The outcomes of endoscopic management in young children with subglottic stenosis

Subglottic stenosis (SGS) is a common cause of obstructed airway in children, and the treatment of pediatric SGS, especially congenital SGS, remains a challenge for the otolaryngologist.

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Pediatric Langerhans cell histiocytosis of the lateral skull base

Describe the presentation, imaging characteristics, management, and outcomes of pediatric patients with Langerhans cell histiocytosis (LCH) of the temporal bone.

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Vocal palsy increases the risk of lower respiratory tract infection in low-risk low-morbidity patients undergoing thyroidectomy for benign disease: a big data analysis

Abstract

Objectives

Thyroidectomy is the commonest and most rapidly-growing operation which places normally-functioning laryngeal nerves at risk of injury. Laryngeal palsy is a major risk-factor for dysphonia, dysphagia, and less commonly, airway obstruction. We investigated the association between post-thyroidectomy vocal palsy and long-term risks of pneumonia and laryngeal failure.

Design

An N=near-all analysis of the English administrative dataset using a previously-validated informatics algorithm to identify young and otherwise low-risk patients undergoing thyroidectomy for benign disease. Information about age, sex, morbidities, social deprivation, and postoperative and late complications were derived.

Main Outcome Measures

Between 2004 and 2012, 43,515 patients between the ages of 20 and 69 who had no history of cancer, neurological, or respiratory disease underwent first-time elective total or hemithyroidectomy without concomitant or late neck dissection, parathyroidectomy, or laryngotracheal surgery for benign thyroid disease. Information about age, sex, morbidities, and in-hospital and late complications was recorded.

Results

Mean age at surgery was 46±12. There was a strong female preponderance (85%) and most patients (89%) had no recorded Charlson morbidities. Most patients (65%) underwent hemithyroidectomy. Late vocal palsy was recorded in 449 (1.03%) patients and its occurrence was an independent risk factor for emergency hospital readmission (n=7113; Hazard Ratio 1.52; 95% Confidence interval 1.21-1.91), hospitalisation for lower respiratory tract infection (n=944; HR 2.04; 95% CI 1.07-3.75), dysphagia (n=564; HR 3.47; 95% CI 1.57-7.65) and gastrostomy/tracheostomy placement (n=80; HR 20.8; 95% CI 2.5-171.2). Independent risk-factors for late vocal palsy were age, burden of morbidities, total thyroidectomy, and postoperative bleeding. Female sex and annual surgeon volume >30 were independently protective.

Conclusions

There is a significant association between post-thyroidectomy vocal palsy and long-term risks of hospital readmission, dysphagia, pneumonia, and gastrostomy/tracheostomy tube placement. This adds weight to the need, from a thyroid surgical perspective, to undertake universal post-thyroidectomy laryngeal surveillance with a focus on postoperative dysphagia and aspiration, and from a medical/respiratory perspective, to initiate investigations to identify occult vocal palsy in patients who present with pneumonia, who have a history of thyroid surgery.

This article is protected by copyright. All rights reserved.

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Long-term outcomes of central neck dissection for cN0 papillary thyroid carcinoma

