Download Canal Wall Reconstruction

Canal Wall Reconstruction--Titanium May Be an Option
Use of Titanium in Repair of External Auditory Canal Defects.
Black B:
Otol Neurotol 2009; 30 (September 2): 930-935
Titanium is easy to use and can be an effective method of canal wall reconstruction.
Background: Canal wall reconstruction is a common theme in mastoid surgery, especially in cases in which
cholesteatoma is concerned. Several techniques have been described over the years. Although many are still
practiced, others have not stood the test of time.
Objective: To describe the technique of canal wall reconstruction using titanium.
Design: Retrospective review.
Participants: The author has used the described titanium sheeting in a total of 56 patients between 2006 and
2008. Average follow-up was 19 months, and mean patient age was 36 years (range, 14 to 58 years).
Methods: A surgical technique using a thin sheet of titanium to reconstruct the external auditory canal is
described. The canal defects are classified into deep external auditory canal, lateral canal wall, and anterior
wall. Principles the author covers are creating slots in nearby bone to keep the titanium from moving and,
whenever possible, covering the metal with natural tissue such as cartilage. In cases involving a very large
defect, a vascular flap should be considered. The author includes drawings as well as intraoperative pictures
demonstrating the technique.
Results: Most reconstructions were small attic defects. Slightly more than half the cases were primary surgery.
In a total of 38 cases, the author underwent a planned second-stage surgery, and 6 of these patients were
found to have residual disease. None were found to have disease that penetrated or outflanked the titanium.
Conclusions: Titanium is easy to use and can be an effective method of canal wall reconstruction.
Reviewer's Comments: Cholesteatoma surgery is notorious for delayed complications, and it remains to be
seen if this technique will stand the test of time. Other issues should also be weighed by surgeons considering
this technique. First, MRI and CT are routinely used for cholesteatoma surveillance. Although titanium is
compatible with both these modalities, it also produces an artifact in the very area where a cholesteatoma is
likely to occur. Second, infection is often an issue in patients requiring mastoid surgery. Foreign material such
as titanium could be a substrate for biofilm formation, making future infections more difficult to treat. Finally,
titanium strongly osteointegrates, which could make it difficult to remove this material in the future should it
become the source of problems. (Reviewer-Benjamin T. Crane, MD).
© 2010, Oakstone Medical Publishing
Keywords: Cholesteatoma, Mastoidectomy, Canal Wall Reconstruction, Titanium
Print Tag: Refer to original journal article
Vestibular Schwannomas--Tumors Smaller, Surgery Less Common
Trends in the Management of Vestibular Schwannomas at Johns Hopkins 1997-2007.
Tan M, Myrie OA, et al:
Laryngoscope 2010; 120 (January): 144-149
Vestibular schwannomas are now being discovered at smaller sizes. The role of observation and
radiation are increasing and the role of surgery is decreasing.
Background: The nature of acoustic neuroma or vestibular schwannoma (VS) management has changed over
the previous decades. At the advent of VS surgery 70 years ago, tumors tended to be very large at
presentation in patients with severe neurological deficits. In this early era, surgery was potentially lifesaving,
but it also carried a significant risk of mortality. Even in the more recent decade, changing technology and
understanding of the natural history of this disease have changed our management.
Objective: To review VS treatment trends over an 11-year period at Johns Hopkins.
Design: Retrospective review.
Participants: 835 patients diagnosed with a unilateral VS between 1997 and 2007.
Methods: Participation required 2 visits within a year of presentation, and patients had to have no prior
treatment. A multivariate regression analysis was also performed.
Interventions: Patients underwent either surgical resection, stereotactic radiation therapy (SRT), or
observation.
Results: Mean age was 53 years, and mean tumor size was 19 mm. Asymmetric hearing loss occurred in
90%. Approximately 75% opted for surgery, 21% had observation, and 3.6% underwent SRT. In 185 patients,
the treatment was unknown; these patients tended to be older with smaller tumors. Patients choosing
observation had tumors >1 cm smaller than those undergoing surgery. There was no difference in tumor size
between surgery and SRT patients. Hearing loss progressed in >95% of patients who chose radiation or
surgery versus 81% of those who were observed. Over the study period, there was a trend away from surgery.
