period was 4.0 years (+/- 2.5) with a mean age at surgery of 13 years (+/- 2.9). Significant improvement was found in quality of life parameters, especially in nasal symptoms showing that FESS is a good treatment in children with CRSwNP. Furthermore, even children with cystic fibrosis showed good results. Although this study shows some promising results with a long follow-up period, it is important to note that is only partly a prospective study. In addition, the outcomes of surgery are based on subjective questionnaires and not physical examinations, which could lead to possible bias

Reference

Long-term results of functional endoscopic sinus surgery in children with chronic rhinosinusitis with nasal polyps.
Cornet ME, Georgalas C, Reinartz SM, Fokkens WJ.
RHINOLOGY
2013;51(4):328-34.

ACTA OTOLARYNGOLOGICA

Round window vibroplasty an effective hearing rehabilitation option in chronic ears
Reviewed by: Victoria Possamai
Mar/Apr 2014 (Vol 23 No 1)
 

This study comes from Uppsala in Sweden, and reports experience with a small group (n=7) of patients in whom the Vibrant Soundbridge active middle ear implant was implanted into the round window. These patients had a diagnosis of cholesteatoma or osteoradionecrosis, with post surgical anatomy precluding effective use of conventional hearing aids. Reasons included need for blind sac closure, non functional middle ears, chronic suppurative otitis media or otitis externa and abnormally shaped external meatus and canal following meatoplasty. The lack of normal middle ear anatomy precluded incus-vibroplasty, and three of the seven had a fixed stapes footplate, though the preference for round rather than oval window implantation in the other patients was not explained. Pre and postoperative, unaided and aided, thresholds were compared. Preoperative aided thresholds were gained from attempted conventional hearing aid use. There was no significant deterioration in residual hearing levels following surgery. Postoperative aided hearing levels were comparable with preoperative levels, in five of seven patients. Of the remaining two patients, one had a deterioration in aided levels post op, the other an improvement, giving a conclusion overall of comparable hearing with some improvement at high frequencies. The Glasgow Benefit Index showed a benefit in all six patients who completed it between +3 to +64 (-100 to +1000 = unchanged). Cone beam computed tomography (CT) was used to assess the position of the implant in relation to the round window membrane (RWM). Authors concluded that the angle of the implant to the RWM is much less important than contact between the floating mass transducer (FMT) and RWM provided by the fascial graft. They also described using further fascia and Tisseel glue to secure the FMT and electrode cable and had no problems with dislocation of the FMT from its position (mean follow up 26 months). This small study suggests this may be an option in patients with complex middle ear disease, for whom conventional hearing aids are not effective.

Reference

Round window vibroplasty in chronic ear surgery:comparison with conventional hearing rehabilitation.
Edfeldt L, Rask-Andersen H.
ACTA OTOLARYNGOLOGICA
2013;133:814-25.

ACTA OTORHINOLARYNGOLICA ITALICA

Transoral robotic surgery for tongue base tumours
Reviewed by: Miles Bannister
Mar/Apr 2014 (Vol 23 No 1)
 

Robotic surgery for upper aero-digestive tract tumours is becoming established in the largest head and neck cancer centres in the UK. Work has mostly centred on laryngeal tumours, though as experience grows, tumours at other sites can be accessed. An ENT team in Rome report a short case series (13 patients) of T1-2 tongue base tumours removed using robotic surgery with synchronous neck dissections for metastatic disease. Patient recovery was quicker after surgery with less morbidity as a less extensive resection was possible – no reconstructions were necessary. These savings in operative time and in-patient stay actually justified the initial cost of the Da Vinci robot. As the precision of robotic surgery permits better functional outcomes after surgery, arguments for further robot procurement may prove irresistible.

Reference

Transoral robotic surgery (TORS) for tongue base tumours
Mercante M, Ruscito P, Pellini R, Cristalli G, Spriano G.
ACTA OTORHINOLARYNGOLICA ITALICA
2013;33:230-5.

AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY

Dynamics and safety of steroid-impregnated nasal packs after ESS
Reviewed by: Edward Fisher
Mar/Apr 2014 (Vol 23 No 1)
 

The use of depot triamcinolone for rhinitis has fallen out of favour in the UK, at least in part because of the lack of control of steroid dosage and dynamics, once the depot has been made. In the post operative group of patients the situation is different, with most patients receiving some sort of medication in the days and weeks following surgery, in addition to douching. The technique of applying steroid as triamcinolone in a foam or (as here) incorporated in a dissolvable pack (here Nasopore was used) seems to have some merit since the main focus of steroid application is the organ in question (the nasal lining). This study looked at blood tests to evaluate the function of the adrenocortical axis in the days following surgery. They found that the systemic effect of this pack was significant and measurable, but lasted 10 days or so before normalising. As always the risk-benefit equation must be considered.

Reference

Systemic effects and safety of triamcinolone-impregnated nasal packing after endoscopic sinus surgery: a randomized double-blinded, placebo-controlled trial
Hong SD, Kim JH, Dhong H-J, Kim JY, Chung S-K, Change YS, Sohn JH.
AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY
2013;27(5):407-10.

AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY

Nasal surgery in sleep-disordered breathing: manage patient expectations
Reviewed by: Edward Fisher
Mar/Apr 2014 (Vol 23 No 1)
 

This compact review of the literature covers the subject of the relevance of nasal obstruction and its treatment to snoring and obstructive sleep apnoea (OSA). The not very surprising conclusion is that managing nasal obstruction can, at best, improve the severity of sleep-disordered breathing symptoms subjectively, but that nasal obstruction is rarely a causative factor in the production of sleep apnoea and snoring. Treatment has a modifying, rather than a curative effect. Surgical treatment had disappointing effects on objective findings such as apnoea-hypopnoea index (AHI) and on other objective parameters for OSA severity. The surgeon should exercise some caution in the promises made to patients prior to nasal interventions in snorers, or those with sleep apnoea. The only real ray of sunshine in this review is that nasal surgery convincingly helps the tolerance of OSA patients to their continuous positive airway pressure (CPAP) machine. This is often the reason that the ENT surgeon is referred such patients.

Reference

The role of the nose in sleep-disordered breathing
Meen EK, Chandra RK.
AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY
2013;27(3):213-20.

AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY

Olfaction, sinusitis and asthma in determining quality of life and depression
Reviewed by: Edward Fisher
Mar/Apr 2014 (Vol 23 No 1)
 

This study looked at quality of life indicators in patients with rhinitis and rhinosinusitis (with and without polyps) and correlated these with a variety of other indices, particularly olfactory function (normosmia / hyposmia / anosmia), asthma and anxiety-depression. Clinicians will not be surprised that quality of life was affected a lot by olfactory dysfunction. Quality of life and anxiety-depression were affected independently by these factors: asthma, chronic rhinosinusitis and olfactory dysfunction.

Reference

Olfactory dysfunction in asthma as risk factors for poor quality of life in upper airway diseases
Katotomichelakis M, Simopoulos E, Zhang N, Tripsianis G, Danielides G, Livaditis M, Bachert C, Danielides V.
AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY
2013;27(4):293-8.

AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY

Scanning in trauma patients with olfactory problems
Reviewed by: Edward Fisher
Mar/Apr 2014 (Vol 23 No 1)
 

This study of head trauma cases attempted to correlate smell disturbance reporting, smell testing and imaging findings [magnetic resonance (MR) and single photon emission computed tomography (SPECT)]. The question of malingering was touched on and also the importance of being able to spot problems in individuals with multiple head trauma such as boxers or other ‘contact sports’ participants. The imaging findings concentrated on the frontal lobes and the olfactory apparatus (such as signs of contusion) and olfactory assessment was made using a threshold test and a qualitative (forced-choice) test, which helped to find malingerers. The sensitivity of MR and SPECT alone were not impressive, but when added together the figures approached or exceeded 90%. These findings were interesting, but I am not convinced that the dual tests will find themselves used routinely in the UK, where the benefit to clinic patients seems uncertain. The matter of monitoring sportsmen is an altogether different topic and involves more than just otolaryngologists: perhaps there should be more monitoring of this at-risk group.

Reference

Estimation of sensitivity and specificity of brain magnetic resonance imaging and single photon emission computed tomography in the diagnosis of olfactory dysfunction after head traumas
Atighechi S, Zolfaghari A, Baradaranfar M, Dadgarnia M.
AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY
2013;27(5):403-6.

AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY

The ‘compensatory turbinate’ is a real phenomenon
Reviewed by: Edward Fisher
Mar/Apr 2014 (Vol 23 No 1)
 

Turbinate surgery of some sort, especially on the contralateral side to a severe septal deviation, is traditional practice in the UK and I recollect an eminent ENT surgeon telling his own surgeon ‘do not forget the turbinate’ as he was being anaesthetised for his own septoplasty. So is this just tradition, or does it have a basis in physiology? The authors have undertaken a meticulous study of computed tomography (CT) scans in children and adults with severe septal deviations versus those with little or no deviation. They measured the cross sectional area of the front, middle and back of the inferior turbinates and compared the side of deviation with the contralateral side. The good news is that the ‘compensatory’ turbinate phenomenon is not seen in children, suggesting that it is an acquired process in patients with deviations. Of course, whether it should be treated surgically is another story, but this anatomical study does tend to support that practice.

Reference

Unilateral inferior turbinate bone hypertrophy: Is it compensatory or congenital
Aslan G, Uzun L, Ugur MB, Uckurt YS, Sagun OF, Yazicilar O.
AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY
2013;27(4):255-9.

BRITISH JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY

In vivo animal model shows no disadvantages of osteosynthesis with pins compared to titanium screws for condylar fractures
Reviewed by: Sampath Chandra Prasad
Mar/Apr 2014 (Vol 23 No 1)
 

The advantages of resorbable pins have been proved in craniofacial surgery. Here, the authors extend its use to fractures of the condylar head, which is surgically challenging. The authors aimed to compare in vivo, the stability of fixation of condylar fractures in sheep using sonic bone welding and standard titanium screws. There were ten patients in each group. The stability of the osteosynthesis and maintenance of the height of the mandibular ramus were assessed. The results were analysed macroscopically, radiologically and histologically. There were no significant differences between the two groups in any parameters. The height decreased by 1-2 mm in both groups compared with the opposite side but this was of no consequence in humans. The volume of the condyle increased considerably in both groups, mainly because callus had formed and it was impossible to immobilise the animals postoperatively. The results showed no significant disadvantages for pin fixation compared with osteosynthesis using titanium screws and they support the use of sonic welding for fractures of the condylar head in humans.

Reference

Treatment of fractures of the condylar head with resorbable pins or titanium screws: an experimental study.
Schneider M, Loukota R, Kuchta A, Stadlinger B, Jung R, Speckl K, Schmiedekampf R, Eckelt U.
BRITISH JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY
2013;51(5):421-7.

BRITISH JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY

Outcomes of transoral robotic surgery for oropharyngeal cancer
Reviewed by: Sampath Chandra Prasad
Mar/Apr 2014 (Vol 23 No 1)
 

Due to the fact that conventional surgery is technically demanding and involves high morbidity, transoral procedures have been developed in recent years. In this prospective study the authors analysed the oncological and functional results of transoral robotic surgery (TORS) to find out if it was suitable as a minimally invasive treatment for oropharyngeal cancer. Thirty-nine patients with oropharyngeal cancer were treated by TORS. The authors assessed overall and disease-free survival by the Kaplan-Meier test. They also used videopharyngography and the functional outcome swallowing scale (FOSS) to evaluate swallowing. They used nasometry to estimate hypernasality, and acoustic waveform analysis to evaluate the voice. Thirty-seven patients (95%) had histologically clear margins of resection. Overall survival at two years was 96% and disease-free survival 92%. An oral diet was tolerable after a mean of six (range 1-18) days. No serious swallowing difficulties were seen on the videopharyngogram. Thirty-six of 38 patients could swallow well (97%) with FOSS scores ranging from 0 to 2 (one patient had a poor score but was able to take an oral diet after postural training). Voices were maintained close to the normal range on the acoustic waveform analysis. The authors conclude that TORS is a valid treatment for selected patients with oropharyngeal cancer and this led to shorter hospital stays with more rapid functional recoveries of swallowing and decannulation.

Reference

Oncological and functional outcomes of transoral robotic surgery for oropharyngeal cancer.
Park YM, Kim WS, Byeon HK, Lee SY, Kim SH.
BRITISH JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY
2013;51(5):408-12.

COCHLEAR IMPLANTS INTERNATIONAL

Neurotrophins and cochlear implants: a promising combination
Reviewed by: Thomas Nikolopoulos
Mar/Apr 2014 (Vol 23 No 1)
 

The authors’ aim was to review the literature with regard to the current trends for treating sensorineural deafness by enhancing spiral ganglion neuron (SGN) survival using neurotrophins combined with cochlear implants, and to identify areas for future research and development. They undertook a literature search on PubMed and Google scholar using terms: neurotrophins, cochlear implants (CIs), and sensorineural to identify the most recent and significant publications. The abstracts were read to identify relevant papers; these were accessed in full and analysed for this review.  Although several papers attempt to investigate the issue, the picture is not yet at all clear. So far experiments using osmotic pumps to deliver neurotrophins have been successful for short-term enhanced survival of SGNs following aminoglycoside ototoxicity in animal models. They have demonstrated the re-sprouting of radial nerve fibres from SGNs towards the source of delivery. In addition electrical stimulation, gene and cell-based therapy have increased SGN survival to varying degrees. However, osmotic pumps carry a high risk of infection, therefore CIs coated in a drug containing polymer or hydrogel are a realistic alternative for sustained delivery of neurotrophins. Increased SGN survival combined with neuronal re-growth raises the possibility for CIs to stimulate discrete SGN populations. Unfortunately, the duration of treatment needed for long-term survival still remains unclear and further work is needed. Therefore, it remains to be seen if this promising combination will have practical and sustainable results in the future.

Reference

Neurotrophins and cochlear implants: A solution to sensorineural deafness?
Sameer MA, Qureishi A, Pearson R, O'Donoghue G.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(3):158-64.

COCHLEAR IMPLANTS INTERNATIONAL

An interesting attempt to combine electric and acoustic hearing stimulation in implantees with full electrode insertion and residual low frequency hearing
Reviewed by: Thomas Nikolopoulos
Mar/Apr 2014 (Vol 23 No 1)
 

The authors assessed the auditory performance of cochlear implant users with electric stimulation (ES) and electro-acoustic stimulation (EAS) with special attention to the processing of low-frequency temporal fine structure. Six implanted patients showing low-frequency residual hearing were fitted with a speech processor that provides both electric and acoustic stimulation. Assessment consisted of monosyllabic speech identification tests in quiet and in noise at different presentation levels, and a pitch discrimination task using harmonic and disharmonic intonating complex sounds. All tasks were performed with ES only and with EAS. The results revealed that speech outcomes in noise showed significant improvement with EAS when compared to ES. Whereas EAS did not yield better results in the harmonic intonation test, the improvements in the disharmonic intonation test were remarkable, suggesting better coding of pitch cues requiring phase locking. The authors concluded that: a) patients with residual hearing in the low-frequency range still have good phase-locking capacities, allowing them to process fine temporal information, b) ES relies mainly on place coding but provides poor low-frequency temporal coding, whereas EAS also provides temporal coding in the low-frequency range, c) patients with residual phase-locking capacities can make use of these cues. This study is very interesting as EAS was used in fully implanted patients who had some residual hearing. However, the numbers are small and a more comprehensive assessment is needed.

Reference

Combined electric and acoustic hearing performance with Zebra® speech processor: Speech reception, place, and temporal coding evaluation.
Vaerenberg B, Péan V, Lesbros G, De Ceulaer G, Schauwers K, Daemers K, Gnansia D, Govaerts PJ.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(3):150-7.

COCHLEAR IMPLANTS INTERNATIONAL

The effect of synchronous multi electrode stimulation on implantees’ discrimination
Reviewed by: Thomas Nikolopoulos
Mar/Apr 2014 (Vol 23 No 1)
 

We all know that the major advances in speech discrimination of cochlear implant devices now rely on the improvement of the speech strategies and the way they stimulate the cochlea. Most cochlear implants implement stimulation strategies which apply sequential electrical pulses to encode acoustic signals such as speech, noise and sounds via electrical stimulation of the auditory nerve. Parallel stimulation of adjacent electrodes has been employed in recent cochlear implant systems in an attempt to further improve coding of pitch information. The authors investigated whether parallel stimulation of three adjacent electrodes enhances rate pitch perception compared with single electrode stimulation. Most comfortable loudness (MCLs) levels were assessed in single and multi electrode condition in 12 subjects. Rate pitch discrimination was determined by means of an adaptive procedure (two-interval two-alternative forced choice, 2I2AFC) at individual MCL in the single- and multi-electrode condition at base frequencies of 100, 200, 283, 400 and 566 pulses per second (pps). The results revealed that to achieve MCL in the multi-electrode condition, significantly higher stimulation current compared with single stimulation was required. No significant difference between single- and multi-electrode condition just noticeable differences in rate discrimination group was found. In contrast, a pairwise comparison of individual results in a subgroup recruited out of successfully completed runs at high base rates showed statistically an improved rate discrimination in 17 of 24 runs in the multi-electrode condition. The authors concluded that there is a potential effect of parallel stimulation on the rate of discrimination. It seems that further refinements and tests are required in order to clarify the issue of synchronous multi-electrode stimulation on implantees’ discrimination.

Reference

New parallel stimulation strategies revisited: Effect of synchronous multi electrode stimulation on rate discrimination in cochlear implant users.
Bahmer A, Baumann U.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(3):142-9.

CURRENT OPINION IN OTOLARYNGOLOGY HEAD AND NECK SURGERY

Are there tests that allow us to diagnose Ménière’s disease?
Reviewed by: Susan A Douglas
Mar/Apr 2014 (Vol 23 No 1)
 

The diagnosis of Ménière's disease has traditionally been clinical. This review considers newly developed and emerging diagnostic techniques for the diagnosis of Ménière's disease. These include cervical and ocular vestibular-evoked myogenic potentials (VEMPs), cochlear hydrous analysis using masking procedures and three dimensional fluid attenuation inversion recovery magnetic resonance imaging (MRI) following instillation of intratympanic gadolinium. The VEMP is a neurophysiological test. VEMP can be measured from the contracted cervical muscles (cVEMP) via the sternocleidomastoid muscle or the extra ocular muscles (oVEMP). Curthoys demonstrated that the otolithic input to the sternocleidomastoid arises mainly from the saccule and that from the inferior oblique, mainly from the utricle. These tests can therefore be used as a measure of utricular and saccular function but they are limited by poor sensitivity. VEMPs are also reduced or absent in vestibular neuritis, benign positional paroxysmal vertigo and vestibular schwannoma. CHAMP (cochlear hydrops analysis masking procedures) testing is a modification of the traditional auditory brainstem response (ABR) where the ABR is masked at different frequencies. The normal response is a prolonged latency delay of wave V but in Ménière's disease the latency is shortened. This test has been reported to have high sensitivity and specificity but this has not been verified in all studies. This appears to be dependent on the definition used for the abnormal latency. Imaging studies have shown reduced or absent perilymph enhancement in patients with Ménière's disease. Intratympanic gadolinium enhanced 3D FLAIR MRI has shown potential as the first in vivo imaging modality for identifying clinically relevant endolymphatic hydrops. Fiorno demonstrated that all patients with Ménière's disease showed abnormal perilymph enhancement, compared to controls who demonstrated no abnormal perilymph enhancement. This is a well written article describing some of the newer diagnostic techniques which may add to the clinical and vestibular testing for Ménière's disease.

Reference

Novel techniques for the diagnosis of Ménière's disease.
Le CH, Truong AQ, Diaz RC.
CURRENT OPINION IN OTOLARYNGOLOGY HEAD AND NECK SURGERY
2013;21:492-6.

EAR AND HEARING

Older persons’ ability to recognise speech in noise
Reviewed by: Vinaya KC Manchaiah
Mar/Apr 2014 (Vol 23 No 1)
 

Speech perception in noise is reported to be one of the most frequent complaints of people with hearing loss. Hearing loss is one of the most frequent chronic conditions associated with older adults; hence they may have reduced ability to recognise speech in noisy situations. The aims of this study included: (1) to investigate whether the rate of decline in older persons’ ability to recognise speech in noise over time differs across age and gender; and (2) to determine the extent to which demographic, health-related, environmental and cognitive factors influence the change in speech-in-noise recognition over time. Large samples of the Longitudinal Ageing Study Amsterdam were used (n = 1298) with the data covering three to seven years of follow-up (mean: 4.9 years; 3025 observations; baseline ages: 57 to 93 years). Hearing ability was measured by a digit triplet speech-in-noise test (SNT) yielding a speech reception threshold in noise (SRTn). Multi-level analyses were used to model the change in SRTn over time. Firstly, interaction terms were used to test differences in rate of decline across subgroups. Secondly, for each of the following factors the authors determined the influence on the change in SRTn: age, gender, educational level, cardiovascular conditions, and information processing speed, fluid intelligence, global cognitive functioning, smoking and alcohol use. This was done by calculating the percentage change. Results suggest that, on average, respondents’ speech reception threshold in noise deteriorated significantly over time. Only information processing speed relevantly influenced the change in speech reception threshold in noise over time. These results indicate that the decline in older persons’ speech-in-noise recognition over time accelerated for older ages. Decline in information processing speed explained a moderate proportion of the SRTn decline. These results also indicate the relevance of declining cognitive abilities of older persons to recognise speech in noisy environments.

Reference

Decline in older persons’ ability to recognize speech in noise: the influence of semographic, health-related, environmental, and cognitive factors
Pronk M, Deeg DJH, Festen JM, Twisk JW, Smits C, Comijs HC, Kramer SE.
EAR AND HEARING
2013;34(6):722-32.

HEAD & FACE MEDICINE

Significant dental rehabilitation by application of a modified miniplate in the hard palate for a patient with a large anterior maxillary defect
Reviewed by: Bilal Gani Taib
Mar/Apr 2014 (Vol 23 No 1)
 

This report describes the use of an H-shaped titanium miniplate inserted into the hard palate with the use of orthodontic elastics in a modified obturator prosthesis to allow immediate placement of the prosthesis and improve its stability in a patient with a large maxillary defect. A 36-year-old man was referred with a diffuse swelling of the anterior maxilla. Magnetic resonance imaging (MRI) and histology revealed this to be a well differentiated squamous cell carcinoma occupying two thirds of the anterior hard palate and skin of the right nasal ala. A right submandibular lymph node was also recognised. Preoperative intra-arterial chemotherapy and radical surgery was planned. The prosthesis was made with two holes in its anterior aspect. The free ends of the H-locking plate were bent to protrude through the holes. Orthodontic elastics retained the prosthesis by securing the two free ends of the H plate through these holes. The denture was fitted and fixed with three screws in the hard palate. The soft tissue was reconstructed with a partially double-folded free radial forearm flap. The prosthesis facilitated retention of the ointment gauze, the facial contour and the ability to ingest a soft diet two weeks after the surgery. The patient was able to insert and remove the prosthesis himself. A more definitive prosthesis with the addition of clasps was also used. The patient declined reconstruction of the maxilla using a bony flap and dental implants. Follow-up two years after the operation has been uneventful. The H-shaped miniplate prevented counter rotation clockwise when biting, may reduce overloading of the remaining teeth and prosthesis induced stomatitis as well as allowing for good postoperative observation of the surgical site. The patient was able to eat a wide range of foods. The risks of using such a technique include the possibility of a screw loosening and mini-plate fractures. However, this was not observed in this case.

Reference

Significant improvement in temporary dental rehabilitation by notable miniplate application in the hard palate for a patient with a large anterior maxillary defect: a case report / technique article.
Ishikawa S, Kik~uchi N, Kobayashi T, Yamanouchi H, Tachibana H, Iino M.
HEAD & FACE MEDICINE
2013;9:34.