Publication date: Available online 14 June 2017
Source:American Journal of Otolaryngology
Author(s): Davide Giordano, Andrea Frasoldati, Enrico Gabrielli, Carmine Pernice, Michele Zini, Andrea Castellucci, Simonetta Piana, Alessia Ciarrocchi, Silvio Cavuto, Verter Barbieri
Objective.The risk-benefit ratio of central neck dissection (CND) in patients affected by papillary thyroid carcinoma (PTC) without clinical or ultrasonographic (US) evidence of neck lymph node metastasis (cN0) is currently debated. The aim of this study was to evaluate long-term outcome of CND on locoregional recurrence, distant metastasis, survival, and postoperative complications in a large series of patients with cN0-PTC.Study Design.Observational retrospective controlled study.MethodsClinical records of patients (n=610) surgically treated for cN0-PTC at the Otolaryngology Unit of the Arcispedale Santa Maria Nuova-IRCCS, Reggio Emilia, Italy, from January 1984 to December 2008, were retrospectively reviewed. Study population was divided into three groups according to surgical treatment: Group A, total thyroidectomy (n=205); Group B, total thyroidectomy and elective ipsilateral CND (n=281); Group C, total thyroidectomy and bilateral CND (n=124).ResultsOf a total of 610 patients, 305 (50%) were classified as low-risk, 278 (45.57%) as intermediate-risk, and 27 (4.43%) as high-risk. Response to initial therapy was excellent in 567 patients (92.95%), acceptable in 21 (3.44%), and incomplete in 22 (3.61%), with no significant differences among groups. Locoregional recurrence was detected in 32 (5.2%) out of 610 patients. Distant metastasis was found in 15 patients (2.5%). Statistical analysis showed no significant differences in the rates of locoregional recurrence (p=0.890) or distant metastasis (p=0.538) among groups. Disease-specific mortality and overall survival did not significantly differ among groups (p=0.248 and 0.223, respectively). Rate of permanent hypoparathyroidism was significantly higher in Group C patients compared to those in Groups A and B.ConclusionCND does not confer any clear advantage in the treatment of low-risk patients, regardless of surgical procedure. Instead, bilateral CND may be effective in limiting disease relapse and/or progression in patients at higher prognostic risk. Our data indicate that elective CND does not confer any clear advantage in terms of locoregional recurrence and long-term survival, as demonstrated by outcomes of the study Groups, regardless of their different prognostic risk. Elective CND allows a more accurate pathologic staging of central neck lymph nodes, despite its increasing the risk of permanent hypoparathyroidism. Intraoperative pathologic staging is a valuable tool to assess the risk of controlateral lymph node metastasis in the central neck compartment and to limit more aggressive surgery only to cases, otherwise understaged, with lymph node metastasis.



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Neck dissection for unknown cancer of the head and neck in the era of chemoradiation

Publication date: Available online 14 June 2017
Source:American Journal of Otolaryngology
Author(s): Mark J. Amsbaugh, Mehran Yusuf, Jeremy Gaskins, Craig Silverman, Kevin Potts, Jeffrey Bumpous, Rebecca Redman, Cesar Perez, Neal Dunlap
PurposeTo report outcomes for patients with cervical lymph node metastases from an unknown primary site of the head and neck treated with either non-operative therapy or neck dissection followed by adjuvant therapy.Materials and MethodsAll patients with squamous cell carcinoma of an unknown primary site of the head or neck seen between 2003 and 2013 were reviewed. The Kaplan-Meier method was used to estimate overall survival, local recurrence free survival, loco-regional recurrence free survival, and progression free survival. The log-rank test and proportional hazards regression were used to analyze factors influencing outcomes.ResultsOf 2258 patients with a new diagnosis of head and neck cancer, no primary site was identified in 66 patients. Twenty-nine patients were treated with definitive non-operative therapy (15 with chemoradiation and 14 with radiation alone). Thirty-seven patients received an upfront neck dissection followed by adjuvant radiation or chemoradiation. Three-year loco-regional recurrence free survival, progression free survival, and overall survival were 55.9%, 55.4%, and 69.4% respectively. Patients treated with preoperative neck dissection had improved local recurrence free survival (96.7% vs 54.1%, p=0.003) and loco-regional recurrence free survival (82.2% vs 46.4%, p=0.068) compared to patients treated with definitive chemoradiation with no difference in overall survival (p=0.641).ConclusionsNeck dissection improved local and regional control but not overall survival in patients with unknown primary squamous cell carcinoma of the head and neck over non-operative therapy alone.



