bluuebunny/crossref_metadata_2025 huggingface dataset:
Open vs. Total Endoscopic Approach to the Thyroid
Authors: Chang Eugene H. , Wright Simon K
Published: August 2008

Objective

1) Learn the TATE approach to the thyroid. 2) Compare open vs. TATE approach.

Methods

From June 2005 to February 2008, 10 patients underwent TATE procedures for hemi‐thyroidectomy with isthmusectomy. We used a control group of 10 consecutive open approaches. Hospital records were reviewed. Postoperatively, patients were asked to rate aspects of their surgery on a scale of 1–5.

Results

Thyroid pathology consisted of benign nodules as well as foci of papillary carcinoma in both groups. No patients in the TATE group required conversion to an open approach. The TATE approach to the thyroid gland added 37 minutes on average to the operative time (142 vs 105). The average of the last 5 TATE approaches decreased (114) compared to the first 5 TATE approaches (170). Blood loss was less in the TATE group (10 to 43). Patients expressed a greater satisfaction with the TATE approach for the surgery (1.375 to 1.5) and the incision (1.375 to 1.4). Patients did express greater pain 24 hrs after surgery in the TATE group (2.625 to 1.7), but this became equivalent 1 week after surgery (1.5 to 1.4). Patients returned to normal activites sooner in the TATE group than the control (2.125 / 2.4). No patients in either group experienced hoarseness 3 months after surgery.

Conclusions

The TATE approach to the thyroid gland is safe. Advantages include the absence of any surgical incisions in the neck and greater patient satisfaction. Operative time is longer in the TATE approach but this differential decreases with operative experience.
Parotid Tumors: Fine‐Needle Aspiration and/or Frozen Section
Authors: Zbaren Peter , Loosli Heinz , Stauffer Edouard
Published: August 2008

Objective

Assess the difficulties of preoperative and intraoperative tumor typing of parotid neoplasms. Know the advantages and pitfalls of fine‐needle‐aspiration cytology (FNAC) and frozen section (FS) analysis in primary parotid neoplasms.

Methods

In 113 parotid neoplasms (70 malignancies and 43 benign tumors) preoperative FNAC as well as intraoperative FS analysis were performed. FNAC and FS findings were analyzed and compared with the final histopathologic diagnosis.

Results

The FNAC smear was non‐diagnostic in 6 tumors. In 2 FS specimens, it was not possible to determine the tumor dignity. FNAC findings and FS findings were both available in 105 neoplasMS The FNAC findings were true positive for malignancy in 54, true negative in 36, false positive in 4, and false negative in 11 tumors. The accuracy, sensitivity, and specificity were 86%, 83%, and 90% respectively. The FS findings were true positive in 60, true negative in 38, false positive in 2, and false negative in 5 tumors. The accuracy, sensitivity, and specificity were 93%, 92% and 95% respectively. The exact histologic tumor typing by FNAC was correct, false or not mentioned in 58%, 20% and 22% true positive or true negative evaluated tumors, and by FS in 83%, 5% and 12% true positive or true negative evaluated tumors.

Conclusions

The current analysis showed a superiority of FS compared with FNAC regarding the diagnosis of malignancy and especially of tumor typing. FNAC alone is not prone in many cases to determine the surgical management of primary parotid carcinomas.
Path‐Positive Specimens in Post ChemoRT Neck Dissections
Authors: Howell Lori K. , Yao Mike , Pytynia Kristen B , Gast Tom
Published: August 2008

Objective

To determine the likelihood of pathologically positive neck dissections after primary chemoradiotherapy for advanced squamous cell carcinoma (SCC) of the head and neck, and to examine the impact of persistent neck disease on regional recurrence, distant metastasis, and survival.

Methods

57 patients with N2 and N3 neck disease undergoing primary chemoradiotherapy for SCC of the oral cavity, oropharynx, larynx, and hypopharynx who underwent post‐treatment neck dissections (PND) from 1999–2007 at the University of Illinois Chicago were evaluated for clinical complete response (CCR) and pathologic complete response (PCR). CCR was determined by physical examination (PE) and CT findings performed 4 to 6 weeks after chemoradiotherapy. Positive predictive value (PPV) was defined as CCR predictive of PCR. We also determined the impact of pathologically positive PND on surgical complications, regional recurrence, distant metastasis, disease‐free survival, and overall survival using the chi‐squared and log‐rank tests.

Results

Of the 57 patients who underwent neck dissections, 17 (30%) had pathologically positive neck dissection specimens. When PE and CT findings showed resolution of disease (CCR), 85% (PPV) of pathologic specimens demonstrated no residual cancer. Conversely, when CCR was not achieved, 40% (NPV) of pathologic specimens demonstrated residual cancer. Positive pathologic disease in PND was associated with worse overall survival (p=0.014).

Conclusions

Persistent neck disease is common in advanced head and neck patients undergoing primary chemoradiotherapy. Failure to achieve CCR increases the likelihood of pathologically positive neck specimens by more than two‐fold.
Radionecrosis after Treating Oral Cavity & Oropharyngeal SCC
Authors: Patel Sundip H , Yao Mike , Brennan Tara
Published: August 2008

Objective

1) The primary goal of this study was to evaluate the incidence of radionecrosis among patients treated with radiation therapy for oral cavity & oropharynx squamous cell carcinoma at our institution. Many patients with oral cavity & oropharyngeal cancers receive radiation to preserve the tongue, knowing the risks of post‐treatment radionecrosis. However, recent protocols have intensified chemo‐radiotherapy in an effort to improve local control while possibly increasing risk. 2) Among those patients with radionecrosis, we also analyzed their cancer treatment regimen, associated risk factors, the severity of the radionecrosis and the resulting treatment they recieved.

