Otolaryngology–Head and Neck Surgery

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Otolaryngology–Head and Neck Surgery  

Last updated May 14, 2019

Original Research

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Upper Airway Stimulation Response in Older Adults with Moderate to Severe Obstructive Sleep Apnea

Kirk Withrow, MD, Sean Evans, MD, John Harwick, MD, Eric Kezirian, MD, Patrick Strollo, MDon Behalf of the ADHERE Registry Investigators

https://doi.org/10.1177/0194599819848709 | First Published May 14, 2019

Abstract

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Objective

To evaluate the impact of age on safety, efficacy, and usage of upper airway stimulation (UAS).

Study Design

Multicenter observational study.

Setting

Thirteen US hospitals and 3 German hospitals.

Subjects and Methods

The ADHERE registry is a multicenter database enrolling patients undergoing UAS implantation from October 2016 to April 2018. Outcome measures included the Epworth Sleepiness Scale, apnea-hypopnea index (AHI), therapy usage, and complications. Data were segmented by age (<65 vs ≥65 years).

Results

Younger adults (n = 365) were a mean ± SD 52.7 ± 7.9 years old and 82% male, with a body mass index of 29.6 ± 3.8. Older adults (n = 235) were 71.1 ± 4.8 years old and 71% male, with a body mass index of 28.8 ± 3.8. Baseline AHI was similar (younger, 36.2 ± 15.9; older, 36.1 ± 14.8). Both groups had lower AHI at 12 months versus baseline (P < .001), but the older group showed a greater reduction (7.6 ± 6.9 vs 11.9 ± 13.4, P = .01). The Epworth Sleepiness Scale score decreased from 12.3 ± 5.4 to 7.1 ± 4.8 (P < .001) among younger adults and from 10.7 ± 5.7 to 6.3 ± 4.4 (P < .001) among older adults. Usage was slightly higher among older adults (6.0 ± 2.0 vs 5.4 ± 2.1 hours/night, P = .02). Surgical time was similar between younger patients (2.4 ± 0.7 hours) and older patients (2.3 ± 0.7 hours, P = .40), with comparably low complications.

Conclusion

AHI reduction and therapy usage were found to be somewhat higher among patients aged ≥65 years who were treated with UAS. Surgical complications were low, in contrast to traditional sleep surgery.

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Clinical Techniques and Technology

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Longus Capitis Reconstruction of the Soft Palate

Jennifer H. Gross, MD, Joseph Zenga, MD, Jeffrey D. Sharon, MD, Ryan S. Jackson, MD, Patrik Pipkorn, MD, MSCI

https://doi.org/10.1177/0194599819849031 | First Published May 14, 2019

Abstract

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Soft palate (SP) reconstruction remains a challenge for the head and neck reconstructive surgeon. One favorable local flap option is the longus capitis muscle (LCM), a deep neck flexor with redundant muscle function, appropriate bulk, and a relatively straightforward surgical harvest. A retrospective review of 3 patients with T2 to T4 tonsil squamous cell carcinoma requiring SP resection and LCM reconstruction at a single institution was performed. Three patients underwent primary transoral resection, all resulting in at least 50% full-thickness SP defects. Reconstruction comprised a superiorly based LCM local flap. Patients underwent adjuvant (chemo)radiation therapy as indicated. Within 3 to 8 months, each patient was tolerating a full oral diet with no dysphagia, nasal regurgitation, or velopharyngeal insufficiency. For select patients with SP defects, a superiorly based LCM flap may provide a functionally acceptable reconstruction with minimal donor site morbidity.

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Clinical Photograph

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Antacid Tablets Oral Treatment Causing Respiratory Distress: An Uncommon Cause of Dyspnea

François Thibouw, MD, Mireille Folia, MD, PhD

https://doi.org/10.1177/0194599819849034 | First Published May 14, 2019

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Original Research

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High-Frequency Ultrasound: A Novel Diagnostic Tool to Measure Pediatric Tonsils in 3 Dimensions

Emily Kay-Rivest, MD, Christine Saint-Martin, MD, MSc, Sam J. Daniel, MD, MSc, FRCSC

https://doi.org/10.1177/0194599819850139 | First Published May 14, 2019

Abstract

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Objective

A wide variety of pathologies can affect the palatine tonsils. Ultrasound is a commonly used modality for assessing head and neck masses in children; however, its use in tonsillar evaluation has not been widely explored. The objective of this study was to measure 3-dimensional tonsillar size with ultrasound, in centimeters, and correlate these measurements with actual ex vivo dimensions on pathology specimens.

Study Design

We performed a prospective cohort study.

Setting

The study was set in a tertiary care children's hospital.

Subjects and Methods

Children undergoing tonsillectomy were included in the study. Transcervical high-frequency ultrasonography (HFU) was performed prior to surgery to obtain 3-dimensional measurements of the right and left palatine tonsils. Mean sizes were compared to ex vivo tonsil measurements and correlations were obtained.