HEARING, BALANCE AND COMMUNICATION

Fatigue in Ménière’s Disease
Reviewed by: Vinaya KC Manchaiah
Mar/Arp 2014 (Vol 23 No 1)
 

Ménière’s Disease is a disorder of the inner ear that can affect hearing and balance to a varying degree. It is characterised by episodes of vertigo, tinnitus and hearing loss. This study was aimed at exploring the role of fatigue and its predisposing and consequential factors and consequences, on quality of life and social participation. A total of 728 members of the Finnish Ménière Association completed a postal survey. Questions focused on the symptoms of Ménière’s Disease, sense of coherence, positive attitude, participation and restriction problems classified by the International Classification of Function (ICF), and general health related quality of life (EQ-5D). Results suggest that 70% of the subjects reported fatigue and in 30% fatigue was moderate or strong. Fatigue was associated with reduced quality of life and complaints of vertigo attacks, balance problems and hearing loss. In addition, mobility related symptoms and mood disorders in a broad sense were the most significant determinants of fatigue. Sense of coherence and attitude were predictors of reduced vitality. Results also suggested that isolation could be a consequence of fatigue. The authors conclude that fatigue is a common complaint in Ménière’s Disease, reducing quality of life and leading to social and personal isolation. Fatigue is also associated with personality trait and anxiety disorders. They suggest that positive attitude and physical activity might help to reduce anxiety and escape the social and personal isolation.

Reference

Fatigue in Ménière’s disease
Levo H, Kentala E, Rasku J, Pyykkõ I.
HEARING, BALANCE AND COMMUNICATION
2013; [E-pub ahead of print] DOI:10.3109/21695717.2013. 835090.

INTERNATIONAL FORUM OF ALLERGY AND RHINOLOGY

United Airways welcomes you on board: prepare for a bumpy ride!
Reviewed by: Christos Georgalas
Mar/Apr 2014 (Vol 23 No 1)
 

Anyone remotely aware of the developments in modern rhinology over the last 20 years knows of the ‘unified airway’ concept: upper and lower airways share comparable histology as well as comparable inflammation pathways. The clinical significance of this is obvious: not only does chronic rhinosinusitis (CRS) often co exist with asthma and lower airway disease, but, more critically, treatment (including, but not limited to surgery) of CRS can help improve lower airway disease. Or so one would let you believe… Despite the near-uniform agreement over this statement, there has been very little good quality research to support it. In this meta-analysis, the authors attempt to bring together all the studies assessing the effect of functional endoscopic sinus surgery (FESS) on asthma disease severity and control. The authors found 22 studies, of which only 11 were prospective and none had a control group (let alone being randomised). The commonest outcome measure was self-reported asthma control, although no study used a validated outcome measure. Only three studies assessed asthma attacks and six admissions for asthma, however in use of medication as well as most subjective outcomes there was a clear improvement following surgery. This however was not obvious in objective measures such as FEV1. A meta-analysis can only be as good as the studies it refers to. Judging from the quality of the studies included, the meta-analysis is more than anything a clear indicator of the need for a randomised controlled trial on the effects of FESS on asthma control.

Reference

A systematic review and meta-analysis of asthma outcomes following endoscopic sinus surgery for chronic rhinosinusitis.
Vashishta R, Soler ZM, Nguyen SA, Schlosser RJ.  
INTERNATIONAL FORUM OF ALLERGY AND RHINOLOGY
2013;3(10):788-94.

INTERNATIONAL JOURNAL OF AUDIOLOGY

Beware of placebo effects in hearing aid trials
Reviewed by: Victor Osei-Lah
Mar/Apr 2014 (Vol 23 No 1)
 

Placebo is not only applicable to medications, but to devices as well. There have been some suggestions that hearing aid benefit and performance can be influenced by the placebo effect. The aim of this study was to investigate the reliability of the placebo effect in hearing aid users. 16 adult hearing aid users aged from 61 years to 86 years took part. All subjects had mild to moderate symmetrical sensorineural hearing loss, normal middle ear function and had been hearing aid users for at least a year. The test hearing aids were two Starkey A312 Strata behind-the-ear hearing aids with the same programming and prescription. One was labelled ‘new’ with a yellow case and the other, conventional with a beige case. For half of the group the casing was switched so that ‘new’ was beige and ‘conventional’ was yellow. The outcome measures were a speech-in-noise test (FAAF), sound quality rating test and personal preference. In the last test, subjects were asked to indicate their hearing aid preference from three options: ‘the new hearing aid is best’, ‘the conventional hearing aid is best’ or ‘I cannot tell any difference’. FAAF scores were significantly higher (almost double) for the ‘new’ than the ‘conventional’ hearing aid in 75% of participants. Only 19% performed worse with the ‘new’ aid. Mean ratings for sound quality were also significantly higher with the ‘new’ hearing aid. 12 participants preferred the ‘new’ hearing aid but none declared preference for the ‘conventional’. The rest were indifferent. The authors conclude that placebo effects have a reliable impact on measures of hearing aid benefit. They suggest that this effect ought to be controlled in hearing aid trials.

Reference

Placebo effects in hearing-aid trials are reliable.
Dawes P, Hopkins R, Munro KJ.
INTERNATIONAL JOURNAL OF AUDIOLOGY
2013;52:472-7.

INTERNATIONAL JOURNAL OF AUDIOLOGY

Delayed-onset hearing loss in Chinese children
Reviewed by: Victor Osei-Lah
Mar/Apr 2014 (Vol 23 No 1)
 

This study was done to emphasise the well accepted fact that newborn hearing screening does not identify all children with congenital permanent hearing loss. A cross-section of 28,546 pre-school children who had previously passed newborn hearing screening in a region in South China consented to the study. They were all tested with transient evoked otoacoustic emissions and 28,006 (98.11%) passed. The rest, 540 (1.89%), received further audiological evaluation at referral centres after which 22 children (0.077% or 0.77/1000) were identified with permanent childhood hearing impairment – eight bilateral moderate, 10 bilateral mild and two each of unilateral mild and unilateral moderate sensorineural hearing loss. The authors conceded that excluding ‘at-risk’ children in this cross-sectional cohort may have contributed to the low prevalence when compared with other studies. Their conclusion is valid: that hearing surveillance in pre-schoolers is essential.

 

Reference

Screening of delayed-onset hearing loss in preschool children in the mid-south of China
Chen G, Fu S, Luo S, Zhang W, Yang G.
INTERNATIONAL JOURNAL OF AUDIOLOGY
2013;52:568-71.

INTERNATIONAL JOURNAL OF AUDIOLOGY

Early cochlear implantation enhances cortical maturation in ANSD children
Reviewed by: Victor Osei-Lah
Mar/Apr 2014 (Vol 23 No 1)
 

Previous studies have shown that the cortical auditory evoked potential (CAEP) P1, a marker for central auditory maturation can be recorded in 50-70% of children with auditory neuropathy spectrum disorder (ANSD). In those children, behavioural and understanding of speech in the presence of degraded signals are likely to be better with hearing aids. The authors studied the effect of maturation in two groups of ANSD who were implanted. The Infant-Toddler Meaningful Auditory Integration Scale (IT-MAIS) was used to obtain a measure of auditory integration in all participants. The first was a retrospective review of 24 ANSD children, all of whom had been fitted with cochlear implants and had about 0.8 years of implant use. The mean age of P1 testing was 3.1 years. The second group of 11 children were studied longitudinally: P1 and IT-MAIS were determined pre and post cochlear implantation. In the first group, P1 responses were present in 100%, but in 11 children the latency was normal while it was delayed in 13 children. The only significant factor that differentiated between normal and delayed P1 latency was age at implantation; latency was normal in the early implanted children (mean age 1.88 years) and delayed in the later implanted children (mean age 4.07 years). Furthermore, the children with earlier latencies had higher behavioural outcomes as determined by their higher IT-MAIS scores. In the longitudinal study, after six months of implant use, P1 latency was normal or improved after implantation in 10 of 11 children (in three, P1 was normal pre implant and remained unchanged, in seven, P1 improved from either ‘delayed’ to ‘normal’ or ‘abnormal’ to ‘delayed’ and in one, a ‘normal’ P1 progressed to ‘delayed’ after implantation). Similarly, there was a significant correlation between P1 latency (maturation) and behavioural outcomes (IT-MAIS scores). These findings led the authors to suggest that there might be a critical period for implanting children with ANSD and the P1 latency could be used as a prognostic biomarker to predict behavioural outcomes in such children.

Reference

Central auditory maturation and behavioural outcome in children with auditory neuropathy spectrum disorder who use cochlear implants
Cardon G, Sharma A.
INTERNATIONAL JOURNAL OF AUDIOLOGY
2013;52:577-86.

INTERNATIONAL JOURNAL OF AUDIOLOGY

Internet-based screening test for occupational noise-induced hearing loss
Reviewed by: Victor Osei-Lah
Mar/Apr 2014 (Vol 23 No 1)
 

The authors tested the reliability of an internet-based speech-in noise test (Earcheck) as a tool to detect the onset of noise-induced hearing loss (NIHL) against the traditional periodic pure tone audiometry (PTA) in a group of construction workers.  The Earcheck test requires subjects to identify 27 words by clicking a corresponding button on a computer, from which the speech reception threshold (SRT) is determined. 249 male construction workers were recruited but only 210 were included in the final analyses. In addition to the Earcheck test, all participants had a seven-frequency PTA (0.5 kHz to 8 kHz). The mean age was 45.7 years (SD 10.0) and job tenure 25.8 years (range one to 46 years, SD 11.4). In 83.3% of participants, the daily noise exposure exceeded 80 dBA. Most participants (70%) reported difficulties in understanding speech in noise compared with 27.7% with difficulties in the quiet. The authors reported significantly positive linear associations between Earcheck and PTA speech-in-noise intelligibility. However, the sensitivity and specificity of the Earcheck in identifying NIHL, were graded as modest (68% and 71% respectively). They discuss factors that could have influenced the specificity and sensitivity including masking levels, learning effects of the tests and the testing environment. Nevertheless, provided the testing procedure is modified, the Earcheck test can be a valuable addition to the tools already used in occupational hearing screening efforts.

Reference

The applicability of a speech-in-noise screening test in occupational hearing conservation.
Leensen MCJ, Dreschler WA.
INTERNATIONAL JOURNAL OF AUDIOLOGY
2013;52:455-65.

INTERNATIONAL JOURNAL OF AUDIOLOGY

Labyrinthine ossification in sudden sensorineural hearing loss
Reviewed by: Victor Osei-Lah
Mar/Apr 2014 (Vol 23 No 1)
 

The push for cochlear implantation for unilateral sudden sensorineural hearing loss (SSNHL) probably prompted this study. Temporal bone images of 64 patients were studied by an experienced radiologist who was blinded to the clinical history of the patients. 55 patients had constructive interference in steady state (CISS) magnetic resonance imaging (MRI) and 18 had high resolution computerised tomography (HRCT) (nine had both MRI and CT). The median durations between onset of the sudden hearing loss and imaging were three days for CT (0 – 730 days) and 42 for MRI (0-820 days). The degree of ossification involving the cochlea and lateral semicircular canal was graded separately between zero and six (zero = nil and six = eburnation). Cochlear ossification was present in 14 patients (12 CT and two MRI). Eight of these were unilateral (seven ipsilateral) and four showed bilateral ossification. Interestingly, in six patients who had cochlear ossification on CT, the MRI was normal. 19 patients showed lateral semicircular canal ossification (12 CT and nine MRI). Of these six patients underwent both CT and MRI and ossification was present in only two on MRI. Overall, 22% of this cohort showed cochlear ossification (30% if the lateral canal ossification is included). The authors admit one limitation of the study to be the small number of patients but advocate for HRCT in patients with SSNHL as cochlear implantation may be required. I have a number of queries with the study. There was no mention of the possible aetiology of the SSNHL although admittedly, most are deemed to be idiopathic. The degree of ossification was not mentioned either. No explanation was offered for why cochlear ossification was present in some contralateral ears. Was there an underlying inflammatory process? In places where cochlear implantation is not contemplated for unilateral SSNHL, I doubt if HRCT could be justified routinely.

Reference

Prevalence of labyrinthine ossification in CT and MR imaging of patients with acute deafness to severe sensorineural hearing loss.
Braun T, Dirr F, Berghaus A, Hempel JM, Krause E, Müller J, Ertl-Wagner B.
INTERNATIONAL JOURNAL OF AUDIOLOGY
2013;52:495 – 499.

INTERNATIONAL JOURNAL OF AUDIOLOGY

Prevention of noise induced hearing loss in vivo
Reviewed by: Victor Osei-Lah
Mar/Apr 2014 (Vol 23 No 1)
 

Noise remains one of the most common causes of deafness (NIHL). Noise causes the spiral modiolar artery (SMA) which forms the strial vascularis to constrict. It has been shown in previous studies that TNF-α induces sphingosine-1-phosphate (SIP), a potent vasoconstrictor of SMA. This experimental study explores the use of a TNF-α antagonist, etanercept, to improve the cochlear microcirculation in order to prevent NIHL. Twelve albino guinea pigs (NIHL animal models) were divided into two treatment groups: group 1 received etanercept and group 2, normal saline. Serial measurements were of capillary diameter, cochlear blood flow and threshold shift [measured by auditory brainstem response (ABR)] were determined at 30 minute intervals up to 210 minutes. Before injecting the animals with the respective solutions, the capillary diameter in the two groups were comparable after 60 minutes of observation. The animals were then subjected to a sustained noise at 106 dB SPL for 30 minutes and received their respective injections. Capillary diameter and cochlear blood were significantly greater in the etanercept group at every point of measurement than in the normal saline group. At onset and immediately after noise exposure, the hearing thresholds in both groups were comparable. Beyond 90 minutes after noise exposure, hearing thresholds in the etanercept group were either maintained or improved whereas those of the controls declined significantly. The authors conclude that etanercept improved cochlear blood flow and prevents permanent threshold shift in noise exposed guinea pigs and may serve as a promising treatment for NIHL.

Reference

TNF-inhibition using etanercept prevents noise-induced hearing loss by improvement of cochlear blood flow in vivo
Arpornchayanon W, Canis M, Ihler F, Settevendemie C, Strieth S.
INTERNATIONAL JOURNAL OF AUDIOLOGY
2013;52:545-52.

INTERNATIONAL JOURNAL OF AUDIOLOGY

Tone pip ABR is a better predictor of hearing than click ABR
Reviewed by: Victor Osei-Lah
Mar/Apr 2014 (Vol 23 No 1)
 

The study was conducted to assess the predictive value of tone pip ABR in babies referred via the newborn hearing screening programme (NHSP), and their behavioural hearing levels at follow-up. 94 babies (188 ears) with a significant hearing impairment born between January 2002 and September 2007 were included. Data from 160 ears were available for analysis all of whom had click ABR thresholds recorded. Tone pip (tp) at 4 kHz was recorded for 34 left and 37 right ears respectively. At 1 kHz, tone pip was recorded in 19 left and 18 right ears. The mean age for behavioural audiometry at follow-up was 3.86 years. Two thirds of the tests were PTA or play audiometry and one third, insert-VRA at four frequencies (0.5 kHz to 4 kHz). The authors present several scatter plots comparing clkABR / tpABR and depicting behavioural thresholds at follow-up. The standard deviation of the difference between the follow-up thresholds and tpABR was 10.5 dB for 4 kHz and 16.8 dB for 1 kHz. Click ABR was a poorer predictor of hearing status at follow-up: a standard deviation difference of between 21.7 dB and 24.7 dB. This study adds weight to the use of frequency-specific measures such as tpABR in neonatal diagnostic audiometry but more work is needed for bone conduction testing.

Reference

Predictive value of hearing assessment by the auditory brainstem response following universal newborn hearing screening.
Stevens J, Boul A, Lear S, Parker G, Ashall-Kelly K, Gratton D.
INTERNATIONAL JOURNAL OF AUDIOLOGY
2013;52:500–6.

INTERNATIONAL JOURNAL OF AUDIOLOGY

What is the best estimate of the 4 kHz air-bone gap?
Reviewed by: Victor Osei-Lah
Mar/Apr 2014 (Vol 23 No 1)
 

Air-bone gap (ABG) at 4 kHz in subjects with no other evidence of conductive hearing loss is commonly seen in clinical audiometry. This is believed to be anomalous but estimates of the size of the ABG are variable in the literature. To provide an accurate estimate, the authors pooled the data of four published and unpublished studies comprising 249 subjects who had normal hearing and 188 others who had sensorineural hearing loss (SNHL). In all subjects, air and bone conduction thresholds were determined for both automated (AMTAS) and manual audiometry. The two studies that tested the normal hearing subjects showed small ABG at 0.5, 1 and 2 kHz (-1.7 to 0.3 dB) and a larger mean ABG at 4 kHz of 10.6 dB. Similarly in the SNHL subjects, small ABGs of -7 to 1.7 dB were seen at 0.5, 1 and 2 kHz compared with a larger ABG of 14.1 dB at 4 kHz. However, the gap at 4 kHz was even larger, the greater the air conduction threshold at that frequency (from 10.1 dB for AC thresholds of 5 to 10 dB to 20.1 dB for AC thresholds above 60 dB), suggestive of a dependence on ABG for cochlear sensitivity in subjects with normal hearing. Age did not affect the 4 kHz ABG. The authors conclude that to avoid the 4 kHz ABG, the Reference Equivalent Threshold Force Level for subjects with SNHL should be adjusted by -14.1dB.

Reference

False air-bone gaps at 4 kHz in listeners with normal hearing and sensorineural hearing loss
Margolis RH, Eikelboom RH, Johnson C, Ginter SM, Swanepoel DW, Moore BCJ.
INTERNATIONAL JOURNAL OF AUDIOLOGY
2013;52:426-532.

INTERNATIONAL JOURNAL OF LANGUAGE AND COMMUNICATION DISORDERS

Maxillary osteotomy effects in cleft lip and palate patients
Reviewed by: Gauri Mankekar
Mar/Apr 2014 (Vol 23 No 1)
 

Currently there is weak evidence regarding the impact of maxillary osteotomy on patients with cleft lip and palate (CLP). Osteotomy is usually performed in adolescence after completion of facial growth to correct abnormal facial structure associated with CLP. The authors of this paper investigated the nature of the effect of maxillary osteotomy on the perceptual outcomes of velopharyngeal function in 12 consecutive patients with CLP. They also studied whether the speech changes seen three months after surgery persisted for longer when the maxilla was more stable. They found that maxillary osteotomy affects patients with and without CLP differently. Surgery impacts speech negatively in patients with CLP and the changes seen at three months postoperatively seem to persist and are stable at 12 months postoperatively. These findings can influence the type of information given to patients with CLP for informed consent prior to maxillary osteotomy. The evidence also suggests that the management of acquired velopharyngeal insufficiency following maxillary osteotomy can be undertaken at an earlier point than the current practice of 12 months postoperatively.

Reference

Effect of maxillary osteotomy on velopharyngeal function.
Pereira VJ, Sell D, Tuomainen J.
INTERNATIONAL JOURNAL OF LANGUAGE AND
COMMUNICATION DISORDERS
2013;48(6):640-50.

JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY

Antibiotic prophylaxis in plastic surgery
Reviewed by: Catherine Treacy
Mar/Apr 2014 (Vol 23 No 1)
 

This paper from Italy prospectively studies 1100 patients over a one year period undergoing elective, reconstructive or cosmetic procedures. They were divided into one of four groups being clean, clean-contaminated, contaminated, or dirty. Those from the last two categories were excluded as were those undergoing antibiotic therapy or postoperative recovery within an intensive care unit. The groups were further subdivided based on whether superficial skin surgery, a clean procedure, microsurgery or prosthetic surgery, and a clean contaminated procedure was used. In total 229 out of 978 patients (23.4%) received antibiotic prophylaxis of either a beta-lactam or clindomycin if allergic. Their results indicated that superficial skin surgery such as local flaps, grafts and mucosal excisions had a 1% infection rate without antibiotics. Clean procedures, such as rhinoplasty, had a 1% infection rate when antibiotics were selectively used. There was a 1.3% infection rate for microsurgical and prosthetic surgery and a 5.3% infection rate with clean-contaminated procedures. With these results they conclude no prophylaxis is required in superficial skin surgery and simple mucosa excisions regardless of co-morbidities. They also state that antibiotic prophylaxis is always indicated in microsurgical operations and prosthetic surgery, and clean contaminated procedures of the oral cavity. They are of the opinion that the best option is clean surgery and rhinoplasty antibiotic prophylaxis only indicated when the operation lasts more than three hours and / or an American Society of Anesthesiologists (ASA) grade of three or more is present.

Reference

Perioperative antibiotic prophylaxis in plastic surgery: a prospective study of 1100 adult patients.
Toia F, D’Arpa S, Massenti MF, Amodio E, Pirrello R, Moschella F.
JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY
2012;65:601-9.

JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY

Don’t forget the internal mammary
Reviewed by: Catherine Treacy
Mar/Apr 2014 (Vol 23 No 1)
 

This paper from Belgium describes seven cases of free flap reconstruction in the vessel depleted neck. Four of the patients had previously had bilateral neck dissections, (unilateral in three), and all had radiation therapy. The reconstruction was for oesophageal stenosis or fistula, five cases of a salivary fistula, and an oral cancer in the other two. No vein grafts were required. The mean pedicle length was 14.3 cm. This easily accessible predictable vessel appears to provide a good alternative to pedicle flaps or when angiography fails to show a suitable readily accessible predictable vessel.

Reference

The role of the internal mammary vessels as recipient vessels in secondary and tertiary head and neck reconstruction.
Roche NA, Houtmeyers P, Vermeersch HF, Stillaert FB, Blondeel PhN.
JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY
2012;65:885-92.

JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY

Fixing the cartilage in microtia
Reviewed by: Catherine Treacy
Mar/Apr 2014 (Vol 23 No 1)
 

This paper arises from the authors’ experience of problems with wires used to fix costal cartilage and to overcome its tendency to return to its original state. They researched four materials over a 24 year period where wire, non absorbable monofilament, absorbable monofilament, and non absorbable sutures had been used. Their sample was heavily weighted as in only 10 of the 122 cases a monofilament suture was used. They did however compare absorbable versus non absorbable techniques and conclude that absorbable sutures were better if they did not encounter the problems of exposure or deformity (thought to be caused by loosening of the fixation material).

Reference

An investigation of the fixation materials for cartilage frames in microtia.
Sakamoto A, Kiyokawa K, Rikimaru H, Watanbe K, Nishi Y.
JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY
2012;65:584-9.

JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY

Is size all that matters?
Reviewed by: Catherine Treacy
Mar/Apr 2014 (Vol 23 No 1)
 

This paper is an attempt to identify mechanisms of why haematomas compromise flaps in the absence of a pressure effect and pedicle thrombosis. It is a literature review relating haematoma to tissue compromise, with a clinical comparison made between free vascularised flaps and rhytidectomy skin flaps. The authors outline that early animal models confirm the detrimental effect of red cell and clot on tissue viability. The review then outlines the interrelated effect of neutrophils, cytokines and activation of complement. They explain how it is not just local pressure effect and support their conclusion that emergency surgical exploration should be considered regardless of tension from the tissue envelope. There is however quite a step between being considered and undertaken.

Reference

Why haematomas cause flap failure: an evidence based paradigm.
Glass GE, Nanchahal J.
JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY
2012;65:903-10.

JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY

K wire fixation of a blowout fracture
Reviewed by: Catherine Treacy
Mar/Apr 2014 (Vol 23 No 1)
 

This paper from Japan examines 18 cases of blowout fractures, where in simple fracture cases after manual reduction of the soft tissue through the antrum, a wire was placed to directly support the fracture segment in five cases, and a bone graft harvested from the maxillary sinus in a further 13. They claim this has the advantages of rigid fixation and minimal morbidity without requiring an orbital approach. Orbital approaches run the risk of reduced visual acuity and blindness. Therefore any approach that could avoid these catastrophes has its merits. I cannot help wondering why somebody would want to use this technique.