Methods

We performed a retrospective review of all adult patients at our tertiary care facility with biopsy proven squamous cell carcinoma of the oral cavity & oropharynx from 1999 to 2007 who completed a full course of radiotherapy at our facility with at least 6 months follow‐up. Medical charts were reviewed for the presence of radionecrosis as well as for other corresponding, pertinent data.

Results

After reviewing 241 patients, a total of 107 patients were included. 5 of 65 with oropharynx disease had radionecrosis, revealing an incidence of 7.7%. Among the oral cavity group there were 8 out of 42 patients with radionecrosis, revealing an incidence of 19%. The overall incidence among our treatment group was 12.1%.

Conclusions

Radiation‐induced necrosis of the oral cavity & oropharynx is still a significant complication in the treatment of head and neck cancer and poses a higher risk in the oral cavity than the oropharynx.
Safety and Efficay of BION Implant During Radiation Therapy
Authors: Sinha Uttam K , Masood Rizwan
Published: August 2008

Objective

To determine the safety and efficacy of BION implants during radiation therapy (XRT) of head and neck cancer (HNC). The implants were placed to treat complications of muscle disuse for swallowing.

Methods

Three patients who underwent surgery for HNC received BION implants. The study was conducted under rules of good clinical practice under an Investigational Device Exemption from the U.S. FDA and monitored by the University of Southern California IRB. The implant was placed 2–3 mm above and parallel to the hypoglossal nerve just proximal to the origin of the ansa cervicalis. Two patients started XRT 3–4 weeks after surgery. The third patient did not need XRT. Two sets of stimulation protocols are used: low (low frequency, supramaximal twitch) and high (strong, fused contractions ‐ 20–30pps).

Results

No postoperative or implant specific complication was noted. During radiation therapy, the implants were stimulated. All patients tolerated stimulation without pain or discomfort. Visible contraction of base of the tongue muscles and muscles of laryngeal elevation was observed by using an external coil. All patients received high stimulation. The patients were provided with the coils and they continue to stimulate these muscles at home 3 times a day for a total of 1h/d. All patients maintained their oral feeding and weight during treatment of cancer.

Conclusions

BION is safe device to implant for stimulation of swallowing muscles. It effectively stimulate the hypoglossal and ansa cervicalis nerves. Robust contraction of swallowing muscles are visible during stimulation.
The Value of FNABs in the Management of Thyroid Lesions
Authors: Mijovic Tamara , Payne Richard J , Rochon Louise , Black Martin J , Hier Michael P , Gologan Olga E , Young Jonathan
Published: August 2008

Objective

Determine the value of fine‐needle aspiration biopsies (FNAB), and stratify the risk of malignancy within the indeterminate FNAB diagnostic category at our institution.

Methods

The preoperative FNABs of 115 consecutive patients who underwent thyroidectomy at a teaching hospital between 2005 and 2007 were reviewed and categorized into 4 groups: negative for malignancy, positive or suspicious for malignancy, indeterminate, and nondiagnostic. The final histopathological diagnosis was then compared with the FNAB result. FNABs reported as follicular or Hurthle cell lesions were considered indeterminate diagnoses, and malignancy rates were calculated within this category.

Results

The FNAB results were as follows: 17% negative for malignancy, 35% positive or suspicious for malignancy, 40% indeterminate, and 8% nondiagnostic. The sensitivity of FNAB in detecting thyroid malignancy was 83%, specificity 92% and accuracy 85%. There were 9 discrepant cases giving a false negative rate of 17% and a false positive rate of 8%. Overall, 52% of the indeterminate cases were carcinomas, with a malignancy rate of 48% for the follicular lesions and 62% for the Hurthle cell lesions. When cytological atypia was present, the rate of malignancy increased to 75% and 83% for the follicular and Hurthle cell lesions, respectively.

Conclusions

Our study confirms that FNAB is an accurate and helpful method for the evaluation of thyroid nodules with results directly correlating with management. Moreover, surgery should be strongly considered for FNABs categorized as indeterminate cases, especially in the presence of cytological atypia. Due to the high false negative rate, benign FNABs require close follow‐up and periodic rebiopsies.
C02 Laser‐assisted Phonosurgery for Benign Glottic Lesions
Authors: Geyer Marcel , Ledda Gian‐Peppino , Tan Neil C , Consultant Roberto Puxeddu
Published: August 2008

Objective

(1) To determine glottic function following carbon dioxide (CO2) laser‐assisted phonosurgery of benign laryngeal disease. (2) To evaluate post‐operative glottic morphology and disease recurrence rate.

Methods

Comparative retrospective case series of patients with benign glottic pathology treated by laser‐assisted phonosurgery over 10 years. 235 consecutive patients had pre‐ and postoperative data collected from objective laryngeal examination, videostroboscopy recording of vocal fold mucosal wave movement, electroacoustic voice analysis of fundamental frequency, jitter, shimmer, and harmonics to noise ratio, as well as perceptual voice evaluation. This data was also compared to that of 20 healthy volunteers. (Statistical analysis: Wilcoxon test and Mann‐Whitney test respectively). Definitive voice and morphologic evaluation was completed after 6 months.

