particular care should be taken so as not to contact the ... - hns - december... · subsite, tumor...

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Take Precautions Against Airway Fires When Using CO2 Laser

Prevention of Airway Fires: Testing the Safety of Endotracheal Tubes and Surgical Devices in a Mechanical Model.

Roy S, Smith LP:

Am J Otolaryngol 2015; 36 (January-February): 63-66

Particular care should be taken so as not to contact the distal tip of a laser-safe endotracheal tube with laser beams because this can result in ignition and an airway fire.

Background: The CO2 laser is commonly used in various head and neck surgical procedures and has been associated with airway fires. Objective: To use a mechanical model of airway surgery to assess the fire risk associated with the use of the CO2 laser or the radiofrequency plasma ablation (RFA) wand. Design: The mechanical model consisted of a closed circuit with either a laser-safe or conventional endotracheal tube (ETT) connected to an anesthesia machine supplying varying concentrations of oxygen. Methods: The CO2 laser was fired at conventional ETTs and laser-safe ETTs at varying supplemental oxygen and wattage levels. Both time to ignition followed by observed flaming and the damage to the ETT were recorded. The experiment was then repeated with the RFA wand at varying settings on coagulation and ablation modes. Results: When the CO2 laser was set at 5 watts and then fired at the conventional ETT, there was observed ignition without sustained flame at O2 concentrations of 21% and 29%. At O2 concentrations >50%, ignition and sustained flame were observed at an average time of 1.5 seconds. Using the laser-safe ETT, no ignition was observed with direct contact of the laser beam with O2 concentrations as high as 60% and up to 2 minutes, although progressive damage to the reinforcing tape and subsequent metal exposure was observed at higher wattages. However, laser beams aimed at the distal tip of the laser-safe ETT resulted in similar ignition and flaming as seen with conventional ETT. The RFA at various settings did not cause any fire, regardless of whether a laser-safe or conventional ETT was used. Conclusions: The laser-safe ETT confers protection against the CO2 laser beam except at its distal-most portion. Airway fires occurred quickly (approximately 1.5 seconds) in this mechanical model when the CO2 beam contacted a conventional ETT at O2 concentrations >50%. Reviewer's Comments: In a series of simple experiments, the authors demonstrated the ease of generating an airway fire with the CO2 laser at a wattage setting that is frequently used in endolaryngeal surgery in conjunction with a conventional ETT and oxygen concentrations >50%. The authors also importantly show that the distal tip of a laser-safe ETT does not confer the same protection against ignition as the proximal portions of the tube. This article serves to highlight the importance of precautions against airway fire when the CO2 laser is used, especially the use of a laser-safe ETT and decreasing supplemental oxygen to the lowest possible level. (Reviewer-Zhen Gooi, MD). © 2014, Oakstone Publishing, LLC

Keywords: Airway Fires, Laser Airway Surgery, Ignition Risk for Endotracheal Tubes

Print Tag: Refer to original journal article


Tumor Site Impacts Risk of Nodal Mets in Oral SCC

Tumour Thickness as a Predictor of Nodal Metastases in Oral Cancer: Comparison Between Tongue and Floor of Mouth

Subsites.

Balasubramanian D, Ebrahimi A, et al:

Oral Oncol 2014; 50 (December): 1165-1168

Elective neck dissection may be warranted in floor of mouth squamous cell carcinoma with a tumor thickness >2 mm.

Background: High-quality evidence suggests that tumor thickness >4 mm in oral cavity cancer incurs a >20% risk of nodal metastases. However, most studies have focused on primary cancers of the tongue rather than including other oral subsites. Objective: To determine if tumor thickness as a predictor of nodal metastases differs between 2 subsites of oral cancer: tongue and floor of mouth (FOM). Design: Retrospective chart review. Participants: Patients with FOM and oral tongue squamous cell carcinomas (SCCs) undergoing surgical treatment between 1987 and 2012 at a tertiary academic center. Methods: The neck was considered positive (N+) if either nodal metastases were detected after elective or therapeutic neck dissection or if a pathologically proven recurrence was identified during follow-up. Multivariable analysis was performed to adjust for the effect of tumor size, thickness, and oral subsite. Results: 343 patients (222 tongue SCCs; 121 FOM SCCs) were included in this study with a median follow-up of 2.3 years. For both subsites, most cancers were staged as either T1 or T2. A tumor thickness of 2.1 to 4 mm had an N+ rate of 41.7% for FOM tumors versus 11.2% for tongue tumors. After adjusting for tumor size and subsite, tumor thickness had a significant association with nodal metastases (P < 0.001). However, when controlling for tumor thickness and size, the FOM subsite had a higher baseline odds of N+ disease (P = 0.016) compared to the tongue subsite. Using logistic regression analysis adjusting for tumor size, the probability of N+ disease increased beyond 20% at a thickness of 1.1 to 2 mm in the FOM subsite and at a thickness of just under 4 mm in the tongue subsite. Conclusions: FOM SCCs have a higher propensity for nodal metastases compared to oral tongue SCCs, and an elective neck dissection should be considered when FOM tumor thickness is >2 mm. Reviewer's Comments: Strengths of this study include the confinement of the data to a single institution to allow for uniformity in histopathological techniques as well as adjustments to account for the effect of tumor size in their statistical analysis. The authors acknowledge that the true rate of N+ disease can only be determined if a neck dissection is performed on all patients, which is not ethically permissible. Nonetheless, the authors demonstrate that the observed effect of tumor thickness and subsite on nodal metastases remains significant, even after excluding patients undergoing therapeutic neck dissections. Based on these data, there should be stronger consideration for elective neck dissections in patients with floor of mouth SCCs >2 mm in thickness. (Reviewer-Zhen Gooi, MD). © 2014, Oakstone Publishing, LLC

Keywords: Oral Cancer, Risk Factors for Nodal Metastases, Tumor Thickness



Exercise Regimen With Jaw Devices Improves Trismus

Treating Trismus: A Prospective Study on Effect and Compliance to Jaw Exercise Therapy in Head and Neck Cancer.

