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Impact of Tonsillectomy With or Without Adenoidectomy on the Acoustic Parameters of the Voice: A Comparative Study [Original Article]

Objective To assess the effects of chronic tonsillitis with or without adenoiditis and the effects of tonsillectomy with or without adenoidectomy on the voice by means of acoustic analysis. Design Prospective case-control study. Setting Yenepoya Medical College Hospital, a tertiary referral hospital. Patients Patients 5 to 26 years old with chronic tonsillitis with or without adenoiditis. Interventions Tonsillectomies were performed under general anesthesia by surgeons using cold steel instruments via a standard capsular dissection technique, and adenoids were removed by curettage. Main Outcome Measures Acoustic analysis of 6 parameters (fundamental frequency, jitter, shimmer, harmonics: noise ratio, long-term average spectrum, and nasalance) 4 weeks after surgery compared with 1 day before surgery. Results Postoperatively, shimmer altered in males, and hypernasality was eliminated in almost all cases. None of the other associations were significant statistically. Conclusions Chronic tonsillitis and tonsillar hypertrophy cause alterations in some acoustic measurements, which make the voice dysharmonic and harsh. Tonsillectomy eliminates nasalance and lowers shimmer. Overall, it does not significantly alter dysphonia owing to disease.

Influence of Single-Trial Results on Clinical Practice: Example of Adenotonsillectomy in Children [Original Article]

Objective To establish whether the results of a 2004 trial on the effectiveness of adenotonsillectomy in children with mild to moderate symptoms of throat infection or adenotonsillar hypertrophy affected physicians' beliefs about the benefits of the operation and influenced clinical practice. Design Prospective prior-posterior study. Setting Academic research. Participants We evaluated beliefs prior and posterior to the 2004 trial regarding the benefits of adenotonsillectomy in a random sample of 120 Dutch otolaryngologists and 120 Dutch general practitioners. Main Outcome Measure Physicians were asked to give their estimates of the probability of recovery during 1 year after adenotonsillectomy or a nonsurgical strategy in 3 scenarios of children aged 3 to 4 years with recurrent throat infection, upper respiratory tract infection (with or without fever), or sleep-related breathing disorder. Results Ninety-four percent of otolaryngologists (n = 46) and 31% of general practitioners (n = 14) were familiar with the 2004 trial results. Posterior beliefs of otolaryngologists and general practitioners did not differ substantially from prior beliefs; overall expectations regarding the benefits of adenotonsillectomy remained high. Conclusion Dissemination of the 2004 trial results did not seem to affect the beliefs of physicians regarding the benefits of adenotonsillectomy. Trial Registration isrctn.org Identifier: ISRCTN04973569

Microcystic Lymphatic Malformations of the Tongue: Diagnosis, Classification, and Treatment [Original Article]

Objective To describe a classification of microcystic lymphatic malformations of the tongue and to investigate different treatment methods. Design Retrospective review of patients treated for microcystic lymphatic malformations of the tongue. Lymphatic malformations were classified into the following 4 groups according to their extent: isolated superficial microcystic lymphatic malformations of the tongue (stage I); isolated lymphatic malformations of the tongue with muscle involvement (stage II; stage IIA, involving a part of the tongue; stage IIB, involving the entire tongue); microcystic lymphatic malformations of the tongue and the floor of mouth (stage III); and extensive microcystic lymphatic malformations involving the tongue, floor of mouth, and further cervical structures (stage IV). Patients Twenty patients with microcystic lymphatic malformation of the tongue. Main Outcome Measures Medical records were reviewed for demographic data and extent and treatment of the lymphatic malformations. Results Three patients had stage I disease; 5 patients, stage II; 3 patients, stage III; and 9 patients, stage IV. In 6 patients, the lymphatic malformations could be completely removed by carbon dioxide laser surgery; the remaining 13 patients had persistent disease. Conclusions The initial stage seems to predict outcome. Carbon dioxide laser therapy provides good results primarily in stages I and IIA lymphatic malformations. In advanced lymphatic malformations (stages IIB, III, and IV), an interdisciplinary approach is necessary, because complete surgical excision is often impossible owing to the diffuse growth behavior, and therefore recurrence and persistence are common.