Results

Evaluation of the pre‐ and postoperative functional results demonstrated a statistically significant improvement in all spectrographically analysed objective voice parameters (p<0.001), with a restored voice quality as good as the control group (p<0.001). Postoperative morphological analysis using videostroboscopic examination confirmed 3 recurrences of granuloma and 1 of Reinke's oedema. Recurrence was estimated objectively if the lesion was analogous to the original pathology. Glottic closure was complete in 96.5% of cases. False vocal fold adduction was normal in 88.5% of cases, with forced hyper‐adduction being present in 11.5%. Phonatory vibration was cord‐cord type in 100% of cases.

Conclusions

Our study demonstrates a statistically significant improvement in all acoustic parameters recorded. Postoperative vocal fold function and mucosal wave morphology were largely restored. CO2 laser‐assisted voice restoration for benign glottic disease is effective.
Calcium Hydroxylapatite Paste for Vocal Rehabilitation
Authors: Gillespie Marion B , Curry Jason A , Dozier Thomas S
Published: August 2008

Objective

Determine the effectiveness of calcium hydroxylapatite paste in vocal rehabilitation in routine clinical practice.

Methods

Retrospective series of adult patients undergoing calcium hydroxylapatite paste injection for vocal fold rehabilitiation over a 3‐year period. Outcomes include change in Voice Handicap Index (VHI) scores, procedure‐related complications, and need for follow‐up vocal procedures.

Results

A total of 23 patients with an average age of 65 years underwent vocal fold rehabilitation with calcium hydroxylapatite injection performed by operative endoscopy. Indications for injection included recurrent laryngeal nerve paralysis in 17 patients and partial cordectomy defects in 6 patients. There were no observed procedure‐related complications. Following injection, 17 patients (74%) had improvement in voice as measured by VHI, 4 had worsening of voice, and 2 were essectially unchanged from baseline. The mean VHI scores improved from 66 (S.D. 4.4) to 35 (S.D. 4.5) after a mean follow‐up time of 2 months (p=0.00001). There was a non‐significant trend toward greater improvement in the VHI scores for the paralysis group compared to the cordectomy group (p=0.09). Six patients required subsequent vocal procedures after the first injection to improve the voice, 4/6 in the cordectomy group and 2/17 in the paralysis group (p=0.02).

Conclusions

Calcium hydroxylapatite injection results in significantly improved vocal scores in the majority of patients. The paste was less satisfactory in patients with cordectomy defects due to poor retention of paste in the scarred vocal remnant. External medialization is usually required in these cases in order to adequately mobilize the scar to produce the volume necessary for satisfactory voice.
CO2 Laser Zenker's Diverticulotomy: 10‐year Experience
Authors: Rebeiz Elie E , Bhatia Nitin
Published: August 2008

Objective

Zenker's diverticula occur primarily in older patients, resulting in dysphagia, aspiration, and weight loss. A number of surgical options are available for treatment. While small diverticula (smaller than 2 cm) may require no surgical treatment, the presence of dysphagia, asiration, may necessitate surgery. Surgical options include both traditional open and endoscopic procedures. Many patients are elderly and cannot undergo open surgical procedures. Endoscopic techniques have become the preferred approaches by physicians because of their safety, effectiveness, and fewer complications.

Methods

Retrospective chart review of 65 patients who underwent endoscopic carbon dioxide (CO2) laser treatment of Zenker's diverticulum at a single tertiary care institution. In some of the procedures, the incision was sealed with a tissue sealant.

Results

Age ranged from 56 to 89 years. All patients had significant improvement in their symptoms such as dysphagia, aspiration, and weight gain. The endoscopic incision was performed in 1 session using the CO2 laser and a microscope. 2 complications (cervical emphysema) were managed conservatively and 1 postoperative bleeding required return to the operating room. The endoscopic exposure was not achieved in 2 patients due to difficult exposure. There were no mortalities. Mean follow‐up was 27 months. There was no recurrence of dysphagia and all patients remained asymptomatic.

Conclusions

CO2 laser endoscopic treatment of symptomatic Zenker's diverticulum is an effective and safe method. It is quick and simple, and permits a short hospital stay and quick return to activities. Tissue sealant provides additional safety and reduces the incidence of postoperative complications.
Impact of Voice and Swallowing Problems in the Elderly
Authors: Turley Richard , Cohen Seth M
Published: August 2008

Objective

1) Evaluate the prevalence of and quality of life impact of voice and swallowing problems in the elderly. 2) Determine treatment trends and barriers to treatment.

Methods

Cross‐sectional study of independent living residents in 2 retirement communities. Main outcome measures include prevalence of dysphonia and dysphagia, Voice Related Quality of Life (VRQOL), 7‐point Likert scale of dysphagia severity, Center for Epidemiologic Studies Depression (CES‐D) scale, and barriers to treatment. Relationship between continuous variables were analyzed with Spearman correlation and between categorical and continuous variables with a t‐test.

Results

248 residents responded, with a mean age of 82.4 years. 19.8% had dysphonia, 13.7% dysphagia, and 6% both. Respondents with more severe swallowing difficulty had greater impairment on the VRQOL (p = 0.04, Spearman correlation = −0.4). Respondents with both dysphonia and dysphagia had greater depression scores than those with neither symptom (mean CES‐D score 15.5 versus 9.9, p = 0.008, t‐test). While 75% of respondents with dysphonia were interested in treatment, only 20.4% and 2.1% had sought treatment for dysphonia and dysphagia, respectively. Being unaware of treatment options, and viewing voice and swallowing trouble as a normal part of aging, were the two most common reasons for not seeking treatment.