Pauli N, Andréll P, et al:

Head Neck 2014; (September 25): epub ahead of print

Patients with trismus should be counseled on the benefits of regular use of jaw opening devices, which have been shown to improve maximal interincisal opening.

Background: Trismus is a debilitating condition adding to the morbidity experienced by patients with head and neck cancer. Objective: To assess the effectiveness of 2 jaw exercise devices for the treatment of trismus. Design: Prospective cohort study. Participants: Patients diagnosed with trismus following head and neck cancer treatment. Methods: Trismus was defined as maximal interincisal opening (MIO) ≤35 mm. Baseline and follow-up MIOs were measured with a ruler between the edges of the incisors of the mandible and maxilla. Patients were randomly assigned to exercise therapy using either the TheraBite® or Engström jaw device and were asked to undergo a 10-week structured exercise program consisting of jaw opening and closing with the device 5 times daily. MIO was assessed at 4, 10, and 12 weeks. Patient quality of life indicators were measured with the Gothenburg Trismus Questionnaire (GTQ). Results: 25 patients were included in each treatment group. Patients using the TheraBite device improved their MIO from baseline by a mean of 7.2 mm (22.9%). Similarly, those using the Engström device improved their MIO from baseline by a mean of 5.5 mm (17.6%), which was not significantly different than that achieved with the TheraBite device. At the conclusion of the study, 84% of TheraBite patients and 60% of Engström patients had MIO >35 mm. Mean exercise frequency was 2.7 and 2.6 times/day for TheraBite and Engström devices, respectively, during the first 4 weeks. After the first 4 weeks, use of the TheraBite device declined to a mean of 1.9 times/day. At 3 months, both patient groups reported significant improvements in assessments of jaw-related problems, eating limitations, and muscular tension as measured by the GTQ. Conclusions: Use of the TheraBite and Engström devices in the treatment of trismus with a structured exercise program leads to improvement of jaw-related problems and quality of life. Reviewer's Comments: This is an interesting article quantifying the improvement conferred by regular, sustained use of the TheraBite and Engström devices for treatment of trismus. Most of the treatment effect was observed within 4 weeks of therapy initiation and was sustained at the final 3-months follow-up. In addition, improvements were obtained despite relatively modest patient compliance with the actual exercise regimen. The authors also demonstrated significant improvements in various quality of life indicators at the 3-month follow-up. Although both intervention groups were small, I believe the information provided in this study gives useful information to counsel patients on the expected improvement that can be obtained following sustained use of these devices. (Reviewer-Zhen Gooi, MD). © 2014, Oakstone Publishing, LLC

Keywords: Head and Neck Cancer, Trismus, Exercise Therapy, Engström Jaw Device, TheraBite



Tracheostomy Dependence High After Laryngeal Cancer Therapy

Persistent Tracheostomy After Primary Chemoradiation for Advanced Laryngeal or Hypopharyngeal Cancer.

Tennant PA, Cash E, et al:

Head Neck 2014; 36 (November): 1628-1633

In patients who undergo chemoradiation therapy for advanced laryngeal cancers, posttreatment tracheostomy dependence rates can be relatively high for those requiring pretreatment tracheostomy.

Background: Recently, the long-term results of the Radiation Therapy Oncology Group laryngeal preservation trial were published, and the authors noted increased rates of noncancer-related mortality among patients treated with chemotherapy for organ preservation for advanced laryngeal and hypopharyngeal cancers. Although organ preservation sounds like a great result, primary chemotherapy for laryngeal cancer is not without serious complications. An end point of which we should be aware is whether the larynx can function after organ-preservation treatment. One parameter is the need for tracheostomy after the treatment. Objective: To determine decannulation rates in a series of patients with advanced laryngeal and hypopharyngeal cancers who require tracheostomy prior to chemoradiation treatment. Design: Retrospective chart review. Participants: 60 patients with mostly stage III and IV supraglottic and hypopharyngeal squamous cell carcinomas. Results: 18 of 60 patients had pretreatment tracheostomy. The tracheostomy rates at 6 months and 12 months after the completion of treatment were calculated. Within this group, the clinical parameters most frequently associated with persistent tracheostomy were hemilarynx fixation and T3/4 stage. Survival was worse for patients who required tracheostomy before chemoradiation (65%) than for those who did not (94%). Patients requiring tracheotomy before chemoradiation had low rates of decannulation. Conclusions: Advanced laryngeal cancer patients who require tracheostomy before chemoradiation have low rates of decannulation and lower rates of survival compared to those who do not require pretreatment tracheostomy. Reviewer's Comments: The major shortfall of this report is the low number of patients in the final analysis. Although the authors started with 60 patients, only 18 required tracheostomy before chemoradiation treatment. Of these, 6 died, so the final number was reduced to 12. Of these remaining 12 patients, 9 still had tracheostomy at 1 year. Given the low number of patients, the actual rates of tracheostomy dependence after chemoradiation are not reliable. However, the take-home message is that organ-preservation treatment for advanced laryngeal cancer is not truly "organ preserving," which should be kept in mind with such high rates of tracheostomy dependence 1 year after chemoradiation treatment. (Reviewer-Young J. Kim, MD, PhD). © 2014, Oakstone Publishing, LLC

Keywords: Advanced Laryngeal or Hypopharyngeal Cancer, Chemoradiation, Tracheostomy



Hypothyroidism Is Late-Onset Complication From Conformal RT

Hypothyroidism After 3-Dimensional Conformal Radiotherapy and Intensity-Modulated Radiotherapy for Head and Neck

Cancers: Prospective Data From 2 Randomized Controlled Trials.

Murthy V, Narang K, et.al:


Hypothyroidism continues to be a common complication after modern 3D conformal radiation therapy and intensity-modulated radiation therapy for the treatment of locally advanced head and neck cancer.

