Otolaryngology- Head and Neck Surgery最新文献

Objective: This systematic review evaluates and compares the efficacy and safety of different intranasal corticosteroid delivery methods for treating chronic rhinosinusitis with nasal polyps (CRSwNP).

Data sources: Embase, Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, and Web of Science were systematically searched from January 1, 1980 to January 9, 2024.

Review methods: Two independent reviewers searched 4 databases for English-language, prospective randomized controlled trials (RCT), comparing different delivery methods of corticosteroids for the treatment of CRSwNP. Studies were excluded for specific reasons (wrong comparisons, wrong intervention, wrong patient population, and wrong route of administration).

Results: The data search identified 2282 studies. After removing duplicates, 1503 studies were screened by title and abstract, with 1479 excluded for not meeting criteria. Eighteen full-text articles were assessed for eligibility, and 5 RCTs were included in the review. Both short- and long-term treatments with nebulizer, aerosol spray, and nasal drop methods demonstrated similar efficacy to oral corticosteroids (OCS) but with a better safety profile. Long-term use of aqueous sprays showed clinical improvement but was less effective than other non-aqueous delivery methods.

Conclusion: Non-aqueous delivery methods, including nebulizers, aerosol sprays, and nasal drops offer a safe alternative to OCS without systemic side effects. Patients using aqueous formulations should be advised on the importance of long-term adherence to achieve symptom improvement.

Objective: To investigate the effectiveness of drug class changes in patients with refractory laryngopharyngeal reflux disease (LPRD).

Study design: Retrospective case series with prospective data.

Setting: Multicenter study.

Methods: The data of patients treated for a refractory LPRD from September 2017 to December 2023 were collected. The effectiveness of drug class changes was assessed through the reflux symptom score (RSS) change. Signs were evaluated with the Reflux Sign Assessment. The RSS reduction was used to categorize the therapeutic responses as mild (20%-40% RSS reduction), moderate (40.1%-60% RSS reduction), high (60.1%-80%), and complete (>80%).

Results: Among the 334 medical records, 74 (22.2%) patients had refractory LPRD defined as no RSS change in the pre- to 3-month posttreatment. The mean age was 52.6 ± 15.5 years. Changing drug class was associated with significant 3- to 6-month posttreatment reductions of RSS and RSA. Thirty patients (39%) did not experience symptom reduction after changing drugs. Changing alginate to magaldrate and magaldrate to alginate was associated with the highest responder rate (76.9%). Changing PPI and alginate/magaldrate molecules led to a response rate of 62.5%. In patients initially treated with a combination of PPI and alginate or magaldrate, changing PPI without changing alginate/magaldrate led to a 37.5% response rate. The baseline RSS was predictive of the 3- and 6-month RSS (therapeutic response).

Conclusion: Changing drug class, especially alginate-to-magaldrate, may be an effective therapeutic approach for patients with a refractory LPRD.

Objective: Accurate management of acute nasoseptal fractures can mitigate cosmetic and functional complications. There is a lack of consensus on the ideal approach to manage acute nasoseptal fractures, which are often addressed with closed nasal and/or septal reduction (CN/SR) but sometimes addressed using an open approach with septoplasty. We aimed to systematically assess and compare outcomes of CN/SR versus open approaches to treat acute nasoseptal fractures.

Data sources: PubMed, Scopus, and CINAHL.

Review methods: Studies evaluating outcomes of adults with acute nasoseptal fractures treated within 3 weeks of injury with either CN/SR or open approach were included. Meta-analysis was performed to examine the pooled frequency of complications including persistent obstruction, cosmetic deformity, and need for revision surgery.

