Otolaryngology Literature Research Articles

A Review of the Diagnosis and Management of Reflux Disease: Toward Creating a Clinical Protocol for the Otolaryngologist

Objectives: Reflux disease, including gastroesophageal reflux disease (GERD) and laryngopharyngeal reflux (LPR), is an extremely common condition which is diagnosed and treated routinely in an otolaryngology practice. There is great variability in the methods of both diagnosis and treatment amongst otolaryngologists. Our aim is to review current clinical practice guidelines on reflux disease, to identify areas of agreement and of controversy, and to begin to work toward a clinical protocol for reflux disease for the otolaryngologist. Study Design: Literature review with discussion. Methods: A PubMed search was performed looking for clinical practice guidelines on either GERD or LPR. Five hundred and seventy articles were identified and the most clinically relevant practice guidelines were selected. Results: Thirteen key articles were identified. Eleven of these come from the gastroenterology literature, and none of them come from the otolaryngology literature. There appears to be a consensus on empiric medication trial as first line therapy for presumed uncomplicated GERD and on prioritizing early identification of patients with severe disease complications. Areas of controversy include the definition of GERD and LPR, which diagnostic algorithm to use in which patient, and the long term management of medical therapy. Conclusions: While there are many clinical aspects of reflux disease that still remain a mystery, there is enough literature to support a rudimentary clinical protocol at this time. As further data become available from outcomes measurements, such a protocol may result in improved quality and standardization. A Review of the Diagnosis and Management of Reflux Disease: Toward Creating a Clinical Protocol for the Otolaryngologist

Mullerectomy for Upper Eyelid Retraction in Graves' Orbitopathy

Conclusions: Muller’s muscle is a sympathetically innervated muscle that inserts upon the upper border of the superior tarsal plate and provides 2 mm of lift. Eyelid retraction is the most common eyelid abnormality in GO. Upper eyelid surgery involves lengthening or weakening of Muller’s muscle and/or the levator aponeurosis. The mullerectomy procedure has received little attention in the otolaryngology literature. Mullerectomy is a safe and effective procedure that has been shown to improve upper eyelid position, lagophthalmos, exposure keratopathy, and patient comfort. The failure rate is low and is most often due to undercorrection. Otolaryngologists should consider mullerectomy as an option for addressing upper eyelid retraction in GO. Mullerectomy was performed via a posterior conjunctival approach. Operative steps include: •Evert the upper eyelid to expose the superior palpebral conjunctiva (Figure 2). •Incise the conjunctiva at the superior tarsal border. •Dissect the conjunctiva from Muller’s muscle by raising a conjunctival flap (Figure 3). •Incise Muller’s muscle above the superior tarsal border. •Dissect Muller’s muscle from the levator aponeurosis (Figure 4). •Excise Muller’s muscle. •Close the conjunctival incision with absorbing sutures.

Endoscopic Anatomy of the Maxillary Strut: A Cadaveric Study

Background: Over the last two decades, the traditional boundaries of endoscopic transnasal surgery have been expanded to access lesions of the anterior skull base. Recent advancements in endoscopic transnasal approaches to the skull base raise the possibility of extending these approaches further. In this cadaveric study, we evaluate the feasibility and extent of exposure of the “maxillary strut” through an endoscopic transnasal approach. The “maxillary strut” is a term that is found sporadically in the neurosurgery and otolaryngology literature to describe the fragment of bone located between the superior orbital fissure and the foramen rotundum. The removal of the maxillary strut theoretically allows access to the middle cranial fossa.

Paranasal Sinuses Fungal Balls in Children

AbstractObjectiveRare cases of fungal balls of paranasal sinuses in children. No case has been reported in young children so far. However, allergic aspergillosis has been reported in young children.MethodA case report of 2 cases of fungal balls of paranasal sinuses in children and review of the current literature concerning fungal balls of paranasal sinuses in children are presented.Result2 cases of fungal balls in paranasal sinuses were diagnosed in children of 9 and 10 years respectively. Both of them presented with nasal obstruction and eye signs provisional diagnosis was based on CT scan findings. FESS was done and fungal balls were subjected to histopathological examination to rule out invasive fungal sinusitis, fungal staining and culture were done which confirmed the diagnosis of Aspergillosis.ConclusionTo our knowledge this is the first case report of fungal balls in PNS in children in otolaryngology literature. Both the patients were males with age of 9 and 10 years respectively.