Results

Seventy-five consecutive children underwent a transcervical HFU, with a total of 150 tonsils analyzed. The mean differences between HFU and pathology measurements were −0.08 cm and −0.24 cm for the right and left craniocaudal axes, −0.19 cm and −0.18 cm for the right and left mediolateral axes, and 0.05 cm and 0.03 cm for the right and left anteroposterior axes. Correlation coefficients between ultrasound and pathology measurements were all above 0.5.

Conclusion

HFU can accurately measure the size of pediatric tonsils in 3 dimensions.

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Original Research

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Salivary Gland Cancers of the Nasopharynx: A Population-Based Analysis of 383 Cases

J. Renee Booth, MD, Aykut A. Unsal, DO, Sandra Tadros, J. Kenneth Byrd, MD, Stilianos E. Kountakis, MD, PhD

https://doi.org/10.1177/0194599819849923 | First Published May 14, 2019

Abstract

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Objectives/Hypothesis

Salivary gland nasopharynx cancers (SGNPCs) are rare malignancies with few cases discussed in the literature. This study represents the largest cohort of SGNPC to date.

Study Design

Retrospective population-based analysis.

Methods

The Surveillance, Epidemiology, and End Results registry from 1973 to 2015 was utilized to extract 383 cases of SGNPC. Data were analyzed for demographic characteristics, incidence, clinicopathologic traits, and outcome prognosticators.

Results

White female patients aged >40 years were most commonly affected. The incidence was measured as 0.019 per 100,000 people. The majority of tumors presented at advanced stages (stage III/IV, 60.8%). Adenoid cystic carcinoma, adenocarcinoma, and mucoepidermoid carcinoma were the most commonly encountered histologies (43.1%, 31.6%, 13.3%, respectively). Cervical node involvement and distant metastasis were measured at 23% and 11.9%, respectively. Mucoepidermoid carcinomas presented with the best disease-specific survival at 5 and 10 years. Asian ethnicity, age <80 years, and earlier American Joint Committee on Cancer stages were positive prognostic factors. The inclusion of surgical therapy improved 5-year outcomes among the most common histologies, except for mucoepidermoid carcinoma.

Conclusions

Salivary gland nasopharyngeal cancer represents a group of rare histologies with similar outcomes as squamous cell carcinomas. However, prognosis is primarily dependent on histologic subtype, race, age, and American Joint Committee on Cancer stage.

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Original Research

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Impact of Distraction Osteogenesis Maxillary Expansion on the Internal Nasal Valve in Obstructive Sleep Apnea

Mohamed Abdelwahab, MD, Audrey Yoon, DDS, MS, Tyler Okland, MD, Sasikarn Poomkonsarn, MD, Chris Gouveia, MD, Stanley Yung-Chuan Liu, MD, DDS

https://doi.org/10.1177/0194599819842808 | First Published May 14, 2019

Abstract

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Objective

To assess the effect of distraction osteogenesis maxillary expansion (DOME) on objective parameters of the internal nasal valve and correlate findings with subjective outcomes.

Study Design

Retrospective cohort study.

Setting

Tertiary referral center.

Subjects and Methods

After Institutional Review Board approval, included subjects were those with obstructive sleep apnea, had undergone DOME from September 2014 to April 2018, and had cone beam computed tomography scans available before and after expansion. Measurement of the internal nasal valve parameters was performed with Invivo6 Software (version 6.0.3). Interrater reliability of all pre- and postexpansion parameters was measured. Patient-reported outcome measures included the Nasal Obstruction and Septoplasty Effectiveness Scale (NOSE) and Epworth Sleepiness Scale scores, and correlation between objective and subjective outcomes were evaluated by Spearman correlation analysis.

Results

Thirty-two subjects met inclusion criteria. All showed significant improvement in their subjective outcomes as well as an increase in their internal valve parameters. Significant correlation was observed between increased angles and improvement in postexpansion NOSE score (right angle, P = .024; left angle, P = .029).

Conclusion

DOME widens the internal nasal valve objectively (dimensions), which correlates significantly with subjective improvement (NOSE scores).

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Original Research

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Analysis of Process-Related Quality Metrics and Survival of Patients with Oral Cavity Squamous Cell Carcinoma

Swathi Appachi, MD, Janki Shah, MD, Chandana Reddy, MS, Andrew Bowen, MD, Shlomo Koyfman, MD, Eric Lamarre, MD

https://doi.org/10.1177/0194599819845864 | First Published May 7, 2019

Abstract

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Objective

To analyze the association of prior reported key quality metrics—neck dissection ≥18 nodes, radiation oncology referral for stage III/IV disease, unplanned surgery ≤14 days, and unplanned readmission ≤30 days—with disease-free survival (DFS) and overall survival (OS) in oral cavity cancer (OCC).

