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European Archives of Oto-Rhino-Laryngology

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ISSN (Print) 1434-4726 - ISSN (Online) 0937-4477
Published by Springer-Verlag

[2216 journals]

Neuromonitoring of the laryngeal nerves in thyroid surgery: a critical appraisal of the literature
- Abstract: Abstract One of the most significant complication of thyroid surgery is injury of the recurrent laryngeal nerve. Injury of the external branch of the superior laryngeal nerve is a less obvious but occasionally significant problem. Recently, neuromonitoring during thyroidectomy has received considerable attention because of literature encouraging its use, but there is no consensus about its advantages and utility. A critical assessment of the literature on neuromonitoring was conducted in order to define its effectiveness, safety, cost-effectiveness and medical-legal impact. Available data does not show results superior to those obtained by traditional anatomical methods of nerve identification during thyroid surgery. Data about cost-effectiveness is scarce. The literature shows inconsistencies in methodology, patient selection and randomization in various published studies which may confound the conclusions of individual investigations. The current recommendation for use in “high risk” patients should be assessed because definition heterogeneity makes identification of these patients difficult. As routine use of neuromonitoring varies according to geography, its use should not be considered to be the standard of care.
  PubDate: 2013-05-18
Neuromonitoring in thyroidectomy: a meta-analysis of effectiveness from randomized controlled trials
- Abstract: Abstract Neuromonitoring in thyroid surgery has been employed to make nerve identification easier and decrease the rates of laryngeal nerve injuries. Several individual randomized controlled trials (RCTs) have been published, which did not identify statistical differences in the rates of recurrent laryngeal nerve (RLN) or external branch of the superior laryngeal nerve (EBSLN) injuries. The objective of this report is to perform meta-analysis of the combined results of individual studies to measure the frequency of RLN and EBSLN injuries in patients who underwent thyroidectomy with routine neuromonitoring in comparison with common practice of search and identification. RCTs comparing routine neuromonitoring versus no use in patients who underwent elective partial or total thyroidectomy were evaluated. Outcomes measured were temporary and definitive palsy of the RLN and EBSLN. A systematic review and meta-analysis was done using random effects model. GRADE was used to classify quality of evidence. Six studies with 1,602 patients and 3,064 nerves at risk were identified. Methodological quality assessment showed high risk of bias in most items. Funnel plot did not reveal publication bias. The risk difference for temporary RLN palsy, definitive RLN palsy, temporary EBSLN palsy, and definitive EBSLN palsy were −2 % (95 % confidence interval −5.1 to 1); 0 % (−1 to 1); −9 % (−15 to −2) and −1 % (−4 to 2), respectively. Quality was rated low or very low in most outcomes due to methodological flaws. Meta-analysis did not demonstrate a statistically significant decrease in the risk of temporary or definitive RLN injury and definitive EBSLN injury with the use of neuromonitoring. The neuromonitoring group had a statistically significant decrease in the risk of temporary EBSLN injury.
  PubDate: 2013-05-17
Surgery and proton pump inhibitors for treatment of vocal process granulomas
- Abstract: Abstract The aim of this study was to analyze the outcomes of vocal process granulomas treated with surgery and proton pump inhibitors and to specify related factors of recurrence. The medical records of patients with diagnosis of vocal process granuloma between 2000 and 2012 were reviewed. All patients were treated with surgery and proton pump inhibitors for at least 1 month. Forty-one patients were reviewed; mean follow-up time was 45 months. There was no recurrence among the patients who had a recent history of intubation. The recurrence rates of contact granuloma was 38.7 %, and significantly related to the frequency of surgery (P = 0.042), but was not significantly associated with the history of acid reflux (P = 0.676) and vocal abuse (P = 0.447), lesion size (P = 0.203) or surgical techniques (P = 0.331). Surgery combined with proton pump inhibitors was partially effective for the vocal process granulomas, especially with intubated patients. However, repeat surgery for recurrent contact granuloma should be preceded with caution due to high recurrence rates.