Miller fisher syndrome presents as an acute voice change to hypernasal speech

The authors describe a 38-year-old man who presented with hypernasality, perioral and acroparesthesia, dyspnea, and dysphagia. Further evaluation revealed a diagnosis of Miller-Fisher syndrome (MFS). MFS is a variant of Guillain-Barré syndrome previously described in neurology and critical care journals; however, there is a paucity of work concerning this disease in the otolaryngology literature. An acute change in voice usually occurs secondary to inflammatory processes as seen after intubation and infection, but can occur as part of a more complex disease entity such as Guillain-Barré or Miller-Fisher syndrome. As such, clinicians should consider this in their evaluation of rhinolalia aperta.

Nasal dressings after endoscopic sinus surgery: what and why?

Nasal dressings are commonly used following endoscopic sinus surgery in an attempt to prevent ongoing bleeding and to modulate the wound healing process. Experience with nasal dressings in the otolaryngologic literature spans more than half a century; however, despite this, there is still little agreement between surgeons on the optimal choice of nasal dressings following endoscopic sinus surgery, or whether nasal dressings are required at all. This paper briefly reviews the past research and examines recent advances in the area of nasal dressings. The ideal nasal dressing is one that is absorbable, hemostatic and improves healing. Although a number of currently available materials may address one of these features, none address all. Currently available dressings that achieve hemostasis worsen wound healing outcomes. However, recent research shows promise with microporous polysaccharide hemospheres and chitosan gel having promising effects on hemostasis, and chitosan gel showing a significant adhesion prevention effect. The sinus surgeon must be aware of the potential advantages and limitations of currently available nasal dressings. The area of wound healing and adhesion prevention remains an area of active research and more prospective controlled trials are needed to define any benefits biomaterials may have.

Do abstracts in otolaryngology journals report study findings accurately?

Objectives Although published abstracts have the advantage of being prominent and concise, their quality in the otolaryngology literature has not been studied. We sought to understand the limitations of relying on abstracts as the sole source of information about published research. In addition, we sought to identify specific opportunities for improving the quality of published articles and their associated abstracts. Methods Studies of original research published in four major otolaryngology journals from January 2008 to June 2008 were included. Each study article and abstract was reviewed separately for 12 domains relating to study design, results, and conclusions. Good inter-rater reliability was established as part of the validation process. Results Four hundred eighteen articles were identified for study, which included 75 percent clinical research and 25 percent basic science. The most common omissions in the abstract when compared with the complete article were study limitations (91% left out of abstract), geographic location (79%), confidence intervals (75%), dropouts or losses (62%), and harms and adverse events (44%). Conversely, the abstract often included information about research design (99%), sample size (92%), source of the data (81%), and quantitative results (67%). These results did not differ significantly with regard to article type, journal, or level of evidence. Conclusions Readers of otolaryngology journals may form biased or inappropriate conclusions if they read only the abstract of a study, particularly with regard to study limitations, adverse events, and subject dropouts or losses. These results highlight the perils of using the abstract as a sole source of information.

Mixed Medullary‐Papillary Carcinoma of the Thyroid: A Case Report

With fewer than 40 cases described in the otolaryngology literature, mixed medullary papillary thyroid carcinoma represents a rare but phenotypically distinct tumor. While isolated medullary carcinoma may be admixed with normal follicular structures, true mixed carcinoma displays morphological and immunological characteristics of medullary and papillary carcinoma within a single lesion. We report the case of a 73-year old woman initially evaluated for a multinodular thyroid goiter. The patient denied a family history of medullary thyroid carcinoma or other endocrine neoplasms. Fine needle aspiration of a nodule of the thyroid isthmus suggested a follicular neoplasm with abundant Hurthle cells and colloid present. Considering these findings, the patient underwent a left thyroid lobectomy with isthmusectomy. Histopathological analysis of the surgical specimen revealed a medullary thyroid carcinoma measuring 0.4 cm in size. Within this lesion, a distinct focus of papillary thyroid carcinoma, follicular variant, measuring 0.1 cm was also identified. Mixed medullary-papillary thyroid carcinoma is a rare clinical entity but merits consideration in the differential diagnosis of thyroid nodules particularly in patients with a family history of thyroid malignancy. The foundation of treatment of this lesion is total thyroidectomy with central compartment node dissection in the clinically N0 neck and dissection of levels II-VII in the node-positive neck.