Reference

Transzygomatic kirschner wire fixation for the treatment of blowout fracture.
Yasumura K, Mikami T, Yabuki Y, Ooishi K, Hosono M, Yamamoto Y, Iwai T, Maegawa J.
JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY
2012;65:875-82.

JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY

Pectoralis minor for facial reanimation
Reviewed by: Catherine Treacy
Mar/Apr 2014 (Vol 23 No 1)
 

This paper from the UK describes a unit’s experience of 561 patients over a 27 year period. Of these, 528 were pectoralis minor muscle, 28 lattissimus dorsi, three gracilis, and two extensor digitorum brevis (EDB). The method involved sural nerve harvest, extended parotidectomy approach and muscle harvest. They assessed 354 patients as having good static position with symmetrical exposure of the teeth in response to emotion. A further 159 patients were assessed as having good movement but without symmetrical complete tooth exposure. The remaining 48 had poor movement or no improvement. A further 153 patients received revisional procedures ranging from debulking of muscle (the most common revision) with adjustment of the nasolabial fold. Late onset tightness of the muscle in the static position affected 13% of patients. The results also suggested that the younger group of patients appeared to fare better than the older.

Reference

Pectoralis minor muscle transfer for unilateral facial palsy reanimation: an experience of 35 years and 637 cases.
Harrison DH, Grobbelaar AO.
JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY
2012;65:845-50.

JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY

Spreader grafts for nasal patency
Reviewed by: Catherine Treacy
Mar/Apr 2014 (Vol 23 No 1)
 

This is an attempt in a paper from Brazil to determine subjectively and objectively the functional results of a spreader graft in an open cosmetic rhinoplasty.  The authors assess 20 patients operated upon by one surgeon, evaluated 90-100 days after the surgery with a questionnaire for the patient and measuring nasal cross sectional area as objective assessment. There was a significant subjective improvement following surgery with a mean minimal change in cross sectional area of 0.3 cm² for the left and no significant change for the right. They conclude by stating open structure rhinoplasty using spreader graft is effective although recognise their short follow-up period and sample size.

Reference

Nasal patency after open rhinoplasty with spreader grafts.
Pochat VD, Alonso N, Mendes RRS, Cunha MS, Menezes JVL.
JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY
2012;65:732-8.

JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY

The geometry of the V-Y and keystone flap
Reviewed by: Catherine Treacy
Mar/Apr 2014 (Vol 23 No 1)
 

This paper applies mathematics to the V-Y flap. The authors  show that the value of the apex angle of the flap should be between 20 and 60o. A value of 40o appears to provide a good compromise between the length of the flap and minimising the size of the defect to be closed. Greater than 40o increases the width of the secondary defect. Less than 40o decreases the length of the flap. Obviously the skin is regarded as a rigid tissue during the calculations. The keystone flap uses the same principles and they claim a small abnormal secondary defect after advancement. This is obviously at the expense of further scarring.

Reference

Geometrical analysis of the V-Y advancement flap applied to a keystone flap.
Pauchot J, Chambert J, Remache D, Elkhyat A, Jacquet E.
JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY
2012;65:1087-95.

JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY

Trapdoor orbital fractures in children
Reviewed by: Catherine Treacy
Mar/Apr 2014 (Vol 23 No 1)
 

This retrospective paper from Toronto examines 18 children who underwent surgical exploration of a trapdoor orbital floor fracture. Sixteen of these 18 patients achieved either complete or near complete resolution of diplopia. The computed tomography (CT) based assessment demonstrated the vulnerability of the inferior rectus muscle due to its close proximity to the orbital floor and lack of periorbital fat for protection. They advocate early surgical intervention. However the average time to surgery in this cohort was 9.7 days. UK practice would suggest that paediatric trapdoor fractures would present soon after the injury and surgery is undertaken as soon as practically possible after the diagnosis is made, often within a few days. In addition they outline the vulnerability of the inferior rectus muscle. In the vast majority of such explorations it is the fat trapped that reduces the ocular motility.

Reference

Paediatric orbital floor trapdoor fractures: outcomes and ct-based morphologic assessment of the inferior rectus muscle.
Neinstein RM, Phillips JH, Forest CR.
JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY
2012;65:869-74.

JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY

Tube feeding in head and neck cancer resection
Reviewed by: Catherine Treacy
Mar/Apr 2014 (Vol 23 No 1)
 

This paper from Glasgow creates an algorithm for patients undergoing head and neck surgery to be fed by nasogastric or percutaneous endoscopic gastrostomy (PEG) feeding. They examine their experiences of consecutive head and neck cancer patients over a five year period. They concluded that all patients undergoing radiotherapy, radiotherapy and chemotherapy, or involving the mandible or T4 carcinoma of the oropharynx required to be PEG fed. They also conclude, as one may expect, the more advanced the tumour and the poorer the dietary consistency score, the more likely that PEG feeding would be required.

Reference

Guideline for prophylactic feeding tube insertion in patients undergoing resection of head and neck cancers.
Jack DR, Dawson FR, Reilly JE, Shoaib T.
JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY
2012;65:610-15.

JOURNAL OF VESTIBULAR RESEARCH

Betahistine treatment in managing vertigo
Reviewed by: Fiona Barker
Mar/Apr 2014 (Vol 23 No 1)
 

Betahistine is still commonly used in the UK and elsewhere as part of the management of vestibular dysfunction and particularly Ménière’s Disease. This paper presents a summary of some of the work done to elucidate the action of histamine in animal models. Links are made to human trials of betahistine both for Ménière’s and for shortening the time course of vestibular compensation in general, but there is little critical appraisal of the differing levels of the quality of evidence cited. The authors conclude that there are likely to be dose and duration effects on the efficacy of betahistine. There is clearly a need for further research in this area and a priority should be that studies are methodologically rigorous and large enough to study dose and duration dependent effects. In an era of supposedly evidence-based medicine, critical appraisal of existing evidence, that could inform future research, is key to ensuring that drug prescription is appropriate, effective and safe.

Reference

Betahistine treatment in managing vertigo and improving vestibular compensation: Clarification
Lacour M.
JOURNAL OF VESTIBULAR RESEARCH
2013;23:139-51.

JOURNAL OF VESTIBULAR RESEARCH

Vestibular dysfunction: prevalence, incidence and need for targeted treatment
Reviewed by: Fiona Barker
Mar/Apr 2014 (Vol 23 No 1)
 

This paper provides a useful summary of research into the prevalence and incidence of various common forms of vestibular dysfunction such as benign paroxysmal positional vertigo (BPPV), migraine and Ménière’s. It also gives an overview of some of the work on the impact of vestibular disorders on quality of life. The link is also made between vestibular dysfunction and falls. As falls are a ‘big hitter’ in terms of chronic disease burden, this is a useful link to make for anyone arguing that closer attention should be paid to vestibular loss. The focus of this paper is to provide a rationale for targeted pharmacologic interventions and as such they highlight some of the gaps in evidence for effective treatments particularly in the case of vestibular loss where the cause is not clearly established or the pathophysiology less well understood. There was relatively little attention given to the research evidence on vestibular rehabilitation. In this paper it was only mentioned in terms of treatment for bilateral vestibular loss whereas there is good evidence to support its use in unilateral vestibular loss. This paper does provide a helpful summary of prevalence, incidence and the need for treatment of vestibular dysfunction. However the summary of treatment options and the evidence for them is somewhat limited and viewed through the prism of the search for pharmacological interventions.

Reference

Vestibular dysfunction: Prevalence, incidence and need for targeted treatment
Agrawal Y, Ward BK, Minor LB.
JOURNAL OF VESTIBULAR RESEARCH
2013;23:113-17.

OTOLARYNGOLOGY-HEAD AND NECK SURGERY

Swallowing exercises for head and neck patients
Reviewed by: Hannah Blanchford
Mar/Apr 2014 (Vol 23 No 1)
 

The prevalence and impact that radiation induced dysphagia has on quality of life has motivated these authors to develop a ‘swallowing preservation protocol’.  It builds on evidence that pre-treatment and early referral for swallowing therapy improves outcomes. The study investigated 85 patients undergoing either radiotherapy or chemoradiotherapy for head and neck cancer. This swallowing preservation protocol was applied before, during and after treatment.  The theory is that exercise of pharyngeal, laryngeal and oral structures maintains a range of motions and counters the effects of radiation induced fibrosis that restricts movement and leads to dysphagia.  Patients met with a speech-language pathologist once a week, starting two weeks before treatment and continuing until two months after treatment. The patients were divided into two groups:  ‘compliant’ or ‘non-compliant’ depending on their self reported use of daily exercises. There was no difference in xerostomia, dysgeusia and odynophagia between the two groups. However, there was an association between the ‘compliant’ group and a faster return to a normal diet. This group was also less likely to develop oesophageal stenosis or require a gastrostomy. The authors acknowledge their study was limited by the two months’ follow-up and lack of other objective swallowing tests. The protocol demands a high level of engagement from patients who are required to attend weekly meetings for education and therapy. This regular contact may be the key to its success, but also, the reason that other centres may find implementing such a programme so difficult.

Reference

Swallowing preservation exercises during chemoradiation therapy maintains swallow function.
Duarte VM, Chhetri DK, Liu YF, Erman AA, Wang MB.
OTOLARYNGOLOGY-HEAD AND NECK SURGERY
2013;149(6):878-84.

SEMINARS IN HEARING

Hearing aids and cognition
Reviewed by: Vinaya KC Manchaiah
Mar/Apr 2014 (Vol 23 No 1)
 

This discussion paper provides a good overview of the role of cognition in hearing aid use and also describes the recent work aimed at determining individual cognitive spare capacity or the ability to process speech heard in noise in ways that may be relevant for communication. In the last decade much work has been done in relation to understanding the importance of cognitive abilities in hearing function and also in understanding how decreased hearing loss and decreased cognitive abilities may have added disadvantage to patients compared to any one problem alone. In addition, it has also been well established that successful listening with advanced signal processing in digital hearing aids is associated with individual working memory capacity, which is the cognitive ability to keep information in mind and process it. Different types of cognitive processing may be required in different situations. For example, when listening in noise it may be necessary to inhibit irrelevant information and appraise misheard information. There is evidence that simply hearing a spoken utterance consumes cognitive resources and may do so to different degrees for different individuals. To determine just how useful different kinds of signal processing are, it is important to examine to what extent they help individual hearing aid users cope with the kind of cognitive demands that may arise in everyday listening situations. These findings have significant implications to both research in this area and more importantly to clinical practice.

Reference

Cognitive spare capacity as a window on hearing aid benefit
Rudner M, Lunner T.
SEMINARS IN HEARING
2013;34(4):298-307.

THE JOURNAL OF LARYNGOLOGY AND OTOLOGY

Information on rhinosinusitis: Does YouTube help?
Reviewed by: Madhup K Chaurasia
Mar/Apr 2014 (Vol 23 No 1)
 

Information is easy to obtain from the internet, but whether it is really useful, particularly for medical conditions, is a matter of speculation and opinion. Chronic rhinosinusitis is one of the commonest ailments affecting quality of life and as claimed by this article, more than the quality is adversely affected by chronic obstructive pulmonary disease. It is therefore only natural that these patients tend to seek information from the internet. In this presentation, the authors have undertaken a detailed analysis of information supplied by selecting the first 100 YouTube videos obtained on searching for ‘sinusitis’. Factors noted were the number of views, the number of likes or dislikes , the uploaded source, symptoms described and a wide range of management options cited in the videos. These were then categorised on merit of the medical information supplied with reference to the European position paper on rhinosinusitis  and nasal polyps management guidelines (2012). A second author separately assessed the videos to provide quality control and statistics were applied to results. Only 45% five per cent of the videos were deemed to be ‘useful’ and 27% contained ‘potentially misleading’ and even ‘dangerous’ content, the presented examples of which reflect most extreme stretches of imagination! Ninety percent of videos uploaded by medical professionals had useful information whereas 43% of those uploaded by individual users were misleading. Individual users selected the shorter and less useful information. No doubt the authors feel there should be a system to direct lay persons to verifiable and credible information, possibly peer reviewed, but whether one can govern the so called freedom of information is another matter!

Reference

YouTube as a source of information on rhinusinusitis: the good, the bad and the ugly.
Biggs TC, Bird JH, Harries PG, Salib RJ.
THE JOURNAL OF LARYNGOLOGY AND OTOLOGY
2013;127:749-54.

THE JOURNAL OF LARYNGOLOGY AND OTOLOGY

Nasal sprays for local anaesthesia can spread infection
Reviewed by: Madhup K Chaurasia
Mar/Apr 2014 (Vol 23 No 1)
 

It is common practice to constitute a solution containing Lidocaine Hydrochloride 5% by volume and 0.5% Phenylephrine Hydrochloride w/v for nasal anaesthesia to carry out various examination procedures and cauterise the nose. Contamination of these solutions and subsequent spread of infection to another patient is taken for granted as something unlikely to happen. This study explores the possibilities of cross-infection between patients resulting from this practice. The study was carried out by using this spray on patients and then doing a culture on the anaesthetic solution. This was supported by another arm of the study which was an in vitro experiment. In this, the spray was done on a growth of staphylococcus and then the solution cultured for these organisms. Interestingly enough both the pump and the bottle proved to be contaminated in two out of 10 patients and the same result was obtained in the in vitro study. This is attributed to the fact that use of these pumps can have a ‘suck back’ effect, drawing bacteria from patients back into the containers. Alternative devices have been mentioned. The authors contend that it is not safe to continue this practice and single use containers should be used and disposed afterwards. This of course will increase the cost but will avoid cross contamination between patients. The study raises a possibly contentious point in terms of costs. One can take some solace from the fact that most patients do not require local anaesthesia.

Reference

Risk of contamination of Lidocaine Hydrochloride and Phenylephrine Hydrochloride topical solution: in vibo and in vitro analyses.
Jog M, Sachitananda R, Syeed K.
THE JOURNAL OF LARYNGOLOGY AND OTOLOGY
2013;127:799-801.

THE JOURNAL OF LARYNGOLOGY AND OTOLOGY

Vocal cord paralysis due to rare causes in upper thorax
Reviewed by: Madhup K Chaurasia
Mar/Apr 2014 (Vol 23 No 1)
 

Generally speaking, paralysis of the right vocal cord draws attention to possible lesions in the brain or skull base and paralysis of the left vocal cord raises suspicion about mediastinal lesions, usually bronchogenic carcinoma. In this interesting article, the authors have emphasised the need for detailed computed tomography (CT) imaging of the upper thorax, which has helped them pick up rare causes of vocal cord paralysis. A case of Ortner’s (cardiovocal) syndrome has been mentioned which caused paralysis due to compression of the left recurrent laryngeal nerve in the aorto-pulmonary window diminished in space by left atrial enlargement. Another case with left vocal cord paralysis had pseudoaneurysm of the aortic arch causing compression. Paralysis of the right laryngeal nerve occurred due to a cervical spinal osteophyte in another patient due to pressure on the nerve behind the inferior cornu of the thyroid cartilage. One patient had right vocal cord paralysis due to a tracheal diverticulum, an incidental anomaly stated to be seen in 1% of autopsies. Finally, a case of tortuous oesophagus causing left vocal cord paralysis has been illustrated. There is a beautiful presentation of CT images in all these cases and minute radiological details of paralysed vocal cords and adjoining structures have been highlighted to identify the paralytic state. These conditions can easily be missed but no doubt the reader would be wary of these rare causes which the authors of this highly illustrative publication have been very fortunate to add to their experience.

Reference

Uncommon and rare causes of vocal fold paralysis detected via imaging.
Sobrino-Guijarro B, Virk JS, Singh A, Lingham RK.
THE JOURNAL OF LARYNGOLOGY AND OTOLOGY
2013;127:691-8.

COCHLEAR IMPLANTS INTERNATIONAL

An adult questionnaire assessing the speech, spatial and qualities of hearing was adapted for use with children, parents and teachers
Reviewed by: Thomas Nikolopoulos
Jan/Feb 2014 (Vol 22 No 6)
 

All objective measures usually need subjective confirmation and this is also true with regard to the assessment of speech, spatial and qualities of hearing in young implantees. Moreover, a broad evaluation of the additional benefit provided to children by a second bilateral cochlear implant requires such an assessment. As no paediatric tool provided detailed evaluation of performance in the areas of daily listening in which benefit was likely to be demonstrated, an adult questionnaire was adapted by the authors of the present study. Items of the Speech, Spatial and Qualities of Hearing Scale (SSQ) focused mainly, although not exclusively, on hearing functions requiring the binaural system. The adapted child, parent and teacher versions of the SSQ retained the structure of rating listening performance in everyday scenarios across the domains of speech perception, spatial hearing and other qualities of hearing. Modifications were minimised, although deletion of some items and wording changes were required, and some subdomains could not be included. Observation periods were introduced so that parents and teachers observe performance prior to providing ratings. The suggested minimum age is 11 years for the child version and five years for the parent and teacher versions. Instructions indicate interview-style administration in which interpretation of the described listening scenarios can be clarified and use of the ruler-style response format demonstrated. Wide application is needed in order to fully evaluate the usefulness of this adapted assessment in implanted children.

Reference

Adaptation of the speech, spatial, and qualities of hearing scale for use with children, parents, and teachers.
Galvin KL, Noble W.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(3):135-41.

COCHLEAR IMPLANTS INTERNATIONAL

Belgium: one of the leading countries in cochlear implantation
Reviewed by: Thomas Nikolopoulos
Jan/Feb 2014 (Vol 22 No 6)
 

It seems that Belgium remains one of the leading countries regarding cochlear implant utilisation / provision. This may very well be attributed to the fact that Belgium, and especially the northern region, Flanders, has been a centre of expertise in cochlear implants and early hearing screening for many years. Some of their surgeons and engineers were pioneers in the development of cochlear implants and in 1998 Flanders was the first region in Europe to implement a universal hearing screening programme for all neonates. The Belgian National Institute for Health and Disability Insurance has reimbursed cochlear implants in children and adults since 1994 and bilateral implantation in children under the age of 12 since February 2010. The evidence shows that in 2010, 93% of severe-to-profound deaf preschool children in Flanders had received cochlear implants and 25% had bilateral implants. Although the situation in adults is less clear, the fact that on average twice as many adults as children are implanted every year in Belgium is very promising.

Reference

Accessibility to cochlear implants in Belgium: State of the art on selection, reimbursement, habilitation, and outcomes in children and adults.
Raeve LD, Wouters A.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(suppl. 1):s18-s25.

COCHLEAR IMPLANTS INTERNATIONAL

Cochlear implantation in the United Kingdom: another developed country with high uptake in children and low uptake in adults
Reviewed by: Thomas Nikolopoulos
Jan/Feb 2014 (Vol 22 No 6)
 

It is well known that the United Kingdom has one of the most organised National Health Services (NHS). The history of cochlear implantation in the UK is interesting as it shows the gradual pathway from private funding to NHS bilateral paediatric cochlear implantation (since 2009). During the period between 1982 and 1990, when a number of individual teams ran programmes using charitable funding, the British Cochlear Implant Group approached the UK Department of Health, who agreed to set up a four-year pilot study of 10 programmes, including one children’s programme. The outcomes were collected and analysed by the Medical Research Council’s Institute of Hearing Research. The results, showing positive outcomes for adults and children, were published in 1995 and subsequently funding was provided directly by the NHS. The implementation of a Universal Newborn Hearing Screening programme in the UK further improved early diagnosis and referral. As a consequence, in 2011 the figures showed that 74% of estimated eligible children aged 0–3 years had received implants and 94% by the age of 17. However, for adults the figures are considerably lower, with only about 5% of those eligible for an implant actually receiving one. The reasons for this include, to a lesser degree, the fact that guidelines by the National Institute of Clinical Excellence (NICE) are stricter than in some other European countries, but mainly because of lack of awareness among candidates and professionals, both of criteria for eligibility and of the potential advantages from cochlear implantation. It seems that the adult population should now be the target in the UK.

Reference

Cochlear implants in the United Kingdom. Awareness and utilization.
Raine C.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(suppl. 1):s32-s37

COCHLEAR IMPLANTS INTERNATIONAL

How implantees or their families choose the cochlear implant model
Reviewed by: Thomas Nikolopoulos
Jan/Feb 2014 (Vol 22 No 6)
 

The authors in this study tried to investigate how patients choose their cochlear implant (CI) model when they are allowed to do so, and which factors are considered most important in the decision-making process. The authors sent a postal survey to 87 families of children with cochlear implants who met certain inclusion criteria. Patients were asked to rate certain factors from 0 to 10 depending on their importance in the decision-making process. Sixty-four patients replied (response rate 74%). In most cases (83%), the parents and / or children were involved in the decision regarding the choice of implant. Eighty-nine percent of patients received information about the choices of CI from the CI team. Patients also accessed information directly from the manufacturer, from other CI users and from websites. The most important factor in choosing a CI model was robustness and reliability (mean score 9.6), followed by comfort (9.4), size / shape (9.2), and control system / ease of use (8.9). All patients were happy with the choices they made. Although many issues are involved in the information provided and the influence of the internet or the market itself, it is always interesting to assess how families choose a certain model of cochlear implant and what they feel is important.

Reference

What factors influence patient and parent choice of cochlear implant model for children?
Clamp PJ, Rotchell T, Maddocks J, Robinson PJ.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(3):130-4.

COCHLEAR IMPLANTS INTERNATIONAL

Listening effort: is it reduced in bilateral implantees?
Reviewed by: Thomas Nikolopoulos
Jan/Feb 2014 (Vol 22 No 6)
 

The authors attempted to investigate the listening effort expended by adolescents and young adults using implants versus their peers with normal hearing when these two groups were achieving similar speech perception scores. In addition, bilateral and unilateral implantation was compared. Eight participants with bilateral cochlear implants and eight with normal hearing aged 10-22 years were included. Using a dual-task paradigm, participants repeated consonant‐nucleus‐consonant words presented in noise and performed a visual matching task. Signal-to-noise ratios were set individually to ensure the word perception task was challenging but manageable for all. Reduced performance on the visual task in the dual-task condition relative to the single-task condition was indicative of the effort expended on the listening task. The results revealed that the cochlear implant group, when using bilateral implants, expended similar levels of listening effort to the normal hearing group when the two groups were achieving similar speech perception scores. For three individuals with cochlear implants, and the group, listening effort was significantly reduced with bilateral compared to unilateral implants. Although the numbers are rather small and there are inherent difficulties in measuring listening effort, these preliminary data suggest that reduced listening effort is a benefit that some individuals gain from bilateral cochlear implants.

Reference

Measuring listening effort expended by adolescents and young adults with unilateral or bilateral cochlear implants or normal hearing.
Hughes KC, Galvin KL.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(3):121-9.

COCHLEAR IMPLANTS INTERNATIONAL

Paediatric cochlear implantation in Japan: a different situation
Reviewed by: Thomas Nikolopoulos
Jan/Feb 2014 (Vol 22 No 6)
 

It is amazing how different the situation is in different countries regarding cochlear implantation rates of utilisation / provision which cannot be attributed entirely to the financial status and the health system of an individual country. The Japanese health-care system covers all aspects of cochlear implantation, from diagnosis to implantation, to mapping and habilitation aftercare. We should also take into account that Japan has the third largest developed economy. However, the uptake rate for cochlear implants is lower than that of countries with similar economic status; Japan has an uptake rate of approximately 1% of potentially suitable subjects of all ages, compared with 5.6% in the USA. With regard to children, only 3-4% of children under the age of three are being implanted at less than 18 months of age. This is in accordance with the Japanese ENT Academy’s guidelines, which currently puts the minimum age limit for implants in children at 18 months. Moreover, there are significant problems in the neonatal screening programmes in various parts of the country. It seems that even the richest countries in the word face considerable problems in screening, diagnosis, implantation and after-care.

Reference

New expectations: Pediatric cochlear implantation in Japan.
Oliver J.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(suppl. 1):s12-s17.