Background: Radiotherapy (RT) for head and neck squamous cell cancer (HNSCC) is associated with many problems, most of which are primarily associated with dysphagia. One important problem that goes underreported is hypothyroidism. The reported incidence of posttreatment clinical hypothyroidism ranges from 6% to 48%, but the true range hovers closer to 20% to 30%. Hypothyroidism typically peaks at 1 to 3 years, but it can occur as early at 4 weeks after RT. Many of these numbers are from standard RT, so the rates of hypothyroidism are not clear with the more standard use of 3D conformal RT (3DCRT) or intensity-modulated RT (IMRT). Objective: To examine the rates of hypothyroidism in HNSCC patients who undergo either 3DCRT or IMRT. Participants: 122 patients with previously untreated HNSCC. Methods: Patients were randomly assigned to undergo 3DCRT at 70 Gy or IMRT at 66 Gy to treat HNSCC. Thyroid function tests were obtained every 3 to 6 months after treatment for 2 years and annually thereafter. Results: 55% of patients developed hypothyroidism at a median of 41 months after RT. IMRT treatment was associated with higher rates of hypothyroidism than was 3DCRT. Multivariate analysis showed that younger age, hypopharynx/larynx primary site, presence of neck disease, and higher dose/fraction were associated with hypothyroidism. Conclusions: In HNSCC patients who undergo either 3DCRT or IMRT, posttreatment hypothyroidism develops at approximately 1 year, which the authors primarily attribute to the higher dose per fraction. Reviewer's Comments: This was a great review. The patients were enrolled in a randomized clinical trial to examine the clinical differences associated with 3DCRT versus IMRT for the treatment of HNSCC. Because the authors were able to obtain regular thyroid function tests, they could assess biochemical, subclinical, and clinical hypothyroidism for a time after treatment. They clearly showed that hypothyroidism is a late-onset complication from RT, even the modern techniques that can reduce the radiation dose to the thyroid bed. For otolaryngologists who routinely manage HNSCC patients, this report, combined with other reports, should prompt regular TSH testing. The authors recommend biannual TSH check during the first 3 years and an annual check thereafter. (Reviewer-Young J. Kim, MD, PhD). © 2014, Oakstone Publishing, LLC

Keywords: Head & Neck Cancers, Conformal Radiation Therapy, Complications, Hypothyroidism



Definitive RT May Be Sufficient for Treating HNCUP

Head and Neck Squamous Cell Carcinoma of Unknown Primary: Neck Dissection and Radiotherapy or Definitive

Radiotherapy.

Demiroz C, Vainshtein JM, et al:


Head and neck carcinoma from unknown primary tumors can be treated with radiotherapy with or without concomitant chemotherapy. However, the evidence in this study is not strong and further studies are needed.

Background: The management of head and neck carcinoma from unknown primary (HNCUP) is controversial, and there is no clear consensus on the best treatment modality. Recent use of the transoral robotic surgery (TORS) for oropharyngeal tumors has allowed some to provide better localization of the primary tumor. Because of this, many surgeons have opted for more surgical approaches in which the unknown primaries are initially treated with neck dissection by TORS for localization, followed by radiotherapy (RT). However if the neck lesion is HPV-positive, there is high probability that the primary site is in the oropharynx, such that the patient can be treated with RT combined with chemotherapy, depending on the staging of the neck disease. Objective: To determine whether the nonsurgical or surgical modality is better in terms of outcomes for the treatment of HNCUP. Design: Retrospective study. Participants: 41 patients with biospy-proven squamous cell carcinoma limited to the cervical lymph nodes without an identifiable primary tumor who were treated at the authors' institution. Methods: Two cohorts were compared: (1) 21 patients who underwent neck dissections followed by adjuvant RT with or without chemotherapy and (2) 19 patients who underwent definitive RT with or without chemotherapy. The inclusion of chemotherapy in both cohorts was determined by the presence of extracapsular extension or advanced nodal disease on presentation. Results: Chemotherapy was administered to 50% of the neck dissection group and 74% of the RT group. The primary outcome measurements were overall survival, progression-free survival, locoregional control, and distant disease relapses. The 2 modalities did not differ in any of the clinical parameters. Conclusions: Both modalities resulted in similar outcomes. The authors favor nonsurgical, definitive RT with or without chemotherapy for the treatment of HNCUP, reserving neck dissection for salvage of regional failure. Reviewer's Comments: The primary problem with this report is that not all neck specimens were characterized as HPV-associated or not. For the cohort that received RT as the definitive treatment modality, this important biomarker could not be obtained. For the neck dissection group, only 60% of the specimens were analyzed for HPV status, and of these, only 32% were positive. In short, the 2 cohorts may have selection bias to confound the results. The authors recognized that the RT group was the more recent group, such that there may be a bias toward more HPV-positive tumors in the RT group, which tend to be radiosensitive. Therefore, this report does not have the best evidence to support that definitive RT with or without chemotherapy is the best modality for the treatment of HNCUP. (Reviewer-Young J. Kim, MD, PhD). © 2014, Oakstone Publishing, LLC

Keywords: Unknown Primary, Treatment, Neck Dissection vs Radiation Therapy



Surgical Closure Methods Affect Fistula Rates After TL

Pharyngocutaneous Fistula After Total Laryngectomy: A Single-Institution Experience, 2001-2012.

Benson EM, Hirata RM, et.al:

Am J Otolaryngol 2015; 36 (January-February): 24-31

The combination of surgical methods, patient comorbidities, and disease characteristics determine the pharyngocutaneous fistula rates after total laryngectomy.