Laryngotracheobronchitis complicated by spontaneous pneumomediastinum

Spontaneous pneumomediastinum (SPM) is an unusual clinical entity that most frequently follows episodes of increased intrathoracic pressures. While typically a benign condition, potentially fatal complications of SPM must be considered and ruled out with each case. We aim to present the first case of croup-associated SPM in the otolaryngology literature and to discuss clinical, diagnostic and management principles. Days following the diagnosis of viral croup, a 7-year-old asthmatic girl presented with unstable vital signs and severe SPM. The patient was urgently taken to the operating room for an endoscopic airway evaluation, which revealed only a mild bacterial croup superinfection. Conservative treatment with inpatient monitoring and antibiotic therapy successfully resolved the episode. SPM should be immediately considered in the differential diagnosis of any patient presenting with cervical emphysema, especially in association with asthma, cough or strenuous activity. Following exclusion of other causes of SPM, conservative and supportive therapies are the mainstays of SPM management.

An Evidence-Based Review of Endoscopic Frontal Sinus Surgery

Endoscopic approaches to treat frontal sinus disease gained in popularity over the past 20 years with a plethora of published studies that emphasize the high success rate of such surgeries. This study was designed to determine the levels of clinical evidence in the otolaryngology literature that address the efficacy of endoscopic approaches in the management of frontal sinus disease including frontal sinusitis. Twenty-three publications that reported the surgical outcomes of endoscopic approaches to treat frontal sinus disease were reviewed. Data were collected regarding the study design, operative technique, number of patients, duration of follow-up, diagnostic method, surgical success rate, and method(s) used to assess surgical outcome. The study designs were a retrospective case series without control (16 articles), prospective case series without control (3 articles), and retrospective case series with internal control (4 articles). Eighty-three percent of the published articles provide an evidence level of IV, while the remaining 17% provide an evidence level of III. The surgical technique was described as frontal sinusotomy (n = 4), frontal sinusotomy or frontal sinus drillout (n = 1), frontal sinus drillout alone (n = 1), endoscopic modified Lothrop procedure (n = 9), Draf types I, II, or III (n = 6); trans-septal frontal sinusotomy (n = 1); and frontal sinus rescue procedure (n = 1). The mean number of subjects was 44, and the average follow-up period was 23.6 months. Surgical success rate ranged from 50 to 100%. Despite the number of reports in the literature that address the surgical outcome of endoscopic approaches for treatment of frontal sinus disease, the majority of these studies have a small population size, short follow-up period, and provide a low clinical evidence level.

Vocal Cord Dysfunction in Amyotrophic Lateral Sclerosis

We describe 4 patients with amyotrophic lateral sclerosis (ALS) and glottic narrowing due to vocal cord dysfunction, and review the literature found using the following search terms: amyotrophic lateral sclerosis, motor neuron disease, stridor, laryngospasm, vocal cord abductor paresis, and hoarseness. Neurological literature rarely reports vocal cord dysfunction in ALS, in contrast to otolaryngology literature (4%-30% of patients with ALS). Both infranuclear and supranuclear mechanisms may play a role. Vocal cord dysfunction can occur at any stage of disease and may account for sudden death in ALS. Treatment of severe cases includes acute airway management and tracheotomy.

Otophyma: a rare and frequently misdiagnosed entity

Otophyma is the term used for sebaceous gland hypertrophy and hyperplasia of the ear. It is usually the end stage of rosacea—a common, chronic, cutaneous disorder of unknown etiology. We hereby present a rare case of otophyma with its clinical features, its etiology, diagnosis, and review of medical and surgical therapy. This patient remained undiagnosed and mismanaged for many years before she was finally diagnosed with this rare condition and successfully managed by surgical technique. To our knowledge, this is the second case of otophyma presented in the otolaryngological literature.