COCHLEAR IMPLANTS INTERNATIONAL

Rapid changes in cochlear implantation in China
Reviewed by: Thomas Nikolopoulos
Jan/Feb 2014 (Vol 22 No 6)
 

China has one of the fastest growing economies in the world. In addition, the numbers of general population and deaf candidates for cochlear implantation are huge in comparison with most other countries in the developed and the developing world. However, the numbers of implantees are rather limited. This situation seems to have changed in the last few years, as by 2010, universal hearing screening programmes had been implemented in 20 of the 32 Chinese provinces. In large cities 95% of babies are screened in hospital-based programmes. In more remote areas babies with high-risk factors for hearing loss are referred to screening centres within one month of birth and leaflets about identifying deafness are distributed. Moreover, China is in the process of developing a national reimbursement scheme for medical care. In 2009, the Chinese government set up a project to implant 1500 children aged one to five over the next three years, and in 2011, the government agreed to fund implants for an additional 17,000 children over four years. However, the situation is still far from ideal as cochlear implant penetration in China is currently less than 5% of potential paediatric candidates. On the other hand, cochlear implantation is continuing to expand at great speed, and it is hoped that the infrastructure and capacity will continue to grow and develop in the coming years.

Reference

Enter the dragon – China’s journey to the hearing world.
Liang Q, Mason B.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(suppl. 1):s26-s31.

HEAD & FACE MEDICINE

Adenomatoid odontogenic tumour associated with odontoma: a case report and critical review of the literature
Reviewed by: Bilal Gani Taib
Jan/Feb 2014 (Vol 22 No 6)
 

Odontogenic tumours and hamartomas encompass a large variety of rare lesions that originate from odontogenic tissue. The nomenclature regarding the various lesions is somewhat confusing as different terms are used to describe similar lesions. In this case a 32 year old male presented with an asymptomatic, well delineated, unilocular, hypodense tumour in the left posterior mandible. These findings suggested a benign cystic odontogenic lesion. The lesion was completely enucleated and the cystic capsule was found to adhere to a thin hard tissue resembling a tissue. Microscopic analysis revealed a cystic cavity with flattened, non keratinised squamous epithelium. In other areas swirls of fusiform cells, ribbons of ameloblast like cells and islands of odontogenic epithelium were observed. However no duct-like structures were found. Despite this, the overwhelming histological evidence led to the diagnosis of adenomatoid odontogenic tumour (AOT) associated with odontoma. No recurrence was identified eight months post surgery. A review of the literature using the different nomenclatures revealed 11 other case reports, with histological images. The mean age of the cohort was 24.4 years old and nine out of 11 of the odontoma associated variants were located in the posterior mandible. This together with the common findings of ducts lined by columnar ameloblast like cells has led the authors to conclude that AOH represents developmental failure of the third molar.

Reference

Adenomatoid odontogenic tumor associated with odontoma: a case report and critical review of the literature.
Gomez RS, Castro WH, Gomes CC, Loyola AM.
HEAD & FACE MEDICINE
2013;9:20.

HEAD & FACE MEDICINE

The detection of oral pre-malignant lesions with an autofluorescence based imaging system (VELscopeTM) – a single blinded clinical evaluation
Reviewed by: Bilal Gani Taib
Jan/Feb 2014 (Vol 22 No 6)
 

The increasing prevalence of oral squamous cell carcinomas (OSCC) is a growing problem in many European countries. This combined with the fact that the disease specific five-year survival rate, especially for patients with advanced oral cancer, has not improved significantly means that early detection of these lesions is vital. Precursor lesions may exist as erythro or leukoplakias. Current standard diagnostic procedure is the conventional oral examination (COE) under white light conditions with a visual and tactile assessment of the whole oral cavity.  One caveat is differentiating between normal mucosa and micro invasive carcinomas. Hence the surgical biopsy is the gold standard in identifying pre malignant or malignant lesions. However, at this stage the lesion is usually cancerous. An alternative technique is the use of auto fluorescence. Used since 1924, the principle is based on naturally occurring fluochromes that are located in the epithelium and the submucosa (e.g. collagen, elastin) and which are irradiated with different excitation wavelengths. When irradiated with wavelengths between 375 and 440 nm, the dysplastic tissue due to a disruption of the fluochromes emits a darker colour whereas healthy tissue remains pale. In order to test this hypothesis a group of 120 patients with suspicious oral pre-malignant lesions were separated into two groups. Group One patients were examined with just the conventional white light regimen whereas Group Two patients were examined using the same technique with the addition of an autofluorescence visualisation device (VELscopeTM). 52 biopsies were obtained from suspicious areas. Despite having a higher sensitivity (22.0%) the autofluorescence visualisation device was found to be less specific (8.4%). This would mean that people would be over diagnosed if they were not used to the device. The autofluorescence outcomes are subjective upon the examiner’s experience, hence any users will require training, as was carried out in this study.

Reference

The detection of oral pre- malignant lesions with an autofluorescence based imaging system (VELscopeTM) - a single blinded clinical evaluation.
Hanken H, Kraatz J, Smeets R, Heiland M, Blessmann M, Eichhorn W, Clauditz TS, Groebe A, Kolk A, Rana M.
HEAD & FACE MEDICINE
2013;9:23.

INTERNATIONAL JOURNAL OF AUDIOLOGY

Appreciation of music after cochlear implantation
Reviewed by: Victor Osei-Lah
Jan/Feb 2014 (Vol 22 No 6)
 

The authors illustrate how musical hearing ability can be exceptionally good in some cochlear implant users by comparing an adult implant user with five adults with normal hearing. The implant user was a 30 year old female who had played the piano for 17 years prior to losing her hearing to autoimmune inner ear disease. She had no residual hearing in the left ear and a moderate to profound loss in the right ear (70 dB to 100dB from 0.25 – 4 kHz). The study was done seven months after bilateral cochlear implantation. The five ‘controls’ were amateur musicians with no formal musical training, all of whom had good sight reading abilities but admitted to not having pitch-perfect abilities. The first experiment was the music perception test (CAPM) which assessed pitch direction discrimination, melody and instrument (timbre) recognition. Experiments Two, Three and Four assessed absolute and relative pitch, consonance rating and melody segregation respectively in both groups. Overall, the implant user’s performance was comparable to the normally-hearing adults. For instance, the user’s pitch direction discrimination thresholds were close to the minimum of 0.5 semitones. Melody recognition was better than the controls but the user fared worse in the recognition of instruments. The authors conclude that a sound processor designed to improve speech perception can provide adequate perception of music but further work on improving fine temporal structure and timbre recognition is needed.

Reference

A cochlear implant user with exceptional musical hearing ability.
Maarefvand M, Marozeau J, Blamey PJ.
INTERNATIONAL JOURNAL OF AUDIOLOGY
2013;52:424–32.

INTERNATIONAL JOURNAL OF AUDIOLOGY

Auditory neuropathy spectrum disorder – to implant or not to implant
Reviewed by: Victor Osei-Lah
Jan/Feb 2014 (Vol 22 No 6)
 

Auditory neuropathy spectrum disorder (ANSD) is increasingly being diagnosed worldwide but rehabilitating children with this condition is challenging. Several studies use speech recognition as the outcome for rehabilitation. The use of cochlear implantation (CI) in ANSD has increased. The authors conducted a systematic review to investigate the evidence base for CI. After applying a strict inclusion and exclusion criteria to several studies published between 1950 and 2012, 27 studies (in children under 16 years) specifying objective speech recognition measures were selected. They were all published between 2006 and 2012. All studies were either observational or cohort studies published in English. The majority of the children were profoundly deaf. 15 studies had no comparison groups and a variety of materials were used to assess speech recognition without specifying the stimulus levels. Pre operative results were rarely reported and the duration of post activation speech discrimination assessment varied widely. Some studies reported no significant differences between ANSD and SNHL scores. Most of the studies did not control for potential confounding factors such as aetiology of hearing loss and developmental status of the children. The authors concluded that whereas the evidence for CI in ANSD is weak, it should not preclude its use as clear benefits have been reported. They discuss the practical and ethical dilemmas for a randomised controlled trial and suggest a multicentre longitudinal study in order to look for better evidence.

Reference

Does cochlear implantation improve speech recognition in children with auditory neuropathy spectrum disorder? A systematic review.
Humphriss R, Hall A, Maddocks J, Macleod J, Sawaya K, Midgley E.
INTERNATIONAL JOURNAL OF AUDIOLOGY
2013;52:442-54.

INTERNATIONAL JOURNAL OF AUDIOLOGY

Back in the ASSR
Reviewed by: Diego Zanetti
Jan/Feb 2014 (Vol 22 No 6)
 

The auditory steady-state evoked responses (ASSR) have been considered reliable for hearing threshold estimation purposes in uncooperative individuals. They have been applied in studies to assess the hearing level of children wearing hearing aids or candidates for a cochlear implant, and in non-cooperative adults when other methods [auditory brainstem response (ABR), slow vertex response (SVR)] do not achieve a satisfactory determination of the auditory threshold morphology. The N1-P2 acoustic change complex (ACC; Ostroff et al, 1998) is an objective method similar to the slow vertex responses (SVR) to brief stimuli (tone pips, clicks, short speech tokens), but is exclusively elicited by changes in continuous sounds. The change introduced in a continuous tone or noise can be  a variation of the frequency or of the intensity, or a silent gap. The cortical response modification determined by these changes can be recorded not only in normal hearing listeners, but also in patients with sensorineural hearing loss, cochlear implants, auditory processing disorders and children as young as six years of age. The authors compared the ACC recordings with the behavioural thresholds of detection of the intensity, frequency and temporal gap in a group of children with sensorineural hearing loss and hearing aids. They observed a good correlation between amplitude changes and the behavioural thresholds, but not with frequency changes or gap detection. In particular, the ACC amplitude increased proportionally to the increment of the change of intensity. This study represents another step forward in the search of a reliable method of assessment of the auditory discrimination abilities in children.

Reference

Prediction of aided and unaided audiograms using sound-field auditory steady-state evoked responses
Shemesh R, Attias J, Magdoub H, Nageris BI
INTERNATIONAL JOURNAL OF AUDIOLOGY
2012;51:746-753

INTERNATIONAL JOURNAL OF AUDIOLOGY

Behavioural versus electrophysiological measures
Reviewed by: Diego Zanetti
Jan/Feb 2014 (Vol 22 No 6)
 

The auditory discrimination abilities of adult listeners are usually tested with psychophysical methods. Conversely, electrophysiological tests are necessarily applied in children and non-cooperative subjects. The N1-P2 acoustic change complex (ACC; Ostroff et al, 1998) is an objective method of detection of sound changes, i.e. recording of the cortical response modification determined by changes in continuous or long standing stimuli. It can be obtained by varying the frequency or the intensity of a pure tone or noise stimulus, or by introducing a silent gap. Despite the morphologic similarity with the slow vertex responses (SVR) to brief stimuli (tone pips, clicks, short speech tokens), the ACC are exclusively elicited by changes in continuous sounds. Interestingly, it can be recorded not only in normal hearing listeners, but also in patients with sensorineural hearing loss, cochlear implants, auditory spectrum disorders and children as young as six years of age. The authors compared the behavioural thresholds of detection of the amplitude and spectrum change and temporal gap with those of the recordings of ACC. They observed a good correlation between the amplitude changes and the behavioural thresholds, but not with frequency changes or gap detection. In particular, the ACC amplitude increased proportionally to the increment of the acoustic change of intensity. This study represents another step forward in the search for a reliable method of assessment of the auditory discrimination abilities in children.

Reference

Auditory discrimination: the relationship between psychophysical and electrophysiological measures.
He S, Grose JH, Buchman CA.
INTERNATIONAL JOURNAL OF AUDIOLOGY
2012;51:771-82.

INTERNATIONAL JOURNAL OF AUDIOLOGY

Chirp vs tone pip stimuli: which is better?
Reviewed by: Victor Osei-Lah
Jan/Feb 2014 (Vol 22 No 6)
 

For several years, broadband clicks have been used to elicit the auditory brainstem response (ABR). Recently, tone-pips which are more frequency specific are being used instead of clicks but they are time-consuming. Another emerging stimulus is the narrow band CE Chirp which has been found to generate much larger amplitude than the tone pip in adults. The three-fold aim of this study was to compare ABR amplitude to tone pip and chirps, to estimate corrected ABR threshold (nHL to eHL) for chirps, and to identify further work needed to make NB CE-Chirps a standard stimulus in children. 30 babies referred via the English Newborn Hearing Screening Programme (NHSP) for diagnostic audiometry were recruited for the study. A total of 42 ears were tested: 21 with 4 kHz stimuli and 21 with 1 kHz stimuli and the response amplitude, response quality (Fmp) and residual noise were compared for both tone pip and chirps. At 4 kHz, 49 waveform pairs satisfying the NHSP clear response criteria were obtained for both stimuli. At 1 kHz, 42 waveform pairs were similarly obtained. The chirp response was larger in 98% of the 4 kHz comparison and for all of the 1 kHz comparisons. The Fmp was also significantly higher for chirps and overall, chirp responses were 64% larger than tone pip responses, closer to those obtained by clicks. Residual noise did not significantly affect the waveforms of either stimulus. The authors suggest that chirps can be an alternative to tone pips especially where ABR amplitudes are low. Another advantage could be significant reductions in time. They suggest further work to make chirps more routinely applicable in NHSP.

Reference

Comparison of ABR response amplitude, test time, and estimation of hearing threshold using frequency specific chirp and tone pip stimuli in newborns.
Ferm I, Lightfoot G, Stevens J.
INTERNATIONAL JOURNAL OF AUDIOLOGY
2013;52:419–23.

INTERNATIONAL JOURNAL OF AUDIOLOGY

Hearing and diet
Reviewed by: Diego Zanetti
Jan/Feb 2014 (Vol 22 No 6)
 

Have you ever considered a relationship between food intake and susceptibility to acquired hearing loss? It is an emerging trend in the field of audiology, although the variability in outcomes across studies hinders the possibility of a clear-cut final statement. One possibility is that dietary quality influences hearing status by mediating vulnerability of the inner ear to noise insult and to age related changes. Uncertain results of current studies are probably related to differences in the measures used to quantify nutrient intake, where in most instances a single nutrient is analysed, failing to recognise interactions between multiple nutrients. The authors examined the potential relationship between diet and hearing by an overall dietary quality approach, based on the Healthy Eating Index (HEI), developed by the US Department of Agriculture’s Center for Nutrition Policy and Promotion. It estimates the conformity of a person’s diet to the US Dietary Guidelines for Americans (Kennedy et al, 1995). Researchers at the University of Florida at Gainesville contrasted the HEI  with the hearing thresholds of a sample of  21,004 adults aged 20 to 69 years, collected during the National Health and Nutrition Examination Survey (1999 -2002). The epidemiological study (Curtin et al, 2012) was based on random selection, within specific demographic distributions, of a sample that was representative of the entire US population. Controlling for age, race / ethnicity, sex, education, diabetes and noise exposure, the authors found, not unexpectedly, a significant negative relationship  between diet and hearing thresholds at higher frequencies, i.e. worse dietary quality was associated with lower hearing sensitivity. No statistically significant relationship between diet and hearing was found at lower frequencies. Taken with caution (and some irony), it seems that “we hear what we eat”. At least, this might apply to the North American population

Reference

Healthy diets, healthy hearing: National Health and Nutrition Examination Survey, 1999 – 2002.
Spankovich C, Le Prell CG.
INTERNATIONAL JOURNAL OF AUDIOLOGY
2013;52:369-76.

INTERNATIONAL JOURNAL OF AUDIOLOGY

Self-service hearing aids?
Reviewed by: Diego Zanetti
Jan/Feb 2014 (Vol 22 No 6)
 

The World Health Organization (WHO) estimates that 639 million people worldwide have a permanent, mild to profound hearing loss; 80% of them live in low- and middle-income nations, especially in parts of the developing world such as sub-Saharan Africa and South Asia. In these countries, fewer than 3% of hearing-impaired individuals have access to hearing aids, owing to lack of an audiological infrastructure. The authors propose a ‘do-it-yourself’ amplification device, designed to be managed entirely by the user without the need for professional support, specialised add-on equipment, or computer access. The user first assembles the low-cost device from a selection of basic hearing-aid parts, then self-administers an automatic, in situ hearing test. The self-fitting hearing aid then applies a prescriptive fitting rule derived from the National Acoustics Laboratory (NAL) to yield an appropriate gain / frequency response and compression parameters. Users may further fine-tune and train the settings to their individual preferences using an onboard button or associated remote control. This interesting study tried to assess the ability of 40 South African and 40 Chinese hearing-impaired adults to  assemble a pair of self-fitting hearing aids by following instructions that were written and illustrated. 95% of South African and 60% of Chinese participants completed the assembly task, either on their own or with assistance from their partners. 63% of South Africans and 18% of Hong Kong participants assembled both hearing aids without errors. A higher level of education, health literacy, younger age and a more prestigious occupation were significantly associated with independent task completion. It can be concluded that individuals of diverse backgrounds can manage the self-fitting hearing-aid assembly task as long as their literacy and cognitive level allow the reading of instructions and captioned illustrations. The consequences of the possible provisions of these kinds of hearing aid to the developing countries are palpable.

Reference

Hearing-aid assembly management among adults from culturally and linguistically diverse backgrounds: Toward the feasibility of self-fitting hearing aids.
Convery E, Keidser G, Caposecco A, Swanepoel DW, Wong LLN, Shen E.
INTERNATIONAL JOURNAL OF AUDIOLOGY
2013;52:385-93.

INTERNATIONAL JOURNAL OF AUDIOLOGY

Targeted surveillance after newborn hearing screening
Reviewed by: Victor Osei-Lah
Jan/Feb 2014 (Vol 22 No 6)
 

Hearing screening of all newborns in England started in 2002 with the Newborn Hearing Screening Programme (NHSP). Whereas early screening can identify babies with significant permanent childhood deafness (PCHI), it is well known that PCHI can occur later in childhood. Traditionally, babies with certain risk factors for hearing loss have been followed up at around age eight months and sometimes later (targeted surveillance), even if they passed the NHSP. The authors, from the NHSP-England programme centre, questioned the evidence-base for this approach by retrospectively analysing data for 2,307,880 children born between 01/04/2006 and 30/09/2009. In that cohort, 69,050 children fulfilled the criteria for targeted surveillance and were offered appointments but only 55.3% (38,192) attended. 76% (29,347) of attendees had satisfactory hearing but only 103 (0.35%) had a PCHI. The rest had a non-permanent hearing impairment or had a mild PCHI. Further analysis of the 103 children identified the five most common risk factors with the highest prevalence of later-onset of PCHI to be: syndromes (other than Down’s) associated with hearing loss; neonatal intensive care unit (NICU) with referral in both ears at otoacoustic emissions (OAE) test and pass result both ears at automated auditory brainstem response (AABR); craniofacial anomaly; Down’s syndrome; and congenital infection. The authors conclude that, “there is no evidence that well babies with a bilateral fail result on the OAE stage of the screen and a bilateral pass result on the AABR stage should be subjected to targeted surveillance”. However, they caution that professionals should be aware of the possibility of later onset PCHI in the remaining children, no matter how small.

Reference

Effectiveness of targeted surveillance to identify moderate to profound permanent childhood hearing impairment in babies with risk factors who pass newborn screening.
Wood SA, Davis AC, Sutton GJ.
INTERNATIONAL JOURNAL OF AUDIOLOGY

INTERNATIONAL JOURNAL OF AUDIOLOGY

The earlier the CI, the best for spoken language
Reviewed by: Diego Zanetti
Jan/Feb 2014 (Vol 22 No 6)
 

The rationale for early cochlear implantation (CI) is to provide auditory signals during the sensitive periods in which spoken language skills develop rapidly in normally hearing children. The auditory information delivered by CI provides much of the critical and complex information necessary for learning spoken language. Despite this, on average, language development in children with CIs lags behind that observed for normally hearing peers. In this prospective work the authors compared the language skills of  98 children who received CIs before 2.5 years with 62 children who received them between 2.5 and five years of age. Language was assessed at four, five, or six years after CI using the Comprehensive Assessment of Spoken Language, a global language comprehension and expressive measure normalised on the analysis of 1700 children in the USA. In general, younger children achieved higher scores than those implanted at a later age for vocabulary, expressive syntax and pragmatic judgments. However, in both groups, some children performed much worse than the group mean, especially for grammar and pragmatics, while some scored brilliantly above the mean. While these occasional individual outcomes remain to be investigated, on average spoken language abilities appear to be directly correlated to the precocity and quality of speech exposure. The number of words heard during the first year after a CI plays a major role in language skills and academic performance at later school age.

Reference

Influence of implantation age on school-age language performance in pediatric cochlear implant users.
Tobey EA, Thal D, Niparko JK, Eisenberg LS, Quittner AL, Wang YY.
INTERNATIONAL JOURNAL OF AUDIOLOGY
2013;52:219-29.

NEUROSURGERY

Shortage of neurosurgeons in the United States?
Reviewed by: Gauri Mankekar
Jan/Feb 2014 (Vol 22 No 6)
 

This is a thought-provoking and well researched article about the neurosurgical workforce in the United States. For the study, the distribution of practising US neurosurgeons was merged with census data to yield density indices of neurosurgeons by state; a survey assessing practice characteristics was emailed to practising neurosurgeons; and a compilation of job advertisements for US neurosurgeons was evaluated. The statistical analysis was inconclusive as many neurosurgeons are subspecialised and the data were not designed to establish patient demand. The authors conclude that there is no rational or objective basis for knowing or even guessing how many neurosurgeons is enough and how many neurosurgical residency positions should be approved or funded. They suggest that demand ratios should be reevaluated by region and subspecialty to consider changes in neurosurgery practice.

Reference

Is there a shortage of neurosurgeons in the United States?
Rosman J, Slane S, Dery B, Vogelbaum MA, Cohen-Gadol AA, Couldwell WT.
NEUROSURGERY
2013;73:354-66.

NEUROSURGERY

Transoral approach to cranio-vertebral junction pathologies
Reviewed by: Gauri Mankekar
Jan/Feb 2014 (Vol 22 No 6)
 


This article reports the evolution and extensive experience of the authors with trans-oral approach to cranio-vertebral pathologies over 30 years. Of the 479 patients operated, nearly half of the operations were performed for rheumatoid myelopathy via a ‘standard’ trans-oral approach and others for congenital abnormalities and tumours. The authors report that the number of cases of rheumatoid disease requiring cranio-vertebral decompression has decreased since the 1990s with the disappearance of the indication. In addition, the evolution of the trans-nasal surgical approach is providing a narrow but less morbid approach to the cranio-vertebral junction. Trans-oral approaches, especially, palate-splitting approaches are associated with significant oropharyngeal morbidity and post-operative oedema. The authors conclude that the trans-oral approach is likely to survive due to its relative simplicity and the advantage of low cerebrospinal fluid (CSF) complication rate when treating lower clival and cranio-vertebral pathologies.

Reference

Evolution of trans-oral surgery: three decades of change in patients, pathologies and indications.
Choi D, Crockard HA.
NEUROSURGERY
2013;73:296-304.

NEUROSURGERY QUARTERLY

Closure of CSF leaks in absence of nasal endoscopy
Reviewed by: Gauri Mankekar
Jan/Feb 2014 (Vol 22 No 6)
 

This study describes the management of cerebrospinal fluid (CSF) rhinorrhoea in six patients in a resource poor practice in Nigeria. Surgical endoscopy is not available in this region due to the costs involved. In such a situation, the author describes a simple intracranial extradural surgical technique for the frontobasal repair of CSF rhinorrhoea. All six patients had post-traumatic complex skull base fractures with associated tension pneumoencephalus. A wide based composite subgaleal pericranial flap was used via a bifrontal craniotomy for repair. The CSF leak stopped immediately in all cases and anosmia was the only procedure related complication. The authors conclude that this technique appears to be very effective in skull base surgical practice in resource poor settings.