Background: Despite advances in head and neck oncologic surgery, it is unclear whether we have reduced the rates of fistulization after total laryngectomy (TL). There are many methods of primary closure, and many centers have adopted flap surgery after the ablative surgery to reduce the fistulization rates. Fistula rates after TL range widely from 3% to 65%, but in most series, these rates range from 10% to 40%. Of course, 1 of the main determinants is the quality of the mucosal tissue at the time of closure -- namely, whether the patient was underwent radiation therapy. Fistulas can compromise quality of life for the patient given that their oral diet may be delayed. Several reports have investigated whether the type of closure or the use of vascularized flaps decreases the fistula formation rates. Objective: To determine the postoperative rates of pharyngocutaneous fistula formation in patients who underwent TL at a single institution. Design: Retrospective study. Participants: 59 patients treated with TL from 2001 to 2012 at the authors' institution. Methods: Patient records were reviewed for tumor stage, surgical methods, treatment characteristics, and fistula formation rates. Results/Conclusions: Patients who underwent pectoralis flap incorporated into the suture line had 1 of the highest fistula rates (50%). The primary suture closure method was associated with decreased fistula rates (11%), whereas stapling methods and onlay pectoralis flaps were associated with statistically nonsignificant increases in fistula rates (43% and 25%, respectively). In terms of preoperative characteristics, the authors separated the nonsalvage TLs from the salvage TLs. For the nonsalvage TLs, patient comorbidities (hypertension, pulmonary disease, age, etc) were associated with increased fistula rates. For the salvage TLs, disease-related parameters (chemoradiotherapy, stage) were associated with increased fistula rates. Reviewer's Comments: One of the main limitations of this study is the small number of patients evaluated. These authors had only 59 patients in this study, while other studies have had more patients. As such, this study's fistula rates that varied with the surgical closure method used were different from the rates reported by other larger studies. Surprisingly, this series showed no correlation between radiation and fistula rates. However, the authors' analysis separately analyzed salvage versus nonsalvage TLs. For nonsalvage TLs, a patient's other comorbidities, such as hypertension and pulmonary diseases, may play a bigger role in determining the fistula rates than they do in a patient undergoing salvage TLs. (Reviewer-Young J. Kim, MD, PhD). © 2014, Oakstone Publishing, LLC

Keywords: Laryngeal Cancer, Total Laryngectomy, Postop Pharyngocutaneous Fistula



Tumor Subsite Affects Positive Margins for Oral Cancers

Positive Surgical Margins in Early Stage Oral Cavity Cancer: An Analysis of 20,602 Cases.

Luryi AL, Chen MM, et al:

Otolaryngol Head Neck Surg 2014; 151 (December): 984-990

Among early stage oral cancer tumors, the retromolar trigone, buccal space, and floor of mouth subsites are associated with positive margins after surgical excisions.

Background: In patients undergoing oral cancer resection, positive margins on the surgical specimens are unfortunate events because they are associated with an increased risk of disease recurrence and overall outcomes. The overall rates of positive margins in oral cavity cancer resections are not trivial (estimated to be 21%), and the oral cavity has the highest rates of positive margins in the head and neck. Objective: Rather than focusing on single-institution series, which are limited by low number of cases, the authors used the National Cancer Database to examine the incidence of positive margins in oral cavity tumors. Design: Retrospective analysis. Methods: 20,602 patients with stage I and II oral cavity cancer were identified in a large database. Clinical parameters and the presence of positive margins were recorded for each patient. Results: 95% of the identified cases had margin status reported. Margins were positive in 7.5% of cases. Clinical parameters associated with positive margins included stage II disease, intermediate- or high-grade tumors, floor of mouth subsite, buccal subsite, and retromolar trigone subsite. Positive margins were associated with the institution where the surgery was performed: nonacademic centers had higher rates of positive margins than did academic centers that handled higher volumes of oral cavity cases. Geographic location of treatment in the U.S. also affected the incidence of positive margins: patients treated in the New England area had the highest rates of positive margins compared to those treated in South Atlantic regions. Conclusions: The incidence of positive margins after resection of early stage oral cavity tumors is affected by treatment facility, hospital case volume, and oral cavity subsites. Reviewer's Comments: As a population study, detailed clinical parameters are not present in this report. Furthermore, population studies do not provide the reasons why positive margins occur. Although those treated in the New England region had higher rates of positive margins, it is not clear whether this might be due to an increased number of nonacademic centers in this geographic region. This study does replicate previous work that subsites are important determinants for positive margins. Retromolar trigone, buccal, and floor of mouth subsites have been previously shown to be associated with positive margins. (Reviewer-Young J. Kim, MD, PhD). © 2014, Oakstone Publishing, LLC

Keywords: Early Stage Oral Cavity Cancer, Positive Surgical Margins, Risk Factors



Best Means of Executing the Rhomboid Flap

Biomechanics of the Rhombic Transposition Flap.

Topp SG, Lovald S, et al:


The rhomboid flap design requires close attention to biomechanical strain and stress.

Background: The rhomboid flap is a transposition flap that is very useful for closing defects that are not on the face and neck. It was initially described in 1946 by Limberg, but it has been re-articulated in variation by subsequent surgeons to minimize the dog-ear deformity at the flap base. Webster and Dufourmentel provided their own variation to the classic rhomboid flap. Larrabee described the biomechanical aspects of this rhomboid flap in porcine models. What has not been appreciated is the hyperelastic and viscoelastic properties of the skin in conjunction with the biomechanics of the skin. Objective: To model the rhomboid flap using a hyperelastic model to account for the stress, strain, and local surface changes after completion of the rhomboid flap. Methods: The authors used a "second-order Yeoh hyperelastic model" to fit excised porcine skin strips used for a rhomboid flap ex vivo. Results: Computer modeling showed that the closure stress and strain forces were reduced with a donor distal-flap angle of 30° and by undermining the defect skin edges to recruit the opposing sides. This computer modeling suggested that deformities arise from magnitude of angle closure at the flap base. Stated differently, the rhomboid flap width dictated the deformity of the surrounding tissue, and the creation of the rhomboid flap angle determined the orientation of the strain on the final closure. The modeling also showed that a square type of defect was most favorable to minimize the stress and strain. Conclusions: The authors have provided a biomechanical guideline for the optimal rhomboid flap. Reviewer's Comments: As a computer modeling, this work may be too theoretical for surgeons. But there are some potential implications from this work. One is that a square defect may be optimal for consequent stress and strain after the closure. However, the more classical rhomboid defect may be helpful to minimize dog-ear deformity. There was no benefit, from a biomechanics standpoint, to increase or sharpen the rhomboid angles beyond the classical rhomboid. In terms of donor flap angulation, the alpha angle manipulation can strongly determine the orientation of the primary strain vector, but this angle may have minimal impact on the risk of standing cutaneous deformity. In short, the Dufourmentel flap is a good option to minimize dog-ear deformity. (Reviewer-Young J. Kim, MD, PhD). © 2014, Oakstone Publishing, LLC

Keywords: Rhomboid Flap, Biomechanical Properties, Optimization



Benefits of Early Tracheostomy

The Effect of Early and Late Tracheotomy on Outcomes in Patients: A Systematic Review and Cumulative Meta-Analysis.