Conclusions

Voice and swallowing problems are common in the elderly but they are not realizing potential treatment benefits. Improved health care services for voice and swallowing problems in the elderly are essential.
p63 Expression in 127 Patients with Laryngeal Cancer
Authors: Cernea Claudio R , De Mello Borba Marcus Antonio , Dias Fernando Luiz , Faria Paulo , Bacchi Carlos , De Castro Costa Andre Leonardo
Published: August 2008

Objective

(1) To evaluate the expression of p63 in laryngeal squamous cell carcinoma (2) To analyze its prognostic significance.

Methods

p63 expression was examined in 127 patients submitted to total laryngectomy between 1998 and 2000 (111 male/16 female; 69 Caucasian/58 non‐Caucasian; 36‐ to 93‐years‐old, median: 58 years). 19 tumors were glottic, 16 supraglottic and 92 transglottic(15%, 13% and 72%, respectively). Two cases were stage I(1.6%), 21 were stage II(16.5%), 82 were stage III(64.6%) and 22 were stage IV(17.3%). 96 patients(75.6%) received adjuvant radiotherapy. The immunohistochemical analysis of the expression of p63 included the following scores: 0: no immunostaining; 1: immunostaining in <30% of neoplastics cells; 2: immunostaining in >30% and <70% of neoplastics cells; and 3: immunostaining in >70% of neoplastics cells.

Results

62 cases had score 3; 60 had score 2; 4 had score 1; and one case did not show any expression (48.8%, 47.2%, 3.1% and 0.8%). Overall survival was 73.9% at 24 months and 59.5% at 60 months. The disease‐free survival was 77.2% and 75.1%, and the disease‐specific survival was 79% and 67% at 24 and 60 months respectively. Uni and multivariate analysis identified that decreased immunoexpression of protein p63 and the involvement of the hypopharynx were statistically significant factors for the risk of recurrence and death by cancer.

Conclusions

p63 expression was highly prevalent in laryngeal squamous cell carcinomas in the present study. Decreased p63 protein expression was statistically associated to the recurrence and death.
The Validity of the Pharyngeal Squeeze Maneuver
Authors: Fuller Scott C. , Belafsky Peter C , Aminpour Shervin , Leonard Rebecca , Rees Catherine J
Published: August 2008

Objective

Pharyngeal strength is essential for safe bolus transit during deglutition. The pharyngeal squeeze maneuver (PSM) is a surrogate measure of pharyngeal strength determined on endoscopic swallow evaluation (FEES). Although several investigations have utilized the PSM, the validity of this diagnostic assessment has never been tested. The purpose of this investigation was to evaluate the clinical validity of the PSM.

Methods

Simultaneous FEES and fluoroscopic swallow evaluations were prospectively performed on 30 consecutive patients being evaluated for dysphagia. The PSM was assessed on all patients and compared to a validated measure of pharyngeal strength on fluoroscopy, the pharyngeal constriction ratio (PCR). As pharyngeal strength diminishes, the PCR increases. The PCR in patients with an intact PSM was compared to the PCR in persons with an absent PSM, with the independent samples t‐test and confirmed with the non‐parametric Mann‐Whitney test.

Results

29 simultaneous FEES‐fluoroscpic swallow studies were performed. 75% (22/29) had an intact PSM and 25% (7/9) had an absent PSM. The mean PRC for the group with an intact PSM was 0.06 (± 0.08), compared to a mean PCR of 0.31 (± 0.20) for individuals with an absent PSM. The PCR was significantly higher, indicating a weaker pharynx, in persons with an absent PSM (p < 0.001).

Conclusions

Pharyngeal strength, as assessed with the PCR, is significantly weaker in persons with an absent PSM. These data suggest that the PSM is a valid surrogate measure of pharyngeal motor integrity.
Transoral Laser Surgery: The Learning Curve
Authors: Bernal‐Sprekelsen Manuel S , Vilaseca Isabel , Alejandro Jose Luis Blanch
Published: August 2008

Objective

To assess the learning curve in transoral laser surgery for malignant tumors of the larynx and hypopharynx.

Methods

Prospective data collection in a SPSS data base from 1998 to 2004. Inclusion criteria: Patients with untreated malignant tumors of the aerodigestive tract treated with curative intent. Patients were divided into consecutive subgroups of n= 50 depending on the experience of the surgeons. Outcome assessment was prformed specifically for number of surgeries per patient, complications, recurrence rates and adjusted survival.

Results

680 patients met the inclusion criteria. Up to 4 groups of increasing consecutive experience could be formed. The number of operations per patients (1,87 operation for group #1 compared to 1.36 for group #4) and the complication rates were significantly reduced with increased experience. Complication rates were linked with a statistical significance to larger tumors (p< 0.0001). Free tumor margins were not related to experience (p=0.307), neither the recurrence rates (the lowest Chi‐square achieved a p=0.088 for the first group of 50 compared to the fourth group of 50). Adjusted survival rates showed a trend of improvement with larger experience when studied individually, but no significant statistical difference was observed (p >0.05).

Conclusions

Assessing surgical experience for new technologies is not as simple, as new joining surgeons profit from experienced colleagues. The complication rate clearly seems to depend on experience; however, patient adjusted survival rates do not.
Vox‐Implants Injection after Partial Laryngectomy
Authors: Ghidini Angelo , Bergamini Giuseppe , Alicandri‐Ciufelli Matteo , Molteni Gabriele , Mattioli Francesco , Presutti Livio , Marchioni Daniele
Published: August 2008

Objective

To illustrate a surgical technique for swallowing rehabilitation of patients after partial laryngectomy and to evaluate quality of life after treatment.