Duration-Related Efficacy of Postoperative Antibiotics Following Pediatric Tonsillectomy: A Prospective, Randomized, Placebo-Controlled Trial [Original Article]

Objective To determine whether a 3-day course of postoperative antibiotics is as effective as a 7-day course in reducing pain and reducing time to resumption of a normal diet and level of activity following pediatric tonsillectomy. Design A prospective, randomized, placebo-controlled trial. Setting Academic medical center. Patients Forty-nine patients were enrolled in the study. Preoperative demographic information was obtained. Interventions Tonsillectomy with or without adenoidectomy was performed by the senior author (J.J.) using electrocautery. Patients were randomized to receive either a 3- or 7-day course of amoxicillin. Main Outcome Measures Parents were asked to record the following information: analgesic use for the first 7 postoperative days, postoperative days the child initiated his or her usual diet and level of activity, and medical treatment for oral hemorrhage or dehydration. Results Of the 49 patients, 26 were randomized to receive 7 days of postoperative antibiotics (group A) and 23 to receive 3 days of antibiotics, followed by 4 days of placebo (group B). Results were obtained for 47 of the enrolled patients (96%). No statistically significant difference was noted between the 2 groups with regard to postoperative pain or time to resumption of a normal diet and level of activity. Conclusion A 3-day course of antibiotics following pediatric tonsillectomy is as effective as a 7-day course with regard to postoperative analgesic use and resumption of normal diet and level of activity. Trial Registration clinicaltrials.gov Identifier: NCT00662987

Clinical Implication of the Olfactory Cleft in Patients With Chronic Rhinosinusitis and Olfactory Loss [Original Article]

Objective To evaluate the relationship between findings via osteomeatal unit computed tomography (OMU CT) of the olfactory cleft and olfactory function in patients with chronic rhinosinusitis (CRS). Design Retrospective review of medical records. Setting Referral center. Participants Two hundred ten patients with CRS who underwent OMU CT and olfactory function tests were included in this study. Main Outcome Measures All the paranasal sinuses were graded via the Lund-Mackay scoring system. The olfactory cleft was graded on a scale of 0 to 4 according to its opacification. Olfactory function was evaluated by the butanol threshold test (BTT) and the 16-odor identification test (OIT). Results The radiologic grade of the olfactory cleft was more significantly correlated with olfactory function than the grades of the paranasal sinuses. In patients without allergy, the BTT and OIT scores were inversely correlated with the CT score of the olfactory cleft. However, in patients with allergy, only the BTT score had a negative correlation with the CT score of the olfactory cleft, whereas the OIT score did not. The OIT score showed a significant negative correlation with the opacification of the olfactory cleft in the mild and moderate CRS group only, whereas the BTT score showed a significant negative correlation in all stages of CRS. Conclusions The opacification of the olfactory cleft had a negative correlation with the olfactory function scores in patients with CRS. The olfactory cleft findings on OMU CT may give some clues to the olfactory function in patients with CRS.

Relative Hypotension and Image Guidance: Tools for Training in Sinus Surgery [Original Article]

Objectives To quantify the safety and efficiency of Postgraduate-Year II head-and-neck-surgery residents who perform endoscopic sinus surgery, to observe any changes that accompanied accrued experience, and to measure and correlate blood loss and temporal efficiency with anesthesia-induced relative hypotension. Design Retrospective study. Setting University of California, San Diego, Medical Center. Patients One hundred two patients with chronic rhinosinusitis operated on between July 1, 2005, and June 30, 2006, by 3 Postgraduate-Year II head-and-neck-surgery residents. Intervention Endoscopic sinus surgery. Main Outcome Measures Operative times, blood loss, case complexity, and anesthetic components were recorded and analyzed. Results One hundred two patients with chronic rhinosinusitis with and without polyposis received operative management. Mean operative time, with the inclusion of injection (10 minutes) and image guidance setup (5 minutes), was 77 minutes. Estimated blood loss averaged 42 mL for patients with chronic rhinosinusitis and 58 mL for patients with chronic rhinosinusitis and nasal polyps. The mean intraoperative blood pressure was 101/65 mm Hg. No major complications occurred. Conclusions Endoscopic sinus surgery may be safely performed by Postgraduate-Year II head-and-neck-surgery residents by means of hypotensive anesthesia techniques and image guidance. Outcome analysis demonstrates minimal blood loss, efficient operative times, and no significant complications.