Reduction in surgical innovation, 1988 to 2006

Objective We hypothesize that increasing regulation of human subject research has reduced the number of published reports of surgical innovation in otolaryngology. Study Design A systematic review of a predetermined subset of otolaryngology literature. Methods We randomly selected half of the articles published in 1988 and 2006 in three prominent journals. After identifying information was concealed, abstracts were classified independently by two authors into three groups: innovation, modification, or neither. Disagreements were resolved by a third author who read the entire article. Proportions were compared with χ 2 analysis. Results The proportion of articles classified as innovation or modification decreased significantly from 67 of 367 (18.3%) in 1988 to 59 of 548 (10.8%) in 2006 ( P = 0.001). The elimination of radiology and pathology quiz cases yielded similar results: 11.1 percent vs 18.9 percent, P = 0.001. Innovation or modification in animal model research also decreased (0.9% vs 3.8%, P = 0.003). Overall, only 4 articles were actually classified as true innovation. Conclusions The frequency of true innovation was low in both years, but articles that described surgical modifications decreased significantly over this 18-year period. One reason may be increased administrative barriers for clinical research approval. Although our analysis cannot determine cause and effect, it is an important finding that deserves further study.

Endoscopic Transnasal Transethmoid Ligation of the Anterior Ethmoid Artery

The current otolaryngologic literature is lacking in basic science investigation regarding endoscopic anterior ethmoid artery (AEA) ligation as part of the armamentarium for epistaxis control. This investigation provides the anatomic rationale for endoscopic ligation of the AEA in the surgical treatment of epistaxis. In addition, it provides tools for identification of this vessel during routine endoscopic sinus surgery. This descriptive cadaver study investigates the feasibility of endoscopic transnasal transethmoid dissection; anatomic description; and clip ligation within the periorbital space of 16 AEA specimens. A careful assessment for skull base penetration and disruption was performed. All 16 anterior ethmoid arteries were readily identified and successfully clipped. The anatomy was carefully observed and described for each specimen, and no inadvertent skull base penetration occurred. This study confirms that endoscopic ligation of the AEA is a safe and feasible technique for the control of epistaxis. Additionally, this anatomic knowledge is beneficial during routine endoscopic sinus surgery if AEA injury should occur. Further evaluation is necessary for clinical application of this technique in the treatment of epistaxis.

Bisphosphonate‐related osteonecrosis of the skull base

Bisphosphonate-related osteonecrosis of the jaw (BRONJ) is reported in up to 18.6% of patients treated with intravenous bisphosphonates and can result in significant morbidity. Most cases are managed by oral surgeons with only a handful of reports appearing in the otolaryngology literature. We present a unique case of extensive BRONJ involving the maxilla, sinuses, and skull base, complicated by sinusitis and an intracranial abscess. This is the first description of BRONJ involving the skull base. The pathogenesis and management of this process are reviewed.

Progressive Mixed Type Hearing Loss in an Adult Male with Osteopetrosis

• Notably: • There are two case series in the Otolaryngology literature, but both are restricted to the infant and juvenile forms of the disease. • There is one large case series relating to the adulttype disease, but it is in the Orthopedics literature and only mentions hearing loss in passing. • There are two similar case reports in the international Otolaryngology literature relating to adulttype osteopetrosis and its otologic consequences.

Vacuum‐assisted closure therapy in the management of head and neck wounds

The wound vacuum-assisted closure (VAC) has been used in many areas of surgery to promote healing and facilitate secondary reconstruction. Until recently, this treatment modality was overlooked in the otolaryngology literature, and the authors propose that its use should be routine in the treatment of complex head and neck wounds. An unbiased cohort study without conflict of interest at two tertiary care centers. All patients treated by the authors presented with complex head and neck wounds from 2005 to 2007 and were subjected to wound VAC therapy. The wound VAC dressing was changed every 72 hours, and the wound etiology, wound site, history of chemotherapy and radiation, hospital duration, gender, outcome, and ancillary procedures were recorded. Nineteen patients with 33 wounds were treated using VAC therapy. Eighty-four percent of these patients healed completely without the need for further surgical intervention. The mean age of this cohort was 63.2 years, with a range of 48-75 years. Males far outnumbered females in this study (17:2). Outpatient therapy commenced at discharge after an average of 11.4 days following a hospital stay ranging between 5 and 28 days. Adjunctive procedures performed during and after VAC therapy included hyperbaric oxygen treatment, dermal grafts, salivary diversion, and regional flap reconstruction. This study shows the applicability and versatility of vacuum-assisted wound closure in the head and neck. Based on our results the authors feel that this mode of therapy should be a routine part of the Otolaryngologist's armamentarium for the treatment of complex and refractory head and neck wounds.