Liu X, Wang HC, et al:


For patients who are ventilated with an endotracheal tube, early tracheostomy may reduce the risk of mortality.

Background: Tracheostomy is one of the more common surgeries that otolaryngologists perform, and the national trend has been to perform the procedure early rather than later. However, the optimal time for tracheostomy is still disputed for patients who are ventilated with an endotracheal tube. Objective: To compare the sequelae of early versus late tracheostomy. Methods: The authors examined the literature for randomized clinical trials that compared early versus late tracheostomy. They defined early tracheostomy as <8 days and late tracheostomy as those undergoing surgery >6 days after intubation. They performed a systematic review and a meta-analysis on this topic to characterize the benefits of early tracheostomy. Results: The authors found 11 randomized clinical trials comprised of 1436 patients, including 708 patients in the early tracheostomy group and 728 in the late tracheostomy group. Multiple clinical parameters were examined, such as mortality and ventilator dependence and ventilator-associated pneumonia. Early tracheostomy was associated with a reduced mortality rate, but this group did not have decreased rates of ventilator dependence. In short, this meta-analysis found that early tracheostomy may improve short-term mortality, but the mechanism behind this correlation is not due to decreased incidence of ventilator-dependent pneumonia. Conclusions: The authors support early tracheostomy, but they argue that more studies need to be performed since the mortality benefit may not come from the increased incidence of ventilator-dependent pneumonia as many have suspected in the past. Reviewer's Comments: As noted, this meta-analysis is hampered by the heterogeneity of the types of patients included in these 2 cohorts. There is an overlap in patients who are considered early tracheostomy versus those who are considered late tracheostomy. Moreover, there is heterogeneity in the types of critically ill patients. They included all types of ventilator-dependent patients, so this dissociation between mortality and ventilation-dependent pneumonia should be stratified with different types of patients. However, this would require a greater number of patients in their analysis. Overall, this was an intriguing study. (Reviewer-Young J. Kim, MD, PhD). © 2014, Oakstone Publishing, LLC

Keywords: Tracheotomy, Mortality, Effect of Ventilator-Dependeny Pneumonia



Differentiating Benign vs Malignant Thyroid Nodules

Contrast-Enhanced Ultrasound for Differentiation of Benign and Malignant Thyroid Lesions: Meta-Analysis.

Yu D, Han Y, et al:


Contrast-enhanced ultrasound has strong promise in the diagnostic workup of thyroid nodules.

Background: High-resolution ultrasound (US) has altered the management of thyroid nodules. Echogenicity, vascularity, shape, irregular margins, and calcifications have been correlated with signs of malignancies. However, none of these features are exclusively correlated with malignancies, and these features can be seen with benign lesions. Recently, contrast-enhanced US (CEUS) has entered the fray with better hope. CEUS can show macro- and microvisualization of the internal vascularity of the thyroid nodules, and others have suggested these may improve the diagnostic accuracy of US in malignant lesions. Objective: To perform a meta-analysis on the effectiveness of CEUS for thyroid nodules. Methods: The authors pooled studies using CEUS prior to thyroidectomy. They calculated sensitivity, specificity, positive likelihood ratio (LR), negative LR, and diagnostic odds ratio of CEUS for malignancy. Results: The authors screened >100 studies, but they were able to analyze 7 studies that included 597 nodules. The sensitivity was 85.0%, specificity was 88.0%, positive LR was 5.8, and negative LR was 0.19. The diagnostic odds ratio was 34.7. Conclusions: CEUS may be an excellent method to incorporate into the workup of thyroid nodules. Reviewer's Comments: CEUS provides much information on the vasculature of the thyroid nodules. A polyphasic washout after contrast injection, early arrival time of contrast, and time to peak contrast were all quantitative assessments associated with malignancy. Heterogeneity of enhancement was also associated with malignancy, but this was deemed more qualitative. The main criticism of this paper, as well as the current field of CEUS, is that there is no clear agreement on the standards as to what to measure or to assess in this new diagnostic modality. Thus, there is significant heterogeneity on what constitutes an optimal positive test or a negative test. This technology is highly promising, but radiologists need to better standardize the final readout from these CEUS studies. (Reviewer-Young J. Kim, MD, PhD). © 2014, Oakstone Publishing, LLC

Keywords: Thyroid Nodules, Contrast-Enhanced Ultrasound, Diagnostic Performance



Diagnosis, Treatment of Cervical Sympathetic Chain Schwannomas

Diagnostic Approach, Treatment, and Outcomes of Cervical Sympathetic Chain Schwannomas: A Global Narrative

Review.

Navaie M, Sharghi LH, et al:


Complete excision of cervical sympathetic chain schwannomas is associated with Horner syndrome and first-bite syndrome.

Background: Schwannomas are unusual benign tumors. An estimated 20% to 40% of schwannomas occur in the head and neck region. Of course, otologists see these cases as acoustic neuromas, but most head and neck schwannomas are nonvestibular; of these, most originate from the vagal nerve. Unfortunately, the knowledge base of cervical sympathetic chain schwannomas is limited by the fact that the literature is littered with case series reports from single institutions, except for 1 review article from 1997. Objective: To perform an updated literature review from 1998 to 2013. Methods: The authors identified 156 articles, of which 51 were reviewed in detail. These 51 reports encompassed 89 schwannomas from the cervical sympathetic chain. The clinical presentations of these 89 cases were summarized in this report. Results: Nearly 70% of the time, these lesions were asymptomatic on presentation with a size that ranged from 2 cm to 4 cm. Average age at presentation was 43 years. CT and/or MRI were used for imaging. Fine-needle aspiration (FNA) was used in about one-third of cases, but these were rarely diagnostic. The imaging modality used tended to be MRI in the United States versus CT scan outside the U.S. Correct diagnosis was noted preoperatively in only 11% of cases. Most of these schwannomas were treated with complete excision, and the postoperative sequelae consisted of Horner syndrome in 91% of cases. The rate of first-bite syndrome was present in 21% of cases. Both sequelae occurred together in about 16% or cases. Conclusions: The clinical history of these unusual schwannomas is summarized. The authors recommend less-than-complete excisions since the postoperative sequelae of these cases are associated with such high morbidity rates. Reviewer's Comments: There are several implications from this descriptive analysis of cervical sympathetic chain schwannomas. FNA is not required, and MRI is recommended for diagnosis. On imaging, there were no cases of these lesions splaying the jugular vein from the carotid artery. In terms of surgery, the morbidity rates associated with full excision were high. Enucleation methods should be strongly considered, given that these are predominantly benign processes. (Reviewer-Young J. Kim, MD, PhD). © 2014, Oakstone Publishing, LLC