Reference

Surgical repair of cerebrospinal rhinorrhoea in a resource poor practice: a low cost surgical technique with case illustrations.
Adeleye AO
NEUROSURGERY QUARTERLY
2013;23(2):127-32.

OTOLARYNGOLOGY-HEAD AND NECK SURGERY

Epistaxis algorithm
Reviewed by: Hannah Blanchford
Jan/Feb 2014 (Vol 22 No 6)
 

This audit of 147 patients in a tertiary care hospital in the USA presenting with idiopathic epistaxis has been used to derive an algorithm for epistaxis management. One of this study’s strengths is that all patients were assessed by an ENT resident at the time of their presentation. The documentation of bleeding points as ‘anterior’ or ‘posterior’ is therefore relatively reliable as nasendoscopy was performed when anterior rhinoscopy was insufficient. The failure rate of patients undergoing chemical cautery with silver nitrate for anterior epistaxis was 21%. The failure rate from non-dissolvable packing was significantly higher (57.4%). Failure was defined as epistaxis requiring intervention within 7 days of initial treatment. For patients requiring admission, mean inpatient stay was shorter in patients who underwent directed vascular control than those treated by packing (5.3 vs 6.8 days). This paper also demonstrated better results for patients presenting with recurrent epistaxis treated by directed vascular control (ligation / embolisation) compared to packing. The recurrence rate of 54.5% after packing for posterior bleeding is a useful figure to consider when counselling patients about their likely inpatient course of treatment. Interestingly, the results didn’t demonstrate a significant difference between recurrence rate and the duration of non-dissolvable packing, providing evidence that shorter packing duration is not associated with treatment failure. Perhaps controversially, the algorithm suggests directed vascular control if initial chemical cautery fails in anterior epistaxis.

Reference

Outcomes analysis in epistaxis: development of a therapeutic algorithm.
Shargorodsky J, Bleier BS, Holbrook E, Cohen JM, Busaba N, Metson R, Gray ST.
 OTOLARYNGOLOGY-HEAD AND NECK SURGERY
2013;149(3):390-8.

OTOLOGY & NEUROTOLOGY

Percutaneous versus transcutaneous bone conduction devices: complications and audiological outcomes
Reviewed by: Rebecca Heywood
Jan/Feb 2014 (Vol 22 No 6)
 

The percutaneous bone anchored hearing aid was originally conceived in order to reduce the attenuation and distortion of sound passing through the skin and soft tissues and also to overcome the discomfort associated with traditional bone conduction devices exerting constant pressure over the mastoid area. Although the bone anchored hearing aid (BAHA) has become very popular in several clinical situations, adverse skin reactions can occur and the osseointegrated implant may be lost through infection or trauma. These complications are particularly prevalent in children. Recently a transcutaneous bone conduction device with intact skin, the Sophono, has been introduced to try to reduce these complications. Here the authors compare adverse effects and audiological outcomes in a group of six paediatric Sophono recipients with a matched control group of six patients using the BAHA. None of the patients suffered any adverse skin reactions in this small group. One Sophono user reported pressure discomfort, which was alleviated by reducing the magnet strength. One BAHA user presented with a loose implant and the abutment was therefore coupled to a second sleeper implant. Not surprisingly the audiological results with the Sophono demonstrated reduced gain compared to the BAHA, particularly at high frequencies where five to 10dB better thresholds were obtained with the latter. These values mirror those reported when transcutaneous and percutaneous bone conduction were compared at the inception of the BAHA. The speech reception threshold was 8dB better with the BAHA than the Sophono. Skull simulator measurements also suggested that the BAHA Divino is 10dB louder than the Sophono. Although this study is small, it suggests that the Sophono is appealing in terms of reduced skin complications and implant loss at the expense of optimal audiological outcome.

Reference

Comparison between a new implantable transcutaneous bone conductor and percutaneous bone-conduction hearing implant.
Hol MKS, Nelissen RC, Agterberg MJH, Cremers CWRJ, Snik AFM.
OTOLOGY & NEUROTOLOGY

OTOLOGY & NEUROTOLOGY

Music appreciation in early-deafened late-implanted cochlear implant recipients
Reviewed by: Rebecca Heywood
Jan/Feb 2014 (Vol 22 No 6)
 

Outcomes in early deafened, late-implanted (EDLI) cochlear implant (CI) recipients are difficult to quantify compared to conventional CI recipients as they do not achieve the same audiological outcomes and outcome has to be measured to a certain degree by quality of life (QoL) measures. The perception of music in post lingually deafened CI users is generally felt to be unsatisfactory, whereas early deafened, early implanted CI users report high enjoyment of music though their ability to perceive music has been shown to be worse than that of post lingually deafened users. In this paper the authors examine self-reported perception and enjoyment of music as a factor which can contribute to QoL in EDLI users. 22 participants, deafened before the age of six and implanted after the age of 16, were studied. They completed the Dutch Musical Background Questionnaire (DMBQ, assessing satisfaction with listening to music, self-perceived quality of music and self-reported perception of the elements of the music), Nijmegen Cochlear Implant Questionnaire (NCIQ, CI specific HRQoL instrument), the Cochlear Implant Functioning Index (to assess auditory related functioning of CI users), Speech, Spatial and Qualities Questionnaire (SSQ, environmental and spatial hearing) and word recognition scores. 60% of participants reported music to sound pleasant. The self-perceived quality of music was reported positively in general. The majority reported that they could follow the lyrics, recognise the instruments and follow the melody. Higher enjoyment and better perception of music did not correlate with higher QoL, better everyday hearing ability or better word recognition, however. The authors comment that although speech perception outcomes in EDLI users tend to be poor compared to EDEI or post lingually deafened users, EDLI users show high enjoyment and satisfaction with listening to music and this may give additional support for CI candidacy in this group.

Reference

Music and quality of life in early-deafened late-implanted adult cochlear implant users.
Fuller C, Mallinckrodt L, Maat B, Baskent D, Free R.
OTOLOGY & NEUROTOLOGY
2013;34:1041.

THE JOURNAL OF LARYNGOLOGY AND OTOLOGY

Concepts in practice of voice rest after surgery
Reviewed by: Madhup K Chaurasia
Jan/Feb 2014 (Vol 22 No 6)
 

Voice rest, complete or relative is widely recommended after surgery on the vocal cords for lesions such as nodules, polyps, granulomas, intermediate lesions and malignancy. Whether this is actually necessary and if there is a uniform practice in the UK, is what this article has endeavoured to establish through a nationwide survey. The survey comprised seven questions with multiple choices and opportunity for further comments. The recipients of the survey were members of the expert panel of ENT UK. The authors first sought clarification of the definitions of ‘complete’ and ‘relative’ voice rest. 86.5% of respondents agreed that complete voice rest meant absolutely no phonation at all. There were variations in the concept of ‘relative’ voice rest but it generally meant not straining the voice as in shouting, using the telephone, singing and likewise. Relative voice rest was most commonly instituted by otolaryngologists for various pathologies of the vocal fold. The number of respondents who advocated relative voice rest varied largely, suggesting that there was no uniformity in the practice. The experience of the respondents and their sub-specialities did not show any association with variations in the use of relative voice rest after surgery. Most respondents advised one to two days of voice rest. The length of time for which the voice rest was advised again showed a wide variation in practice and neither was this consistent for specific pathologies. However, surgeons with less than 10 years’ experience were more likely to recommend fewer days of voice rest. Once again, the advice was not related to the length of experience or sub-speciality of the respondents. In the discussion the authors emphasise the lack of consistency in institution of complete or relative voice rest after vocal fold surgery. The study however does not take into account the compliance or post-operative voice quality. Some studies in literature suggest that the use of relative voice rest is as good as complete voice rest, the latter being disadvantageous because it leads to deprivation. There is mention of experimental studies which suggest that phonation contributes to the remodelling of the vocal fold matrix and may perhaps encourage rather than hamper repair. The study reveals a very wide variation in practice and emphasises the need for more research to standardise the use of voice rest, relative or complete.

Reference

Voice rest after vocal fold surgery: current practice and evidence.
Coombes AC, Carswell AC, Carswell AJ, Tierney PA.
THE JOURNAL OF LARYNGOLOGY AND OTOLOGY
2013;127:773-9.

THE JOURNAL OF LARYNGOLOGY AND OTOLOGY

Do microbials play an important role in persistently discharging mastoid cavities?
Reviewed by: Madhup K Chaurasia
Jan/Feb 2014 (Vol 22 No 6)
 

The aetiology of a persistently discharging mastoid cavity ranges from environmental / medical conditions such as diabetes, poor hygiene, immune deficiency and radiation, through factors relating to the cavity dimensions such as the facial ridge and residual pathology, to antecedents which cause the ear problem such as cholesteatoma and perforation. Little has been published about the role of microbes perpetuating mastoid cavity instability and whether the solution lies in medicinal treatment or revision surgery. In this study the authors included 121 revision procedures for unstable open cavities on 101 patients. Pre-operative or intra-operative swabs were taken for aerobic, anaerobic and fungal cultures based on clinically evident infection in the cavity. 42 out of 79 culture specimens produced no growth, 37 had a positive result and in five there were multiple microbials cultured. The commonest organisms were staphylococcus aureus and pseudomonas aeruginosa. Six out of 15 staphylococcus aureus specimens showed resistance to Penicillin but all were susceptible to Cefalexin and Flucloxacillin. As for p-aeruginosa, two were resistant to Gentamicin but all sensitive to Ciprofloxacin. E-coli was grown in one specimen and was resistant to all oral antibiotics tested, but sensitive to meropenem and amikacin. There were no significantly different findings in terms of positive culture in patients with and without cholesteatoma. The authors contend that antimicrobial resistance, as found in this study, was insignificant, and is therefore not responsible for continuation of instability in an open mastoid cavity. The role of microbials is further side-lined by the fact that less than half the specimens produced positive cultures. The solution therefore lies in revision or obliteration of the mastoid cavity. In revision, emphasis should be placed on surgical factors such as the facial ridge, the mastoid tip and good saucerisation. For obliteration, the authors prefer the superior and inferiorly based flaps which appears highly successful. This article provokes thought towards the cost of aural clinics and emphasises the role of early intervention in unstable mastoid cavities.

Reference

Unique microbiology of chronically unstable canal wall down tympanomastoid cavities: considerations for surgical revision.
Gulth MB, Tan BYB, Santermara BL, Atlas MD.
THE JOURNAL OF LARYNGOLOGY AND OTOLOGY
2013;127:458-62.

THE JOURNAL OF LARYNGOLOGY AND OTOLOGY

Head mirror or electrical head light?
Reviewed by: Madhup K Chaurasia
Jan/Feb 2014 (Vol 22 No 6)
 

Instrumentation changes as technology develops. It is not always true that these changes are distinctively beneficial. Whilst it is understood that head mirrors are a bit difficult to get used to, it is a matter of speculation whether the head lights help one to see more. This study attempts to answer the question. A comparison was made between three types of head lights and the head mirror in terms of the illuminance achieved and the field of illumination. It was noted that the head lights provided brighter illumination whereas with the head mirror a better field of illumination was achieved. Visual identification and acuity was carried out by use of the Landolt C table which was down scaled and placed inside the nasopharynx of a full scale skull model. A comparison of visual results was made between a group of 13 medical students and 10 otolaryngology specialists. In the student group the mean number of letters identified with a head light and head mirror were not statistically different. It was the consultant group who proved to have a better visual acuity with the head mirror. In a review of the literature, interesting deployment of reflected light as far back as in 1585 is mentioned. The head mirror has shown some advantage in examining deep narrow spaces without producing shadows. It is therefore contended that in skilful hands the head mirror has an advantage over the head light in providing alignment with the optical axis and thus reducing blind spots. The article provides an interesting comparison of devices but in terms of practicality, and perhaps with invention of an everlasting battery, the head light will have the upper hand.

Reference

Head mirror versus head light: illumination, visual identification and visual acuity for otolaryngological examination.
Lin CH, Hsu HT, Chen BY, Huon LK, Lin YZ, Hung SH.
THE JOURNAL OF LARYNGOLOGY AND OTOLOGY
2013;127:744-8.

THE JOURNAL OF LARYNGOLOGY AND OTOLOGY

Improvement of voice with anti-reflux treatment
Reviewed by: Madhup K Chaurasia
Jan/Feb 2014 (Vol 22 No 6)
 

Voice changes are often associated with laryngopharyngeal reflux (LPR). This is a very common problem seen in the practice of otolaryngology. Due to wide variation in the symptoms and signs of LPR, diagnosis can be difficult unless a 24-hour pH monitoring is carried out. In this study the assessment of LPR was done by reflux symptom index scores and the assessment of voice was done by voice symptom scale scores. The assessments were made in the first appointment and then three months later. Some of the patients were also assessed after six months. It was noted that the reflex symptom index score was reduced after treatment with anti-reflux medication after three months suggesting an improvement in the reflux. The same was true of patients who were assessed at six months, who showed a further reduction in reflux symptom index scores. The voice symptom scale was also reduced at three and six months. These findings were statistically significant. There was also a statistically significant correlation between the improvement in reflux symptom index scores and the improvement in voice symptom scale scores. A few studies with similar results are quoted in the literature, one of which did not show any improvement with anti-reflux treatment. All patients in this study also received voice therapy and therefore there is some debate as to which of the two treatments was more effective. The authors emphasise that LPR causes deterioration of voice and its management should include anti-reflux treatment for prolonged time. The signs and symptoms of LPR remain controversial, at least to some extent, but it can be said that improvement in voice is a useful achievement, as noted in this study, and it perhaps justifies the use of PPIs.

Reference

The effect of anti-reflux treatment on subjective voice measurements of patients with larynogopharyngeal reflux.
Beech TJ, Cambell G, McDermott AL, Patch AJ.
THE JOURNAL OF LARYNGOLOGY AND OTOLOGY
2013;127:590-4.

THE JOURNAL OF LARYNGOLOGY AND OTOLOGY

Monitoring anticoagulant and antiplatelet therapy in patients with epistaxis
Reviewed by: Madhup K Chaurasia
Jan/Feb 2014 (Vol 22 No 6)
 

Epistaxis is one of the most common problems in otolaryngology and, according to this publication, formed 1% of all emergency admissions in the unit. In recent years, there has been a sharp rise in the use of antiplatelet and anticoagulant medication used for atrial fibrillation, cardiovascular accidents, pulmonary embolism and deep vein thrombosis. Their use is crucial in patients with metallic heart valves. This study describes a two-phased audit on interference with antiplatelets and anticoagulants in patients admitted with epistaxis. In the first phase, the retrospective data was collected on various aspects of management, withholding anticoagulant / antiplatelet therapy, bleeding after discharge of such patients and any embolic or cardiac episodes. An algorithm was then devised and implemented. In patients in whom bleeding was controlled with nasal packing, aspirin and clopidogril were not withheld at all. If warfarin was given for ‘relative’ indications, such as atrial fibrillations without complications and single deep vein thrombosis (DVT), it was omitted only whilst the packs were in situ and then restarted immediately thereafter. If patients had ‘absolute’ indications for anticoagulants, such as a stroke / cerebrovascular accident (CVA), DVT, pulmonary embolism (PE) and metallic heart valves, warfarin was continued. If the international normalised ratio (INR) was above normal range, warfarin was omitted to bring it down into the therapeutic range. In patients with uncontrolled bleeding, a discussion was arranged with the haematology department and cardiologists. Aspirin was withheld whilst packs were in situ but Clopidogrel was continued, unless discussion with the cardiologist allowed it to be withdrawn. As for warfarin in uncontrolled bleeding situations, if given for relative indications, it was omitted whilst the packs were in situ and restarted immediately thereafter. If warfarin was used for absolute indications, haematological advice was always sought and full reversal was considered with or without heparin infusion, depending on its indications and cardiology advice. In this way the authors greatly reduced the incidence of withdrawal of anticoagulant and antiplatelet medication and this did not result in any untoward complications from the cardiac or haematological point of view. It is suggested that the protocol should be standardised and the management of cases of epistaxis should not be detrimental to patients suffering from more serious conditions.

Reference

Treatment algorithm for oral anticoagulant and antiplatelet therapy in epistaxis patients.
Biggs TC, Baruah P, Mainwaring J, Harries BG, Salib RJ.
THE JOURNAL OF LARYNGOLOGY AND OTOLOGY

THE JOURNAL OF LARYNGOLOGY AND OTOLOGY

Pre-emptive anaesthesia for control of post tonsillectomy pain in children
Reviewed by: Madhup K Chaurasia
Jan/Feb 2014 (Vol 22 No 6)
 

Poor control of pain after tonsillectomy results in a poor recovery phase characterised by discomfort, nausea, vomiting and continued need for analgesia. This also can delay discharge which is desired early in the present economic climate. In this study the authors compare peri-operative and post-operative severity of pain by having a control group of 80 children who had only local infiltration of surgery with a study group that received pre-emptive analgesia by way of rectal diclofenac (2mg per kg) intravenous paracetamol (15mg per kg) and intravenous Tramadol (2mg per kg) administered over 15 minutes during the induction of general anaesthesia. The study appears to be adequately randomised. Tonsillectomy was done by dissection. The nurses who assessed pain were blinded to this study. Pain assessment was done in the intra-operative phase by assessing haemodynamic parameters such as heart rate and arterial pressure values. In the post-operative period visual analogue scale was used and the requirement for analgesia noted. Results showed that in the control group – that is children receiving only infiltration anaesthesia – increased pain during surgery was observed, in terms of increased heart rate and arterial pressure values, the former being statistically significant. There was also a higher requirement for analgesia during the stay in the hospital but no delay in resuming oral intake. At home children who did not receive pre-emptive analgesia (the control group) had much higher pain scores and required far more analgesia than the study group. There was also a lower incidence of post operative nausea and vomiting in this study group. The authors emphasise that immediate pre operative administration of analgesia is an important factor in controlling pain during and after tonsillectomy.

Reference

Pre-emptive triple analgesia protocol for tonsillectomy pain control in children: double-blind, randomised, controlled, clinical trial.
El-Fattah AMA, Ramzy E.
THE JOURNAL OF LARYNGOLOGY AND OTOLOGY
2013;127:383-91.

THE JOURNAL OF LARYNGOLOGY AND OTOLOGY

Symptoms without pathology – is it somatisation?
Reviewed by: Madhup K Chaurasia
Jan/Feb 2014 (Vol 22 No 6)
 

It is estimated that about a third of all patients attending primary and secondary health care centres have symptoms which cannot be supported with clinical findings or investigations. Are these due to somatisation or do they have a real cause? Somatoform disorder is characterised by failure to explain symptoms of a known medical condition, there sometimes being a related medical condition to this, and the symptoms cause distress. They are not accounted for by another mental disorder and are not intentionally produced or feigned. In this revealing article, the authors have discussed the possible aetiology of such situations. This comprises psychopathology such as children ‘somatising’ symptoms exhibited by other members of the family, selective perception influences and habitual attention to a part of their own body causing them to habitually focus on a body part. The role of depression and anxiety have also been implicated and as they decrease, the symptoms resolve. Hypochondriasis may be connected with somatisation. There follows an interesting discussion on specific ENT conditions and the authors have tried to draw a line between the possibility of somatisation and actual causes. Dizziness has been attributed to anxiety and this can also produce some positive results. Tinnitus, which essentially is considered to be due to de-afferentation of tono-topically organised central auditory structures, results in random activity of neurons in the auditory cortex. However there is often a complex correlation of tinnitus with depression and anxiety. Many patients present with apparent Eustachian tube dysfunction but normal tympanogram. Treatments have only a placebo effect. The cause of impaired hearing with normal audiogram is often obscure, and may be related to auditory psychological and linguistic factors. Catarrhal and postnasal drip is essentially a misnomer and this may be due to altered sensations and sensitivity to normal mucus production. Clearing the throat may often form a habit. Other conditions mentioned are atypical facial pain, dryness of the nose, globus pharynges and functional dysphonia. The message conveyed here is that most medical explanations bypass the reality of symptoms. The authors feel that the patient’s symptoms should be legitimised and a tangible mechanism for the symptoms should be offered. The solution lies in offering cognitive behaviour therapy and dealing with comorbid depression and anxiety. Psychological help is useful in patients with related problems. The information here is valuable and can help avoid unnecessary surgery, cut costs and improve patient satisfaction.

Reference

Medically unexplained symptoms and somatisation in ENT.
Ullas G, McClelland L, Jones NS.
THE JOURNAL OF LARYNGOLOGY AND OTOLOGY
2013;127:452-7.

THE JOURNAL OF LARYNGOLOGY AND OTOLOGY

The role of rhinology care, pathways and primary care
Reviewed by: Madhup K Chaurasia
Jan/Feb 2014 (Vol 22 No 6)
 

One of the commonest referrals in otolaryngology is of patients suffering from rhinosinusitis. As per one survey in England, the condition affects 13.7% of the population. It is therefore important that these referrals should be appropriate and thus help in reducing time and cost of management. In 2007 primary care guidelines were formulated by the European Position Paper on the primary care diagnosis and management of rhinosinusitis and nasal polyps. Based on this, the authors devised an algorithm for primary care management and referral of patients with rhinosinusitis. This involved treating the condition with intra nasal steroid sprays for about 12 weeks with the addition of antibiotics if the discharge from the nose was purulent. The protocol also applied to bilateral nasal polyps but if the polyps were unilateral, a fast track referral was advised. Oral antihistamines were recommended if there were symptoms of allergy. If the treatment failed CT scan of the sinuses with skin prick tests was recommended and after this a referral to secondary care was considered appropriate. 55 consecutive referrals were audited. It was noted that only 22% of patient referrals complied with the suggested primary care pathway. The duration of symptoms was reported in only 78% of patients and only 61% had findings of a nasal examination recorded. There was even greater variation in the duration of treatment, ranging from four weeks to four years. This study therefore showed that the suggested primary care pathway did not reduce the number of referrals, nor was it practised in most patients. Undoubtedly this suggests that a lot of work is yet to be done. Reasons for failure of compliance have not been mentioned, but it does appear that the short training period in otolaryngology does not foster enough confidence in every General Practitioner to manage these cases.

Reference

Do rhinology care pathways in primary care influence the quality of referrals to secondary care?
Su N, Cheang PP, Khalia H.
THE JOURNAL OF LARYNGOLOGY AND OTOLOGY
2013;127:364-7.

THE JOURNAL OF LARYNGOLOGY AND OTOLOGY

The significance of bony changes in patients with nasal polyposis
Reviewed by: Madhup K Chaurasia
Jan/Feb 2014 (Vol 22 No 6)
 

A computed tomography (CT) scan for paranasal sinuses is an important pre-operative investigation and plays a significant role in the management of these cases. Bony involvement, especially erosion of the bones of the paranasal sinuses, is generally considered in relation to the nature of the polyposis – whether benign, intermediate or malignant. In this detailed study correlating radiological changes picked up on CT scans in patients with nasal polyposis, the authors have emphasised the significance of these changes in relation to the severity of the polyposis based on Lund Mackay score and the nature of these polyps. This is a retrospective analysis of 104 patients with nasal polyps, compared with a gender matched control group. The three main changes noted were expansion, erosion and thickening of the bones. It was the medial wall of the orbit which most frequently showed bony erosion and expansion. Bony thickening was most often seen in the sphenoid sinus walls. Ninety-three percent of the patients with nasal polyps showed bony changes, whereas none of these changes were noted in the control group. These changes have bearings on the outcome of surgery and also serve as a warning against risk of damage especially to the medial wall of the orbit. There was also a correlation between the severity of polyps and the total expansion, erosion and thickening score and this may help to explain higher complication rates in patients who have very extensive polyposis because the bones are involved as well. The presence of bony changes may also help in deciding whether or not to send the polyps for histology. The article provides useful reading and adds an important dimension to the management of chronic rhinosinusitis, also hinting that the bony changes are not always associated with malignancy.

Reference

Sino nasal bony changes in nasal polyposis: prevalence and relationship to disease severity.
Siddiqui J, Millard R, Eweiss AZ, Beale T, Lund VJ.
THE JOURNAL OF LARYNGOLOGY AND OTOLOGY
2013;127:755-9.