Methods

A longitudinal prospective study. 11 patients with persistent swallowing impairment after partial laryngectomy were included in the study. Swallowing disorders were diagnosed with videofluoroscopy and FEES (fiberoptic endoscopic evaluation of swallowing), and were quantified by 2 scales (a dysphagia score and a modified Penetration‐Aspiration scale). A self‐evaluation questionnaire about quality of life after polydimethylsiloxane (PDMS) injection was submitted to each patient (EORTC‐QLQ 30). After identification of site of inhalation of bolus, PDMS was injected into the neoglottis to fill the neoglottic gap in order to obtain a better continence of the neolarynx. Aerodynamics and acoustic analysis were assessed before and after treatment.

Results

Average follow‐up was 25 months (range 5–39). All patients showed an improvement both in the dysphagia score and in the modified Penetration‐Aspiration scale. Average improvement was 2.6 points in the dysphagia score (p=0.0042) and 2.1 in the modified Penetration‐Aspiration scale (p=0.0043). MPT showed an average improvement of 5 sec (p=0,037). The quality of life assessment showed a subjective improvement in each patient.

Conclusions

PDMS injection can be a useful technique in surgical rehabilitation of swallowing in patients who underwent partial laryngectomy. FEES is a very important tool in identifying anatomical alterations that can cause incorrect passage of bolus in the airways during deglutition. Filling these regions with PDMS can avoid passage of food into the airways, thus improving deglutition and voice and by consequence, patients’ quality of life.
Chorda Tympani in Chronic Inflammatory Middle Ear Disease
Authors: Goyal Arun , Singh P P , Dash Gautam
Published: August 2008

Objective

To study the effect of chronic inflammatory middle ear disease on gustatory function of chorda tympani nerve.

Methods

A prospective study was performed in 2007 on 85 patients of unilateral chronic inflammatory middle ear disease of both cholesteatomatous and noncholesteatomatous type. Gustatory assessment on both sides of the tongue was performed using dry taste strips. Taste strips were made of filter paper soaked in four different taste solutions of four different concentrations each and dried. The taste score is the number of correctly identified taste strips. Results were analyzed using Analysis of Variance (ANOVA) and t‐test.

Results

Comparison of mean taste scores on the side of diseased ear with normal ear was done. On the diseased side, the mean taste score was 9.16 and on the normal side, the mean taste score was 13.24. The difference between the two was found to be statistically significant (p<0.0001). The results were also analyzed for various other parameters like type, duration, and location of disease. Site of cholesteatoma was found to have a significant effect on the taste score of the diseased side. Patients having postero‐superior retraction pocket cholesteatoma had significantly lower taste scores as compared to those having cholesteatoma at other sites (p=0.008).

Conclusions

A patient of chronic inflammatory middle ear disease already has dysfunctional chorda tympani and is unlikely to notice a change in the taste sensation in the event of cutting of the nerve during the course of an ear surgery.
Clinical Usefulness of the VEMP Test in Vestibular Diagnosis
Authors: Bhansali Sanjay
Published: August 2008

Objective

1) Assess the clinical usefulness of the VEMP test in identifying vestibular disease. 2) Evaluate the criteria used for a positive VEMP test.

Methods

We prospectively evaluated 166 consecutive patients complaining of dizziness with a neurotologic examination including spontaneous nystagmus, head‐shake testing, gaze testing, and Hallpike maneuver. ENG testing and MRI scanning were done when indicated. All underwent VEMP testing. We considered 30% and 40% amplitude asymmetry criteria as abnormal for peripheral, and 17 msec latency abnormal for central disease and compared these with the complete clinical evaluation.

Results

44 patients had no VEMP response and were excluded. Analysis of the remaining 122 patients showed that 47% of patients with a peripheral vestibular disorder had an abnormal VEMP, using the 30% amplitude asymmetry criterion (p<0.001) (Fisher Exact Test), and 29% had an abnormal VEMP using the 40% criterion (p<0.001). The likelihood of a false positive was very low (3%, p<0.001). 42% of patients diagnosed with central vestibular dysfunction had delayed latency responses and the false positive rate was 2% (p<0.001).

Conclusions

The very low false positive rate (high specificity) indicates that an abnormal VEMP test is a good predictor of the presence of vestibular dysfunction, but a normal VEMP test does not exclude it. More patients with vestibular disease are identified (47% vs. 29%) just as accurately using a 30% rather than 40% criterion for a positive test. VEMP testing appears to be a valuable addition to the vestibular test battery and should be considered in the evaluation of dizzy patients.
cVEMP Testing in Patients with a Third Mobile Window
Authors: Eppsteiner Robert Walter , Lee Daniel J , Roditi Rachel E , Sauter Todd B
Published: August 2008

Objective

To determine the usefulness of cervical vestibular‐evoked auditory potential (cVEMP) testing for the evaluation of patients with and without a third mobile window (superior canal dehiscence or large vestibular aqueduct).

Methods

A retrospective review of charts from patients who underwent cVEMP testing at a single tertiary referral center was performed. The cVEMP is a vestibular reflex generated by an air‐conducted stimuli, causing an inhibitory potential in the ipsilateral sternocleidomastoid muscle measured by external electrodes. cVEMP results were correlated with demographic characteristics, hearing testing, diagnosis, and imaging. Mean cVEMP thresholds (at 500 Hz) and amplitudes (@ 95dB nHL and 500 Hz) were compared between ears and between patients with and without a third mobile window (TMW). Unequal variance t‐Test was used to determine significance. Patients were excluded if they had a history of Meniere's disease, middle ear disease or otologic surgery.

