Journal of Otolaryngology - Head & Neck Surgery最新文献

Background: Intracochlear fibrosis and inflammation remain important limitations in cochlear implantation (CI). Glucocorticoids are routinely used to ameliorate the inflammatory response following CI. This study investigates the long-term effects of an intratympanically-applied triamcinolone-acetonide suspension on intracochlear impedance changes in CI recipients and investigates differences in drug concentrations and timepoints of injection.

Methods: A total of 87 patients were included in the study, of whom 39 received an intratympanically-applied triamcinolone-acetonide suspension at either 10 or 40 mg/ml, 1 hour or 24 hours prior to cochlear implantation, while 48 patients served as an untreated control group. Electrode impedances were measured and compared over a period of 3 years following cochlear implantation.

Results: The preoperative intratympanic application of a triamcinolone-acetonide suspension resulted in significantly lower mean impedances following cochlear implantation compared with an untreated control group at first fitting (4.66 ± 1.3 kΩ to 5.90 ± 1.4 kΩ, P = .0001), with sustained reduction observed over 3 months. A sustained reduction was observed after spatial grouping of the electrode contacts, with significant improvements in both the middle cochlear region over a 24 month period (from 3.97 ± 1.3 kΩ to 5.85 ± 1.3 kΩ, P = .049) and the basal region over a 6 month period (from 5.02 ± 1.3 kΩ to 5.85 ± 1.3 kΩ, P = .008). The injection of 10 mg/ml of triamcinolone-acetonide 1 hour prior to cochlear implantation resulted in higher impedances compared with 40 mg/ml and 24 hour time interval until surgery.

Conclusion: A single preoperative intratympanic injection of triamcinolone-acetonide significantly reduces electrode impedances across the entire cochlea. This effect is sustained for up to 2 years, after which impedances gradually equalize between the groups. A preoperative triamcinolone-acetonide injection could therefore be a favorable approach to attenuate the immediate tissue response following cochlear implantation.

Objective: The objective of this study was to compare the outcomes of endoscopic cartilage myringoplasty (ECM) with or without plasma radiofrequency (RF) tuboplasty (PRT) for repairing chronic large perforation with Eustachian tube dysfunction (ETD).

Materials and methods: Chronic large perforations with ETD were randomly divided into receiving ECM or ECM plus PRT. During the 24 months follow-up, the Eustachian tube score (ETS), Eustachian Tube Dysfunction Questionnaire-7 (ETDQ-7), ET inflammation scale, hearing results, and graft success rate of the patients were analyzed.

Results: A total of 61 subjects were included in the study. Difference of ETS was significant before and after surgery in the ECM + PRT group (P < .05) but the ECM group was not (P > .05). Also, significant between-group difference was found regardless of post-24 months ETS and improvement value. Postoperative ETDQ-7 scores were significantly reduced compared with preoperative ETDQ-7 scores in both groups (P < .05), also, significant between-group difference was found regardless of post-24 months ETDQ-7 scores and improvement value. The graft success rate was 86.7% in the ECM group and 96.8% in the ECM + PRT group at postoperative 24 months (P > .05). In addition, although the ECM + PRT group showed a better air-bone gap improvement than the ECM group, the difference was not significant (13.01 ± 2.97 vs 10.92 ± 0.69 dB; P > .05). No PRT procedure-related serious adverse events were reported during the follow-up process. No patients developed atelectasis or otitis media with effusion in either group.

Conclusion: ECM combined with low-temperature PRT did not affect the graft success rate but showed a better long-term improvement in ETS and ETDQ-7 than cartilage myringoplasty for the treatment of chronic perforation with ETD. In addition, although PRT showed a better hearing improvement, the difference was not significant between the 2 groups.

Importance: Head and neck squamous cell carcinomas (HNSCC) are responsible for a significant amount of morbidity and mortality in Canada. Surgical margins are one of the most important factors used to guide treatment; however, currently there is a lack of consensus on the ideal surgical margin definition, sampling, and assessment method.

Objective: To understand the current perspectives and practice patterns of Canadian head and neck surgeons with respect to surgical margin: (1) definition, (2) sampling, (3) pathological assessment.

Design: A 24-question cross-sectional survey was sent via email through the Canadian Society of Otolaryngology-Head & Neck Surgery (CSOHNS), and responses were gathered from December 19, 2023, to March 12, 2024. Responses were aggregated and reported using descriptive statistics.

Setting/participants: The survey was conducted in Canada among self-reported staff head and neck oncology surgeons with membership in the CSOHNS.

Results: A total of 36 staff head and neck oncology surgeons responded from across Canada. The most common (58.3%) definition of a negative surgical margin for oral cavity HNSCC was ">5 mm formalin fixed paraffin embedded distance." To obtain surgical margins, surgeons were split with 44.1% using only a tumor bed approach and 32.4% using only a specimen-driven approach. A dedicated head and neck pathologist is always available more commonly for final pathological assessment (63.6%) versus intraoperative frozen section assessment (15.5%). Finally, most surgeons reported having a synoptic standardized reporting system for annotating margin status (78.8%).

