Journal of Otolaryngology - Head & Neck Surgery最新文献

Background: A vestibular implant can partially restore vestibular function by providing motion information through implanted electrodes. During vestibular implantation, various obstructions of the semicircular canals, such as protein deposits, fibrosis, and ossification, can be encountered. The objective was to explore the relationship between preoperative imaging and intraoperative findings of semicircular canal obstruction and to develop surgical strategies for dealing with obstructions of the semicircular canal(s) in patients eligible for vestibular implantation.

Methods: Patients undergoing vestibulocochlear implantation (in an active clinical trial) were included in the current study when preoperative imaging indicated an obstruction in the semicircular canal. Preoperative imaging consisted of CT and MRI scans. During surgery, the bony semicircular canals were skeletonized ("bluelined") to identify the course of the canals and create a fenestration to insert the electrodes. The aim was to place the electrodes in the semicircular canal ampullae. Surgical strategies were developed to deal with the soft tissue obstructions. These procedures were evaluated intraoperatively with microscopic visualization, postoperatively with CT imaging.

Results: The three included patients suffered from bilateral vestibulopathy and hearing loss due to autosomal dominant nonsyndromic sensorineural deafness 9 (DFNA9). A soft tissue obstruction was predicted in one semicircular canal (2 patients) or two semicircular canals (1 patient), based on preoperative imaging. Intraoperatively, bluelining the semicircular canals aided in identifying these locations, by revealing a "whiteline" instead of blueline. Depending on the nature and location of the obstruction, different surgical procedures were employed to facilitate proper electrode insertion. These were as follows: a dummy electrode was used to probe the soft tissue, the obstructive tissue was removed, and/or a bypass fenestration was created. In all patients, the electrodes could be implanted in the semicircular canal ampullae. Based on these first experiences, a diagnostic and surgical guide to deal with obstructions of the semicircular canals during vestibular implantation was developed.

Conclusions: Preoperative imaging can indicate locations of obstructions in the SCCs. Different surgical procedures can be applied to enable appropriate electrode positioning in the SCC ampulla. This article describes the first experiences with obstructions of the semicircular canals during intralabyrinthine vestibular implantation and presents a diagnostic and surgical guide.

Trial registration: ABR NL73492.068.20, METC20-087 (Maastricht University Medical Center) and NAC 11-080 (Geneva University Hospitals).

ImportanceRecently, the Québec public health care system established a pilot project to cover costs of molecular testing for select patients with cytologically-indeterminate thyroid nodules.ObjectiveThis study aimed to evaluate the clinical utility of the ThyroSeqv3 molecular test pilot project at McGill University in surgical management of thyroid nodules within Canada's single-payer health care system.DesignMulticenter cohort study, in liaison with the Québec Health Ministry.SettingJewish General Hospital and Royal Victoria Hospital in Montreal, Canada.ParticipantsPatients with a Bethesda III or IV and TIRADS 3 or 4 thyroid nodule measuring between 1 and 4 cm in size on ultrasound were analyzed across pre- and post-pilot project phases.InterventionThe pre-pilot project surgical control group included patients who underwent surgical intervention, excluding those who opted for out-of-pocket molecular testing. The post-pilot project surgical exposure group encompassed participants in the pilot project, undergoing publicly-funded ThyroSeqv3 molecular testing and subsequent surgical intervention.Main Outcome MeasuresSurgical malignancy/noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP) rate.ResultsA total of 314 patients qualified for the pilot project, with 207 (65.9%) having Bethesda III nodules and 107 (34.1%) having Bethesda IV nodules. Molecular testing yielded a result of negative in 238 (75.8%) cases and positive in 76 (24.2%) cases. Histopathology reports of positive patients who opted for surgery revealed a surgical malignancy/NIFTP rate of 73.1%. The surgical malignancy/NIFTP rate at our institution prior to the implementation of the pilot project for patients adhering to the inclusion criteria was statistically significantly lower at 47.9% (P = .0025).ConclusionsThe ThyroSeqv3 molecular test pilot project has improved upon physicians' traditional clinical practice by enabling a wider patient population to access this otherwise costly technology. It not only curtailed futile diagnostic hemithyroidectomies but also led to a more discerning allocation of surgeries, as corroborated by an increased surgical malignancy/NIFTP rate post-implementation.RelevanceThe results of our study suggest that publicly-funded molecular testing could contribute positively to the Canadian single-payer health care system by optimizing patient outcomes as well as fiscal policy.