Results

63 patients received cVEMP testing, of which 8 had either unilateral or bilateral TMW. 114 non‐TMW ears were compared to 10 ears with TMW. Ears with TMW had a lower mean threshold (68 dB nHL) vs. non‐TMW (83 dB nHL) (p<0.003) and a higher mean amplitude (321?V) vs. non‐TMW (78?V)(p<0.009).

Conclusions

Patients with TMW have lower thresholds and higher amplitudes on cVEMP testing. This study supports the use of cVEMPs to diagnose TMW in patients who present with an unexplained air‐bone gap, autophony, aural fullness, or dizziness.
Endoscopic Management of Acquired Cholesteatoma
Authors: Molteni Gabriele , Marchioni Daniele , Mattioli Francesco , Ghidini Angelo , Alicandri‐Ciufelli Matteo , Presutti Livio
Published: August 2008

Objective

The purpose of this study was to examine the utility of using an endoscope in cholesteatoma surgery and to demonstrate how it allows a reduction in the incidence of residual disease.

Methods

A prospective study. A total of 53 ears with acquired cholesteatoma (primary) were resected. 20 cases were resected using a canal wall up (CWU) technique, 6 cases using a canal wall down (CWD) technique, and in 27 cases a transcanal tympanotomyatticotomy was performed. All of the patients in our study group underwent an explorative and operative endoscopic ear surgery complementary to the operating microscope to uncover and remove residual cholesteatoma.

Results

In the primary surgery after completion of microscopic cleaning, the overall incidence of intraoperative residual disease detected with the endoscope was 37.5%. The sinus tympani was the most common site of intraoperative residuals, followed by the anterior epitympanic recess and protympanum. Out of the 20 CWU cases, 12 second‐look endoscopies were performed. Two recurrences were identified, both in the sinus tympani. There were no significant complications associated with the 53 endoscopic procedures.

Conclusions

The endoscope allowed a better understanding of cholesteatoma and improved eradication of residual disease from hidden areas such as the anterior epitympanic recess, retrotympanum and hypotympanum not yet controllable by operating microscope.
Hearing Restoration with the RWI in Mixed Hearing Losses
Authors: Colletti Vittorio , Carner Marco , Veronese Sheila , Colletti Liliana
Published: August 2008

Objective

The indications of the Vibrant Soundbridge (VSB), presently limited to the patients with sensorineural hearing loss (HL) and normal middle ear function, have been extended to include patients with mixed HL due to congenital or acquired ossicular chain defects. The FMT of the VSB placed onto the RW, round window implant (RWI), has allowed optimal amplification in patients with moderate‐to‐severe mixed HL who, at present, do not have good options for adequate functional rehabiliation.

Methods

27 patients were unsuitable candidates for air and bone conductive hearing aids (BCHAs and ACHAs) and osseointegrative implants (BAHAs) and were treated with RWI. The patients were subdivided in 3 groups in relation to the etiologies and the performed surgeries. The first group includes 15 adults with unsuccessful OPLs (9 canal‐wall‐up (CWU) and 6 canal‐wall‐down (CWD) tympanoplasty); the second group includes 8 adult patients with CSOM, operated on dry radical or modified RCs; and the third group includes 4 patients, 2 children aged 1‐ and 10‐years‐old, and 2 adults with severe congenital malformations of the auricle combined with atresia of the outer ear canal and malformations of the ossicular chain. RWI surgeries will be illustrated in detail for each group.

Results

Significant improvements were observed in puretone threshold and speech understanding after surgery and at different follow‐ups (12–24 months), with no complications.

Conclusions

The post‐operative results suggest that RWI offers a viable treatment option for patients with severe mixed HL, regardless of the etiology of HL and previous surgeries.
Imaging Correlation of DFNB1 vs Non‐DFNB1 Hearing Loss
Authors: Kochhar Amit , Angeli Simon I , Dave Sandeep , Liu Xue‐Zhong
Published: August 2008

Objective

To evaluate temporal bone computerized tomography (CT) findings in children with DFNB1 hearing loss (HL) and non‐DFNB1 deaf children, using absolute measurements and visual inspection.

Methods

A retrospective case‐control series (1998 to 2005) was performed at an academic tertiary center. Children with non‐syndromic HL were diagnosed as DFNB1 or non‐DFNB1 after screening for GJB2 allele variants and the large GJB6 deletion. After matching for degree of HL, temporal bone CT images were compared in a cohort of 8 DFNB1 children (16 ears) to 9 non‐DFNB1 children (18 ears). Visual criteria and absolute measurements were compared against normative values established by Purcell (2003). Absolute measurements between groups were compared using the student t‐test. Non‐parametric statistical tests were used when appropriate. Significance level was 0.05.

Results

Visual inspection failed to identify 2 patients with abnormalities found using absolute measurements. There was a statistically significant difference in the prevalence of abnormal temporal bone CT findings between DFNB1 (1 of 16 ears) and non‐DFNB1 (10 of 18 ears) (p<0.0031, Fisher exact test). Of the absolute measurements, only the mean vestibule width in the non‐DFNB1 group (4.195 ± 0.5 mm) was significantly greater than in the DFNB1 group (3.65 ± 0.2 mm) (p < 0.001).

Conclusions

Visual inspection of temporal bone CT images alone may not adequately identify anomalies and should be used in conjunction with absolute CT measurements. Abnormal temporal bone CT findings are significantly less likely in children with DFNB1 when compared to non‐DFNB1 children, despite matching for a similar degree of HL.
Optical Fiber for CO2 Laser Otosclerosis Surgery
Authors: Lesinski S George , Giesken Kylie
Published: August 2008

Objective

To determine the safety and efficacy of new handheld optical fibers for CO2 laser stapedotomy and stapedectomy revision. Advantages of the new CO2 optic fibers are: convenience, reliability and precision. Disadvantages are: special adaptor required for laser console, limited spot size and cost. Omniguides’ handheld optic fibers introduce a safe, effective, and precise delivery system for CO2 laser otosclerosis surgery.