Results: Of 1630 unique articles identified, 27 were included (63% retrospective, 29.6% prospective, 7.4% randomized controlled trial). Data included 1117 patients (n = 712 CN/SR, n = 423 open approach), with a mean age of 30.5 years. Patients who underwent CN/SR only were more likely to experience persistent obstruction compared to patients who underwent open approach (22.2% [95% confidence interval, CI, 8.7%-39.5%] vs 5.9% [95% CI, 2.4%-10.7%], P < .0001). Patients who underwent CN/SR were more likely to require revision surgery within 3 years (30.9% [95% CI, 15.8%-48.4%] vs 6.0% [95% CI, 3.3%-9.9%], P < .0001.

Conclusion: Patients with nasoseptal fractures who underwent open septoplasty in the acute period were less likely to experience complications. Prospective trials are needed to confirm results of this meta-analysis.

Objective: To determine the relationship between pretreatment neutrophil-to-lymphocyte ratio (NLR) and 6-month progression-free survival (PFS)/2-year overall survival (OS) among patients with recurrent or metastatic (R/M) oral cavity cancer on pembrolizumab.

Study design: This study was a retrospective, observational study performed at a tertiary care academic center.

Setting: Participants included patients with oral cavity squamous cell carcinoma (OCSCC) who began pembrolizumab treatment at the University of California, San Francisco between May 2016 and May 2022.

Methods: The primary outcome was a 6-month PFS. The secondary outcome was a 2-year OS. NLR was treated as a continuous variable. Disease progression was determined using radiographic criteria, adopted from the Response Evaluation Criteria in Solid Tumors.

Results: Fifty-two patients with OCSCC were included. Immune checkpoint inhibitor (ICI) indication was recurrence/metastasis for all patients. The median pretreatment NLR was 5.7 (interquartile range: 3.6-7.6). Twenty-seven (55%) patients received pembrolizumab alone. Of those receiving treatment for R/M prior to ICI, 9 (18%) received salvage surgery and adjuvant therapy, 2 (4%) received chemotherapy alone, 1 (2%) received chemoradiation, and 10 (20%) received salvage surgery. Nineteen (36.5%) patients had distant metastases at the start of ICI. Six-month PFS was 46%. Two-year OS was 44%. NLR was independently associated with 6-month PFS [hazard ratio, HR: 1.05 (95% confidence interval, CI: 1.01-1.11), P = .028] and 2-year OS [HR: 1.12 (95% CI: 1.05-1.20), P < .001].

Conclusion: Higher pretreatment NLR was associated with poorer 6-month PFS and 2-year OS in OCSCC patients treated with pembrolizumab.

Objective: Evaluate the management options for congenital nasal pyriform aperture stenosis (CNPAS).

Study design: Case series.

Setting: Tertiary referral children's hospital.

Methods: The medical records of CNPAS patients managed from January 2015 to 2023 were reviewed for medical history, management, and outcomes.

Results: Fifteen patients met inclusion criteria. Six patients (40.0%) had a central mega incisor and 4 (26.7%) had holoprosencephaly. Three (20%) patients were managed with medications alone. Mean PA width was similar between patients managed medically versus those managed surgically (mean width 6.2 ± 0.15 mm vs 6.1 ± 0.38 mm). Median age at first procedure was 50 (range 8-263) days. Seven (46.7%) underwent an initial balloon nasal dilation and 5 (33.3%) underwent an open sublabial repair. Operative time was lower in the balloon dilation group (mean 27 vs 104 minutes). Five patients had a single balloon dilation and 2 required revision procedures: 1 underwent a second balloon dilation, and 1 patient underwent a subsequent open sublabial procedure. Four patients with an initial open sublabial approach returned to the operating room for nasal balloon dilation or debridement due to nasal synechiae.

Conclusion: There has been general shift towards minimally invasive surgery. In our series, 8 (53.3%) patients were managed successfully with medical therapy or a single nasal balloon dilation procedure. Of those who underwent an open surgical repair, most (4/5) required a revision procedure due to synechiae. Given the relative success and lower operative time of balloon dilation, this option should be considered in the management algorithm for CNPAS.