Study Design

A retrospective chart review.

Setting

A tertiary care center from 1995 to 2016.

Subjects and Methods

Data from patients with OCC who underwent primary surgery were studied. The association of quality metrics and pathology with DFS/OS was determined by Cox proportional hazards regression analysis.

Results

A total of 514 patients were included, and 398 (77.4%) underwent elective neck dissection. Key metrics were not associated with DFS on analysis, but higher pathologic stage and extracapsular extension (ECE) were. When stratified by stage, unplanned readmission within 30 days was associated with decreased survival on multivariate analysis (HR = 0.40; 95% CI, 0.20-0.85; P = .02) for patients with clinical stage III or IV disease. ECE was associated with decreased survival among these patients as well. Neck dissection with ≤18 nodes (HR = 0.62; 95% CI, 0.44-0.86; P = .004) and unplanned surgery within 14 days (HR = 0.56; 95% CI, 0.32-0.96; P = .03) were associated with decreased survival on univariate analysis but not on multivariate analysis. ECE and higher-stage disease were associated with decreased OS on multivariate analysis.

Conclusion

In this study, aggressive pathology, rather than adherence to key quality metrics, was associated with lower DFS and OS among patients with OCC. More studies are needed to elucidate the association of quality metrics with survival.

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Original Research

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Feasibility of High-Resolution Computed Tomography Imaging for Obtaining Ear Impressions for Hearing Aid Fitting

Chin-Kuo Chen, MD, PhD, Li-Chun Hsieh, MD, PhD, Yuan-Chuan Chiang, PhD, Wei-De Cheng, MS

https://doi.org/10.1177/0194599819847938 | First Published May 7, 2019

Abstract

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Objective

This study investigated the feasibility of obtaining ear impressions for hearing aids by using 3-dimensional high-resolution computed tomography (HRCT) images.

Study Design

Case series.

Setting

One referral tertiary center.

Subjects and Methods

Hearing-impaired adults who were fitted with 1 or 2 behind-the-ear hearing aid(s) and had undergone temporal bone HRCT for various ear pathologies were enrolled in this study. Earmolds were fabricated from the impressions obtained using the conventional ear canal silicone injection technique and the HRCT reconstructed technique. Outer ear canal resonance frequencies and amplitude in open ears and those measured with silicon and HRCT reconstructed earmolds were determined through real-ear gain measurements, including real-ear unaided gain (REUG) and real-ear occluded gain (REOG), for comparison.

Results

A total of 50 HRCT reconstructed earmolds were compared with 50 conventional silicon injection earmolds. The average value of open ear canal resonance amplitude (REUG) for each ear was 0.41 to 16.76 dB. No statistically significant difference in resonance amplitude (REOG) was observed between silicon and reconstructed earmolds (paired t test, P > .05). The mean insertion loss (REOG-REUG) at all frequencies also did not differ significantly between the two earmolds (paired t test, P > .05).

Conclusion

According to our real-ear measurements, acoustic characteristics of the HRCT reconstructed earmolds were compatible with those of the silicone injection earmolds. Despite concerns about increased cost and radiation exposure, the HRCT reconstructed technique is a clinically useful and applicable method and can reduce potential safety complications for difficult cases.

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Systematic Review/Meta-analysis

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The Influence of Cochlear Implantation on Tinnitus in Patients with Single-Sided Deafness: A Systematic Review

Nicole Peter, MD, Nuwan Liyanage, MSc, Flurin Pfiffner, PhD, Alexander Huber, MD, Tobias Kleinjung, MD

https://doi.org/10.1177/0194599819846084 | First Published May 7, 2019

Abstract

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Objectives

This systematic review provides an overview of the available studies (published by January 29, 2018) with descriptive data analysis about the influence of cochlear implantation on tinnitus in patients with single-sided deafness (SSD).

Data Sources

PubMed, EMBASE, Web of Science, Cochrane Library, and Google Scholar.

Review Methods

Original studies about the influence of cochlear implantation on tinnitus, measured with different tinnitus questionnaires or visual analog scale, in patients with SSD were included. The pre- and postimplantation tinnitus scores of the included studies were extracted for the further systematic review.

Results

The systematic search yielded 1028 studies. After evaluating titles, abstracts, and full texts, 1011 of these were dismissed. From the remaining 17 studies, 4 showed a low directness of evidence or high risk of bias and were therefore excluded. Due to the nature of cochlear implantation in SSD, only cohort studies and no randomized trials exist, which limits the evaluation in a systematic review. Generally, the mean tinnitus questionnaire scores decreased after cochlear implantation in these 13 studies with a total of 153 patients. The most widely used tinnitus questionnaire was the Tinnitus Handicap Inventory. In these studies, 34.2% of patients demonstrated complete suppression, 53.7% an improvement, 7.3% a stable value, and 4.9% an increase of tinnitus, and none of the patients reported an induction of tinnitus.

