Laryngoscope最新文献

Objective(s): To determine the accuracy of conventional and diffusion-weighted (DWI) MRI for the differential diagnosis between mucopyocele and mucocele using surgical diagnosis as a reference.

Methods: This retrospective study included patients referred to our institution between March 2017 and February 2024 for paranasal sinus MRI to characterize an expansile non-enhanced sinus filling on CT. The T1 and T2 signal intensities were recorded, as well as the presence of restriction diffusion, of the penumbra sign, the double rim sign, and the presence of parietal micro-abscesses. Quantitative apparent diffusion coefficient values were also recorded.

Results: The study included 74 patients aged 18 to 88 years (mean age: 60.4 ± 17.7 years). Of these, 43 had a mucopyocele and 31 had a mucocele. The T1 high signal intensity was different amongst groups as an hypersignal was present in 35.5% of mucoceles and only 4.7% of mucopyoceles (p = 0.02). The T2 signal did not differ between the two groups (p = 0.59). The double rim sign and the presence of parietal micro-abscesses demonstrated 96.8% and 100% specificities, respectively, but were predominantly located in the maxillary sinus. The penumbra sign exhibited a sensitivity of 60.5% and a specificity of 67.7%. All mucopyoceles exhibited a diffusion restriction with an apparent diffusion coefficient of less than 0.78 × 10-3 mm²/s.

Conclusion: DWI is the most useful MRI tool for the accurate differential diagnosis between mucopyocele and mucocele in non-enhanced sinus fillings.

Level of evidence: III (case-control study) Laryngoscope, 2024.

Objective/hypothesis: To compare the systemic changes following two office-based procedures-subepithelial vocal fold steroid injections (VFSI) and vocal fold augmentation (VFA), and to characterize the magnitude and chronicity of the effects observed.

Study design: Prospective, controlled before-after comparative study.

Methods: Patients prospectively underwent VFSI with 0.8-2 mg of dexamethasone or VFA. Serum cortisol, white cell count (WCC), and C-reactive protein (CRP) were measured at day 0 (pre-procedure), 1 and 7. Salivary cortisol was measured at baseline and daily for 7 days post-procedure.

Results: Fourteen patients underwent VFSI and 36 VFA. At baseline serum cortisol measured 304.6 ± 116.6 nmol/L and fell significantly to 48.1 ± 41.8 nmol/L 1 day following dexamethasone injection (p = 0.001) and recovered by day 7 to 303.7 ± 78.7 nmol/L. Salivary cortisol demonstrated a similar pattern with significant recovery demonstrated by day 3 (p = 0.001). White cell counts were affected by the systemic absorption of exogenous steroid and normalized by day 7. Patients who underwent VFA demonstrated no significant change in their serum or salivary cortisol and no significant change in their WCC. No significant changes in CRP or patient's physiological parameters were observed in either procedure.

Conclusion: Our findings demonstrate systemic absorption of dexamethasone following VFSI, with acute hypothalamic-pituitary-adrenal (HPA) axis suppression which normalizes day 3 post-procedurally.

Level of evidence: 3 Laryngoscope, 2024.

Objective: Unilateral thin clear rhinorrhea (UTCR) may represent a variety of pathologies including cerebrospinal fluid (CSF) rhinorrhea. Beta-2 transferrin (B2Tf) gel electrophoresis (GE) has become the preferred testing modality due to reportedly high sensitivity (87%-100%) and specificity (71%-100%). However, there have been relatively few studies assessing its diagnostic accuracy. The purpose of this single-institution study was to determine the accuracy of B2Tf GE in detecting CSF rhinorrhea.

Methods: A single-center retrospective review was conducted from 2016 and 2024 for all patients who presented with UTCR and underwent B2Tf GE. Institutional review board approval was obtained. The gold standard for diagnostic confirmation of true and false positives (TP, FP) as well as false negatives (FN) was endoscopic exploration. The gold standard for true negative (TN) was response to medical therapy.

Results: A total of 105 patients underwent 149 B2Tf GE tests. 40 (38.1%) patients were diagnosed with CSF rhinorrhea. Of the 149 B2-Tf GE tests, there were 51 TPs, 72 TNs, 20 FPs, and 6 FNs yielding 89.5% sensitivity, 78.3% specificity, 71.8% positive predictive value, and 92.3% negative predictive value, respectively. Of the false results the most common causes for error were purulent sinusitis (n = 6, 23.1%), possible mucous contamination from nose-blowing during collection (n = 3, 11.5%), patient collection error (n = 3, 11.5%), and blood contamination (n = 1, 3.8%).

Conclusion: Although these single-institutional data demonstrate test accuracy within ranges previously reported in the literature, they also demonstrate diagnostic limitations. Future studies should explore reasons for erroneous B2Tf GE results and how these may change clinical decision-making.

Level of evidence: IV Laryngoscope, 2024.

Objective: This study aimed to determine the predictive factors of abnormal MRI findings in patients with asymmetrical sensorineural hearing loss (ASNHL).

Study design: A retrospective review of medical records.

Setting: A tertiary care hospital.