Conclusions/relevance: The results of this survey provide a current-state analysis of head and neck surgeons across Canada and set the stage for future efforts to be directed toward standardizing the collection method and reporting criteria for surgical margins in HNSCC.

Background: Adenotonsillectomy is one of the most common surgical procedures worldwide. The current standard for securing the airway in patients undergoing adenotonsillectomy is endotracheal tube (ETT) intubation. Several studies have investigated the use of the laryngeal mask airway (LMA) in this procedure. We conducted a systematic review and meta-analysis to compare the safety and efficacy of the LMA versus ETT in adenotonsillectomy.

Method: Databases were searched from inception to 2022 for randomized controlled trials and comparative studies. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. The primary outcome is the rate of perioperative respiratory adverse events (PRAEs). Secondary outcomes included the rate of conversion to ETT, desaturations, nausea/vomiting, and surgical time. A subgroup analysis, risk of bias, publication bias, and Grading of Recommendations Assessment, Development, and Evaluation (GRADE) assessments were also performed.

Results: Twelve studies were included in the analysis (4176 patients). The mean overall conversion to ETT was 8.36% [95% confidence interval (CI) = 8.17, 8.54], and for the pediatric group 8.27% (95% CI = 8.08, 8.47). The mean rate of conversion to ETT secondary to complications was 2.89% (95% CI = 2.76, 3.03) while the rest was from poor surgical access. Overall, there was no significant difference in PRAEs [odds ratio (OR) 1.16, 95% CI = 0.60, 2.22], desaturations (OR 0.79, 95% CI = 0.38, 1.64), or minor complications (OR 0.89, 95% CI = 0.50, 1.55). The use of LMA yielded significantly shorter operative time (mean difference -4.38 minutes, 95% CI = -8.28, -0.49) and emergence time (mean difference -4.15 minutes, 95% CI = -5.63, -2.67).

Conclusion: For adenotonsillectomy surgery, LMA is a safe alternative to ETT and requires less operative time. Careful patient selection and judgment of the surgeon and anesthesiologist are necessary, especially given the 8% conversion to ETT rate.

Importance: A gap in knowledge exists concerning the functional outcomes and complications when comparing various surgical approaches for retropharyngeal lymph node (RPLN) metastases.

Objective: To explore perioperative outcomes, functional outcomes, and complications associated in the treatment of RPLN metastases.

Design: The Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews (PRISMA-ScR) protocol was used to conduct a scoping review of the PubMed and Scopus databases.

Review methods: We systematically searched 2 databases from inception to January 2023 for articles examining the treatment approaches and postoperative outcomes in the retropharyngeal space. We included English records about surgical approaches, complications, functional outcomes for patients >18 years old with retropharyngeal lymphadenopathy.

Results: One-hundred ninety-nine articles were identified, of which 17 were included in the analysis. Three studies assessed RPLN dissection in the postradiation setting. We identified limited knowledge about functional outcomes and complications following surgery for retropharyngeal lymphadenopathy. Overall, acute postoperative dysphagia was documented in 35/170 patients (20.5%). However, the assessment of dysphagia was limited, and not described in the majority of studies. The overall rate of postoperative neuropathy and hematoma were 4.1% and 4.7%, respectively. No postoperative hematomas were documented in the transcervical approach.

Conclusion: Our findings underscore the need for further research on postoperative outcomes following RPLN dissection. We recommend further studies focusing on objective swallow assessments and long-term outcomes of either surgical approaches.

Background: There is a dearth of information on the effects of bone conductive devices on temporal processing in individuals with single-sided deafness (SSD). This study investigates the effect of an adhesive bone conductive device on temporal processing in adults with SSD.

Methods: A prospective cohort study of temporal processing in adults with SSD was undertaken. Outcome measures were the pitch pattern test (PPT) and the duration pattern test (DPT) scores, sound field pure tone audiometric (PTA) averaged hearing thresholds, and word recognition scores (WRS). These were measured under 3 conditions: unaided in quiet, unaided in noise, and aided in noise. Eight SSD novice hearing amplification users were recruited.

Results: The adhesive bone conduction device (BCD) resulted in a statistically-significant improvement (Wilcoxon signed ranks test, P = .018) in median [interquartile range (IQR)] PPT score, 65% (IQR = 35.5), and DPT score, 38% (IQR = 42.5) in noise.

Conclusions: Adults with SSD demonstrated improved temporal processing scores with masking of the normal-hearing ear when using an adhesive BCD placed behind the deafened ear.