WORLD JOURNAL OF SURGICAL ONCOLOGY

Intra-operative hypoglossal nerve monitoring
Reviewed by: Gauri Mankekar
Jan/Feb 2014 (Vol 22 No 6)
 

In this article, the authors report the use of intra-operative hypoglossal nerve monitoring in four patients who underwent extensive oral surgery for tongue lesions. One patient had squamous cell carcinoma of the anterior aspect of the tongue; the second patient had recurrence of squamous cell carcinoma tongue and had history of previous surgery; the third patient (child aged six years) had hemangiolymphangioma of the right side of neck, floor of mouth and tongue and the fourth patient had obstructing macroglossia due to amyloidosis, secondary to multiple myeloma. All patients underwent extensive variations of glossectomy with floor of mouth resection and neck dissection. The authors used intra-operative hypoglossal nerve monitoring but did not compromise on the margin in patients with carcinoma and sacrificed the hypoglossal nerve when it was involved by tumour. The authors suggest that intra-operative hypoglossal nerve monitoring should not be used in patients undergoing a classic hemiglossectomy for the first time for a tongue or floor of mouth lesion as it increases cost to the patient. Also in cases of carcinoma, it is difficult to compromise positive margins in order to preserve function. The authors recommend usage of intra-operative hypoglossal nerve monitoring in challenging cases wherein patients have undergone prior surgery and have complicated anatomical conditions, scar and fibrotic tissue.

Reference

Hypoglossal nerve monitoring, a potential application of intraoperative nerve monitoring in head and neck surgery.
Duque CS , Londoño AF, Penagos AM , Urquijo DP, Dueñas JP.
WORLD JOURNAL OF SURGICAL ONCOLOGY
2013;11:225.

WORLD JOURNAL OF SURGICAL ONCOLOGY

Malignant melanoma in the oesophagus
Reviewed by: Gauri Mankekar
Jan/Feb 2014 (Vol 22 No 6)
 

Melanoma is usually a malignant cutaneous tumour but can rarely occur on mucosal surfaces like the oesophagus, especially in the elderly. The authors present a rare case of oesophageal melanoma occurring in a 60 year old man with a history of 50 years of smoking. The patient underwent a diagnostic endoscopy for dysphagia and chest pain and was found to have a polypoidal tumour in the lower third of the oesophagus, which on biopsy was compatible with malignant melanoma. A transhiatal oesophagectomy with subcarinal lymphadenectomy and isoperistaltic gastric tube replacement of the oesophagus was performed. Nine months after surgery, the patient developed ischaemic colitis, and metastasis in the mesentery. His disease progressed and he died one year after the oesophagectomy. The authors conclude that diagnosis of this rare condition is difficult and usually made late as the symptoms are non specific and there is often a low suspicion level due to the rarity of the disease. This is especially so in the absence of evident melanin granules, as diagnostic errors may occur, because the lesions are not considered as showing clearly differentiated carcinoma. Although radiological studies such as oesophagography, computed tomography and magnetic resonance imaging can identify and locate the tumour, the diagnosis can only be established by upper digestive endoscopy with biopsy and immunohistochemical studies.

Reference

Primary malignant melanoma of the esophagus: a rare and aggressive disease.
Morita F, Ribeiro Jr U, Tacconi MR , Takeda FR, Rafael da Rocha J, de Ligabó G, de Melo E, Pollara WM, Cecconello I.
WORLD JOURNAL OF SURGICAL ONCOLOGY
2013;11:210.

AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY

Sense of smell and sexual desire: more work needed on this!
Reviewed by: Mr Edward W. Fisher
Jan/Feb 2014 (Vol 22 No 6)
 

This small study from the University of Padua in Italy aimed to find a link between sexual desire (using an established measure) with the olfactory threshold to n-butanol threshold using Sniffin’ sticks. They looked at a group of older men (at or over 65 years) and young men (20-36 years). The back-story is that pheromones are thought to play a part in human sexuality, and olfactory threshold could reasonably be considered to have some link to a person’s receptiveness to pheromones and that declining sexual desire with old age could in some way link to fewer olfactory neurones. Not surprisingly, the older men had poorer indices for sexual desire and olfactory function compared to the younger group – but within the younger group there was a correlation between sexual desire and olfactory acuity, which was absent in the older group. The authors are surprised at the lack of correlation in the older group and wonder whether this is because sexual desire in older men is more complex, perhaps with more psychological inputs than in the younger group.

Reference

Olfactory sensitivity and sexual desire in young adult and elderly men: an introductory investigation
Ottaviano G, Zuccarello D, Frasson G, Scarpa B, Nardello E, Foresta C, Marioni G, Staffieri A.
AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY
2013;27(3):157-61.

AUDIOLOGICAL MEDICINE

Auditory cortical responses in noise
Reviewed by: Mr Diego Zanetti
Jan/Feb 2014 (Vol 22 No 6)
 

The perception, segregation and identification of a significant sound pattern in background noise rely upon the integrity of the cochlea and on the processing of the incoming signal at various levels in the central auditory nervous system (CANS). Its interpretation is then performed by the auditory cortical areas, which are usually studied by electrophysiological methods such as late auditory evoked potentials, or slow vertex responses. To date, there is little knowledge of the effects of background noise on these auditory cortical potentials. The authors conducted a clinical trial on 20 normal hearing young subjects; they evoked the cortical potentials with a standard oddball paradigm with binaural stimulation and competitive noise at different signal-to-noise ratios (SNRs) (quiet, +20, +10, 0dB). The amplitude and latency of the N1, P2 and P3 waves were measured for each SNR. As expected, no significant differences in the morphology or the parameters of the responses were observed between the quiet and +20 SNR condition; when the noise level increased, significant latency shifts and amplitude of the N1, P2, and P3 waves were detected. The results indicate a significant change in the activity of higher-order neurons in the auditory area when challenged with concurrent sound and noise. These normative data constitute the basis for further clinical studies that could shed light on the mechanisms of central processing of relevant sound, such as speech, in a noisy environment. The consequences would be an improvement of the strategies applied in auditory rehabilitation methods and technological advances by the hearing aid and cochlear implant manufacturers.

Reference

Auditory cortical processing in noise in normal-hearing young adults.
McCullagh J, Musiek FE, Shinn JB.
AUDIOLOGICAL MEDICINE
2012;10:114-21.

COCHLEAR IMPLANTS INTERNATIONAL

A new American Cochlear Implant Alliance Foundation
Reviewed by: Mr Thomas Nikolopoulos
Jan/Feb 2014 (Vol 22 No 6)
 

It is now emerging that of the estimated population of candidates in the USA who could benefit from a cochlear implant, only a small percentage receives one. The authors attribute this fact to the low awareness among both the general public and the medical community, the lack of universally sanctioned medical / clinical guidelines for best practices in cochlear implantation and audiology after-care, and the funding problems in both the private and public sector. The authors believe that the situation may be improved by a new non-profit organisation that brings together surgeons, audiologists, speech and language pathologists and representatives of cochlear implant manufacturers, as well as deaf people with and without implants. This new organisation is the American Cochlear Implant Alliance Foundation, or the ‘ACI Alliance’. The mission of the ACI Alliance is to advance access to the gift of hearing provided by cochlear implantation through research, advocacy and awareness. It is committed to eliminating barriers to cochlear implantation by sponsoring research, driving heightened awareness and advocating for improved access to cochlear implants for patients of all ages across the USA. It seems that the establishment of similar non-profit organisations across countries may indeed improve the situation and give deaf people better access to cochlear implants.

Reference

ACI Alliance – The American Cochlear Implant Alliance Foundation.
Niparko JK, Zwolan T.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(suppl. 1):s2-s3.

COCHLEAR IMPLANTS INTERNATIONAL

Biofilms are one of the most important threats in cochlear implantation
Reviewed by: Mr Thomas Nikolopoulos
Jan/Feb 2014 (Vol 22 No 6)
 

Acute and chronic otitis media are very significant complications following cochlear implant surgery and are sometimes related to implant extrusion, wound breakdown, or even meningitis. However, the literature is rather poor regarding optimal methods of investigation and management, especially taking into account the fact that some of these patients have to undergo explantation and revision surgery. This paper describes a case of a two-year-old child who had a recurrent infection and wound breakdown following implantation that led to explantation, although the patient had systemic antibiotics and surgical repair. The microbiology evaluation revealed biofilm in the magnet pocket and S aureus. Finally the child was implanted in the other ear. The authors suggest early explantation in cases with wound breakdown, especially with exposure of the implant and in patients with longstanding infection. In cases which are diagnosed early and in cases with no wound breakdown they recommend a beta lactam antibiotic with rifampicin as the first line treatment. Of course these recommendations cannot be based on a small number of cases and large studies or meta-analyses should help us reach a consensus on this important issue.

Reference

Case report – Biofilm infection of a cochlear implant.
Vaid N, Vaid S, Manikoth M.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(2):117-119.

COCHLEAR IMPLANTS INTERNATIONAL

Utilisation and awareness of cochlear implants in the United States
Reviewed by: Mr Thomas Nikolopoulos
Jan/Feb 2014 (Vol 22 No 6)
 

This article reviews all issues around cochlear implantation in the USA and tries to explain low utilisation rates. The author takes into account three facts: first that there are approximately 35 million adults with measurable hearing loss in the United States, secondly that around one to 1.5 million children and adults (with severe to profound hearing loss) are potential implant candidates, and thirdly that less than 100,000 adults and children have received a cochlear implant; she concludes that the utilisation rate is approximately 5-6% among the candidate population. This is rather alarming when we take into consideration that 70-90% of people with severe and profound hearing loss use amplification in the USA. This very low utilisation rate is attributed by the author to various factors, including the lack of widely accepted ‘best clinical practices’ and the opposition of the deaf community and the various misconceptions or lack of accurate information related to cochlear implantation. It is amazing that in 2013 we still discuss such issues and that as yet there is no consensus among professionals, health authorities and deaf organisations in order to ensure management options and access to cochlear implantation when appropriate for all deaf adults and children.

Reference

Cochlear implantation in the world’s largest medical device market: Utilization and awareness of cochlear implants in the United States.
Sorkin DL.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(suppl. 1):s4-s12.

ACTA OTORHINOLARYNGOLOGICA ITALICA

Accessory nerve monitoring in neck dissection
Reviewed by: Miles Bannister
Nov/Dec 2013 (Vol 22 No 5)
 

Accessory nerve injury rates increase with the extent of neck dissection, so nerve monitoring in these cases is uncontroversial. The shoulder syndrome that can result is defined as a deficit in movement or scapula winging. This small series (25 cases) reveals no such cases following intra-operative nerve monitoring, though shoulder pain unsurprisingly remains in 88% of patients at 12 months. Whilst this is a useful prospective study, it provides no such control group for comparison. However, when compared to historical complication rates reported by others, the article should offer enough evidence for those wishing to change practice; a medico-legal case for such nerve monitoring may soon be irresistible too.

Reference

Minimizing shoulder syndrome with intra-operative spinal accessory nerve monitoring for neck dissection.
Lee C-H, Huang N-C, Chen H-C, Chen M-K.
ACTA OTORHINOLARYNGOLOGICA ITALICA
2013;33:93-6.

ACTA OTORHINOLARYNGOLOGICA ITALICA

Submandibular gland removal in oral cavity cancer
Reviewed by: Miles Bannister
Nov/Dec 2013 (Vol 22 No 5)
 

Conservation surgery and organ preservation has been an issue of growing importance for almost 20 years. Submandibular gland sacrifice to control metastatic neck disease in the treatment of oral cavity squamous cell carcinoma can produce xerostomia with resulting osteoradionecrosis of the jaw. This article presents the third largest series evaluating gland involvement, asking whether the gland can be preserved, whilst lymph nodes alone are dissected. 5.5% of glands were affected by metastases, overwhelmingly by direct invasion (8/13 cases); other metastases developed in the presence of level 1 lymph node involvement. The authors therefore argue that submandibular glands can safely be preserved in the absence of invasion or lymph node metastases. The article is informative and the study’s retrospective nature is sound, particularly as level 1 evidence for this dilemma will remain elusive.

Reference

Is it necessary to remove submandibular glands in squamous cell carcinomas of the oral cavity?
Basaran B, Ulusan M, Orhan K, Orhan S, Gunes S, Suoglu Y.
ACTA OTORHINOLARYNGOLOGICA ITALICA
2013;33:88-92.

ANNALS OF OTOLOGY, RHINOLOGY& LARYNGOLOGY

Confirming diagnosis of cholesteatoma on CT?
Reviewed by: Mr Maher El Alami
Nov/Dec 2013 (Vol 22 No 5)
 

Computed tomography (CT) bone densitometry may help to distinguish inflammation from cholesteatoma on CT (Hounsfield Units on CT). Ninety-one patients undergoing mastoid surgery for chronic middle ear disease had pre-operative CT scan densitometry. Intraoperatively the extent of their disease was mapped and the clinical diagnosis was confirmed by histological analysis. Revision cases were excluded. Seventy-eight were identified as having cholesteatoma in different parts of the middle ear and often with other associated pathologies (effusion, granuloma, granulations). 61.5% of cholesteatomas had typical bone erosion visible on CT. CTs were reviewed by three different examiners blinded to the patient’s details. Even though CT densitometry managed to distinguish isolated non-cholesteatomatous lesions on CT it failed to distinguish cholesteatoma from inflammatory conditions. This study however helped to arrive at a better system for describing and comparing pre- and intraoperative findings in the ear. An interesting study looking at cholesteatoma diagnosis and the limitations of preoperative imaging.

Reference

Is preoperative computed tomographic density measurement of soft tissue helpful in diagnosis of cholesteatoma?
Dong-Hee L, Choung-Soo K, Chang-Woo P, Dae-Young C.
ANNALS OF OTOLOGY, RHINOLOGY & LARYNGOLOGY
121(12):792-97.

ANNALS OF OTOLOGY, RHINOLOGY& LARYNGOLOGY

Rise of the machines: transaxillary robotic thyroid surgery
Reviewed by: Mr Maher El Alami
Nov/Dec 2013 (Vol 22 No 5)
 

Approaching the thyroid gland via the axilla is an interesting concept and the use of a surgical robot offers the option of surgery without a neck incision. Initially the surgery has been performed by two ipsilateral axillary incisions; the authors in this series describe their experience for total thyroidectomy through one incison. Twenty-nine patients over a year-long period were included. Indication for surgery was papillary thyroid cancer and inclusion criteria were thyroid lobe size smaller than 6.5cm, BMI < 35, excluding patients with neck metastasis and previous neck treatment. Approach was via a unilateral 8-9cm axillary incision and dissection was performed by cautery and harmonic scalpel. The technique is described in detail and some pictures are included. Mean operative time was 178 minutes. There was no postoperative hypocalcaemia, but two cases of transient hoarseness (side was not specified) with clear tumour margins. Robotic surgery has attracted a lot of interest and introduces new possibilities in surgery.

Reference

Single-incison robot assisted transaxillary surgery for early-stage papillary thyroid cancer.
Ciabatti PG, Burali G, D’ascanio L.
ANNALS OF OTOLOGY, RHINOLOGY & LARYNGOLOGY
121(12):811-15.

ANNALS OF THE ROYAL COLLEGE OF SURGEONS OF ENGLAND

T-14 to the rescue!
Reviewed by: Ananth Vijendren
Nov/Dec 2013 (Vol 22 No 5)
 

In this climate of NHS reforms and economic struggle, procedures concluded to have ‘limited clinical benefit’ have come under immense scrutiny by various members of the health care profession. Top of this list is tonsillectomy. The authors thus set out to rectify this misconception by using a validated patient reported outcome measure questionnaire, the Paediatric Throat Disorders Outcome Test (T-14) to measure the benefits of tonsillectomy and adenotonsillectomy in children under the age of 16. Fifty-four children undergoing the procedure for recurrent tonsillitis and obstructive sleep apnoea were recruited. The questionnaires were completed preoperatively and at three and six months post surgery, where significant improvements were seen (p < 0.0001). This paper adds further evidence to the 2009 position paper published by ENT UK that tonsillectomy produces profound changes in a patient’s quality of life and should therefore justify its clinical value as a funded NHS procedure.

Reference

Application of the paediatric throat disorders outcome test (T-14) for tonsillectomy and adenotonsillectomy.
K Konieczny, TC Biggs, S Caldera.
ANNALS OF THE ROYAL COLLEGE OF SURGEONS OF ENGLAND
2013;95:410-14.

BMC EAR, NOSE AND THROAT DISORDERS

Inability to smell your coffee?
Reviewed by: Gauri Mankekar
Nov/Dec 2013 (Vol 22 No 5)
 

In this study, the authors reviewed replies of 1000 patients with anosmia, to their online survey. The patients submitted an account of their subjective experiences of how they have been affected by anosmia and, in addition, they answered 43 specific questions about the consequences of their olfactory dysfunction. The study revealed that anosmia affects quality of life and causes practical problems. Smell loss-induced social isolation and smell loss-induced anhedonia can severely influence quality of life. Imagine not being able to smell your partner’s perfume or your favourite early morning cuppa! The authors found that the practical problems were less severe and were mainly related to hazard avoidance, food related and problems in managing odours. Not being able to change children’s nappies when they are “stinky” can cause parenting issues. The authors conclude that, while the practical problems of olfactory dysfunction are dwarfed by those of visual impairments, smell loss-induced social isolation and smell loss-induced motivational anhedonia have outsized detrimental effects on quality of life of these patients and a comprehensive solution can only be provided by research into an effective treatment.

Reference

Hidden consequences of olfactory dysfunction: a patient report series.
Keller A, Malaspina D.
BMC EAR, NOSE AND THROAT DISORDERS
2013;13(8):1-20.

BMC EAR, NOSE AND THROAT DISORDERS

Microbiology of otorrhoea in North Ethiopia
Reviewed by: Gauri Mankekar
Nov/Dec 2013 (Vol 22 No 5)
 

In this retrospective study over three years, the authors reviewed results of a total of 228 ear discharge samples which were tested for bacterial isolation. Of these 204 (89.5%) cases were found to have bacterial isolates; 115 (56.4%) were gram negative bacteria; predominantly proteus species (27.5%). Of individuals who had ear infection, 185 (90.7%) had single bacterial infection while 19 (9.3%) had mixed infections. And of all the bacterial isolates, 192 (94.1%) had multiple antibiotic resistant pattern – non-Lactose Fermenter Gram Negative Rods (46.0%), Klebsiella species (47.7%) and Pseudomonas species (48.5%) were resistant against the commonly used antibiotics. The authors conclude that in view of the very high prevalence of ear infection in the study area with majority of the bacterial isolates being resistant to multiple antibiotics, susceptibility testing is mandatory before prescribing any antibiotics.

Reference

Bacterial isolates and drug susceptibility patterns of ear discharge from patients with ear infection at Gondar University Hospital, Northwest Ethiopia.
Muluye D, Wondimeneh Y, Ferede G, Moges F, Nega T.
BMC EAR, NOSE AND THROAT DISORDERS
2013;13(10):1-5.

BRITISH JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY

A preliminary report on the use of endoscope and concealed incisions for small benign tumours of the accessory parotid gland
Reviewed by: Sampath Chandra Prasad
Nov/Dec 2013 (Vol 22 No 5)
 

While the most common conventional approaches for benign tumours of the parotid gland are the standard parotidectomy incision, a modified standard parotidectomy incision and a face lift incision, the authors have used a modified endoscopic approach with minimal concealed incisions for the resection of benign tumours of the accessory parotid gland in five patients. They described three incisions, the first of which is 1.5-2cm long, and applied at the margin of the tragus. Two additional incisions each 1cm long were applied, one along the inferior postauricular crease behind the lobule of the ear and the other in the temporal region of the scalp above the hairline. The incision at the margin of the tragus was continued as far as the parotid capsule. The skin flaps were dissected and raised above the surface of the capsule and a surgical plane developed. The two additional incisions were continued subcutaneously to connect to the tunnel. A rigid 30° 4mm endoscope was introduced through any of the incisions with the other two used for instrumentation. Sufficient illumination and magnification allowed for clear identification of the buccal branch of the facial nerve and other anatomical structures which were preserved. In all five cases, the tumours were confined to the accessory lobe of the parotid, with tumour sizes between 0.7 to 2.5cm in diameter. In all cases, the tumour and surrounding tissues were completely resected and removed by extracapsular dissection without damage to the facial nerve in any of the cases. The authors conclude that though this procedure provides excellent cosmesis in comparison with modified standard parotidectomy incisions and facelift incisions, the procedure is more time consuming but only until the technique had been mastered. The small number of cases is a limitation of the study and the authors need to define the limits of application of this technique in terms of the site, size and nature of the tumours in the parotid.

Reference

Minimally invasive endoscopic resection of benign tumors of the accessory parotid gland: an updated approach.
Li B, Zhang L, Zhao Z, Shen G, Wang X.
BRITISH JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY
2013;51(4):342-6.

BRITISH JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY

Balloon catheter sialoplasty – a histological analysis
Reviewed by: Sampath Chandra Prasad
Nov/Dec 2013 (Vol 22 No 5)
 

Obstructive sialoadenitis is the most common non-neoplastic disorder of the salivary glands. By using an expandable balloon catheter to dilate ductal stenosis during sialoendoscopy it is possible to dilate a stenotic duct and remove large stones with or without a basket. However, the use of different angiocatheters or dedicated balloons is still empirical. In this pilot study the authors assessed the feasibility and safety of balloon dilatation of the submandibular gland (Wharton's duct) to standardise its clinical application for the treatment of patients with obstructive sialadinitis. They performed balloon catheter sialoplasty on four ducts from two fresh adult cadavers. They used a non-compliant dilating balloon catheter 6mm in diameter at a pressure of 12 × 10(5)Pa for a total of three minutes and then examined the ducts histologically. There was no serious acute damage to the wall of Wharton's duct apart from minor changes on the epithelium. There was no interruption in the full thickness, or laceration of the mucosal epithelium. Although this is a small study, they have shown the safety of balloon catheter sialoplasty for the first time as assessed histologically after dilatation of the duct.

Reference

Balloon catheter sialoplasty: a safety and feasibility pilot study.
Sionis S, Vedele A, Brennan PA, Fanni D, Puxeddu R.
BRITISH JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY
2013;51(3):228-30.

BRITISH JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY

Use of spacers for mandibular defects after resection of mandible preceding definitive osseous reconstruction
Reviewed by: Sampath Chandra Prasad
Nov/Dec 2013 (Vol 22 No 5)
 

The authors propose the use of rigid polyethylene and silicon spacers in mandibular defects as an interim measure before definitive osseous reconstruction after mandibular resections for locally aggressive benign disease. The authors point out that the current intermediate reconstruction systems provide only structural rigidity to reconstitute mandibular continuity and some degree of soft tissue support. They fail to meet the demands of maintenance of space and are not designed to facilitate re-entry and removal. Even more problematic is intermediate condylar reconstruction, which has not been intelligently designed. They propose to redesign intermediate reconstruction prosthesis to provide not only immediate structural rigidity and to support the healing of soft tissues, but also to maintain an adequate space for reconstruction while remaining technically simple to insert and remove. A virtual model using computed tomography (CT) and 3-Matic software was made that allowed three dimensional printing of a silica plaster replica of the neomandible on which a custom plate was adapted. The mandibular segment was resected through an intraoral approach and spacer introduced. The spacer consisted of a rigid condyle / ramus unit (ultra-high molecular weight polyethylene) and a separate flexible body spacer (inert, non-toxic medical and food grade silicon rubber). The spacer was left in place for six to eight weeks and definitive reconstruction performed through an extraoral approach using corticocancellous bone graft. 38 patients were treated this way. Thirty-seven patients had uncomplicated mucosal healing and only one patient (who did not adhere to follow up protocol) had large mucosal dehiscence over the spacer. The authors argue that while primary reconstruction saves time and resources, it is seldom in the patient’s best interests and may result in compromised aesthetic and functional results that are difficult or impossible to rectify. They point out that secondary reconstruction of the mandible defect can be effected in a patient who is in physiologically optimal condition and better able to withstand reconstructive surgery. It allows the surgeon to reassess not only the adequacy of the excision but also the cosmetic outcomes of the reconstruction during healing and if necessary make changes in the final reconstructive plan to optimise the aesthetic result. Finally, grafting in an environment that is sealed from the oral cavity improves the likelihood of uncomplicated healing.