Treatment of Postviral Olfactory Loss With Glucocorticoids, Ginkgo biloba, and Mometasone Nasal Spray [Original Article]

Objective To analyze the efficacy of treating postviral olfactory loss with glucocorticoids, Ginkgo biloba, and mometasone furoate nasal spray. Design Randomized trial. Setting Academic research. Patients Seventy-one patients who were diagnosed as having postviral olfactory loss. Main Outcome Measures All patients underwent olfactory function tests, including the butanol threshold test (BTT) and the cross-cultural smell identification test (CCSIT), and follow-up tests were performed 4 weeks later. In the interim, 28 patients were treated with prednisolone for 2 weeks (monotherapy), and the other 43 patients were treated with prednisolone for 2 weeks plus G biloba for 4 weeks (combination therapy). All patients used mometasone nasal spray twice daily for 4 weeks. Results Scores on the BTT and CCSIT significantly increased after treatment in both groups (P < .001 for both). The mean (SD) BTT score changes were 1.4 (2.2) in the monotherapy group and 2.2 (2.9) in the combination therapy group (P = .22). The mean (SD) CCSIT score changes were 0.9 (1.7) in the monotherapy group and 1.9 (2.7) in the combination therapy group (P = .11). On the BTT, the treatment response (defined as a score increase of ≥3) rates were 32% (9 of 28) in the monotherapy group and 37% (16 of 43) in the combination therapy group (P = .66), and the odds ratio was 1.25 (95% confidence interval, 0.46-3.42). On the CCSIT, the treatment response rates were 14% (4 of 28) in the monotherapy group and 33% (14 of 43) in the combination therapy group (P = .08), and the odds ratio was 2.89 (95% confidence interval, 0.84-9.97). Conclusions Olfactory function in patients with postviral olfactory loss was significantly improved by both treatment modalities. Although the treatment response was not statistically different between the monotherapy group and the combination therapy group, the addition of G biloba showed a tendency of greater efficacy in the treatment of postviral olfactory loss.

The Hemostatic and Hemodynamic Effects of Epinephrine During Endoscopic Sinus Surgery: A Randomized Clinical Trial [Original Article]

Objective To assess the hemodynamic and hemostatic effects of 2 different concentrations of epinephrine in local anesthetic used during functional endoscopic sinus surgery (FESS). Injection of local anesthetic containing epinephrine during endoscopic sinus surgery, while providing hemostasis, has been associated with cardiac adverse effects such as tachycardia, hypertension, as well as arrhythmias. Design Double-blind, randomized clinical trial. Setting Tertiary referral center. Patients A total of 140 patients undergoing FESS randomly divided into 2 groups, with group 1 receiving lidocaine hydrochloride, 2%, with 1:100 000 epinephrine and group 2, lidocaine, 2%, with 1:200 000 epinephrine. Main Outcome Measures Baseline and postinjection hemodynamic parameters were recorded at 1-minute intervals for 5 minutes. Patient demographics, the extent of surgery, and the presence of polyps were recorded in both groups. Hemodynamic and hemostatic parameters and intraoperative blood loss were compared. Results Significant hemodynamic fluctuations were noted following injection of lidocaine, 2%, with 1:100 000 epinephrine (group 1). Increases in heart rate and systolic, diastolic, and mean arterial blood pressure were noted in group 1 patients. The increase was found to be significant (P < .001) in the first and second minutes after injection and decreased to baseline level by the fifth minute. This fluctuation was not noted in group 2 patients, who received lidocaine, 2%, with 1:200 000 epinephrine. Using a standardized scale to assess surgical bleeding, no statistical difference in the 2 groups was observed (P > .05). Conclusion Submucosal injection of lidocaine, 2%, with 1:200 000 epinephrine during FESS does not lead to hemodynamic fluctuations or increased intraoperative bleeding compared with lidocaine, 2%, with 1:100 000 epinephrine. Trial Registration clinicaltrials.gov Identifier: NCT00852410

A New Surgical Method of Dynamic Nasal Valve Collapse [Original Article]

Objective To describe a technique for internal nasal valve collapse using radiofrequency-induced thermotherapy (RFITT). Design Prospective study. Setting Academic research center. Patients A total of 28 patients with nasal obstruction due to inspiratory nasal valve collapse were included in this study. Intervention Radiofrequency-induced thermotherapy. Main Outcome Measures Visual analog scale score. Results Severity of obstruction scores improved in all patients, with the mean score improving at the left nostril from 8.2 before treatment to 3.4 after treatment and at the right nostril from 8.9 before treatment to 4.1 after treatment. The outcomes were measured using visual analog scale score before treatment and at 16 weeks after treatment. Improvement was shown in severity of obstruction (P < .001). Conclusions This new method appears to be safe, quick, bloodless, and painless. These good, encouraging preliminary results must be confirmed by further study and long-term follow-up.