  PubDate: 2013-05-16
Using bilaterally fascioperichondrial flaps with a distal and a proximal base combined with conventional otoplasty
- Abstract: Abstract Prominent ears are the most common aesthetic abnormality of the external ear. Mustardè sutures and conchal setback are usually used for otoplasty, additional various cartilage-manipulation methods are also presented. One adjunctive technique that is often used involves the elevation of a fascial flap beneath which is sutured for additional cover, potentially reducing the risk of complications and recurrence. In the literature, this flap is traditionally raised with a proximal or distal base but it can be raised both distally and proximally with a number of advantages as we demonstrate. This article presents a technique to raise the fascioperichondrial flap with both a proximal and a distal base as an addition to conventional otoplasty. One hundred consecutive patients, followed up for at least 12 months, have been reviewed. One hundred ninety otoplasties were performed in 100 patients (10 unilateral), 65 women and 35 men. The mean age was 20.6 years, and the mean follow-up time was 16.3 months, respectively. No patient has developed skin necrosis or suture extrusion. In two patients (One bilateral and one unilateral for a total of three ears) a further procedure has been required to improve symmetry (1.5 %). Using the retro auricular fascioperichondrial flap combined with other techniques offers good results and can be used as a standard procedure in the surgical treatment of prominent ears.
  PubDate: 2013-05-14
Drug-induced sleep endoscopy: a two drug comparison and simultaneous polysomnography
- Abstract: Abstract The purpose of the present study was to compare pharyngeal and polysomnographical findings during drug-induced sleep endoscopy (DISE) performed with either propofol or midazolam as a single sedative agent. It is prospective, non-randomized, double-blinded case series study. Sixteen patients with sleep disordered breathing were sedated first with propofol and after full wake up with midazolam. Simultaneous polysomnography (PSG) was performed. We compared the zones of obstruction and vibration found with both drugs using the VOTE classification. Simultaneous PSG findings are also compared. There were 15 men and one woman; the mean age was 42.7 years old, mean body mass index 26.9 kg/m2. Average DISE duration was 20 min with Propofol and 14.3 min with Midazolam. The induced sleep stage obtained was N2 with both drugs. Outpatient physical exam did not correlate with drug-induced sleep findings. There was a good correlation between DISE results with both drugs in all the areas of collapse except the velum (p < 0.005). Using a continuous perfusion, there is a good agreement in the findings observed in DISE performed with propofol and midazolam and PSG.
  PubDate: 2013-05-12
Patient specific or routine preoperative workup in septoplasty: which one is cost-effective'
- Abstract: Abstract This study aimed at determining the limits of preoperative investigation and calculate estimated cost analysis in septoplasty with and without turbinate surgery. A retrospective chart review. The study was conducted at secondary referral center. A retrospective chart review of patients who have undergone septoplasty over a 1-year period was performed. The need for routine (battery testing) versus patient specific preoperative workup of 380 septoplasty patients was evaluated. Mean age of the patients was 31.5 ± 4.6. The patients were classified into three groups according to preoperative routine laboratory testing results: (1) normal group (2) abnormal group and (3) abnormal out of action limit group. Medical records were revaluated by an anesthesiologist and ear nose throat doctor according to preoperative American Society of Anesthesiologists guidelines to calculate estimated possible costs in case of patient specific preoperative workup. Three hundred seventy-seven patients were within ASA 1 group and three patients were within ASA 2. According to preoperative battery testing results, 5.8 % of the patients (n = 22) were in group 1, 93.4 % (n = 355) were in group 2, 0.8 % (n = 3) were in group 3. Surgery was postponed due to concomitant pathologies for about 44 days (10–180 days) in four patients (1.1 %). Preoperative routine laboratory testing costs were calculated as $41.08 ± 6.69 (40.25–128.78) per patient. When medical records were reevaluated retrospectively, estimated cost per patient would be $8.91 ± 10.40 (7.18–79.91) if patient specific preoperative workup were done. Individual preoperative testing would save $12,226.78 annually and total cost would decrease from $15,612.41 to $3,385.62. (p = 0.001). Patient-specific preoperative workup is more cost effective than routine battery testing in septoplasty with and without turbinate surgery.