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Temporal bone computed tomography findings associated with feasibility of endoscopic ear surgery

Publication date: Available online 14 June 2017
Source:American Journal of Otolaryngology
Author(s): Dunia Abdul-Aziz, Elliott D. Kozin, Brian M. Lin, Kevin Wong, Parth V. Shah, Aaron K. Remenschneider, Lukas D. Landegger, Amy F. Juliano, Michael S. Cohen, Daniel J. Lee
PurposeThere are no formal radiologic criteria to stratify patients for transcanal (TEES) or transmastoid endoscopic ear surgery for resection of cholesteatoma. We aim to determine 1) whether standard preoperative computed tomography (CT) findings are associated with the need for conversion to a transmastoid approach and 2) the amount of time added for conversion from TEES to transmastoid techniques.Materials and methodsRetrospective chart review of consecutive pediatric and adult cases of TEES for primary cholesteatoma from 2013 through 2015 (n=52). TEES cases were defined as endoscope-only procedures that did not require a transmastoid approach (n=33). Conversion cases were defined as procedures that began as TEES however, required conversion to a transmastoid approach due to the inability to complete cholesteatoma removal (n=19). Preoperative CT findings and total operating room (OR) times of TEES and conversion cases were compared.ResultsPreoperative CT scan characteristics that were associated with conversion included tegmen erosion (p=0.026), malleus erosion (p<0.001), incus erosion (p=0.009), mastoid opacification (p=0.009), soft tissue opacification extending into the aditus ad antrum (p=0.009) and into antrum (p=0.006). Total OR time for TEES cases was significantly shorter than conversion cases (median 143min versus 217min, p<0.001).ConclusionsPreoperative CT findings, notably extension of soft tissue in the aditus ad antrum, antrum and mastoid, are associated with need for conversion to transmastoid technique to achieve removal of cholesteatoma. Endoscope-only cases were significantly faster than cases that required conversion to a transmastoid approach.



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The effects of fibroblast growth factor-2 delivered via a Gelfoam patch on the regeneration of myringosclerotic traumatic eardrum perforations lying close to the malleus

Publication date: Available online 14 June 2017
Source:American Journal of Otolaryngology
Author(s): Zhong-hai Jin, Yi-Han Dong, Zi-Han Lou
ObjectiveWe evaluated the effects of fibroblast growth factor-2 (FGF-2) delivered via a Gelfoam patch on the regeneration of myringosclerotic traumatic tympanic membrane perforations (TMPs) lying close to the malleus.Study designA prospective, randomized, controlled clinical study.SettingA university-affiliated teaching hospital.Subjects and methodsWe prospectively analyzed, in a randomized manner, the outcomes of treatment for traumatic TMPs constituting >25% of the tympanic membrane. The closure rates, closure times, and otorrhea rates were compared among patients treated via FGF-2-containing Gelfoam patches, Gelfoam patches alone, and observation only.ResultsWe analyzed data from 138 patients. The perforation closure rates in the FGF-2 plus Gelfoam patch, Gelfoam patch, and observation alone groups were 97.9, 89.8, and 70.7%, respectively. Both the FGF-2 plus Gelfoam and Gelfoam alone groups exhibited significantly higher closure rates than the observational group (both p<0.05).The mean closure times were 15.7±5.1, 24.8±4.9, and 35.7±9.2days in the FGF-2 plus Gelfoam patch, Gelfoam patch alone, and observation alone groups, respectively. The FGF-2 plus Gelfoam patch group exhibited a significantly shorter closure time than the Gelfoam patch alone and observation alone groups (p<0.05). The incidences of purulent otorrhea were 14.6, 6.1, and 4.9% in the FGF-2 plus Gelfoam patch, Gelfoam patch alone, and observation alone groups, respectively. Surprisingly, 7 of 7 (100.0%) perforations associated with purulent otorrhea completely closed in the FGF-2 plus Gelfoam patch group; however, no such perforation healed in either the Gelfoam alone or observation alone group.ConclusionsFGF-2 plus Gelfoam patching significantly shortened the closure time compared to observation and Gelfoam patching alone, and it significantly improved the closure rate (compared to observation alone) of myringosclerotic perforations lying close the malleus. FGF-2 plus Gelfoam patching is a valuable, minimally invasive alternative treatment that may be readily applied to outpatient settings.