Methods: Patients with asymmetries of ≥10 dB in at least 1 frequency, who underwent an MRI study of the temporal bone or brain during 2019-2021, were included. Age, sex, clinical symptoms, past medical history, and audiometric parameters, including pure tone thresholds, speech reception thresholds, and speech discrimination scores, were retrieved from the electronic database. The MRI findings reported by radiologists were reviewed and extracted.

Results: Of 390 patients, 50 (12.8%) patients had relevant abnormal MRI findings that could explain ASNHL. The most prevalent abnormal MRI finding was an internal acoustic canal (IAC) or cerebellopontine angle (CPA) tumor (n = 38; 76.0%), with other notable abnormalities including labyrinthitis, stroke, mucocele, and epidermoid. Multiple logistic regression analysis highlighted that hearing asymmetry of 15 dB at 1000 Hz (OR = 4.8; 95% CI 2.2-10.5) was a significant variable. The proposed predictor demonstrated 84% sensitivity and 48% specificity in detecting abnormal MRI findings.

Conclusion: A hearing asymmetry of 15 dB at 1000 Hz was an important clinical predictor of abnormal MRI findings in patients with ASNHL. This finding has the potential to serve as a referral guide for further MRI investigations.

Level of evidence: Level 3 Laryngoscope, 2024.

Soleus muscle necrosis is a rare complication following fibula free flap harvest for mandibular reconstruction. This report presents a case of soleus necrosis without compartment syndrome or infection and reviews the blood supply of the soleus muscle in 24 patients. Variations in the vascular anatomy of the soleus muscle, particularly reliance on the peroneal artery, may predispose to this complication. Clinicians should consider soleus muscle necrosis in patients with atypical donor site pain after fibula harvest. Laryngoscope, 2024.

Objectives: Limited normative reference data are available for validated outcomes of flexible endoscopic evaluation of swallowing (FEES). We aimed to examine healthy swallowing via FEES in community-dwelling healthy adults to derive a preliminary reference dataset of normative validated FEES outcomes to guide clinical interpretation and diagnostic decision-making.

Methods: Adults with no history of dysphagia-related disease underwent simultaneous videofluoroscopy and FEES imaging using a standardized 11-item bolus protocol. Trained raters performed duplicate, independent, blinded ratings of the New Zealand Secretion Scale (NZSS), Penetration-Aspiration Scale (PAS), and Dynamic Imaging Grade of Swallowing Toxicity-FEES (DIGEST-FEES) validated scales. Descriptive statistics were performed at the bolus (PAS) and participant level (NZSS, DIGEST-FEES).

Results: 361 swallows from 33 community-dwelling adults (36.6 ± 14.7 years old) were analyzed. In rank order, distribution profiles were: (1) NZSS: 95% normal (NZSS = 0), 5% abnormal (NZSS = 4); (2) Worst PAS: 73% safe (PAS 1-2, n = 24), 21% penetration above the true vocal folds (PAS 3, n = 7), 6% deep penetration to the true vocal folds (PAS = 5, n = 2); (3) DIGEST-FEES Safety Grades: 91% Grade 0 (normal, n = 30), 9% Grade 1 (mild impairment, n = 3); (4) DIGEST-FEES Efficiency Grades: 73% Grade 0 (normal, n = 24), 24% Grade 1 (mild impairment, n = 8), 3% Grade 2 (moderate impairment, n = 1).

Conclusion: This preliminary healthy FEES dataset highlights variation in swallowing safety and efficiency and suggests careful interpretation of FEES outcomes to avoid over-pathologizing impairment. Future studies are warranted to obtain additional normative data in diverse populations to further understand normal variation in FEES outcomes to guide clinically meaningful diagnostic cut-points.

Level of evidence: Level 3 Laryngoscope, 2024.

Objective: Topical nasal decongestants (TNDs) are used to reduce nasal soft tissue edema and obstruction. However, after frequent TND use, patients can develop rhinitis medicamentosa (RM) with rebound nasal edema and obstruction. Management of RM has centered largely on TND cessation ± intranasal corticosteroids. The purpose of this study was to compare nasal obstruction outcomes following nasal obstruction surgery in patients with versus without RM.

Methods: A retrospective case-control study was conducted with adult patients who underwent bilateral inferior turbinate reduction (ITR) with or without septoplasty and nasal valve repair. Patients with versus without RM were assessed. RM was defined as at least daily TND use for ≥4 weeks. Preoperative and postoperative Nasal Obstruction Symptom Evaluation (NOSE) scores, and long-term TND cessation rates were collected. NOSE score changes were compared between patients with versus without RM.

Results: Of the 36 RM patients, mean age was 52.0 years, and 63.9% were male. Of 116 non-RM patients, mean age was 41.6 years, and 46.6% were male. Postoperative NOSE scores were collected at a mean 972.1 days postoperatively for RM patients, and 565.0 days for non-RM patients. Mean NOSE score reductions were - 9.8 for RM and - 8.6 for non-RM patients, both of which were significant (p < 0.0001). NOSE score reductions were not significantly between the two groups (p = 0.2438). Long-term TND cessation was maintained in 86.1% of RM patients.