Keywords: Cervical Sympathetic Chain Schwannomas, Clinical History, Postop Complications



Assessing Functional Outcome in Head, Neck Cancer

Assessment of Functional Outcomes in Patients With Head and Neck Cancer According to the International Classification

of Functioning, Disability and Health Core Sets From the Perspective of the Multi-Professional Team: Results of 4 Delphi

Surveys.

Kirschneck M, Sabariego C, et al:

Head Neck 2014; 36 (July): 954-968

Measurement of functional outcome in patients with head and neck cancer is still evolving.

Background: Quality of life (QOL) and our ability to maximize this parameter is an important aspect of oncologic care. Improvements in quality of life, however, require a valid and reproducible means of assessing this hard-to-measure clinical parameter. Several instruments are available for head and neck surgeons to measure QOL. One is the University of Washington QOL instrument, but this may not be externally valid for other countries. A more comprehensive measurement is to assess the patient's overall function. The World Health Organization has developed the International Classification of Functioning, Disability, and Health Core Set for Head and Neck Cancer (ICF-HNC). Objective: To use the ICF-HNC as a reference to develop national functional instruments that can be used in Germany. Methods: Much like the International Classification of Diseases codes, the ICF was developed to classify human functioning. The authors, therefore, defined patient "functional outcomes" using ICF definitions. To implement a QOL assessment, the authors used surveys among physicians, physiotherapists, psychologists, and social workers to determine and characterize which aspects of the ICF-HNC codes were appropriate for the head and neck cancer population. Four electronic Delphi surveys targeted health care providers who would care for head and neck cancer patients in Germany. These surveys were used to develop a guideline to measure functional outcomes in head and neck cancer patients. The surveys consisted of 4 rounds of "yes or no" questions to determine whether specific ICF categories were relevant to head and neck cancer patients. Results: From the large categories, 33 categories were selected. These categories were thought to be relevant to the respondents. Conclusions: These 33 assessment tools can provide information regarding therapy monitoring, diet, pain, psychosocial issues, and other relevant tools and were chosen as future assessment tools. Reviewer's Comments: There were several take-home messages. (1) There are no clear standardized tools or instruments outside of the United States to measure function in patients with head and neck cancer. As such, reports from the past that claim QOL from other countries outside of the U.S. must be closely analyzed for their validity. There are no standardized tools for measuring functional outcomes in countries such as Germany. (2) Recommendations on how to interpret information from these functional instruments are missing, so guidelines must be developed to propose a standardized set of assessment tools for functional outcomes. (3) Validated tools were rarely used by health care providers caring for patients with head and neck cancer. There are a few limitations to this study. The prominent limitation is that this study was undertaken in Germany. How these findings apply to head and neck surgeons in the U.S. is uncertain. (Reviewer-Young J. Kim, MD, PhD). © 2014, Oakstone Publishing, LLC

Keywords: Head& Neck Cancer, Quality of Life Outcomes, Assessment



Antibiotics Improve Middle Ear Effusion in Acute Otitis Media

Effect of Antimicrobial Treatment of Acute Otitis Media on the Daily Disappearance of Middle Ear Effusion: A Placebo-

Controlled Trial.

Tapiainen T, Kujala T, et al:

JAMA Pediatr 2014; 168 (July): 635-641

Antibiotics may be effective in reducing the duration of middle ear effusion as well as the risk of developing persistent middle ear effusion in children with acute otitis media.

Background: It is widely accepted that antibiotics can be used to treat acute otitis media, although its effects on improving symptoms are modest. Some believe antibiotics could have a role in the reduction of middle ear effusion. As persistent middle ear effusion has been associated with hearing loss and developmental delay, effective treatments are needed. Objective: To examine if antibiotic treatment for acute otitis media affects the duration of middle ear effusion. Design: Randomized, double-blind, placebo-controlled trial of children ages 5 months to 15 years in Finland. Methods: Children were eligible if they presented with an episode of acute otitis media. They received either amoxicillin-clavulanate for 7 days or a placebo. Main outcome of interest was time until middle ear effusion resolved. Other outcomes included improved tympanogram findings and time until normal pneumatic otoscopy. Tympanometers were distributed for home use and measurements. Results: Over the study period, 84 children were randomized in this study. Nearly all children completed the study. Although it took 4.7 weeks for middle ear effusion to resolve in the placebo group, it took only 2.7 weeks in the antibiotic group, which was a statistically significant result. Otoscopic examinations returned to normal 1.4 weeks sooner in the antibiotic group. By day 14, almost 70% of children in the antibiotic group had normal tympanometry versus only 28% of those in the placebo group. By day 60, only 5% of children in the antibiotic group had persistent middle ear effusion versus 24% of those in the placebo group. Conclusions: Antibiotics may be effective in reducing the duration of middle ear effusion as well as the risk of developing persistent middle ear effusion. Reviewer's Comments: Antibiotics were effective in significantly reducing the time until the resolution of middle ear effusion in children with acute otitis media. Antibiotic use also affects the chance of a child with acute otitis media developing persistent middle ear effusion. Given that persistent middle ear effusion has been associated with hearing impairment, antibiotic use may be helpful in improvement in that area as well. Although this should not be read as a call to overuse antibiotics, it does appear that antibiotics may be more useful in the treatment of acute otitis media than some think. (Reviewer-Aaron E. Carroll, MD, MS). © 2014, Oakstone Publishing, LLC

Keywords: Acute Otitis Media, Effect of Antibiotics on Middle Ear Effusion



Effect of New Pneumococcal Vaccine on Sinusitis

Impact of the 13-Valent Pneumococcal Conjugate Vaccine on Chronic Sinusitis Associated With Streptococcus

pneumoniae in Children.