Type VIII oral–facial–digital syndrome. A rare case series of a forgotten syndrome subtype

Summary The oral–facial–digital (OFD) syndrome is a constellation of clinical syndromes having similar characteristics like involvement of cleft lip, cleft palate, tongue clefts or hamartomas, hypertelorism and limb abnormalities which include hand, foot malformations, and central abnormalities. OFD type VIII shares a special place in OFDS due to its X linked recessive nature of transmission and very few cases have been reported of this syndrome (only one series by Edward 1988). In view of very limited number of such reports in Otolaryngological literature, we intend to describe this rare case series of type VIII OFDS for recognition among pediatric otolaryngologists so that early diagnosis and intervention can be done. We describe three cases of OFD VIII to highlight their diverse manifestations, diagnostic workup and management issues.

Spontaneous Nasal Septal Perforation With Antiangiogenic Bevacizumab Therapy

Otolaryngologists should be made aware of a newer cause of nasal septal perforations resulting from the more recent antiangiogenic therapy used to treat malignancies. This case describes a 52-year-old white woman who developed a spontaneous nasal septal perforation after given the antiangiogenic drug, bevacizumab, for metastatic ovarian cancer treatment. Bevacizumab is a recently developed monoclonal antibody against vascular endothelial growth factor receptor used to inhibit angiogenesis. The patient was ultimately treated with a nasal septal button with good symptom relief. This case documents the first report in the otolaryngology literature describing this new etiology for nasal septal perforations.

Randomized controlled studies and the treatment of middle-ear effusions and tonsillar pharyngitis: How random are the studies and what are their limitations?

To determine the applicability and external validity of randomized control studies (RCTs) in the light of patient susceptibilities and vulnerabilities to the sequelae of otitis media with effusion (OME) and tonsillar pharyngitis (T&A) and the composition of their cohorts. RCTs for OME and T&A were analyzed to determine which intrinsic and extrinsic susceptibilities to the otolaryngic disease and its sequelae were included or excluded and the composition of the cohort. A Medline and a Science Direct search were performed for all RCTs concerning OME and T&A through 2007. The articles selected to be included in this study are the OME RCTs that reported language and/or hearing outcomes and the T&A RCT studies in which the outcome measure was infection, alleviation of airway obstruction, and/or quality of life. These were analyzed for their inclusion or exclusion of intrinsic and extrinsic susceptibilities to the otolaryngic disease and their sequelae and the composition of the cohort. The pertinent otolaryngologic literature was assessed to determine applicable risk factors. The analysis of the inclusion or exclusion of risk factors showed that for OME 0 percent were included and 16 percent were excluded, and there were no data for 84 percent. The T&A findings were similar in that 1 percent of risk factors were included, 8 percent excluded, and there were no data for 92 percent. Both the OME and the T&A cohorts data were similar in that approximately half of the suitable candidates completed the study; 25 percent of the OME and 13 percent of the T&A enrolled subjects were either withdrawn or placed into a different experimental group. On the average, with data available, it took 4.6 years to recruit the OME sample and 5.5 years to recruit the T&A sample. The results of RCTs for these conditions are only applicable to narrowly defined and highly circumscribed populations. They cannot be generalized to the entire patient population because of their limited external validity. Future RCT protocols should be designed to control for the intrinsic and extrinsic susceptibilities that result in a propensity to acquire the disease and/or an exacerbation of the disease's sequelae. These studies would determine the most effective strategies for preventing disorders and/or their deleterious sequelae.