Methods

Prospective study of 25 consecutive otosclerosis patients. Researchers at Massachusetts Institute of Technology have developed a flexible optical fiber (photonic bandgap reflector) which can deliver CO2 laser energy through a handheld probe with minimal loss of laser energy. Omniguide introduced a 0.9 mm (O.D.) fiber in 2007 specifically for otologic surgery. This clinical study analyzes the safety and effectiveness of this new technology for CO2 laser otosclerosis surgery. To determine appropriate energy parameters, stapedotomy was performed in the laboratory on human temporal bones. Subsequently, 25 consecutive otosclerosis patients underwent CO2 laser stapedotomy (21) or stapedectomy revision (4) employing these handheld fibers. 6‐month post op audiograms were analyzed for air/bone gaps and nerve loss according to AAO‐HNS guidelines.

Results

21/21 primary and 3/4 revision patients closed the air/bone gap to within 15 decibels (mean 0.5, 1, 2, 3 KHz). There was no nerve loss at these frequencies. Three patients demonstrated a slight loss at 4 KHz (2–15 db, 1–20 db) compared with their preop audiograMS These results compare favorably with previous otosclerosis surgery performed by the author with microscope mounted CO2 lasers.

Conclusions

Advantages of the new CO2 optic fibers are: convenience, reliability and precision. Disadvantages are: special adaptor required for laser console, limited spot size and cost. Omniguides’ handheld optic fibers introduce a safe, effective and precise delivery system for CO2 laser otosclerosis surgery.
Piezosurgery® in Otologic Surgery: Four Years’ Experience
Authors: Salami Angelo , Dellepiane Massimo , Mora Renzo
Published: August 2008

Objective

Piezosurgery® is a new instrument which is able to cut the bone without necrosis and non‐mineralized tissues damage. The aim of this work has been to report our experience with Piezosurgery® in otologic surgery.

Methods

We have performed Piezosurgery® in platinotomy, mastoidectomy, antroatticotomy, posterior tympanotomy, facial nerve decompression (in its tympanic segment) and excision of middle ear tumours (glomus tympanicum tumour and B‐cell non Hodgkin lymphoma). The piezoelectric device uses low frequency ultrasonic waves (24.7–29.5 kHz); the applied power can be modulated between 2.8 and 16W, and is programmed in accordance to the density of the bone. For platinotomy, a specific operative program was created to avoid involuntary error of the power regulation. The equipment consists of two hand‐pieces, two inserts, and two peristaltic pumps connected to the control unit; the width, the thickness and the angle of the inserts vary in relation to the power that is applied, the bone density, and the surgical techniques that they are used for.

Results

In each surgical technique, Piezosurgery® provided excellent control without side effects on the adjacent structures of the middle and inner ear.

Conclusions

Piezosurgery® is a new and revolutionary osteotomy technique utilizing the microvibrations of scalpels at ultrasonic frequency, so that soft tissue (nerve, vessel) will not be damaged even upon accidental contact with the cutting tip. The vibration frequency of Piezosurgery® is optimal for mineralized tissue and doesn't cut the adjacent soft tissue, minimizing the risk of harming the adjacent tissues: this renders the piezoelectric device ideal for otologic bone surgery.
Practice Guidelines for Sudden Sensorineural Hearing Loss
Authors: Friedland David Richard , Shemirani Nima L.
Published: August 2008

Objective

To identify and compare patterns of treatment for sudden sensorineural hearing loss among otolaryngologists and primary care physicians.

Methods

A multiple choice and Likert scale survey was mailed to 1,306 otolaryngologists and primary care physicians throughout our state, regarding treatment and management approaches to SSNHL. Survey answers were analyzed by scope of practice and years of experience. Treatment protocols were compared among family practitioners, internists, general otolaryngologists, and otologists.

Results

A surprisingly large number of general practitioners treat SSNHL independent of an otolaryngologist. General practitioners as a group, however, are significantly less impressed than otolaryngologists that steroids are an effective treatment (p<0.0001). Over 99% of otolaryngologists start oral steroids at evaluation, as compared to approximately 30% of all general practitioners. Of those general practitioners treating on their own, without otolaryngology consultation, 78% use oral steroids. The vast majority of otolaryngologists start therapy with at least 60 mg of prednisone, while lower doses and Medrol dose packs are more commonly used by general practitioners. Otolaryngologists are more likely to treat with steroids beyond 1 week of hearing loss onset, while general practitioners overwhelmingly will only treat within the first week. Over 50% of otolaryngologists also add anti‐viral medications.

Conclusions

Significant differences exist in the management of SSNHL between otolaryngologists and general practitioners. The lack of strong evidence‐based guidelines for the treatment of SSNHL may underlie the variability in management by first‐line providers.
Prospective Study of the DizzyFIX for the Treatment of BPPV
Authors: Bromwich Matthew A. , Hughes Brian Donald , Raymond Marc Real , Sukerman Sydney , Parnes Lorne S
Published: August 2008

Objective

1) Develop and test a new dynamic visual device for the treatment of Benign Paroxysmal Positional Vertigo (BPPV). 2) Study the efficacy of self‐treatment using the DizzyFIX device compared with standard office treatment.