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A quality study of family-centered care coordination to improve care for children undergoing tracheostomy and the quality of life for their caregivers

Publication date: August 2017
Source:International Journal of Pediatric Otorhinolaryngology, Volume 99
Author(s): Christopher Hartnick, Gillian Diercks, Vanessa De Guzman, Elizabeth Hartnick, Jeanne Van Cleave, Kevin Callans
ImportanceApproximately 4000 U.S. children undergo tracheostomy yearly [1], and these surgeries often result in hospital re-admissions that have definite cost and caregiver burdens due to complications that are avoidable with proper training and support.ObjectiveTo assess the impact of a Family-Centered Care Coordination (FCCC) program on the quality of care received by children undergoing tracheostomy and their caregivers.DesignCaregivers of children undergoing tracheostomies from January 2012 to January 2013 and then a different set of caregivers of children undergoing tracheostomies from January 2015 to January 2016 completed both the Pediatric Tracheostomy Health Status Instrument (PTHSI) 1 month after discharge and the Medical Complications Associated with Pediatric Tracheostomy (MCAT) questionnaire 6 months after initial tracheostomy. To assess complication rates, these same sets of caregivers were asked to complete the MCAT and only those who provided complete medical data for all 6 months were included for comparative analysis.SettingThe PTHSI and MCAT were administered at Massachusetts Eye and Ear in a hospital setting.ParticipantsTen caregivers of children undergoing tracheostomies completed the PTHSI before FCCC program implementation and12 caregivers then completed the PTHSI after FCCC implementation. For each of the 2 groups, 5 caregivers provided complete data on the MCAT questionnaires.ExposuresFCCC is a collection of programs, policies, and tools designed to ensure safe transition home for children undergoing tracheostomies, reduce re-admission rates, and minimize "caregiver burden".Main outcomes and measuresThe PTHSI is a validated caregiver quality of life instrument that was supplemented by the MCAT which records post-discharge medical issues following tracheostomy that relate specifically to the tracheotomy placement.ResultsThe time to first follow-up appointment decreased from 6.4 weeks (SD = 1.52) to 6 days (SD = 0.18) with FCCC implementation. The total MCAT scores decreased from 15.2 (SD = 1.1) to 1.3 (SD = 1.3) (Wilcoxon sum rank test: P < 0.016) whereas neither PTHSI scores (P = 0.32) nor the specific caregiver burden domain (P = 0.18) demonstrated a significant change.Conclusionsand Relevance: By reducing the time to first follow-up after tracheostomy and by optimizing caregiver tracheostomy tube care and teaching, children's quality of care and caregiver burden can be significantly improved.



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Pediatric invasive fungal rhinosinusitis: An investigation of 17 patients

Publication date: August 2017
Source:International Journal of Pediatric Otorhinolaryngology, Volume 99
Author(s): Daniel Vinh, Michael Yim, Ankhi Dutta, John K. Jones, Wei Zhang, Matthew Sitton
PurposeTo investigate outcomes of pediatric patients at a single institution with invasive fungal rhinosinusitis (IFRS) and to determine variables that impact overall survival.MethodsAll pediatric patients at a large tertiary children's hospital diagnosed with IFRS confirmed by surgical pathology from 2009 to 2015 were retrospectively reviewed. Demographics, underlying diseases, symptoms, antifungal therapy, absolute neutrophil count (ANC), surgical management,and outcomes were analyzed.ResultsSeventeen patients were identified with IFRS with an average age of 8.7 years and 53% male. Hematologic malignancy was the most common (n = 13) underlying disease. The most common presenting symptoms were fever (82%) and congestion (41%). 15 patients had severe neutropenia (Absolute Neutrophil Count (ANC) < 500) within 2 weeks prior to diagnosis. The average ANC at time of diagnosis was 1420 cells/uL. 16 patients were treated with serial nasal endoscopy and debridement, while 1 patient was treated with an open approach. 16 received combination antifungals while 1 was treated with amphotericin monotherapy. The most common genus cultured was Fusarium (n = 6). The average number of surgical interventions was 3.4, with the average interval between interventions 6.2 days. 13 of 17 (76%) were cleared of IFRS. Overall survival at 6 months was 41%.ConclusionPediatric IFRS is a life-threatening disease that requires a coordinated surgical and medical approach. Despite a relatively high local control rate, overall mortality remains disappointingly high, reflecting the disease's underlying pathogenesis - lack of host defense and risk of disseminated fungal infection. Further investigation is necessary to reveal optimal management with regards to antifungal therapy, surgery, and utility of labs.