  PubDate: 2013-05-12
Role of transnasal oesophagoscopy in diagnosis of early malignancy in the area of the oesophagus and hypopharynx. A review of the literature
- PubDate: 2013-05-12
Does rheumatoid arthritis have an effect on audiovestibular tests'
- Abstract: Abstract The study aimed to determine the characteristics of hearing loss, vestibular responses and the incidence of vestibular disturbances in RA patients. This prospective study was performed at the Otolaryngology Department of Bozok University School of Medicine between May and November 2012. Eighty-one RA patients (69 women and 12 men) with a mean age of 40.8 ± 13.4 years (23–67 years) and 81 healthy controls (67 women and 14 men) with a mean age of 41.3 ± 13.8 years (24–66 years). Each subject was tested with low and high-frequency audiometry by a single experienced investigator under standard audiometric testing conditions. For each set of tests, mean values of air and bone conduction at each frequency and tympanometric values were calculated for the study groups. Videonystagmography (VNG) including smooth pursuit, saccade, positional, and caloric tests were also performed. The mean air conduction threshold values at high frequencies (4,000, 6,000, and 8,000 Hz) in RA group were lower than control groups. The difference between mean air conduction threshold values of the control groups against RA group at high frequencies were statistically significant (p < 0.05). There was no statistically significance between the two groups in tympanometric values (p < 0.05). VNG testing revealed central abnormalities in twenty patients (24.69 %), peripheral abnormalities in five patients (6.17 %), and mixed abnormalities in six patients (7.4 %). There was no association between VNG abnormalities in patients with RA and age, sex, duration of disease, accompanying vertigo complaint, the laboratory findings and hearing levels (p < 0.05). Our findings suggest an association of RA and audiovestibular system dysfunction regardless clinical and demographic situation of patients. We assume the hearing and vestibular disturbances in RA are more prevalent than previously recognized. Also hearing losses in high frequencies in RA patients may be considered as an indicator of cochlear involvement in this disease.
  PubDate: 2013-05-12
ENT-HNS education: what undergraduate students want'
- PubDate: 2013-05-11
Preemptive peritonsillar infiltration with lidocaine for relief of bipolar adult post-tonsillectomy pain: a randomized, double-blinded clinical study
- Abstract: Abstract There are discordant results in the studies of the peritonsillar infiltration in adults undergoing the tonsillectomy. The study is to compare the effect of the preemptive peritonsillar infiltration with lidocaine in bipolar tonsillectomy in adult. 172 adult patients were randomly located into five groups before tonsillectomy: group 0: without the peritonsillar infiltration, group 1: for 3 ml normal saline with 1:200,000 epinephrine per tonsil, group 2: for 3 ml 1 %lidocaine with 1:200,000 epinephrine per tonsil, group 3: for 8 ml normal saline with 1:200,000 epinephrine per tonsil, group 4: for 8 ml lidocaine with 1:200,000 epinephrine per tonsil. The post-operative pain in the following 7 days was assessed by visual analog scale. Operation time and post-operative bleeding were also recorded. No significant differences were found between operative times, post-tonsillectomy hemorrhage between the five groups. The differences between pain scores of the group 0, group 1 and group 2 were not statistically significant (P > 0.05). The differences between pain scores of group 3, group 4 against group 0, group 1, group 2 were statistically significant (P < 0.05). We found the volume of peritonsillar infiltration might contribute to the relief of pain of the bipolar post-tonsillectomy.