Decompression of the Orbital Apex: An Alternate Approach to Surgical Excision for Radiographically Benign Orbital Apex Tumors [Original Article]

Objective To study the outcome of patients with orbital apex lesions treated with endoscopic decompression alone. Design Retrospective medical chart review with a mean follow-up of 25.6 months. Setting Departments of Ophthalmology and Otolaryngology, University of Washington, Seattle. Patients Five individuals seen at the University of Washington Medical Center from November 2003 through December 2005 with visual disturbance caused by orbital apex lesions as documented by preoperative magnetic resonance imaging or computed tomographic scan. Intervention All patients underwent endoscopic decompression of the medial wall of the orbital apex with incision of the periorbita. Main Outcome Measures Postoperative visual acuity, presence or absence of a relative afferent pupillary defect, color vision, and visual field were recorded. Results All 5 patients presented with visual field deficits, 4 of whom improved postoperatively. Three patients had dyschromatopsia preoperatively, 2 of whom improved postoperatively. Visual acuity improved or stabilized in 4 of 5 patients postoperatively. One patient had progressive visual loss during the course of her follow-up, which, after obtaining postoperative imaging, was attributed to inadequate decompression of the apex at its most posterior aspect. This same patient also developed postoperative sinusitis that resolved with antibiotic treatment. Two patients developed diplopia, 1 in primary gaze requiring treatment with prismatic lenses. All patients presented with and maintained normal intraocular pressures. Conclusion Orbital apex lesions can often be effectively and relatively safely treated by endoscopic decompression alone.

The Role of Pectoralis Major Muscle Flap in Salvage Total Laryngectomy [Original Article]

Objective To assess the utility of the pectoralis major muscle flap (PMMF) in patients undergoing salvage total laryngectomy. Design Retrospective cohort analysis. Setting Tertiary care cancer center. Patients The study included 461 patients who underwent laryngectomy. Eighty of them underwent salvage surgery with primary pharyngeal closure. Interventions Of the 80 patients, 69 (86%) underwent primary pharyngeal closure alone and 11 (14%) underwent a PMMF, which was used to buttress the pharyngeal suture line. Main Outcome Measure Two hundred thirty-six variables were recorded for each patient. Complications related to pharyngeal closure were measured. Results Sixty-four percent of the patients who underwent PMMF also underwent chemoradiation therapy as the initial definitive treatment compared with 25% in the non-PMMF group (P = .03). On multivariate analysis, chemoradiation therapy was the only independent predictor of pharyngocutaneous fistula formation (relative risk, 1.82; P = .02). Nevertheless, the pharyngocutaneous fistula rate was similar in the PMMF (27%) and the non-PMMF (24%) groups. Furthermore, similar durations of tube feeding, days to oral feeding, and hospitalization period were recorded in both groups. Conclusion The PMMF should be used judiciously as a surgical adjunct in high-risk patients, with the goal of minimizing the risk for the development of a pharyngocutaneous fistula.

Metastatic Carcinoma of the Neck of Unknown Primary Origin: Evolution and Efficacy of the Modern Workup [Original Article]

Objective To assess the efficacy of various diagnostic modalities in detecting occult primary tumor location. Design Retrospective medical record study. Setting Academic head and neck oncology practice. Patients A total of 183 consecutive patients with metastatic carcinoma of the neck from an unknown primary tumor during a 10-year period, after exclusion of those with previous history of head and neck cancer, a primary tumor site evident on physical examination, or primary tumors of the neck. Main Outcome Measures Identification of primary tumor location by various imaging modalities and panendoscopy with directed biopsies. Results Primary tumor location was identified in 84 patients (45.9%). Preoperative imaging (computed tomography [CT], magnetic resonance imaging, positron emission tomography [PET], and/or PET-CT fusion scan) identified sites suggestive of primary tumor location in 69 patients. Subsequent directed biopsy of these sites yielded positive results in 42 cases (60.9%). The rate of successful identification of a primary tumor for each of the imaging modalities was as follows: CT scan of the neck, 14 of 146 patients (9.6%); magnetic resonance imaging of the neck, 0 of 13 patients (0%); whole-body PET scan, 6 of 41 patients (14.6%); and PET-CT fusion study, 23 of 52 patients (44.2%) (P = .001). The highest yield in identifying primary tumor sites was obtained in patients who had undergone PET-CT plus panendoscopy with directed biopsies with or without tonsillectomy: 31 of 52 patients (59.6%). Conclusion Diagnostic workup including PET-CT, alongside panendoscopy with directed biopsies including bilateral tonsillectomy, offers the greatest likelihood of successfully identifying occult primary tumor location.