ImportanceThis study investigates the potential of brain-derived neurotrophic factor (BDNF) as treatment for sensorineural hearing loss (SNHL) in a guinea pig model to potentially advance hearing restoration strategies. The correlation between oxidation-reduction (REDOX) potential in blood and perilymph is evaluated to confirm using blood as a proxy for perilymph in further study.ObjectivesTo evaluate hearing following 2 intracochlear applications of BDNF as a therapy for hearing loss. To evaluate for correlation in REDOX potential of perilymph and auditory brainstem response (ABR).Study DesignPositive-control animal preclinical study.SettingTranslational laboratory science.ParticipantsAnimal model (guinea pigs).Intervention or ExposuresSNHL was created in 15 guinea pigs using intraperitoneal cisplatin (CDDP). SNHL was confirmed via ABR testing. Left ears received 2 intracochlear applications of BDNF in varying doses, 30 days apart. Right ears received saline as controls.Main Outcome MeasuresHearing threshold was determined using ABR testing. Animals underwent terminal surgery to measure the REDOX potential in cerebrospinal fluid (CSF) and blood. Analysis of variance for repeated measures using the SPSS v27 software was employed.ResultsVariable, subtotal hearing loss was established utilizing CDDP. Animal ABR thresholds after CDDP, prior to first BDNF application, were worse than baseline. There was no improvement in hearing thresholds when treated and nontreated ears were compared. Varying doses of BDNF did not produce differences in hearing thresholds. The REDOX potential of perilymph, blood, and CSF correlate in the same animal; however, the values themselves were significantly different.Conclusions and RelevanceThere is no improvement in guinea pig hearing with 2 intracochlear applications of BDNF when applied as described in this paper. Previous work suggested possible subclinical gain with 1 application; however, with 2 applications we found no improvement. The REDOX potential of blood and CSF correlates within an animal, suggesting blood may be used as a proxy for REDOX measures in perilymph.

Importance: Nasal irrigation (NI) is effective in the treatment of sinonasal disease; however, its efficacy in treating otologic conditions is undetermined. Chronic otorrhea (CO) is an important complication in children with tympanostomy tubes (TT), requiring additional treatment.

Objective: Determine potential factors of NI that put children with TT at risk of developing CO.

Study design: Case-control study.

Setting: Single tertiary level of care pediatric hospital.

Participants: Consecutive patients under the age of 18 with bilateral TT presenting between June and September 2023 were selected.

Intervention: All patients in this study used NI.

Main outcome measures: The main outcome was the development of CO, defined as 10 or more consecutive days of ear drainage despite proper treatment.

Results: Twenty consecutive patients with CO were recruited and compared to 100 consecutive controls without CO. The mean age was similar, with 22.9 ± 18.4 months for the CO group and 25.2 ± 16.4 months for the control group (P = .59). An immediate discharge occurred more frequently in the CO group (80%) than in the control group (46%, P = .005; OR: 4.70; 95% CI: 1.5-13.5). A fast rate of administration of NI was more prevalent in the CO group (75%) compared to the control group (51%, P = .049; OR: 2.88; 95% CI: 1.0-7.6). TT insertion under local anesthesia occurred more frequently in the CO group (45%) than in the control group (22%, P = .03; OR: 2.9; 95% CI: 1.1-7.4). No statistical difference was found between groups in the frequency and volume of NI. No patients with CO used a small volume of NI (≤5 mL).