Methods

A prospective cohort design was used to study a newly developed device for the improved performance of particle repositioning maneuver (PRM). From September 2007 to March 2008, patients with active BPPV were seen in 4 different clinical practices (n=40). Patients used the device as their only treatment modality. Subjective patient reports of resolution were recorded at one week. The Dix‐Hallpike maneuver was used to measure objective resolution at one week. Patient outcome using the device was compared with retrospective physician guided controls (n=40) using a Chi squared test.

Results

All patients reported being able to use and understand the device. 100% of patients in the prospective cohort reported either a cure or some improvement. At one week, 90% of these patients had a negative Dix‐Hallpike test. This rate was comparable to that of the standard physician‐guided treatment group who had a success of 83%. A significant difference in success between groups was not demonstrated (p=0.174).

Conclusions

The use of this new device enabled patients to conduct an effective PRM on their own without physician training and to achieve success rates similar to those of an otolaryngologist.
The Effects of Cochlear Implantation on Vestibular Function
Authors: Melvin Thuy‐Anh N. , Migliaccio Americo , Carey John P , Della Santina Charles Coleman
Published: August 2008

Objective

1) Measure vestibular function before and after cochlear implantation (CI) using a battery of tests covering the full range of stimulus frequencies over which the normal angular vestibulo‐ocular reflex (VOR) stabilizes gaze.

Methods

Semicircular canal (SCC) function was assayed using head impulse test during 3‐dimensional scleral search coil eye movement recordings (HIT), dynamic visual acuity during rapid head movements (DVA), head‐shake nystagmus (HSN), and caloric electronystagmography (ENG). Saccular function was determined using vestibular‐evoked myogenic potentials (VEMP). Patient self‐assessment via the dizziness handicap inventory (DHI) and clinical head impulse testing (cHIT) were also measured.

Results

One of 28 post‐implanted ears (4%) suffered severe loss of vestibular function in all 3 SCCs. HSN revealed no change in 11 subjects. ENG revealed new hypofunction in 1 of 16 ears (6%). Passive DVA revealed no significant change for 16 implanted ears. VEMP revealed significant increase or disappearance in threshold in 5 of 16 ears (31%). DHI scores were variable and correlated poorly with objective tests. The cHIT performed by one otolaryngologist in 14 subjects exhibited 44% sensitivity and 94% specificity for detection of severe hypofunction confirmed via quantitative HIT.

Conclusions

CI carries a small but nontrivial risk of iatrogenic vestibular hypofunction in the implanted ear. For bilateral simultaneous‐CI, the risk of bilateral vestibular hypofunction is ∼0.16%, comparable to the likelihood of meningitis. The cHIT was highly specific for vestibular hypofunction in this study, but likely depends heavily on the examiner's threshold for abnormal.
Update of ABI Outcomes in Non‐tumor Adults
Authors: Colletti Vittorio , Shannon Robert V. , Carner Marco , Veronese Sheila , Colletti Liliana
Published: August 2008

Objective

The traditional indication for auditory brainstem implants (ABIs) is neurofibromatosis type 2 (NF2) in subjects older than 12 years. In our department, the indications for ABIs have been extended to non‐tumor children and adults with cochlear or cochlear nerve injuries or malfunctions who would not benefit from a cochlear implant. The results obtained in non‐tumor adults are reported in this study.

Methods

In our department, from April 1997 to February 2008, ABIs have been implanted in a total of 114 patients (83 adults and 31 children) for different tumor and non‐tumor diseases. 15 patients out of 114 have elsewhere previously had a CI with no sound detection. The retrosigmoid‐transmeatal approach was used in all tumor patients and the retrosigmoid approach was used in all non‐tumor patients.

Results

All patients had a functioning implantation, and reported auditory sensations with activation of various numbers of electrodes. At 1 year after implantations, non‐tumor adults scored from 10% to 100% in open set speech perception tests (average 57%), and tumor patients scored from 5% to 30% (average 11%). The difference between these results is statistically significant (p < 0.01).

Conclusions

Hearing outcomes are better in non‐tumor than tumor patients, with a significant number of non‐tumor patients that are able to understand speech at a level comparable to that of the most successful cochlear implant users, including conversational telephone use.
Airway Management of Epiglottitis: A National Perspective
Authors: Acevedo Jason L , Lander Lina , Choi Sukgi S , Shah Rahul K
Published: August 2008

Objective

To describe demographics and utilization in the treatment of epiglottitis.

Methods

The Kids’ Inpatient Database (KID) was used to extract data for patients 7 years old and younger with a diagnosis of epiglottitis; children undergoing airway intervention (intubation or tracheostomy) were studied.

Results

33 patients were identified that were either intubated (n=31) or had a tracheotomy (n=3); 1 patient that had a tracheotomy was intubated prior. The mean age of patients was 1.7 years old; 58% being 2 years older or less. 52% were male, and 42% were Caucasian. Average length of stay was 17.7 days (range=0–199). January and October were the most common months for admission (n=5, each). Of admissions ‐ Texas and Massachusetts handled the most (n=4, each). Average total charges were $83860. Private insurance was the primary payor in 55% of cases; 18% patients were discharged to shortterm care facilities. 73% of cases were managed at teaching hospitals; all tracheotomies were at teaching hospitals. There were no mortalities.

Conclusions

In the post‐HiB era, epiglottitis has become a rare entity. Of children under 7 years of age, only 33 required airway intervention in the 36 states sampled in 2003. More than half of affected children were, on average, 2 years old and younger. Airway intervention for epiglottitis is associated with high total charges and prolonged hospitalization. Epiglottitis is a rare, expensive, and protracted disease to treat in the HiB vaccine era. The infrequency of this disease has significant implications for resident education and training.