  PubDate: 2013-05-11
Trans-oral resection of large parapharyngeal space tumours
- Abstract: Abstract The aim of this study is to describe minimally invasive trans-oral approach for resection of parapharyngeal space (PPS) tumours and to demonstrate surgical technique, resection, repair and outcomes. Five cases were prospectively included in the study. The data collected include age, sex, site, size, pathology, radiological investigations, surgical excision, complications and outcomes. Three females and two male patients underwent trans-oral resection of PPS tumours sized 4–8 cm. The pathology included two deep lobe parotid tumours, one schwannoma, one hibernoma and one primary adenocarcinoma arising form the minor salivary gland. All tumours were resected completely without any technical difficulty. The healing was quick and by primary intention. Patients resumed oral feeding on recovery from general anaesthesia and did not require any significant analgesia beyond the first 2 days. Patient with adenocarcinoma received postoperative radiotherapy and remained disease-free during 4 years post-treatment. No recurrences were observed in patients with benign tumours. No neurovascular injury occurred during surgery and no secondary bleeding was observed. We have demonstrated successful and safe execution of trans-oral resection of large PPS tumours. There were no intra and post-operative complications and there has been no recurrence during the follow-up period. In our experience, it appears to be efficient, safe and minimally invasive compared to the established techniques.
  PubDate: 2013-05-10
Outcome after elective neck dissection and observation for the treatment of the clinically node-negative neck (cN0) in squamous cell carcinoma of the oropharynx
- Abstract: Abstract Optimal elective neck treatment in node-negative (cN0) oropharyngeal squamous cell carcinoma (OPSCC) patients is still controversially discussed. Retrospective chart review of 49 cT1-3 cN0 cM0 OPSCC patients, who had undergone surgical resection of the primary and either elective neck dissection (END) (n = 32) or observation (OBS) (n = 17) of the neck was performed. For systematic review of literature, Pubmed and EMBASE were searched for clinical studies including data on both END and OBS of the neck in cN0 OPSCC patients. Estimated 5-year overall survival (OS) rate was 82 % for END and 76 % for OBS [hazard ratio (HR) = 1.01]. Estimated 5-year disease-free survival (DFS) rate was 78 % for END and 67 % for OBS (HR = 1.79); 5-year DSS rate was 97 % (END) and 81 % (OBS) (HR = 2.22). None of the primary outcome variables (OS, DFS, DSS) revealed statistically significant effects for the treatment assignments. Hazard ratios implied an advantage for END. Systematic review of literature yielded only retrospective chart reviews and no data meeting our selection criteria for further data analysis. Due to lack of high-level evidence, the decision for END in cN0 OPSCC remains a diagnostic and therapeutic challenge. The demonstrated clinical equipoise would provide a solid basis for a multicentric, randomized trial.
  PubDate: 2013-05-10
Response to “Letter to the Editor” by Balta et al. entitled “Other inflammatory markers ought to be kept in mind when assessing the mean platelet volume in clinical practice”
- PubDate: 2013-05-09
Would an endosteal CI-electrode make sense' Comparison of the auditory nerve excitability from different stimulation sites using ESRT measurements and mathematical models
- Abstract: Abstract Regarding potential endosteal cochlear implant electrodes, the primary goal of this paper is to compare different intra- and extra-cochlear stimulation sites in terms of current strengths needed for stimulating the auditory nerve. Our study was performed during routine cochlear implantation using needle electrodes for electric stimulation and by visually recording electrically elicited stapedius reflexes (ESRT) as a measure for the stimulus transfer. Of course this rather simple setup only allows rough estimations, which, however, may provide further arguments whether or not to proceed with the concept of an endosteal electrode. In addition, a mathematical model is being developed. In a pilot study, intra-operative electric stimuli were applied via a needle electrode commonly used for the promontory stimulation test. Thus, stapedius reflex thresholds (ESRTs), electrically elicited via the needle from different points inside and outside the cochlea served as indicators for the suitability of different electrode positions towards the modiolus. Tests were performed on 11 CI-recipients. In addition, the extension of electrical fields from different stimulation sites is simulated in a mathematical cochlea model. In most patients ESRT measurements could be performed and evaluated. Thus an “endosteal” stimulation seems possible, although the current intensities must be higher than at intraluminal stimulation sites. Moreover, our model calculations confirm that the extension of electric fields is less favourable with increasing distance from the electrode to the ganglion nerve cells. In terms of hearing, the concept of an endosteal electrode should only be promoted, if its superiority for hearing preservation can be proven, e.g. in animal experiments. However, for other indications like the electric suppression of tinnitus, further research seems advisable. Levels of evidence: N/A
  PubDate: 2013-05-09
Drain removal and aspiration to treat low output chylous fistula
- Abstract: Abstract Chylous fistula following neck dissection is difficult to treat. We hypothesized that timely removal of the suction drain followed by daily aspiration might aid in resolution of the condition. The study model is prospective cohort study. Out of 170 consecutive neck dissections, 7 (4 %) developed chylous fistula postoperatively. Retaining the suction drain was associated with resolution of the fistula in only one case. The remaining six had peak 24 h outputs between 85 and 675 ml that showed no significant fall despite maximal conservative treatment. Suction drain removal followed by daily needle aspiration however led to cessation of the fistula in all six cases. No patient required surgical re-exploration. Drain removal was associated with a significant fall in the volume of chylous output (p = 0.002). In selected cases of low output chylous fistula, suction drain removal and daily needle aspiration is an effective treatment option.