Background: Long surgical wait times have long plagued health systems in Canada and abroad. This backlog and associated strain on health human resources has been exacerbated by the COVID-19 pandemic, affecting surgeries of varying degrees of urgency across all surgical specialties, including head and neck surgery. Single-entry models (SEMs) are being increasingly studied as one possible strategy to help manage surgical wait times, and a growing number of health systems have implemented SEMs within departments such as otolaryngology-head and neck surgery. We sought to evaluate the views of head and neck surgeons at all 8 designated head and neck cancer centers across Ontario on the role of SEMs in managing surgical backlogs.

Results: We interviewed 10 Ontario head and neck surgeons on the role of SEMs in managing wait times within the field. The following themes were elicited from interview transcripts: (1) anticipated positive impact, (2) barriers to implementation, (3) patient experience, and (4) roadmap to implementation. Participants agreed that SEMs may have utility for certain types of surgeries if implemented to address local needs. They also believe this model would have the greatest impact if employed together with other approaches, such as increasing operating room time or nursing availability.

Conclusion: Our results highlighted the necessity for a nuanced approach to single-entry model implementation in head and neck surgery. While participants recognized the utility of SEMs for high-volume and low-variation surgeries, participants remained divided on the optimal approach to triaging patients necessitating more complex oncologic treatments. Deliberate collaboration among stakeholder organizations and senior surgeons will be critical if SEMs are to succeed in an intricate and political healthcare environment.

Background: Cisplatin-based chemoradiation is a standard treatment for many patients with human papillomavirus (HPV)-positive oropharyngeal squamous cell carcinoma (OPSCC), an etiologically distinct subset of head and neck cancer. Although associated with good long-term survival, clinical risk factors for ototoxicity have been understudied in this population. This study aimed to evaluate clinical predictors associated with ototoxicity in HPV-positive OPSCC patients treated with cisplatin chemoradiation.

Methods: This retrospective case-control study included 201 adult patients (>18 years) with histologically confirmed HPV-positive OPSCC who received cisplatin chemoradiation as their primary treatment from 2001 and 2019 at a single tertiary cancer center. Ototoxicity was determined using baseline and follow-up audiometry and the Common Terminology Criteria for Adverse Events v5.0 grading criteria (Grade ≥2). Multivariable logistic regression [adjusted odds ratio (aOR)] identified significant predictors that increased the odds of ototoxicity.

Results: A total of 201 patients [165 males; median (IQR) age, 57 (11) years] were included in the study. The incidence of ototoxicity in the worst ear was 56.2%, with the greatest hearing loss occurring at high frequencies (4-8 kHz), resulting in a loss of 12.5 dB at 4 to 6 kHz and 20 dB at 6 to 8 kHz. High-dose cisplatin administration compared to weekly administration [aOR 4.93 (95% CI: 1.84-14.99), P = .003], a higher mean cochlear radiation dose [aOR 1.58 (95% CI: 1.12-2.30), P = .01], smoking history [aOR 2.89 (95% CI: 1.51-5.63), P = .001], and a 10 year increase in age [aOR 2.07 (95% CI: 1.25-3.52), P = .006] were each independently associated with increased odds of ototoxicity.

Conclusions: Clinical predictors of ototoxicity in HPV-positive OPSCC patients treated with cisplatin-based chemoradiation include the use of a high-dose cisplatin regimen, higher cochlear radiation doses, a history of smoking, and older age. With the rising incidence of this malignancy in Western countries and overall improved survivorship, our research motivates future studies into risk stratification and earlier interventions to mitigate and reduce the risk of ototoxicity.

Background: In microvascular head and neck reconstruction, ischemia of the free flap tissue is inevitable during microsurgical anastomosis and may affect microvascular free flap perfusion, which is a prerequisite for flap viability and a parameter commonly used for flap monitoring. The aim of this study was to investigate the influence of the number of ischemia intervals and ischemia duration on flap perfusion.

Methods: Intraoperative and postoperative flap blood flow, hemoglobin concentration, and hemoglobin oxygen saturation at 2 and 8 mm tissue depths, as measured with the O2C tissue oxygen analysis system, were retrospectively analyzed for 330 patients who underwent microvascular head and neck reconstruction between 2011 and 2020. Perfusion values were compared between patients without (control patients) and with a second ischemia interval (early or late) and examined with regard to ischemia duration.

Results: Intraoperative and postoperative flap blood flow at 8 mm tissue depth were lower in patients with early second ischemia intervals than in control patients [102.0 arbitrary units (AU) vs 122.0 AU, P = .030; 107.0 AU vs 128.0 AU, P = .023]. Both differences persisted in multivariable analysis. Intraoperative and postoperative flap blood flow at 8 mm tissue depth correlated weakly negatively with ischemia duration in control patients (r = -.145, P = .020; r = -.124, P = .048). Both associations did not persist in multivariable analysis.

Conclusions: The observed decrease in microvascular flap blood flow after early second ischemia intervals may reflect ischemia-related vascular flap tissue damage and should be considered as a confounding variable in flap perfusion monitoring.