Conclusion

This review shows a clear improvement of tinnitus complaints after cochlear implantation in patients with SSD. Therefore, tinnitus might be considered as an additional indication for cochlear implantation in SSD.

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Original Research

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Human Otopathology of Cochlear Implant Drill-out Procedures

Danielle R. Trakimas, MSE, Reuven Ishai, MD, Elliott D. Kozin, MD, Joseph B. Nadol, Jr., MD, Aaron K. Remenschneider, MD, MPH

https://doi.org/10.1177/0194599819847636 | First Published May 7, 2019

Abstract

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Objective

Human otopathology following drill-out procedures for cochlear implantation (CI) in cases with labyrinthitis ossificans (LO) has not been previously described. This study uses the high sensitivity of histopathology to (1) evaluate surgical drill-out technique with associated intracochlear findings and (2) quantify spiral ganglion neuron populations in a series of patients with LO who underwent CI.

Study Design

Retrospective otopathology study.

Setting

Otopathology laboratory.

Subjects and Methods

Temporal bone (TB) specimens from cases with evidence of preoperative intracochlear fibroossification that required a drill-out procedure for CI electrode array insertion were included. All cases were histopathologically evaluated and 3-dimensional reconstructions of the cochleae were performed to interpret drilling paths and electrode trajectories.

Results

Five TB specimens were identified, of which 4 underwent drill-out of the basal turn of the cochlea and 1 underwent a radical cochlear drill-out. In multiple TBs, drilling was imprecise with resultant damage to essential structures. Two TBs showed injury to the modiolus, which was associated with substantially decreased or even absent neuronal populations within these areas. In addition, 2 cases with inadequate drill-out or extensive LO of the basal turn resulted in extracochlear placement of electrode arrays into the vestibule due to persistent obstruction within the basal turn.

Conclusion

Otopathology highlights the challenges of drill-out procedures in cases of LO. Imprecise drilling paths, due to distortion of normal cochlear anatomy, risk injury to the modiolus and adjacent neurons as well as extracochlear placement of electrode arrays, both of which may contribute to poorer hearing outcomes.

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Original Research

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Organ Function Preservation Failure after (Chemo)Radiotherapy in Head and Neck Cancer: A Retrospective Cohort Analysis

Jolien Heukelom, MD, Arash Navran, MD, Zeno A. R. Gouw, MD, Margot E. Tesselaar, MD, PhD, Charlotte L. Zuur, MD, PhD, Erik van Werkhoven, PhD, Jan-Jakob Sonke, PhD, Coen R. N. Rasch, MD, PhD, Abrahim Al-Mamgani, MD, PhD

https://doi.org/10.1177/0194599819846073 | First Published May 7, 2019

Abstract

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Objective

The aim of the current study was to determine the incidence of organ function preservation failure (OFPF) in patients with head and neck squamous cell carcinoma (HNSCC) treated by (chemo)radiotherapy and to identify its risk factors.

Study Design

Retrospective cohort analysis.

Setting

Tertiary cancer care center.

Subjects and Methods

A single-center retrospective cohort analysis was done (n = 703) in which OFPF after (chemo)radiotherapy was assessed. OFPF was defined as local failure or pure functional failure in the absence of local failure because of major surgical intervention (total laryngectomy, commando resection, permanent tracheostomy) or feeding tube dependence >2 years.

Results

OFPF occurred in 153 patients (21.8%). Reasons for OFPF were local failure in 103 patients (14.6%) and functional failure in 50 patients (7.2%). Evidence of functional failure included need for total laryngectomy (n = 9, 1.3%), commando resection (n = 2, 0.3%), permanent tracheostomy (n = 16, 2.3%), and/or long-term feeding tube for functional reasons (n = 23, 3.3%). In a Cox proportional hazards model, OFPF was worse for patients with T4 tumors (hazard ratio [HR] <0.5 and P < .001 for all other stages), for laryngeal vs oropharyngeal cancer (HR, 1.83; 95% confidence interval [CI], 1.20-2.79, P = .005, hypopharyngeal not significant), and for smokers (HR, 1.68; 95% CI, 1.10-2.56, P = .015). Exploratory multivariate analysis by tumor site showed that T4 tumor and pretreatment tracheostomy were the strongest predictive factors for OFPF in laryngeal and hypopharyngeal carcinoma while T4 tumor and smoking were predictive for poor OFPF in oropharyngeal carcinoma.

Conclusion

This work shows a detrimental effect of smoking on functional outcomes after (chemo-)radiotherapy for HNSCC. Moreover, T4 tumor, laryngeal subsite, and pretreatment tracheostomy are strong predictors of OFPF.

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