  PubDate: 2013-05-08
Open mini-incision parathyroidectomy for solitary parathyroid adenoma
- Abstract: Abstract Parathyroid surgery is the acceptable definitive treatment for primary hyperparathyroidism (pHPT) due to parathyroid adenoma. Open mini-incision parathyroidectomy (O-MIP) has an excellent cure rate and minimal morbidity. We aim to demonstrate the safety, efficacy and subjective patient satisfaction of O-MIP and investigate the accuracy of pre-operative radiological localisation in relation to operative findings. A retrospective review of patients who underwent O-MIP for pHPT due to solitary parathyroid adenoma from April 2006 to August 2012 was performed. All patients were initially investigated by an endocrinologist to confirm pHPT with pre-operative localisation imaging using ultrasound scan (USS) and 99mTc-sestamibi (MIBI). One hundred and fifty consecutive patients were included with a median age of 62 years. Pre-operative USS and MIBI scans were concordant in 71 % of cases. In combined modality (USS and MIBI), localisation was 94.8 % accurate. There was 95.5 % identification of parathyroid tissue confirmed by intra-operative frozen section. Ninety-one percent of patients were treated as a day case. The median operative time was 60 min. The mean pre-operative calcium level was 2.98 mmol/l, and the short-to-medium term mean calcium level was 2.49 (Paired t test, p < 0.001). There was no significant complication. O-MIP confers significant advantages over the traditional gold standard treatment of bilateral neck exploration. Accurate localisation is the key to successful O-MIP. In experienced hands, ultrasound and MIBI may be the only pre-operative investigations required for accurate localisation.
  PubDate: 2013-05-08
Inner ear damage following electric current and lightning injury: a literature review
- Abstract: Abstract Audiovestibular sequelae of electrical injury, due to lightning or electric current, are probably much more common than indicated in literature. The aim of the study was to review the impact of electrical injury on the cochleovestibular system. Studies were identified through Medline, Embase, CINAHL and eMedicine databases. Medical Subject Headings used were ‘electrical injury’, ‘lightning’, ‘deafness’ and ‘vertigo’. All prospective and retrospective studies, case series and case reports of patients with cochlear or vestibular damage due to lightning or electrical current injury were included. Studies limited to external and middle ear injuries were excluded. Thirty-five articles met the inclusion criteria. Fifteen reported audiovestibular damage following electric current injury (domestic or industrial); a further 15 reported lightning injuries and five concerned pathophysiology and management. There were no histological studies of electrical current injury to the human audiovestibular system. The commonest acoustic insult after lightning injury is conductive hearing loss secondary to tympanic membrane rupture and the most frequent vestibular symptom is transient vertigo. Electrical current injuries predominantly cause pure sensorineural hearing loss and may significantly increase a patient’s lifetime risk of vertigo. Theories for cochleovestibular damage in electrical injury include disruption of inner ear anatomy, electrical conductance, hypoxia, vascular effects and stress response hypothesis. The pathophysiology of cochleovestibular damage following electrical injury is unresolved. The mechanism of injury following lightning strike is likely to be quite different from that following domestic or industrial electrical injury. The formulation of an audiovestibular management protocol for patients who have suffered electrical injuries and systematic reporting of all such events is recommended.