Olarte L, Hulten KG, et al:

Pediatr Infect Dis J 2014; 33 (October): 1033-1036

The incidence of pneumococcal sinusitis decreased after introduction of the pneumococcal 13 vaccine.

Objective: To evaluate the impact of the new pneumococcal conjugate 13-valent vaccine on chronic bacterial sinusitis in children. Methods: The authors reviewed data from cultures at Texas Children's Hospital that were obtained from ear, nose, and throat-acquired endoscopic suctioning of the sinuses. Children previously diagnosed with chronic sinusitis were included in this study. Pneumococcal isolates were serotyped to look at specific strains that were included in the vaccine before and after introduction of the pneumococcal 13 vaccine. The authors also reviewed susceptibility testing for resistance. Results: 652 children had endoscopic sinus surgery and cultures performed. Of these, 245 were in the pre-pneumococcal 13 era and 407 were after introduction of the pneumococcal 13 vaccine. A total of 22% of the pre-pneumococcal vaccine group had a positive pneumococcal culture, and 9% of the post-pneumococcal 13 vaccine group had a positive culture. In the beginning of the study in 2009, there were 19 cases of pneumococcal sinusitis. By 2013, these rates dropped to 5. There were other comorbid conditions, which included ear infections, allergic rhinitis, asthma, and gastroesophageal reflux. In the pre-pneumococcal 13 vaccine group, 33% had serotypes that were included in the pneumococcal 13 vaccine. There was a 30% drop in the number of isolate vaccine serotypes after the pneumococcal 13 vaccine was started. The most common serotype reduced was the pathogenic 19A. Resistance to penicillin was most commonly found in the 19A serotype; as the 19A rates dropped, so did the overall resistance rates. Some children had poly-organism growth, which included nontypeable Haemophilus influenzae and Moraxella catarrhalis and Staphylococcus aureus. Conclusions: Pneumococcal sinusitis decreased after introduction of the pneumococcal 13 vaccine. Reviewer's Comments: Many years ago in a review in Practical Review in Pediatrics, a study warned about the rise of 19A serotype after the pneumococcal 7 vaccine was introduced. The concern was that as the vaccine decreased the top 7 strains, non-vaccine strains would increase and fill the void. The 19A represented a more resistant serotype. The 13-valent vaccine was effective to reduce this serotype and its drug resistance. The vaccine was designed to prevent bacteremia and meningitis infections. The benefit of reducing bacterial sinusitis is a bonus. History can always repeat itself with another serotype replacing the pathogenic 19A. Surveillance is key to help determine which serotypes will be added to the next version of the pneumococcal vaccine that is currently being studied. (Reviewer-Charles I. Schwartz, MD). © 2014, Oakstone Publishing, LLC

Keywords: Chronic Bacterial Sinusitis, Pneumococcal Sinusitis, Effect of Vaccine



Risk Factors for Postop Tympanostomy Tube Obstruction

Risk Factors Associated With Postoperative Tympanostomy Tube Obstruction.

Conrad DE, Levi JR, et al:

JAMA Otolaryngol Head Neck Surg 2014; 140 (August): 727-730

In a recent study evaluating risk factors for ear tube obstruction after myringotomy and tympanostomy tube placement, 10% of ear tubes were clogged after placement, and the most common fluid associated with occlusion was serous.

Objective: To review the risk factors for ear tube obstruction after myringotomy and tympanostomy tube placement. Design: Retrospective review of the records of pediatric patients who underwent myringotomy and tympanostomy tube placement from 2007 to 2011 at the Alfred I. duPont Hospital for Children in Delaware. Records of patients who had identical fluid types in each ear were included. Methods: 248 patients met the inclusion criteria. Demographics of the patients and type of middle ear fluid were recorded. Specific eardrops were given based on the type of fluid. If it is was mucoid or purulent, patients were given ciprofloxacin/dexamethasone drops for 7 days. If it was serous or no fluid, sulfacetamide drops were given for 3 days. Tube obstruction was determined at the 3-week postoperative visit. Results: Of 248 patients, 61% were boys and mean age was 5.5 years. Half of the patients were aged <2 years. A total of 207 patients had tubes placed only, 28 had tubes placed and adenoids removed, and 13 had tubes placed and adenotonsillectomy. Fluid types were as follows: 43% no fluid, 38% mucoid, 10% serous, 5% purulent, and 4% mucopurulent. Of the patients, 10.6% had blockage of ≥1 tubes. Cases with any type of fluid were more likely to obstruct than those with no fluid. Serous fluid had the highest rate of tube blockage at 20%. Patients with no fluid were 3 times more likely to have patent tubes at follow-up. There was no statistical significance as related to demographics or procedures done in addition to tube placement. Patients aged <2 years versus the older group had an obstruction rate of 13.7% versus 7.3%. The younger group was more likely than the older group to have a second set of tubes (18% vs 4%, respectively). Conclusions: 10% of ear tubes were clogged after placement, and serous fluid was the most common fluid associated with occlusion prior to surgery. Reviewer's Comments: Pediatricians need to be aware that nearly 1 out of 10 patients may have occluded tubes after surgery. Many pediatricians will see patients prior to their postoperative visit for sick or well visits, and it important to visualize the patency of the tube. The authors hypothesized that the presence of the steroid with the antibiotic and the longer length of treatment given to patients with the non-serous fluid type could have been the reason for non-blockage. There have been previous studies for chronic draining ears. The ciprofloxacin/dexamethasone combination was superior to antibiotics alone. Additional studies may be needed to see if all patients given the longer course with steroid/antibiotic would have a reduction in the rate of obstruction for all pre-operation fluid types. (Reviewer-Charles I. Schwartz, MD). © 2014, Oakstone Publishing, LLC

Keywords: Tympanostomy Tube, Obstruction, Myringotomy


© 2014, Oakstone Publishing, LLC • 2700 Corporate Drive • Suite 100 • Birmingham, AL 35242 205-991-5188 • 1-800-633-4743 • www.practicalreviews.com • [email protected]

Printed copy is provided for your convenience.