Conclusion and relevance: A fast rate of administration of NI was correlated with an increased risk of CO. Patients should be encouraged to apply gentle pressure as it could potentially prevent this complication.

Importance: Idiopathic facial nerve palsy (FNP) has devastating sequelae and is potentially linked to coronavirus disease-19 (COVID-19).

Objective: The rate of FNP was compared in the pandemic versus pre-pandemic periods. Furthermore, the risk of FNP was estimated among the COVID-19 vaccinated group.

Design: Systematic review and meta-analysis.

Setting: An electronic search was conducted in 7 databases: Scopus, Web of Science core collection, PubMed, Cochrane Central Register of Controlled Trials, MEDLINE, Embase, and CINAHL.

Participants: English observational studies investigating an association between idiopathic FNP and COVID-19 or its vaccination were included, irrespective of patients' demographics.

Exposures: COVID-19 or COVID-19 vaccine.

Main outcome measures: Change in FNP incidence between the pre-pandemic and pandemic periods; risk of developing FNP in individuals vaccinated against COVID-19 compared to those who were unvaccinated against COVID-19.

Results: After excluding duplicates, the search yielded 906 related articles, of which 118 articles were included. The risk of FNP was statistically significantly higher during the COVID-19 pandemic than the pre-pandemic period (RR: 1.68, [95% CI: 1.16-2.43], P = .01). A nonsignificant increase in FNP risk was identified among COVID-19 vaccinated individuals compared to unvaccinated individuals (overall OR: 1.07, [95% CI: 0.85-1.35], P = .55).

Conclusions and relevance: A remarkable increase in FNP rates was identified during the pandemic compared to pre-pandemic, which seemed unlikely to be attributed to COVID-19 vaccination.

Importance: In patients with head and neck squamous cell carcinoma (HNSCC), the discovery of a second synchronous primary cancer of the aerodigestive tract (SSPCA) significantly impacts management and prognosis. Recent advances in imaging have increasingly allowed for identifying SSPCA before performing panendoscopy, raising questions about the latter's role.

Objective: To establish the incidence of SSPCA and panendoscopy's impact on management. Complications and costs associated with panendoscopy were also assessed.

Design: Systematic review following the preferred reporting items for systematic reviews and meta-analysis guidelines.

Setting: Operating room panendoscopy.

Participants: Identifiable HNSCC undergoing initial staging workup.

Intervention: Panendoscopy under general anesthesia for SSPCA detection.

Main outcome measures: Incidence of SSPCA in HNSCC, change in management caused by panendoscopy, incidence of panendoscopy complications, costs for panendoscopy.

Results: 51 studies were included (n = 19,914 patients). SSPCA was present in 6.4% (n = 467/7262) of all panendoscopies. Among patients who had a prior computed tomography (CT) of the neck and chest, a change in management resulting from SSPCA detected through panendoscopy occurred in only 1.1% of cases (n = 3/268), and in 0% of cases for those who had a positron-emission tomography-computed tomography (PET) (n = 0/544). The rate of major complications of panendoscopy was 0.7% (n = 58/8386). Only two recent studies in a private healthcare system reported panendoscopy costs ranging from $3802 USD to $17,296 USD.

Conclusions: The role of panendoscopy in the initial workup of HNSCC should be limited to confirming suspicious findings from initial CT or PET. The incidence of major complications for panendoscopy is low but carries a significant financial burden for patients in the private American healthcare system. More studies are needed to assess the cost-effectiveness of panendoscopies for SSPCA detection in a public healthcare system.

Relevance: Confirms the lack of benefit for systematic panendoscopy for SSPCA detection in HNSCC patients when initial workup includes a CT of the neck and chest or PET.