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Hearing aids for otitis media with effusion: Do children use them?

Publication date: August 2017
Source:International Journal of Pediatric Otorhinolaryngology, Volume 99
Author(s): Richard Wei Chern Gan, Parisa Overton, Claire Benton, Matija Daniel
IntroductionENT surgeons may refer children with otitis media with effusion (OME) to audiology for consideration of hearing aids. They are an option for the treatment of OME, but are only effective if the child actually wears them. Our study investigated what proportion of children referred for hearing aids actually receive them, and whether children use them.MethodRetrospective study of children referred to audiology from November 2013 to August 2014, including 70 children referred by ENT for hearing aids for OME, plus a further 5 children with OME given hearing aids through direct access audiology service.ResultsDuring the study period, there were 202 referrals of children to audiology, of which 70 (34.7%) were for consideration of hearing aids for OME. Of these 70 referred children, 37 (52.9%) were not fitted with hearing aids due to normal audiometry (23), asymptomatic mild hearing loss (7), nonattendance (3), clinical decision to just monitor hearing (1), parental decline (2), and unrecorded reason (1). A total of 38 children (including direct access patients) were fitted with hearing aids for OME. Majority (36/38) of children issued aids used them, 16 all day, 7 only at school, 1 only at home, 3 only when needed, and 9 used them for an unspecified duration; 1 child's use of hearing aids was unrecorded, and 1 child refused to use it. 21 were fitted bilaterally and 17 unilaterally. 37 were behind the ear aids and 1 a BAHA softband.ConclusionsA third of referrals to paediatric audiology by ENT are for consideration of hearing aids for OME. Only about half of children referred to audiology for hearing aids for OME actually receive them, as by the time they see audiology the hearing loss has frequently resolved or is asymptomatic so that aiding is unwarranted. Once fitted, they appear to be well accepted. Hearing aids have fair utilization in children fitted with them for OME.



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Intracochlear schwannoma

Abstract

We report about a patient, who in 2005, as a 37-year-old, experienced a sudden, mild to moderate, mid-frequency sensorineural hearing loss in the right ear, along with tinnitus and mild dizziness. MRI of the temporal bone revealed a very small (1 mm) enhancing lesion in the second turn of the right cochlea after injection of contrast medium. Hearing gradually deteriorated, with complete hearing loss in 2015. At this time, an MRI scan showed a lesion completely filling the cochlea.

The tumor was removed through a subtotal cochleoectomy. The cochlea was partially reconstructed with cartilage and fascia. A cochlea implant dummy electrode was inserted as a placeholder in order to try to preserve a channel within the most likely fibrosing "neocochlea" during follow-up MRI examinations.

Vestibular function tests 2 months postoperatively showed preserved caloric excitability and a normal vestibulo-ocular reflex (video head impulse test, vHIT) in all three planes. The patient is free of vertigo.

Intralabyrinthine schwannomas (ILS) are a rare differential diagnosis of sudden hearing loss. Surgical removal of an intracochlear ILS through partial or subtotal cochleoectomy with preservation of vestibular function is possible.

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Molekulare, komponenten-basierte Diagnostik in der HNO-ärztlichen Allergologie

Zusammenfassung

Die molekulare, komponentenbasierte Diagnostik („component-resolved diagnostics", CRD) setzt sich neben der Wissenschaft auch mehr und mehr in der alltäglichen klinischen Routine durch. Sie bietet eine höhere diagnostische Sicherheit in Bezug auf das zugrunde liegende Allergen, kann bei der Klärung von Kreuzreaktionen und Polysensibilisierungen helfen und bietet damit die Möglichkeit einer individuellen personalisierten Therapieplanung. Bei Anaphylaxien und Lebensmittelallergien ist darüber hinaus eine Abschätzung des Risikos in Bezug auf das Wiederauftreten sowie die Schwere der zu erwartenden Reaktion möglich. Mit dem immensen Wissenszuwachs sollte eine gezielte Aus- und Weiterbildung der klinisch tätigen Allergologen auf dem Gebiet der molekularen Allergologie einhergehen.

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