Reference

Interim reconstruction and space maintenance of mandibular continuity defects preceding definitive osseous reconstruction.
Ferreti C, Rikhotso E, Muthray E, Reyneke J.
BRITISH JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY
2013;51(4):319-25.

COCHLEAR IMPLANTS INTERNATIONAL

Can bilaterally implanted children identify emotion in speech and music?
Reviewed by: Thomas Nikolopoulos
Nov/Dec 2013 (Vol 22 No 5)
 

It is now the time to explore specific issues of the everyday life of implanted children. Identification of emotion in speech and music is an important element in children’s quality of life. The present study examined the ability of prelingually deaf children with bilateral implants to identify emotion (i.e. happiness or sadness) in speech and music. The authors performed two experiments. Participants in experiment one were 14 prelingually deaf children from five to seven years of age who had bilateral implants and 18 normally hearing children from four to six years of age. They judged whether linguistically neutral utterances produced by a man and woman sounded happy or sad. Participants in experiment two were 14 bilateral implant users from four to six years of age and the same normally hearing children as in experiment one. They judged whether synthesised piano excerpts sounded happy or sad. The results revealed that bilaterally implanted children’s accuracy of identifying happiness and sadness in speech was well above chance levels but significantly below the accuracy achieved by children with normal hearing. Similarly, their accuracy of identifying happiness and sadness in music was well above chance levels but significantly below that of children with normal hearing, who performed at ceiling. For the 12 implant users who participated in both experiments, performance on the speech task correlated significantly with performance on the music task and implant experience was correlated with performance on both tasks. Another study showing us that implanted children’s quality of life does not depend only on speech perception and production. Device strategies should be modified accordingly.

Reference

Children with bilateral cochlear implants identify emotion in speech and music.
Volkova A, Trehub SE, Schellenberg EG, Papsin BC,
Gordon KA.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(2):80-91.

COCHLEAR IMPLANTS INTERNATIONAL

Force controlled robotic drill in cochlear implantation
Reviewed by: Thomas Nikolopoulos
Nov/Dec 2013 (Vol 22 No 5)
 

As hearing preservation has been the aim of a growing number of implant procedures, minimising the trauma sustained by the cochlea during cochleostomy has emerged as a key issue. The aim of this paper was firstly, to assess the cochlea disturbances during manual and robotic cochleostomy formation and secondly, to determine whether the use of a smart micro-drill would be feasible during human cochlear implantation. The disturbances within the cochlea during cochleostomy formation were analysed in a porcine specimen by creating a third window cochleostomy, preserving the underlying endosteal membrane, on the anterior aspect of the basal turn of the cochlea. A laser vibrometer was aimed at this third window, to assess its movement while a traditional cochleostomy was performed. Six cochleostomies were performed in total, three manually and three with a smart micro-drill. The smart micro-drill was further used to perform live human robotic cochleostomies on three adult patients undergoing cochlear implantation. The results revealed that in the porcine trial, the smart micro-drill preserved the endosteal membrane in all three cases. The velocity of movement of the endosteal membrane during manual cochleostomy was approximately 20 times higher on average and 100 times greater in peak velocity, than for robotic cochleostomy. Moreover, the robot was safely utilised in theatre in all three cases and successfully created a bony cochleostomy while preserving the underlying endosteal membrane. It seems that the smart micro-drill may have some very important advantages in hearing preservation cochlear implant surgery. However, more patients and reproducible conditions and results are needed to confirm the results of this interesting study.

Reference

A smart micro-drill for cochleostomy formation: a comparison of cochlear disturbances with manual drilling and a human trial.
Coulson CJ, Assadi MZ, Taylor RP, Du X, Brett PN, Reid AP, Proops DW.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(2):98-106.

COCHLEAR IMPLANTS INTERNATIONAL

Pragmatics and free conversation of school age deaf implanted children
Reviewed by: Thomas Nikolopoulos
Nov/Dec 2013 (Vol 22 Nov 5)
 

Most outcome studies in paediatric cochlear implantation focus on speech perception and speech production. However, everyday life is related to pragmatics and free conversation. The present study investigated the conversational skills of 20 children with cochlear implants, aged between nine and 12 years, in free conversation with their hearing peers. The pragmatic skills of these 20 deaf / hearing pairs or dyads were compared with the pragmatic skills of 20 hearing / hearing dyads. Pragmatic skills were analysed in terms of conversational balance, conversational turn types and conversational maintenance. The impact of the participants’ level of speech intelligibility was also investigated. The results revealed that children with cochlear implants tend to dominate conversations with their hearing peers. They initiated more topics, took longer turns, asked more questions and tended to make more personal comments while their hearing friends tended to use more conversational devices and minimal answers. In contrast, pairs of matched hearing children were very balanced in all of these aspects of conversation. It was a very interesting finding that speech intelligibility did not appear to impact consistently on the pragmatic skills of the children with cochlear implants but all children had a relatively high level of speech intelligibility. Although the number of studied children is small, the results encourage us to assess implanted children in a less traditional way and explore their everyday life rather than evaluate them with laboratory type tests

Reference

The conversational skills of school-aged children with cochlear implants.
Toe DM, Paatsch LE.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(2):67-79.

COCHLEAR IMPLANTS INTERNATIONAL

Software analysis for cochlear implant signals
Reviewed by: Thomas Nikolopoulos
Nov/Dec 2013 (Vol 22 No 5)
 

Besides surgery and (re)habilitation, basic science and related electronic and audiology refinements are very important in the field of cochlear implantation and especially in the development of new technology. Being able to display and analyse the output of a speech processor that encodes the parameters of complex stimuli to be presented by a cochlear implant is useful for software and hardware development as well as for diagnostic purposes. As the authors state, this firstly requires appropriate hardware that is able to receive and decode the radio frequency (RF)-coded signals, and then processing of the decoded data using suitable software. The PCI-IF6 clinical hardware together with the Implant Communicator and Matlab Toolbox research software libraries, are supposed to provide the necessary functionality. RFcap is a standalone Matlab application that encapsulates the relevant functions to capture, display, and analyse the RF-coded signals. Such an analysis tool can be applied in basic research and clinical diagnostics. It remains to be seen if this tool can help us in current clinical practice and if it can contribute to new technology development.

Reference

RFcap: a software analysis tool for multichannel cochlear implant signals.
Kong LW, Dillier N
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(2):107-16.

HEAD & FACE MEDICINE

Esthesioneuroblastoma: one of the causes of proptosis
Reviewed by: Bilal Gani Taib
Nov/Dec 2013 (Vol 22 No 5)
 

Esthesioneuroblastoma is a rare neuroectodermal malignant nasal cavity neoplasm originating from the sensory olfactory epithelium. First described in 1924 its incidence follows a bimodal distribution, which peaks in the second and sixth decades. Both genders are affected equally and owing to its non specific symptoms there is usually a long prodromal period. Local rates of recurrence and / or metastases after treatment are between 25-50%; despite this, the five year disease free survival rate is 80%. A 60-year-old gentleman presented with nasal obstruction and bleeding, a bulging of the left eye, together with a decrease in visual acuity over one and a half years. He also noticed a rapidly increasing swelling over the nasal bridge and associated headaches and neck pain. His past medical and family history were insignificant. Local examination revealed a diffuse, firm, non tender swelling with irregular margins in the glabella, left maxillary and nasal bridge regions. There was also proptosis of the left eye with anterior, inferior and lateral deviation of the eyeball. No evidence of metastatic spread was found. In this case a fine cut computed tomography (CT) scan as opposed to a magnetic resonance imaging (MRI) scan was used to locate the extent of the mass to both nasal cavities and ethmoid sinuses with a destroyed nasal septum. The mass extended laterally into the left infratemporal region with destruction of the posterolateral wall of the left maxillary sinus. Additionally there was left infraorbital extension via the destruction of the medial wall of the left orbit resulting in the proptosis. Superiorly the mass extended to the frontal sinuses but there was no intracranial involvement. Inferiorly there was destruction of the hard palate with intraoral extension. Histopathology revealed monomorphic malignant round cell tumours with a rosette formation consistent with esthesioneuroblastoma. The patient was advised to have chemotherapy / radiotherapy. Chemotherapy is usually offered to patients with locally advanced or metastatic disease. A combination of radiotherapy and surgery yields the best curative rates.

Reference

Esthesioneuroblastoma: one of the causes of proptosis.
Ansari S, Ahmad K, Dhungel K, Gupta MK, Amanullah MF.
HEAD & FACE MEDICINE
2013;9:19.

INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY

Nasal packing after septoplasty [Title added by PC]
Reviewed by: Christos Georgalas
Nov/Dec 2013 (Vol 22 No 5)
 

“Primum non nocere” – first, do no harm. This ancient adage stands true today as much as always. However, in this time of patient-friendly and cost-conscious care it could be rephrased to also include, “First, avoid causing the patient unnecessary discomfort”, as well as, “First, avoid spending resources unwisely”. Doctors tend to be a rather conservative bunch: despite the fact that nasal packing after septoplasty has been shown in a number of studies to be unnecessary, it is still used in some practices (thankfully, rarely nowadays in the UK or in the Netherlands). This well designed and performed meta analysis is a good example of putting good science and statistics in the service of good old-fashioned common sense. The authors assessed eleven randomised control trials from a total of 1477 patients, as well as three prospective and two retrospective studies. It was clear from the comparison that, while nasal packing did not decrease bleeding, septal hematomas or perforations, adhesions or residual deviated nasal septum, it was associated with increased postoperative infection. Indeed, it is in assessing the incidence of uncommon events such as complications that meta analysis shows its value. A clinically important but statistically difficult to prove decrease of a complication from 2% to 1% , while it will not show in any study with less than 1000 participants, can be identified when results are pooled. There were some grey areas in the meta analysis, namely the presence of significant heterogeneity as well as the non disclosure in some studies of whether the patients underwent inferior turbinate surgery. However, overall the results are clear and convincing: in modern septal surgery, there is very little use for nasal packing.

Reference

Is nasal packing necessary after septoplasty? A meta-analysis.
Banglawala SM, Gill M, Sommer DD, Psaltis A, Schlosser R, Gupta M.
INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY
2013;3:418-24.

INTERNATIONAL JOURNAL OF AUDIOLOGY

Feelings about the non-use of the hearing aid
Reviewed by: Diego Zanetti
Nov/Dec 2013 (Vol 22 No 5)
 

The negative psychosocial consequences of untreated hearing loss, namely social isolation, loneliness and depression can be softened by hearing aids (HAs), which can increase quality of life. However, many adults with a hearing loss do not seek help, and less than half of those who do decide to adopt hearing aids. In many international reports, up to a quarter of the adults who own hearing aids never or hardly ever use them. To provide these ‘non-users’ with the best help, hearing care professionals need to have an in-depth understanding of the non-users’ beliefs and feelings with regard to the non-use. In this qualitative study, 11 hearing aid owners (aged 54 – 80 years) who reported that they never or hardly ever used their HA underwent an individual face-to-face semi-structured interview, aimed at exploring their beliefs and feelings towards their non-use. The results included indifference, self-annoyance, frustration, powerlessness, shame, and guilt. Their feelings were related to beliefs about: (1) the severity of their hearing handicap with and without hearing aids; (2) who or what was responsible for the non-use; and (3) the attitudes of significant others towards the non-use. In conclusion, hearing-aid non-users differ in their beliefs and feelings towards the non-use, and a patient-centred approach is needed.

Reference

Qualitative interviews on the beliefs and feelings of adults towards their ownership, but non-use of hearing aids.
Linssen AM, Joore MA, Rianne KH, Minten RKH, van Leeuwen YDC, Anteunis LJC.
INTERNATIONAL JOURNAL OF AUDIOLOGY
2013;52:358-66.

INTERNATIONAL JOURNAL OF AUDIOLOGY

How does the vibrant sound bridge compare with hearing aids?
Reviewed by: Victor Osei-Lah
Nov/Dec 2013 (Vol 22 No 5)
 

The vibrant sound bridge (VSB) provides another choice for patients with conductive and mixed hearing loss who for a variety of reasons cannot use conventional hearing aids satisfactorily. The aim of this study was threefold: to determine the effects of VSB-round window (RW) surgery, to establish the effect on hearing by the VSB-RW application in individuals with a mixed hearing loss or conductive hearing loss, and to compare these results with hearing outcomes obtained with traditional hearings aids (speech perception in quiet and in noise test situations). Eighteen adults were recruited, 13 of whom had a mixed loss and five, pure conductive loss. All patients had used conventional hearing aids in the preceding two years. The outcome measures analysed were postoperative surgical findings / experience, bilateral bone conductive thresholds pre- and postoperatively, VSB-aided thresholds versus pre-operative unaided thresholds, pre- and postoperative speech recognition in quiet and noise. Postoperative testing was done quarterly over 12 months. Five patients required revision surgery; otherwise there were no surgical complications. Bone conduction thresholds remained largely unchanged post-operatively but VSB-aided thresholds were at least 40dB better than unaided preoperative levels. Whereas speech recognition in quiet with the VSB was comparable to hearing aids, speech recognition in noise was far superior with the VSB. The authors discuss the limitations of the study and recommend a thorough preoperative assessment and a bone anchored hearing aid (BAHA) trial before considering VSB.

Reference

A comparative study of hearing aids and round window application of the vibrant sound bridge (VSB) for patients with mixed or conductive hearing loss.
Marino R, Linton N, Eikelboom RH, Statham E, Rajan GP.
INTERNATIONAL JOURNAL OF AUDIOLOGY
2013;52:209–18.

INTERNATIONAL JOURNAL OF AUDIOLOGY

Methods for obtaining VEMPs by bone conduction
Reviewed by: Victor Osei-Lah
Nov/Dec 2013 (Vol 22 No 5)
 

The best way to achieve satisfactory muscle tension for eliciting vestibular evoked myogenic potentials (VEMPs) continues to exercise the minds of clinicians. Two of these methods are head elevation (subject supine) and head rotation (subject sitting upright). This study compared these two methods to elicit cervical VEMP (cVEMP) by bone conduction (BC). Two groups of 20 adult volunteers who had no ear disorders were recruited. The first group was younger, aged 23-38 years and the second group was older, aged 41-60 years. Initially, cVEMPs was elicited by the head elevation method while tapping Fz (midline of hairline) and inion (occiput) randomly with the bone conductor. The test was repeated on a different day by the head rotation method. The parameters of VEMPs analysed were the response rate, p13 and n23 latencies, p13-n23 amplitude and asymmetry ratio. The Fz and inion responses were compared in the two age groups. Tapping the inion elicited response in 100% of subjects regardless of method of achieving muscle contraction, compared with 65-70% from Fz. The difference was statistically significant. However, Fz yielded shorter p13 and n23 latencies than inion stimulation. There were no significant differences in VEMP characteristics between the two age groups. The authors conclude that BC at the inion is the optimal method of eliciting BC cVEMP by either the head elevation or rotation method.

Reference

Comparison of head elevation versus rotation methods for eliciting cervical vestibular-evoked myogenic potentials via bone-conducted vibration.
Tseng C-C, Wang S-J, Young Y-H.
INTERNATIONAL JOURNAL OF AUDIOLOGY
2013;52:200–6.

INTERNATIONAL JOURNAL OF AUDIOLOGY

Self-service hearing aids?
Reviewed by: Diego Zanetti
Nov/Dec 2013 (Vol 22 No 5)
 

The World Health Organization (WHO) estimates that 639 million people worldwide have a permanent, mild to profound hearing loss. 80% of them live in low- and middle-income nations, especially in parts of the developing world such as sub-Saharan Africa and South Asia. In these countries, fewer than 3% of hearing-impaired individuals have access to hearing aids, owing to the lack of an audiological infrastructure. The authors propose a ‘do-it-yourself’ amplification device, designed to be managed entirely by the user without the need for professional support, specialised add-on equipment, or computer access. The user first assembles the low-cost device from a selection of basic hearing-aid parts, then self-administers an automatic, in situ hearing test. The self-fitting hearing aid then applies a prescriptive fitting rule derived from the National Acoustic Laboratories (NAL) to yield an appropriate gain / frequency response and compression parameters. Users may further fine-tune and train the settings to their individual preferences using an onboard button or associated remote control. This interesting study tried to assess the ability of 40 South African and 40 Chinese hearing-impaired adults to assemble a pair of self-fitting hearing aids by following instructions that were written and illustrated. 95% of South African and 60% of Chinese participants completed the assembly task, either on their own or with assistance from their partners. 63% of South Africans and 18% of Hong Kong participants assembled both hearing aids without errors. A higher level of education, health literacy, younger age and a more prestigious occupation were significantly associated with independent task completion. It can be concluded that individuals of diverse backgrounds can manage the self-fitting hearing-aid assembly task as long as their literacy and cognitive level allow the reading of instructions and captioned illustrations. The benefits of the possible provision of these kinds of hearing aids to developing countries seem obvious.

Reference

Hearing-aid assembly management among adults from culturally and linguistically diverse backgrounds: toward the feasibility of self-fitting hearing aids.
Convery E, Keidser G, Caposecco A, Swanepoel DW, Wong LLN, Shen E.
INTERNATIONAL JOURNAL OF AUDIOLOGY
2013;52:385-93.

INTERNATIONAL JOURNAL OF AUDIOLOGY

The earlier the cochlear implantation, the better for spoken language
Reviewed by: Diego Zanetti
Nov/Dec 2013 (Vol 22 No 5)
 

The rationale for early cochlear implantation (CI) is to provide auditory signals during the sensitive periods in which spoken language skills develop rapidly in children with normal hearing. Despite the auditory information delivered by CI, providing much of the critical and complex information necessary for learning spoken language, on average, language development in children with CIs lags behind that observed for normal hearing peers. In this prospective work the authors compared the language skills of 98 children who received CIs before the age of two and a half with 62 children who received them between two and a half and five years of age. Language was assessed four, five or six years after CI using the Comprehensive Assessment of Spoken Language, a global language comprehension and expressive measure normalised on the analysis of 1700 children in the USA. In general, younger children achieved higher scores than those implanted at a later age for vocabulary, expressive syntax and pragmatic judgments. However, in both groups, some children performed much worse than the group mean, especially for grammar and pragmatics, while some scored well above the mean. While these occasional individual outcomes remain to be investigated, on average spoken language abilities appear to be directly correlated to the precocity and quality of speech exposure. The number of words heard during the first year after CI has a major effect on language skills and academic performance at school age.

Reference

Influence of implantation age on school-age language performance in pediatric cochlear implant users.
Tobey EA, Thal D, Niparko JK, Eisenberg LS, Quittner AL, Wang YY.
INTERNATIONAL JOURNAL OF AUDIOLOGY
2013;52:219–29.

INTERNATIONAL JOURNAL OF LANGUAGE AND COMMUNICATION DISORDERS

Impact of adolescent speech problems on psychological well-being
Reviewed by: Gauri Mankekar
Nov/Dec 2013 (Vol No 5)
 

It is known that developmental stuttering is associated with poorer psychological well-being in adulthood. This paper highlights the impact of other developmental speech problems on psychological outcomes, or the impact of stuttering and speech problems. The British birth cohort dataset consisted of 217 cohort members who stuttered and 301 cohort members who had other kinds of speech problem at age 16, and 15,694 cohort members who had experienced neither stuttering nor other speech difficulties. The analysis showed that adolescents who experience speech difficulties other than stuttering are more likely than controls to be at risk of poorer mental health in adulthood. The authors suggest a need for therapeutic provision to address psychosocial issues for both stuttering and other developmental speech disorders in adulthood, as well as further research into the consequences.

Reference

The impact of adolescent stuttering and other speech problems on psychological well-being in adulthood: evidence from a birth cohort study.
McAllister J, Collier J, Shepstone L.
INTERNATIONAL JOURNAL OF LANGUAGE AND COMMUNICATION DISORDERS
2013;48:458-68.

INTERNATIONAL JOURNAL OF LANGUAGE AND COMMUNICATION DISORDERS

Study of gestures in aphasic patients
Reviewed by: Gauri Mankekar
Nov/Dec 2013 (Vol 22 No 5)
 

Gesture increases in the general population when speech is spatial in nature. This study aimed to describe the frequency and variability of spatial language and gesture use by three participants with aphasia in comparison to nine control participants. Participants with aphasia used significantly more gestures and also used gestures without spoken phrases when spatial vocabulary was unavailable. There were differences between participants with regards to the types of gestures that they used when they were unable to access language. Analysis of the gestures produced by people with aphasia suggests that they may provide an insight into their underlying language impairment. This study provides information about spatial gesture frequency and type in aphasia and adds to the existing knowledge about locative preposition difficulty in aphasic language.

Reference

Use of spatial communication in aphasia.
Johnson S, Cocks N, Dipper L.
INTERNATIONAL JOURNAL OF LANGUAGE AND COMMUNICATION DISORDERS
2013;48:469-76.

JOURNAL OF VESTIBULAR RESEARCH

A low-cost gaze stabilisation test
Reviewed by: Victor Osei-Lah
Nov/Dec 2013 (Vol 22 No 5)
 

The computerised Gaze Stabilisation Test (CGST) is one of two tests used to measure the functional integrity of the vestibulo-ocular reflex (VOR). It measures the maximum head movement velocity at which an individual can accurately perceive a fixed-sized target (optotype) at least 60% of the time. The other test is computerised Dynamic Visual Acuity which measures change in visual acuity at a fixed velocity of head movement. Due to cost, CGST is not readily available. The authors devised a low-cost new GST (NGST) and this study tests the ease of application and test-retest reliability in 20 healthy subjects aged 20 to 40 years. The set-up and procedure for both were similar but the cost of the equipment for NGST was around $100; CGST costs at least 50 times more. All subjects attended two sessions for both CGST and NGST. At each session, static visual acuity (SVA) and maximum head movement scores for both passive and active head movements were obtained. As expected, there was a strong positive correlation between visits for CGST. For NGST, there was a strong positive correlation for active head excursion degrees and a moderate correlation for head movement velocity between the two visits. Performance for passive head movement was better during the second visit. The degree of head excursion was found to influence participants’ ability to identify the optoptype in the new test. At 130°/sec, only 70% gave correct responses but when 100°/sec was used as a cut-off point, the correct response rate increased to 95%-100% for both passive and active head movements. The authors conclude that NGST is cheap, easy to administer, with good test-retest reliability. The next challenge is to determine an accurate cut-off point for head excursions and to test patients with vestibular pathology.

Reference

Development of a new gaze stabilization test.
Lee C, Honaker JA.
JOURNAL OF VESTIBULAR RESEARCH
2013;23:77-84.

JOURNAL OF VESTIBULAR RESEARCH

Migraine and vertigo: more than a chance association
Reviewed by: Victor Osei-Lah
Nov/Dec 2013 (Vol 22 No 5)
 

The distinct clinical entity of vestibular migraine (migrainous vertigo) is now well accepted in neurotological practice. This paper provides yet more evidence for how common vestibular symptoms are in migraineurs than in patients with tension-type headaches (TTH). The authors analysed data for 5111 patients with a primary headache disorder attending a tertiary headache centre over a 10-year period. The key vestibular symptoms were vertigo, dizziness and motion sickness but childhood equivalents of migraine, particularly cyclical vomiting and recurrent abdominal pains, were considered. There were two groups: migraine with vestibular symptoms (MwV) and migraine without vestibular symptoms (MwoV). Migraine was further sub-divided to those with aura (MwA) and without aura (MwoA). Of the 5111 patients, 1880 had migraine and 3231 had TTH. There was a female preponderance. Dizziness and vertigo were significantly more common in the migraineurs than TTH (p<0.0001). Of the 1880 migraineurs, 20.3% had MwV and the rest MwoV. The MwA patients were twice and 10 times as likely as those with MwoA and TTH respectively to have at least one vestibular symptom. A past history of cyclical vomiting or recurrent abdominal pains was very common in the MwV group. This finding is an established fact. Although very common in migraine sufferers, one may take issue with motion sickness being considered as a key vestibular symptom. The findings in this study provide further evidence for the link between migraine and vertigo.