ImportanceThe extent of surgical resection for papillary thyroid carcinoma (PTCs) located in the isthmus has remained a matter of considerable debate.ObjectiveTo investigate the association between the extent of wide-field isthmusectomy and complications and recurrences.DesignClinicopathologic documents of patients who received total thyroidectomy and wide-field isthmusectomy were recorded.SettingA retrospective review study.ParticipantsPatients with single tumor in the isthmus with no cervical lymph node metastasis were selected.Intervention or ExposuresPatients received total thyroidectomy with neck dissection, or wide-field isthmusectomy with paratracheal and prelaryngeal lymph node dissection.Main Outcome MeasuresThe locoregional results, complications, and rate of patients who were not required to receive thyroid-stimulating hormone suppression therapy were compared.ResultsA total of 389 patients were included in the study and divided into 3 groups. One hundred and nineteen (30.6%) patients were performed with wide-field isthmusectomy with a distance <0.5 cm (Group I), and 190 (48.8%) patients with a distance ≥0.5 cm (Group II). Eighty (20.6%) underwent total thyroidectomy (Group III). Eighty (67.2%) of 119 patients in Group I and 125 (65.8%) of 190 patients in Group II did not take medication at the mean follow-up of 37 months. Locoregional recurrence developed in 22 patients (18.5%) of Group I, 16 (8.4%) patients of Group II, and 5 (2.6%) patients of Group III. The overall morbidity was 6 (5.0%) in Group I, 14 (7.4%) in Group II, and 21 (26.5%) in Group III.ConclusionsWide-field isthmusectomy with a 0.5 cm distance may be a sufficient treatment for selected patients with PTC limited to the isthmus.RelevanceWild-field isthmusectomy and limited neck dissection may be a sufficient procedure for isthmic PTC. Further research is needed to determine whether prophylactic central compartment neck dissection can be omitted during isthmusectomy for these patients.

ImportanceNasalance exercises (also known as resonance exercises) are widely used in voice therapy. Understanding their effects can guide therapeutic approaches and surgical decisions.ObjectiveTo analyze the immediate effects of nasalance exercises on vocal fold oscillation in patients with vocal fold mass lesions and a recommendation for phonosurgery.DesignProspective observational study following the STROBE guidelines.SettingDepartment of Phoniatrics, university hospital.ParticipantsSeven patients with vocal fold mass lesions (6 with polyps, 1 with Reinke edema) and indication for surgery.Intervention/ExposuresParticipants performed nasalance exercises for 10 minutes. Recordings were taken before the exercise (pre), immediately after (post0), and 10 minutes after completion (post10). Subjects phonated vowel [i:] on a sustained pitch (250 Hz for females, 125 Hz for males) at a comfortable level of loudness.Main Outcome MeasuresData were collected using transnasal high-speed videoendoscopy, a Rothenberg mask for airflow measurement, electroglottography, and audio recordings. Extracted parameters were: nasalance, open quotient (OQ), closing quotient (ClQ), sound pressure level (SPL), Jitter, and cepstral peak prominence (CPP).ResultsNasalance increased immediately after the exercises for 6 out of 7 subjects. OQ values varied: they increased in 3 subjects, decreased in 3, and remained unchanged in 1. No consistent relationship was found between SPL and ClQ. Jitter increased in 5 subjects. CPP did not show clear tendencies. The effects on voice parameters did not persist 10 minutes postexercise. There were no significant correlations with age, sex, or preintervention voice indices (Voice Handicap Index, Dysphonia Severity Index).ConclusionsIn patients with organic dysphonia and an indication for surgery, a raised nasalance value directly after the execution of nasalance exercises does not necessarily lead to stabilized voice parameters, and the possible effects do not seem to be persistent.RelevanceNasalance exercises might not provide sustained benefits in stabilizing vocal fold vibrations in subjects with an indication for surgery.