Level of evidence: 4:

Objective: High-resolution manometry (HRM) provides measures of esophageal function which are used to classify esophageal motility disorders based on the Chicago Classification system. Upper esophageal sphincter (UES) measures are obtained from HRM, but are not included in the classification system, rendering the relationship between UES measures and esophageal motility disorders unclear. Furthermore, changes in the acceptable amount of esophageal dysfunction between versions of this classification system has created controversy. The objective of this study was to determine the relationship between UES measures and esophageal function.

Study design: Cross-sectional study.

Setting: Referral centre.

Methods: HRM studies from the Calgary Gut Motility Center were reviewed for UES mean basal pressure, mean residual pressure, relaxation time-to-nadir, relaxation duration, and recovery time. Patients were grouped by number of failed swallows according to different iterations of the Chicago Classification: 0 to 4 (Group 1), 5 to 7 (Group 2), and 8 to 10 (Group 3).

Results: 2114 patients (65.1% female, median age 56 y) were included. There were significant increases in UES mean basal pressure (P < .001), mean residual pressure (P < .001), relaxation duration (P < .001), and recovery time (P < .001) between groups. Positive correlations existed between number of failed swallows and UES mean basal pressure (r = 0.143; P < .001), mean residual pressure (r = 0.201; P < .001), relaxation duration (r = 0.145; P < .001), and recovery time (r = 0.168; P < .001).

Conclusions: Differences in UES measures exist among patients with failed swallows, with a positive correlation between UES dysfunction and increasing dysmotility. Our findings illustrate that UES measures are closely related to esophageal function, and that even minor esophageal dysfunction is related to UES dysfunction.

Objective: To validate the feasibility of an innovative nasal lining-framework complex (NLFC) for reconstructing total nasal defects.

Study design: Retrospective cohort study.

Methods: This NLFC is composed of forearm flap and support framework. Twenty-four patients were followed up for a minimum of 17 months in 5 centers. Patients' medical history data were retrospectively analyzed. Visual Analog Scale (VAS) of surgeons and patients was used to evaluate the aesthetic effects and self-satisfaction. The Nasal Obstruction Symptom Evaluation (NOSE) questionnaire and Rhinoplasty Outcome Evaluation (ROE) questionnaire were used for functional assessment.

Results: Reconstruction surgeries were all successfully completed. The flaps healed well in all patients, and there were no signs of ischemic necrosis. The healing time of the wound was 10 to 14 days, except for 1 case with infection. The nasal lining was reconstructed and no significant contracture was observed. The average VAS of surgeons was 4.29 ± 0.69 (range 3-5). The mean VAS score of patients was 3.75 ± 0.79 (range 2-5). There was a significant positive correlation between patients' and surgeons' VAS scores (P = .007, r = .5355). The results of the NOSE questionnaire showed that all patients had no obvious ventilation restriction, and only 3 patients mildly felt that the nasal inspirations were slightly insufficient during exercise or exertion. The mean ROE of the patients was 21 ± 1.96 (range 18-25).

Conclusion: This NLFC is suitable for total nasal reconstruction, which can provide effective support to prevent flap collapse and retraction and ensure good nasal ventilation.

Level of evidence: Level IV, therapeutic study.

Objective: Patients with refractory chronic cough (RCC) are being seen in increasing numbers within otolaryngology clinics. Identifying the next steps in the evaluation and management of cough in patients who have had first-line treatment for gastroesophageal reflux, sinonasal disease, pulmonary disease, and angiotensin-converting enzyme inhibitor-related cough is paramount. This state-of-the-art review focuses on emerging treatments for RCC from an otolaryngology perspective.

Data sources: Pubmed.

Review methods: The available literature on chronic cough, with a focus on RCC, emerging paradigms concerning pathophysiology, and evolving treatment approaches was reviewed and summarized.