  PubDate: 2013-05-07
Treatment of obstructive sleep apnea hypopnea syndrome caused by glossoptosis with tongue-base suspension
- Abstract: Abstract The objective of the study was to evaluate a surgical method to treat patients with obstructive sleep apnea hypopnea syndrome (OSAHS) caused by suspected glossoptosis. Seventy-eight patients with OSAHS caused by suspected glossoptosis were non-randomly divided into two groups. The 45 patients in the first group received uvulopalatopharyngoplasty (UPPP) and tongue-base suspension (Repose). The 33 patients in the second group received UPPP alone. Follow-up was conducted over 6 months, and polysomnography was used to determine the effects of treatment. Follow-up results revealed that the apnea–hypopnea index (AHI) and ESS scores of the patients from both groups were substantially decreased compared to the corresponding values before surgery. The lowest oxygen saturation (LaSo2) of both groups was improved, compared to the level before surgery. The degree of improvement in patients treated with UPPP + Repose was significantly greater than that seen in patients treated with UPPP alone. In the UPPP + Repose group, 17 patients were cured, 23 showed marked improvement, and 5 did not improve. In the UPPP alone group, 1 patient was cured, 16 showed marked improvement, and 16 did not improve. The marked improvement rates of the two groups were 88.9 and 51.5 %, respectively, a significant difference. Patients who show glossopharyngeal obstruction during sleep, and have normal glossopharyngeal airway morphology when awake, should be suspected to have glossoptosis. Repose surgery is an effective operation for the patients with OSAHS suspected glossoptosis.
  PubDate: 2013-05-07
A perspective of comparative salivary and breast pathology. Part I: microstructural aspects, adaptations and cellular events
- Abstract: Abstract This is the first part of a review comparing the pathology of salivary and mammary glands. Here, less obvious similarities and differences in functional histology and their influences on pathology are examined with emphasis on myoepithelial cells, stromal components, analogues of mucosa-associated lymphoid tissue, steroid receptors, and intraparenchymal cells of monocytic lineage. Particular cell phenotypes (oncocytic, apocrine, neuroendocrine and clear) are critically evaluated and responses to atrophy, infarction and fine-needle aspiration biopsy procedures are highlighted together with aspects of metaplasia, regeneration, ageing and microcalcification. Areas of controversy or uncertainty which may benefit from further investigations are also discussed.
  PubDate: 2013-05-07
Efficacy of OK-432 sclerotherapy in treatment of lymphatic malformations: long-term follow-up results
- Abstract: Abstract Lymphatic malformations (LMs) are rare congenital tumors of the lymphatic system often affecting the head and neck area. Because of cosmetic and functional symptoms most patients need to be treated. Traditionally surgical treatment has been considered to be the first-line treatment for LM. However, it is challenging because of the need for complete excision. The risk of poor cosmetic result and damage to surrounding structures is high. Since Ogita presented OK-432 as a treatment for LM in 1987, it has been widely used as the primary treatment. Many papers have been published on this topic but with relatively short follow-up times. We present a material of 36 LMs treated with OK-432 during the period of 1999–2009 and with an average follow-up time of 6 years. Immediate post-treatment results were compared with the late follow-up findings. Primary and late response to therapy was evaluated with an MRI scan by measuring the change in lesion size. At the follow-up visit, all patients were clinically examined and they answered a symptom questionnaire. Later 26/36 patients were also available for a quality of life questionnaire. Primarily 67 % demonstrated a complete or marked response. At the follow-up 64 % showed a complete or marked response, in 11 % the final response was better than the initially observed and only 2 patients had relapsed. The initial response predicted the long-term outcome accurately and the effect of OK-432 sclerotherapy seems to be long lasting. According to the MRI evaluation 80 % and subjectively 94 % of the patients benefitted from the treatment. Quality of life questionnaire showed high post-treatment satisfaction. We found OK-432 sclerotherapy to be a safe and effective treatment with a long lasting effect in the management of macrocystic LMs.
  PubDate: 2013-05-07