To earn credit, quiz must be taken online.

Otolaryngology—Head & Neck Surgery

Volume 24 Number 11: December 30, 2014 Quiz Code: 33089P

To complete the quiz for credit, log onto www.practicalreviews.com. If you have not previously registered at the site, click on “New Customer Registration” located in the right navigational bar and follow the directions. You will need your account number (located above your name on the Table of Contents) and your mailing zip code. To access the quiz, click on the “Take a Quiz” link located in the right navigational bar. Enter the quiz code and select your answers. Once you click Submit, you will receive immediate notification of your score.

Quiz Questions

1. The entire shaft of the laser-safe endotracheal tube is resis-tant to ignition and flammability when making contact with a CO2 laser beam. Circle one: True False

2. In patients with oral squamous cell carcinoma, the propensity for nodal metastases is the same for floor of mouth tumors and oral tongue tumors. Circle one: True False

3. Most patients using jaw opening devices in tandem with a structured exercise regimen for the treatment of trismus have an improvement in maximal interincisal opening at 3 months. Circle one: True False

4. In a study by Young et al, >80% of the advanced laryngeal cancer patients who receive tracheostomy before chemo-radiation can be decannulated after treatment is completed. Circle one: True False

5. Among patients receiving modern intensity-modulated radi-ation therapy for the treatment of locally advanced head and neck cancer, TSH levels do not need to be checked beyond 6 months after completing treatment. Circle one: True False

6. Radiotherapy with concurrent chemotherapy is the standard of care for head and neck carcinoma from unknown primary tumors. Circle one: True False

7. In patients undergoing total laryngectomy, pectoralis flaps incorporated into the suture line definitively reduce the rates of postoperative pharyngocutaneous fistula formation. Circle one: True False

8. Among early stage oral cancer tumors, tumor grade is not associated with positive margins after surgical excision. Circle one: True False

9. The square defect is the worst type of defect for minimizing the stress and strain associated with a classical rhomboid flap. Circle one: True False

10. For patients who are ventilated with an endotracheal tube, early tracheostomy is not associated with a reduced risk of mortality. Circle one: True False

11. Contrast-enhanced ultrasound has a diagnostic odds ratio of 34.7 in the assessment of malignancy in thyroid nodules. Circle one: True False

12. After excision of cervical sympathetic chain schwannomas, first-bite syndrome occurs in <1% of cases. Circle one: True False

13. Outside of the United States, there are no clear standardized instruments to measure overall function in patients with head and neck cancer. Circle one: True False

14. Antibiotics may be effective in reducing the duration of middle ear effusion in children with acute otitis media. Circle one: True False

15. The incidence of pneumococcal sinusitis in children decreased after introduction of the pneumococcal 13 vaccine. Circle one: True False

16. In children undergoing myringotomy and tympanostomy tube placement, purulent and mucopurulent fluids at the time of sur-gery were the most common types of fluids that led to obstruc-tion of ear tubes postoperatively. Circle one: True False

© 2014, Oakstone Publishing, LLC • 2700 Corporate Drive • Suite 100 • Birmingham, AL 35242 205-991-5188 • 1-800-633-4743 • www.practicalreviews.com • [email protected]

Otolaryngology—Head & Neck Surgery Answers for Volume 24 Number 10: December 15, 2014

Quiz Code: 33042P

1. T A diagnosis of radiographic extracapsular extension

of metastatic lymph nodes in oropharyngeal carcinoma is shown to have a negative impact on overall survival.

2. T In patients with Bell palsy, the addition of intratympanic steroids to standard treatment with systemic steroids and antiviral medications appears to shorten the recovery time.

3. F Among the various surgical approaches to thyroid-ectomy, microscope-assisted thyroidectomy is definitively superior for reducing complication rates.

4. F As a treatment modality for early stage glottic squa-mous cell carcinoma, transoral laser microsurgery appears to confer significantly worse survival outcomes compared to that seen with radiation therapy.

5. T Following total thyroidectomy, the risk of postoperative hypocalcemia is increased in patients with a lower intact parathyroid hormone level, female gender, and a diagnosis of thyroid malignancy.

6. T Treatment with topical intranasal steroid spray may improve the resolution rate of otitis media with effusion associated with adenoid hypertrophy.

7. F After osteocutaneous free flap surgeries, hospital dis-charge rates to rehabilitation facilities are similar for patients aged ≥70 years and for those aged <70 years.

8. T For decontaminating flexible fiberoptic laryngoscopes, Cidex soaks can reduce bacterial contamination to a level similar to that achieved using reprocessing machines.

9. F Dilatations and adjuvant anti-inflammatory agents can cure subglottic stenosis in patients with Wegener granulomatosis.

10. F Hispanic race is not a risk factor for the occurrence of angioedema.

11. F Laryngotracheal stenosis surgery approached endo-scopically always requires that it be managed as an in-patient surgery.

12. F In patients with parotid gland lesions, 5 "high prob-ability" features seen on MRI are associated with a sensi-tivity >80% for identifying pleomorphic adenoma.

13. T The incidence of venous thromboembolism in the perioperative period does not differ significantly for hos-pitalized otolaryngology patients who do or do not receive chemoprophylaxis.

14. F Following implementation of duty hour regulations, there has been a definite decrease in the number of key indicator cases performed by otolaryngology residents.

15. T In young infants, wheezing is almost 3 times more likely to occur in children with vitamin D insufficiency than in normal controls.

16. F For patients with low-volume follicular lymphoma, giving maintenance Rituxan on a regular schedule is significantly more efficacious than is treatment with Rituxan given only at disease progression.

particular care should be taken so as not to contact the ... - hns - december... · subsite, tumor...

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