Conclusions: Guided by a more detailed understanding of refractory cough physiology, a myriad of new treatment options have been developed to treat RCC. These are primarily aimed at disrupting what is thought to be a hypersensitive cough reflex, whether by a dampening of its sensory inputs or an alteration in motor activity, and are inclusive of neuromodulator treatments, superior laryngeal nerve blockade, vocal fold augmentation, botulinum toxin injection, topical capsaicin, and potentially the eventual use of P2X3 antagonists. Improved laryngopharyngeal reflux diagnosis and management, as well as the potential benefit of behavioral cough suppression therapy, are also discussed.

Implications for practice: The literature supporting each of these strategies is growing-and as more patients with RCC seek otolaryngology care, knowledge of these various approaches may improve the overall treatment of this condition.

Objective: Toxic shock syndrome (TSS) is a rare but serious complication after sinonasal surgery and a commonly cited consideration for prescribing antibiotics when nasal packing or stents are placed. Most reports are limited to case reports or small series. The aim of this systematic review was to describe the incidence, risk factors, and clinical course of patients who developed TSS as a complication of endoscopic sinus surgery (ESS) and/or septoplasty.

Data sources: A systematic review was conducted using MEDLINE, EMBASE, CINAHL, Web of Science, and Cochrane Library databases.

Review methods: Eligibility criteria were patients of any age who developed TSS as a complication of ESS and/or septoplasty.

Results: Twenty-five studies were included in the final review. Seventy cases were identified over 38 years (1982-2020). The pooled incidence of TSS after sinonasal surgery was 0.0003 (0.0002-0.0004, 95% confidence interval, CI) or 30 per 100,000 persons. Among 33 patients with single-subject data, mean age was 33.8 years (29.73-37.87, 95% CI). Seventeen (51.5%) patients had nasal packing, 3 (9.1%) had stents, 5 (15.2%) had both, 7 (21.2%) had none. Fourteen (42.4%) patients had nonabsorbable packing and 5 (15.2%) had absorbable packing. Sixteen (48%) patients received peri-operative antibiotics. Thirty-two (97%) patients had full recovery.

Conclusion: The incidence of TSS after sinonasal surgery is very rare. TSS can occur with and without nasal packing and prophylactic antibiotics were not protective. Outcomes were favorable with appropriate recognition and management. Further study is needed to determine which patients are most at risk for TSS.

Objective: To calculate the minimal clinically important difference (MCID) for the Vestibular Migraine Patient Assessment Tool and Handicap Inventory (VM-PATHI).

Study design: Prospective cohort study.

Setting: A single tertiary care balance and falls center.

Methods: Fifty-three subjects meeting Barany Society criteria for vestibular migraine (VM) or probable VM were included and divided into 3 treatment groups. Treatment was not standardized, instead, management was decided individually between each patient and their provider. All subjects completed VM-PATHI before and after intervention. A Global Rating of Change (GRoC) questionnaire was also completed following intervention. Anchor-based methods, using a GRoC questionnaire, were utilized to estimate the MCID that produced the highest sensitivity and specificity on a receiver operating characteristic (ROC) curve.

Results: Forty-three subjects were classified as responders and 10 were classified as nonresponders. The mean VM-PATHI pretreatment score minus the posttreatment score between the responders (mean = 14, SD 13) and nonresponders (mean = 4 SD = 12) was statistically significant (mean difference = 10, 95% confidence interval, CI [1, 20], P = .03). The VM-PATHI score change cutoff that best differentiated between responders and nonresponders was a VM-PATHI change of 6. Thus, the MCID was defined as a change of 6 points (sensitivity = 72%, specificity = 70%). The area under the ROC curve was 0.89, 95% CI [0.80, 0.98], which demonstrates an excellent ability for the VM-PATHI score change to discriminate between responders and nonresponders. The average change in VM-PATHI scores was 9 points (SD 11) for those with "a little better" rating on the GRoC, 14 points (SD 14) for those with a "moderately better" rating, and 20 points (SD 13) for those with a "very much better" rating.

Conclusion: Patients with VM are likely to demonstrate clinical improvement if their VM-PATHI score decreases by 6 or more.