Reference

The prevalence of vestibular symptoms in migraine or tension-type headache.
Akdala G, Özge A, Ergör G.
JOURNAL OF VESTIBULAR RESEARCH
2013;23:101-6.

JOURNAL OF VESTIBULAR RESEARCH

Moving scenes and the dizzy patient
Reviewed by: Victor Osei-Lah
Nov/Dec 2013 (Vol 22 No 5)
 

The observation that some patients with vestibular dysfunction find moving scenes or highly textured visual scenes intolerable is well known. This has been called visual vertigo or space and motion discomfort. A clinical experiment was done to measure the type and severity of symptoms of such patients. The authors recruited seven subjects with peripheral vestibular disorders and 25 healthy controls for the study. The subjects with vestibular disorders completed standard questionnaires to obtain a measure of their functional handicaps. All subjects performed gaze movements within a computerised virtual environment (BNAVE) which had the capacity to vary the visual environment i.e. ‘optic flow’ in terms of contrast and spatial frequency. The visual environment was changed for each visit (two days apart) during which subjects performed eight different head and eye coordination tasks within the BNAVE. Symptoms before and after each task were assessed with the Simulator Sickness Questionnaire (SSQ) and Subjective Unit of Discomfort (SUD) rates were determined. The results were not surprising but provide some experimental evidence for visual vertigo. Although symptoms of anxiety, oculomotor distress and disorientation were apparent in all subjects the longer the exposure to visual motion, symptoms were significantly worse in the vestibular group.

Reference

Symptoms elicited in persons with vestibular dysfunction while performing gaze movements in optic flow environments.
Whitney SL, Sparto PJ, Cook JR, Redfern MS, Furman JM.
JOURNAL OF VESTIBULAR RESEARCH
2013;23:51-60.

JOURNAL OF VESTIBULAR RESEARCH

Types of head-shaking nystagmus in Menière’s patients
Reviewed by: Victor Osei-Lah
Nov/Dec 2013 (Vol 22 No 5)
 

Head shaking nystagmus (HSN) is a valuable sign for the identification of peripheral vestibular asymmetry. This retrospective study was done to characterise the types of HSN seen in patients with definite Ménière’s disease (MD). Sixty-five patients were evaluated. The slow phase velocity (SPV) of nystagmus after shaking the head in the horizontal plane at 2Hz was recorded for one minute and the results were compared with the degree of caloric canal paresis (CP). In some patients, vertical or perverted nystagmus was elicited even though the headshaking was in the horizontal plane. Forty-four patients (68%) had pathologic HSN compared with 28 patients (43%) who had significant CP. Statistically, there was no correlation between the two. This is not surprising considering the difference in the stimulus frequency (0.003 Hz for caloric and 2 Hz for headshaking). Therefore, the authors’ claim that HSN is more sensitive than caloric test in MD patients is not entirely accurate. Pure horizontal HSN (PHSN) was present in 49% but in 46%, the nystagmus was mixed (horizontal and vertical). In four patients, HSN was perverted (i.e. vertical with no horizontal component). Thus in more than half of the patients, a vertical nystagmus was present. Although perverted-HSN is considered a cerebellar sign, the authors argue that a weak PHSN (SPV ≤ 4°/s) can be seen in MD. One key finding that distinguishes HSN of MD from that of vestibular neuritis is that in the latter, the nystagmus peaks immediately after headshaking whereas the peak is often delayed in MD.

Reference

Two-dimensional analysis of head-shaking nystagmus in patients with Menière’s disease.
Kim CH, Shin JE, Kim TS, Shim BS, Park HJ.
JOURNAL OF VESTIBULAR RESEARCH
2013; 23: 95-100.

JOURNAL OF VESTIBULAR RESEARCH

White matter lesions, dizziness and risk of falling in the elderly
Reviewed by: Victor Osei-Lah
Nov/Dec 2013 (Vol 22 No 5)
 

Balance difficulties are common in the elderly. The causes are often multifactorial. In this study the authors studied the effects of white matter changes and orthostatic hypotension on dizziness and verticality. Twenty-four adults with a history of orthostatic hypotension (OH) aged over 65 years were recruited. There were two control groups: a) 26 elderly (> 65 years) subjects without OH and b) 21 middle aged (< 65 years) with OH. All subjects had dizziness and completed the Dizziness Handicap Inventory (DHI). Vestibular assessment included the Subjective Visual Vertical (SVV), bithermal air caloric and static posturography. White matter lesions (WMLs) on magnetic resonance imaging (MRI) were divided into two groups: deep white matter (DWMH) and periventricular (PVH). Perception of verticality was most prominent in the elderly male with OH and was significantly worse than in any of the other groups. Another key finding was that the greater the volume of WMLs the worse the SVV in males (p<0.05). The authors suggest that WMLs in combination with OH are involved in the perception of verticality, which in turn induces subjective dizziness. Although extensive WMLs are anecdotally thought to induce subjective dizziness in the elderly, it would have been interesting if the authors had taken the opportunity to study the effect of WMLs without OH. That said, this study provides further evidence that dizziness could be caused by cerebral hypoperfusion.

Reference

The association between impaired perception of verticality and cerebral white matter lesions in the elderly patients with orthostatic hypotension.
Aokia M, Tanaka K, Wakaoka T, Kuze B, Hayashi H, Mizuta K, Ito Y.
JOURNAL OF VESTIBULAR RESEARCH
2013;23:85-93.

NEUROSURGERY

Nasal morbidity after endoscopic transnasal surgery for skull base tumours
Reviewed by: Gauri Mankekar
Nov/Dec 2013 (Vol 22 No 5)
 

Endoscopic skull base surgery has become the most popular approach for removal of skull base tumours. This approach requires resection of structures known to contribute to sense of smell and mucociliary transport. This study, for the first time, attempts to evaluate the effects of this approach on sinonasal symptoms, olfaction and mucociliary transport (MCT). Patients with pituitary tumours underwent a transnasal trans-sphenoidal endoscopic approach (TTEA) whereas patients with other benign parasellar tumours underwent an expanded endonasal approach (EEA) with a vascularised septal flap. Patients’ symptoms were assessed with Visual Analogue scale, olfactometry (Barcelona smell test) and MCT saccharin test before and three months after surgery. The authors found that there was a short-term (three months) negative impact on patients’ olfaction and mucociliary clearance in the EEA group, but not in the TTEA group. They suggest that patients should be informed about the loss of smell to avoid litigation, and surgeons should modify flaps to avoid damaging olfactory neuroepithelium, especially in EEA.

Reference

Impairment of olfaction and mucociliary clearance after expanded endonasal approach using vascularized septal flap reconstruction for skull base tumours.
Alobid I, Ensenat J, Marino-Sanchez F, de Notaris M, Centellas S, Mullol J, Bernal- Sprekelsen M
NEUROSURGERY
2013;72: 540-6.

NEUROSURGERY

Olfactory mucosa and nerve repair
Reviewed by: Showkat Mirza
Nov/Dec 2013 (Vol 22 No 5)
 

Autotransplantation of olfactory ensheathing cells (OEC) into the damaged central nervous system is a potential therapeutic strategy for spinal cord injuries. One limiting factor has been the poor OEC yields from human mucosal biopsies. The authors describe a surgical technique for obtaining human olfactory mucosa from the superior turbinate, which was performed on 43 patients who were undergoing endoscopic sinus surgery. They found a greater yield of OECs was obtained from patients of a younger age. Patients with worse mucosal disease yielded poorer cultures. A higher yield of OECs was obtained from specimens harvested from the more caudal portions of the superior turbinate, that is closer to the cribriform plate. A useful contribution to establishing a uniform technique for obtaining human OECs from the nasal cavity.

Reference

Culture of olfactory ensheathing cells for central nerve repair: the limitations and potential of endoscopic olfactory mucosal biopsy.
Kachramanoglou C, Law S, Andrews P, Li Daqing, Choi D.
NEUROSURGERY
2013;72:170-9.

 

PEDIATRIC ALLERGY AND IMMUNOLOGY

Adenotonsillar hypertrophy (ATH): is there a local allergy?
Reviewed by: Evangelia Tsakiropoulou
Nov/Dec 2013 (Vol 22 No 5)
 

This is an interesting study aiming to answer the question: “Is there localised allergic reaction in the adenotonsillar tissues, which is not always reflected by an assay of systemic IgE?”. The study was conducted in southern China and enrolled 83 children between two and 13 years old, with ATH before adenotonsillectomy. Specific-IgE (sIgE) against 31 allergens was tested in the serum of all children and sIgE against 15 allergens were detected in adenotonsillar tissues from 20 of them. The main finding of the study is that all children were locally sensitised to more than two allergens at both tonsils and adenoid tissues, even though half of them did not test positive for sIgE antibodies in serum. Additionally, the most prevalent allergen in both tonsillar and adenoid tissues, was Dermatophagoides pteronyssius, followed by milk, D. farinae, Blomia tropicalis, and dog dander. Interestingly, the positive rate of sIgE antibodies in adenoids or tonsils was significantly higher than that in the serum. This supports the hypothesis of local atopy. A significant limitation in the present study, as the authors state, is that pollen allergens were not tested, also the relative small sample size. The findings suggest that there may be a potential localised allergic reaction in the adenotonsillar tissues even if not accompanied by systemic atopy in ATH children. On this basis, topical anti-inflammatory medication and specific immunotherapy in ATH could have a quite promising role, even, as the authors suggest, after adenotonsillectomy in cases with residual adenoids.

Reference

Local atopy is more relevant than serum sIgE in reflecting allergy in childhood adenotonsillar hypertrophy.
Zhang X, Sun B, Li S, Jin H, Zhong N, Zeng G.
PEDIATRIC ALLERGY AND IMMUNOLOGY
2013;24:422–6.

THE JOURNAL OF LARYNGOLOGY AND OTOLOGY

Early detection of nasal pharyngeal carcinoma with narrow band imaging
Reviewed by: Madhup K Chaurasia
Nov/Dec 2013 (Vol 22 No 5)
 

Nasopharyngeal carcinoma is highly prevalent in certain ethnic groups and is the sixth most common cancer affecting males. The presentation is usually delayed, with other features such as neck swelling from lymph node metastasis heralding this malignancy. The use of narrow band imaging and its superiority over white light is discussed in this article. Thirty patients with nasopharyngeal mass underwent examination with narrow band imaging and all were subjected to histological diagnosis. In the 21 patients who had no malignancy, the narrow band imaging showed regularly arranged follicular pattern and each follicle was composed of a pale centre with a surrounding dark periphery. In the eight patients with nasopharyngeal carcinoma narrow band imaging showed absence of such surface patterns and a reversal in the colouring of follicular patters and irregularity in their appearance. These had a dark brown centre and pale periphery. There was also brown speckling but this was also present in patients with adenoid tissue. The role of narrow band imaging and various features suggested to be diagnostic of malignancy have been discussed in the literature. It seems to be generally agreed that benign cases show well marked follicular patterns with much larger proportion of pale areas as compared to the brown periphery which is reversed in malignancy. Malignant lesions also present with irregular engorged vascular patterns or microvascular proliferative patterns. Controversy, however, does exist and some studies do not consider these findings specific of malignancy. In this particular study there is a clear demarcation of findings between malignant and non-malignant lesions but whether these criteria can be applied with certainty and exclude the necessity for histology cannot be established with a study involving a small number of cases. However, the article makes interesting reading and shows that narrow band imaging is undoubtedly helpful in increasing the suspicion where applicable.

Reference

Use of narrow band imaging in detection of nasopharyngeal carcinoma.
Thong JF, Loke D, Karumathil R, Sivasankarannair, Mok M.
THE JOURNAL OF LARYNGOLOGY AND OTOLOGY
2013;127:163-9.

THE JOURNAL OF LARYNGOLOGY AND OTOLOGY

Myringoplasty and hearing improvement
Reviewed by: Madhup K Chaurasia
Nov/Dec 2013 (Vol 22 No 5)
 

Hearing improvement is one of the aims of myringoplasty, but another reason for performing this operation is to achieve a closed middle ear cavity which is free from infection and discharge. An intact eardrum also allows the patient to swim without having to take strict precautions. In this study the authors carried out 169 operations on 160 patients. These were all adults. Perforations were classified as small (< 20%), medium (20-50%) and large (over 50%). The operations were done on ears without cholesteatoma and where no ossiculoplasty or mastoidectomy was required. In these 169 operations 15% acquired closure of the air bone gap within 10 decibels and 54% of cases had hearing thresholds which were better than 30 decibels postoperatively. The best hearing improvement occurred in the large perforations. The authors attribute this to a greater areal ratio pre- and postoperatively with increased area of the intact tympanic membrane. The hearing gain was smaller in patients with continuing otitis media, erosion of the ossicular chain and fixation of stapes. Prolonged chronic ear infection also resulted in some cochlear hearing loss. The message here seems to be that hearing gain in adults after myringoplasty should be stated with guarded optimism, and factors other than acquiring hearing gain should be considered for better quality of life.

Reference

Factors affecting hearing improvement following successful repair of tympanic membrane.
Thiel G, Mills RP, Mills N.
THE JOURNAL OF LARYNGOLOGY AND OTOLOGY
2013;127:349-53.

THE JOURNAL OF LARYNGOLOGY AND OTOLOGY

The role of image guidance in rhinology and anterior skull base surgery
Reviewed by: Madhup K Chaurasia
Nov/Dec 2013 (Vol 22 No 5)
 

Locating anatomic sites during the course of an operation may be a challenging situation in functional endoscopic sinus surgery, especially if these have been distorted by previous surgery or tumour.  This is a single institution study in which a comparison was made between 174 patients undergoing surgery with image guidance and 134 without. All operations were performed by the senior author over a five year period. Anatomical localisation was achieved by optical tracking technology provided by Brain Lab which is a passive marking system. High resolution computed tomography (CT) imaging of the nose and the paranasal sinuses was done preoperatively and three dimensional images were constructed in axial, coronal and sagittal planes. Results showed an increasing tendency to perform image guidance surgery over the five year period. Image guidance surgery was used mainly for intermediate and advanced cases. Cases with tumours formed the highest percentage (71%) of patients undergoing image guidance surgery. This was followed by cases with sino-nasal polyposis where revision surgery was performed in cases with distorted anatomy. The authors have categorised the extent of sinus surgery and established valid criteria for resorting to image guidance although they contend that the facility should not replace sound anatomical knowledge of these complex anatomic regions. There were no major complications in either group although there were more minor complications in the imaged guidance group, possibly due to the complexity of these cases. The findings agree with the AAOHNS published guidelines on the use of image guidance surgery in rhinology.

Reference

Image guidance in rhinology and anterior skull base surgery: five year single institution experience.
Visvanathan V, McGarry DW.
THE JOURNAL OF LARYNGOLOGY AND OTOLOGY
2013;127:159-62

ACTA OTOLARYNGOLOGICA

Lumbar drains for traumatic CSF rhinorrhea
Reviewed by: Victoria Possamia
Sep/Oct 2013 (Vol 22 No 4)
 

This study from South Korea retrospectively reviewed patients treated for traumatic CSF rhinorrhea, both accidental and iatrogenic. The 117 patients are divided into those treated conservatively (n = 61) and those treated surgically (n = 56). The conservative group were treated for seven days with simple bed rest, head elevation, and avoiding nose blowing and Valsalva manoeuvres. If the leak persisted beyond seven days a lumbar drain (LD) was inserted for 4-7 days, draining 180mls/day. There was no difference found between the two groups with respect to recurrence rate or incidence of meningitis. However the authors do concede that drains may have a role in those patients whose leak does not settle with simple measures, as this study does not compare the speed of resolution with or without a drain, because all patients received the LD after seven days. The more interesting group is the post surgical patients who were either treated with or without additional LD insertion at the time of surgery. There were no differences between the two groups in clinicopathological factors to suggest that the severity of case differed between those treated with or without drains. The study found no difference in recurrence rate, incidence of meningitis or duration of hospital stay. The authors point out the high levels of observation and active management required with a drain in situ and potential risks associated with their use. The lack of a difference in outcome is therefore important in suggesting that the risk : benefit ratio favours not using post operative LDs.

Reference

The effectiveness of lumbar drainage in the conservative and surgical treatment of traumatic cerebrospinal fluid rhinorrhea.

Yeo NK, Cho GS, Kim GJ, Lim GC, Jang YJ, Lee BJ, Chung YS

ACTA OTOLARYNGOLOGICA

2013;133:82-90.

ACTA OTORHINOLARYNGOLOGICA ITALICA

Predicting neck dissection wound dehiscence
Reviewed by: Miles Bannister
Sep/Oct 2013 (Vol 22 No 4)
 

As medical management for metastatic neck disease has improved and in certain cases become the preferred treatment option, fewer dissections are being performed on the untreated neck. This paper from Rome offers an insight into which patients are most at risk from wound complications and demonstrates, again, how much Italy has to offer the head and neck oncology profession. This large retrospective study of 119 patients revealed greater rates of haematoma, dehiscence, flap necrosis and chyle leakage in patients after chemo-radiotherapy (p = 0.001) and in those patients undergoing radical neck dissections (p = 0.05), confirming previous work from Arkansas and Edinburgh. General patient health did not influence wound dehiscence. The article reviews the basic science research explaining the conclusions, advocates better counselling for patients undergoing neck dissection in such circumstances and is available in English.

Reference

Predictive factors for postoperative wound complications after neck dissection.
Pellini R, Mercante G, Marchese C, Terenzi V, Sperduti I, Manciocco V, Ruscito P, Cristalli G, Marchesi P, Pichi B, Spriano G.
ACTA OTORHINOLARYNGOLOGICA ITALICA
2013;33:16-22.

ALLERGY

Does Acupuncture work on patients with Allergic rhinitis?
Reviewed by: Laith Tapponi
Sep/Oct 2013 (Vol 22 No 4)
 

This is a multicentre, randomised, controlled large study of 238 participants, carried out by the Department of Medical Research in Daejeon, South Korea. The aim of this study was to present and to evaluate the efficacy and safety of acupuncture in the treatment of allergic rhinitis. Acupuncture did show a significantly greater effect on symptoms of allergic rhinitis. Similar studies need to be carried out in Europe and the UK.

 

Reference

A multicentre, randomized, controlled trial testing the effects of acupuncture on allergic rhinitis.
Choi SM, Park J-E, Li S-S, Jung H, Zi M, Kim T-H, Jung S, Kim A, Shin M, Sul J-U, Hong Z, Jiping Z, Lee S, Liyun H, Kang K, Baoyan L. ALLERGY
2013;68:365-74.

ALLERGY

New era in aspirin desensitisation?
Reviewed by: Evangelia Tsakiropoulou
Sep/Oct 2013 (Vol 22 No 4)
 

The coexistence of asthma and aspirin sensitivity in patients with nasal polyposis is a medical condition, known as Samter's triad or aspirin-exacerbated respiratory disease (AERD). Patients with this condition often present with recurrent nasal polyps and their management still remains problematic for the ENT surgeon. Many protocols of aspirin desensitisation have been proposed; however, quite a high incidence of side-effects is reported. Seventy patients with nasal polyps and AERD were included in this well conducted double-blind placebo-controlled study. The aim of the study was to investigate the efficacy of a low-dose aspirin desensitisation protocol. All patients underwent sinus surgery and treatment with topical nasal steroids. The protocol included an aspirin dose of 180 mg on the first day and of 800 mg on the second. The maintenance dose from the third day onwards was 100 mg daily. All patients were followed up to 36 months. The authors observed a trend in reduction of nasal polyp recurrence in the desensitisation group. They attribute the lack of significance to the high dropout rate. However, the low-maintenance aspirin dose of 100 mg daily might be another reason. We cannot overcome the fact that in the literature there is contradictory evidence about the clinical efficacy of 100 and 300 mg aspirin dosages. They also report significant improvement in the quality of life and reduction of clinical symptoms such as nasal airway obstruction, postnasal drip, headache and impairment of olfactory function. Additionally, no severe aspirin-related side-effects were observed. Although further studies are needed, low-dose aspirin desensitisation seems to be a promising therapeutic postoperative option in cases of recurrent nasal polyposis.

Reference

Low-dose aspirin desensitization in individuals with aspirin-exacerbated respiratory disease.
Fruth K, Pogorzelski B, Schmidtmann I, Springer J, Fennan N, Fraessdorf N, Boessert A, Schaefer D, Gosepath J, Mann WJ.
ALLERGY
2013;68:659–65.

AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY

Making sinus surgery simulators more ‘real’ in appearance
Reviewed by: Edward Fisher
Sep/Oct 2013 (Vol 22 No 4)
 

Endoscopic sinus surgery (ESS) training includes cadaver dissection and supervised operating, but the benefits of simulation in training are acknowledged in an increasing number of surgical disciplines. The learning curve in sinus surgery has been described for many years and simulation has the advantage of allowing some of this learning to happen without the risk of complications in real patients. The realism of the graphics used in widely available systems often leave much to be desired and this paper describes some textures and lighting effects which were used to augment the existing models in the simulation software. The method used incorporated haptic feedback from instruments and the authors claim that the software can be used on existing off-the-shelf hardware. The pictures shown in the paper were impressive and a step forward from the unsatisfactory ‘matt’ appearance of tissues that I have seen up to now. This approach seems to be where the future of ESS training lies

Reference

Towards photorealism in endoscopic sinus surgery simulation.
Ruthenbeck GS, Hobson J, Carney AS, Sloan S, Sacks R, Reynolds KJ.
AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY
2013;27(2):138-43.

AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY

Subtle voice changes after nasal airway surgery and FESS
Reviewed by: Edward Fisher
Sep/Oct 2013 (Vol 22 No 4)
 

This study looked at nasalance and acoustic voice parameters after a wide variety of nasal surgery: septum / turbinate surgery, endoscopic sinus surgery and a combination of both. We often notice in clinical practice that the voice changes transiently after surgery (becoming more ‘nasal’) but this settles with time. This is exactly what was found in this study, with the initial nasalance change (an increase, evident at 1 month post-operatively) settling after a period of 3-6 months, depending on the precise parameter chosen. This offers some reassurance when operating on voice professionals who have concurrent nasal problems.

Reference

Nasalance change after sinonasal surgery: analysis of voice after septoturbinoplasty and endoscopic sinus surgery.
Kim YH, Lee SH, Park CW, Cho JH.
AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY
2013;27(1):67-70.

AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY

Topical steroids and systemic steroids work better for polyps than topical alone
Reviewed by: Edward Fisher
Sep/Oct 2013 (Vol 22 No 4)
 

This randomised study does not surprise, but shows nicely that having a two week course of prednisolone (50mg per day) followed by topical mometasone furoate spray is more effective for all symptoms in nasal polyp patients (judged at seven and 12 weeks) than the use of spray alone. Risks for steroid unresponsiveness were massive polyposis and endoscopic signs of middle meatal discharge. Hyposmia / anosmia was more resistant to improvement than other symptoms, which is no surprise. No ancillary measures such as saline douching were used, which is a pity, since this has become much more commonplace as a routine ancillary treatment for polyp patients.

Reference

Does oral prednisolone increase the efficacy of subsequent nasal steroids in treating nasal polyposis.
Kirstreesakul V, Wongsritrang K, Ruttanaphol S.
AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY
2012;26(6):455-62

ANNALS OF OTOLOGY, RHINOLOGY& LARYNGOLOGY

Smoking and nasal polyposis
Reviewed by: Mr Maher El Alami
Sep/Oct 2013 (Vol 22 No 4