Salvage Treatment of Late Neck Metastasis in Esthesioneuroblastoma: A Meta-analysis [Original Article]

Objective Esthesioneuroblastoma (ENB) is an uncommon tumor of the sinonasal region with a 20% rate of neck metastases. To our knowledge, the rate of neck metastases occurring 6 or more months after diagnosis has not been well characterized. The rate of successful salvage of these late neck metastases, defined in this study as disease-free survival for at least 1 year, has not been previously reported. Design Meta-analysis examining 33 articles published since 1990. Patients A total of 678 patients with ENB with 79 patients with neck metastases occurring 6 or more months after the initial diagnosis. Interventions Patients were grouped according to treatment with surgery, radiotherapy, or combined surgery and radiotherapy. Main Outcome Measures The rate of successful salvage of late neck metastases, defined as disease-free survival for at least 1 year, was compared for the 3 treatment groups. Results The rate of cervical metastases was 20.2%, with a 12.4% rate of late neck metastases. The combined successful salvage rate for late neck metastases with surgery, radiation, or combined therapy was 31.2%. An odds ratio (OR) analysis revealed that surgery plus radiation provided a statistically significant increase in the rate of successful salvage in patients with late neck metastases, with an OR of 8.6 vs single modality therapy and a number-needed-to-treat of 3. We found no difference in the OR for successful salvage for surgery alone vs radiation alone (OR, 1.5). Conclusion Treatment of neck metastases occurring 6 or more months after an initial diagnosis of ENB with combined surgery and radiotherapy provides a statistically significant survival advantage vs single-modality therapy.

Reduced {gamma}-Catenin Expression and Poor Survival in Oral Squamous Cell Carcinoma [Original Article]

Objective To investigate whether reduced expression of -, β-, or -catenin predicts poor survival in oral squamous cell carcinoma (OSCC). Design Immunohistochemical analyses of a retrospective cohort. Setting University-affiliated hospital. Patients One hundred twenty-four patients with OSCC. Main Outcome Measure The prognostic value of -catenin expression on disease-specific survival in different T and N category groups in patients with OSCC. Results Reduced expression of -catenin correlated with poor tumor differentiation of OSCC (P = .04). Patients with reduced -catenin expression in the primary tumor had significantly more frequent lymph node metastasis than did patients with normal -catenin expression (P = . 03). Reduced expression of -catenin (004) but not of -catenin (P = .25) or β-catenin (P = .48) correlated with poor clinical outcome. Reduced -catenin expression predicted poor disease-specific survival also in the 92 patients with T1 or T2 tumors (P = . 02). In multivariate analysis, advanced T category (P = . 04), neck lymph node metastases (P = . 01), and reduced -catenin expression (P = . 05) were independently related to poor survival. Conclusions Reduced expression of -catenin was associated with poor differentiation of OSCC, with neck lymph node metastases, and, more importantly, with poor disease-specific survival. Loss of -catenin expression seems to contribute to metastatic properties of OSCC. Evaluation of the expression pattern of -catenin may be useful for predicting outcome in patients with OSCC.

Geriatric Thyroidectomy: Safety of Thyroid Surgery in an Aging Population [Original Article]

Objective To ascertain whether there are incremental risks associated with thyroid surgery in the elderly population. Design Prospective analysis of a consecutive single-surgeon series of patients undergoing thyroid surgery at an academic health center. Setting Tertiary care health center. Patients The study included patients aged 21 to 35 years and patients 65 years and older who underwent thyroidectomy. Main Outcome Measures Pathology reports, complications (including rates of temporary and permanent hypocalcemia and temporary and permanent true vocal fold [TVF] paralysis), and need for admission or readmission were included in the analysis. Results There were 86 youthful patients who underwent thyroidectomy between November 2003 and December of 2007; 44 elderly patients underwent surgery during that same time frame. There were no deaths in either cohort, no hematomas, and no cases of permanent TVF paralysis. The elderly patients had a similar rate of complications when compared with the youthful patients, including transient hypocalcemia (12.5% vs 11.1%, respectively) and temporary TVF paresis (2.9% vs 3.9%), but a higher rate of readmission (4.5% vs 1.2%, P = .26). Conclusions Thyroid surgeons will be faced more often with the prospect of elective thyroid surgery in patients of advanced age as an increasingly aged population emerges and the prevalence of thyroid nodules and thyroid cancer increases. Thyroid surgery in elderly patients is safe and no more dangerous than surgery in youthful patients. There is a slightly higher rate of readmission.

Branchial Cleft Cyst Causing Carotid Sinus Syndrome [Clinical Note]

Narrow Duplicated Internal Auditory Canal: A Rare Inner Ear Malformation With Sensorineural Hearing Loss [Clinical Note]