Conclusion: Patients with and without RM achieved similar long-term significant NOSE score reductions following nasal obstruction surgery, and 86.1% of RM patients maintained long-term TND cessation.

Level of evidence: Level 3 evidence Laryngoscope, 2024.

Background: Cholesteatoma, a destructive middle ear condition, poses challenges due to its variable clinical presentation and propensity for recurrence. Understanding its molecular underpinnings could enhance prognostication and guide therapeutic interventions. This study investigates the association between cholesteatoma aggressiveness, as assessed by the Middle Ear Risk Index (MERI), and the expression of miRNA-21 and IL-6 genes.

Methods: A cross-sectional observational study involving 30 patients with cholesteatoma undergoing tympanomastoid exploration was conducted. MERI scores were calculated preoperatively, and cholesteatoma tissue was analyzed for miRNA-21 and IL-6 gene expression using RT-PCR. Statistical analysis was performed to correlate MERI scores with gene expression levels.

Results: The majority (80%) of patients exhibited severe MERI scores, correlating with extensive middle ear pathology and necessitating canal wall-down (CWD) mastoidectomy. Higher miRNA-21 and IL-6 gene expression levels were observed in cholesteatoma tissues, indicating local aggressiveness and inflammatory activity. Significant moderate correlations were found between MERI scores and miRNA-21 (Pearson correlation = 0.579, p = 0.001) and IL-6 gene expression (Pearson correlation = 0.388, p = 0.034). Patients with severe MERI scores had elevated miRNA-21 and IL-6 levels, suggesting a more aggressive disease phenotype.

Conclusion: MERI scores demonstrated utility in predicting cholesteatoma aggressiveness, with higher scores correlating with elevated miRNA-21 and IL-6 expression. These findings suggest a potential role for MERI in guiding surgical decision-making and prognostication. Future research on targeted therapies based on molecular mechanisms holds promise for improving cholesteatoma management.

Level of evidence: 3 Laryngoscope, 2024.

Objective(s): To assess the impact of a novel 3D-printed simulation model with Brainlab Image Guidance on enhancing otolaryngology residents' skills and confidence in performing transcervical intralaryngeal injection (TII) compared with conventional training methods.

Methods: Utilizing a 3D-printed larynx model derived from computed tomography (CT) scans, this study involved 16 otolaryngology residents divided into two groups for TII training: one with Brainlab Image Guidance (LMIG) and the other without (LM). Pre- and post-training evaluations measured participants' confidence while the Brainlab system measured the accuracy of their needle placements.

Results: After training, participants exhibited a significant increase in confidence with an average rise from 1.56 to 2.75 on a 5-point scale. The LMIG group outperformed the LM group in accuracy achieving statistically significant reductions in target distances after training (3.5 mm right, 3.6 mm left). The LMIG also demonstrated a significantly greater increase in procedural confidence over the LM group after training.

Conclusion: The TII laryngeal model with Brainlab Image Guidance significantly improves procedural confidence and accuracy among otolaryngology residents, signifying potential advantage over a more conventional training approach. The model's realistic tactile and live instrument positioning feedback augments the process of surgical skill refinement in a controlled, risk-free, simulation environment.

Level of evidence: NA Laryngoscope, 2024.

Objective: The objective was to assess Potsic, EAONO/JOS, STAMCO, and ChOLE cholesteatoma staging systems in a large homogenous pediatric cohort with long-term follow-up and propose an evidence-based improved version.

Study design: Cohort study.

Setting: Retrospective study in a tertiary referral center.

Methods: Children with congenital or acquired cholesteatoma who underwent surgery between 2008 and 2015 and had a minimum of five years follow-up were included. ROC areas under curve (AUCs) were performed for the residual disease proportion, total number of surgeries, hearing, and C-index for recurrence proportion at the last follow-up.

Results: Data from 271 ears with cholesteatoma were collected. Mean age at diagnosis was 7.9 years and 77 (28%) were congenital. Almost all patients (99%) had a canal wall up approach. The mean follow-up was 97.8 months. The Potsic classification, initially designed for congenital cholesteatoma, had the highest AUCs for residual disease rate and for number of surgeries outcomes (respectively 0.73 [0.67-0.78] and 0.71 [0.66-0.77]). For recurrence rate, all the classifications' C-index were low (<0.7). For postoperative hearing, STAMCO ossicular subscore had the highest AUC (0.73 [0.67-0.79]). The Mod-Pot staging system (modified Potsic), including stapes superstructure status and anterior epitympanum or supratubal involvement, improved the Potsic performance especially for postoperative hearing with AUC 0.73 [0.67-0.80], p < 0.001.

Conclusion: The Potsic, ChOLE, EAONO/JOS, and STAMCO cholesteatoma classifications may be used in children, but in this specific population, their contribution remains limited to predict outcome. The Mod-Pot classification improved the performance of pediatric cholesteatoma classification while remaining simple and intuitive.

Level of evidence: 3 Laryngoscope, 2024.