ImportanceThere is a limited understanding of anterior commissure (AC) involvement in glottic squamous cell carcinoma (SCC), particularly when comparing T1b, T2a with AC involvement (T2AC), and T2a without AC involvement (T2noAC).ObjectiveThe aim of this study was to compare oncological and functional outcomes in T1b, T2AC, and T2noAC glottic SCC following transoral laser microsurgery (TLM).DesignRetrospective chart review.SettingThe Queen Elizabeth II Health Science Centre (Halifax, Nova Scotia) from January 1, 2002, to December 31, 2022.Intervention and ExposuresA retrospective chart review was completed using prospectively-collected data for patients treated with TLM for T1b and T2a glottic SCC. Exclusion criteria included previous treatment for a laryngeal cancer and T2b glottic SCC.Main Outcome MeasuresOncological outcomes were assessed using margin status, local control (LC), disease-specific survival (DSS), overall survival (OS), and laryngeal preservation (LP). Functional outcomes were measured using the abbreviated Voice Handicap Index-10 (VHI-10).ResultsIn total, 117 patients were included (T1b = 46, T2AC = 53, T2noAC = 18). Positive margins were higher in the T2AC group (15.1%) than in T1b (4.3%) and T2noAC (5.6%; P = .208). At 5 years, there were no significant differences in LC (T1b = 80.8%, T2AC = 70.3%, T2noAC = 76.2%; P = .26), DSS (T1b = 100%, T2AC = 90.2%, T2noAC = 93.8%; P = .45), OS (T1b = 88.3%, T2AC = 76.1%, T2noAC = 93.8%; P = .69), or LP (T1b = 94.3%, T2AC = 92.1%, T2noAC = 94.4%; P = .74). Significant improvements in VHI-10 scores from the pre- to postoperative period were only noted in the T1b cohort, at the 6 months (P = .017) and the 12 months (P = .00143).ConclusionsNo significant differences in both oncological and functional outcomes were noted between T1b, T2AC, and T2noAC glottic SCCs. Further stratifying based on the degree and pattern of AC involvement with larger sample sizes may provide important prognostic factors.RelevanceThis study highlights that T2 glottic SCCs with normal vocal fold mobility are a heterogenous group, and it may be beneficial to further stratify these cancers according to AC involvement, particularly when considering TLM.

ImportanceChronic rhinitis (CR) affects quality of life and often coexists with obstructive sleep apnea (OSA), a comorbidity that may increase surgical risks. Understanding OSA's impact on outcomes of minimally invasive nasal surgery is clinically relevant.ObjectiveTo evaluate the efficacy and safety of minimally invasive nasal surgery for CR and assess the influence of OSA on postoperative complications and symptom relief.DesignRetrospective cohort study.SettingSingle tertiary medical center in Taiwan.ParticipantsA total of 325 CR patients underwent nasal surgery between March 2023 and June 2024. Based on sleep study results, patients were stratified into OSA (n = 48) and non-OSA (n = 277) groups.Exposure or InterventionMinimally invasive nasal surgery, including radiofrequency inferior turbinate reduction and/or posterior nasal nerve neurolysis. Patients receiving adjunctive procedures (eg, septoplasty, uvulopalatopharyngoplasty, and tonsillectomy) were excluded.Main Outcome MeasuresPostoperative complications (eg, epistaxis) within 1 month and symptom relief based on reflective total nasal symptom score and nasal obstruction symptom evaluation.ResultsOSA [odds ratio (OR), 5.105; 95% confidence interval (CI), 1.222-21.328; P = .025] and hypertension (OR, 5.809; 95% CI, 1.134-29.744; P = .035) were independent risk factors for major epistaxis. OSA patients had higher overall complication rates (22.9% vs 4.3%, P = .005), epistaxis (18.8% vs 3.6%, P = .012), and major epistaxis (14.6% vs 1.8%, P = .018). Both groups showed significant symptom improvement postoperatively (P < .001).ConclusionMinimally invasive nasal surgery improves CR symptoms regardless of OSA. However, OSA and hypertension are linked to increased complication risk and require careful perioperative management.RelevanceThese findings support tailored preoperative assessment and multidisciplinary care to optimize safety and outcomes in CR patients with OSA.