In the first 2 years, 89% underwent surgery; this number decreased to 65% in the final 2 years. During these
periods, observation increased from 9.9% to 30%, and tumor size decreased from 2.3 to 1.9 cm. A multivariate
regression analysis indicated that observation was favored with older age and later year of presentation, while
those with larger tumors and more hearing loss favored surgery.
Conclusions: Vestibular schwannomas now present at smaller sizes with SRT, and observation is becoming
more frequent, while surgery is becoming less frequent.
Reviewer's Comments: I was surprised at the relatively large mean tumor size in this study (approximately 2
cm), and the high percentage of patients who chose surgery. In my experience, most schwannomas present
smaller. The reason for this may be the selection criteria that required 2 visits within the first year. Many
patients who are sent to a surgeon for a very small tumor are asked to get a follow-up MRI in a year, and those
patients would not have been included. This study may underestimate the number of patients receiving
radiation since some patients never consult a surgeon before therapy. This paper identifies some interesting
trends in the management of VS, notably that tumors are now being discovered smaller and are more likely to
be observed than be surgically removed. Radiation is also becoming more popular. (Reviewer-Benjamin T.
Crane, MD).
© 2010, Oakstone Medical Publishing
Keywords: Acoustic Neuroma, Vestibular Schwannoma, Radiation, Hearing Preservation, MRI
Print Tag: Refer to original journal article
New Device for Rehabilitation of Single-Sided Deafness
Preliminary Evaluation of a Novel Bone-Conduction Device for Single-Sided Deafness.
Popelka GR, Derebery J, et al:
Otol Neurotol 2009; October 9 (): epub ahead of print
A new device for single-sided deafness offers some promise in that it is able to reproduce a broad
frequency range and does not require surgery.
Background: There are approximately 60,000 new cases of single-sided deafness (SSD) per year in the
United States. Traditional hearing aids are generally not beneficial for these patients because they do not have
an adequate hearing reserve. In the past, contralateral routing of sound (CROS) hearing aids were used, but
these are often poorly tolerated by patients. Bone-anchored sound processors have gained momentum. This
paper presents a new device that delivers bone-conducted sound to the teeth in the form of vibration.
Objective: To evaluate a novel bone-conduction device.
Participants: 12 individuals with normal hearing and 5 patients with SSD.
Methods: These experiments were designed to assess oral health, auditory performance, and physical
comfort. Dental wear was measured using human molars in a simulation representing 1.5 years of use. To
assess auditory performance, 12 individuals with normal hearing and 5 subjects with SSD were evaluated.
Pure tone audiometry, speech discrimination, and Hearing in Noise Tests (HINT) were performed. Physical
comfort was determined by having subjects wear the oral appliance and a behind-the-ear device for a 2-day
period. Patients rated the devices on a 6-point scale.
Results: The devices did not produce significant dental wear and were less abrasive than standard electric
tooth brushes. Auditory performance demonstrated that the device was able to reproduce frequencies from
250 to 12,000 Hz. A minority of subjects found the vibrotactile sensation of the device uncomfortable at very
low frequency. However, the authors note that these low frequencies are probably not necessary to reproduce
since the head shadow effect is not significant at these frequencies. Speech intelligibility through the device
was found to be similar to that from standard audiometry. Preliminary HINT revealed that the SSD patients
were able to improve speech intelligibility by about 37% using the device.
Conclusions: This new device is as comfortable as traditional hearing aids. It also has some potential
advantages in that the microphone placement is optimized, it has a larger frequency range, and no surgery is
required.
Reviewer's Comments: Patients with SSD have many options, but each one has disadvantages. This paper
introduces a new device that is not yet available to patients but will likely become available in some form in the
coming years. Patients with SSD often ask me what the future will hold for hearing restoration. None of us
knows for sure, but, based on these preliminary results, this device does hold promise. (Reviewer-Benjamin T.
Crane, MD).
© 2010, Oakstone Medical Publishing
Keywords: Hearing Loss, Hearing Aid, Single-Sided Deafness, Dental Appliance
Print Tag: Refer to original journal article
Is Genetic Testing Required in Patients With Paragangliomas?
Head and Neck Paragangliomas in Von Hippel-Lindau Disease and Multiple Endocrine Neoplasia Type 2.
Boedeker CC, Erlic Z, et al:
J Clin Endocrinol Metab 2009; 94 (June): 1938-1944
Genetic testing in patients with paragangliomas is useful only in patients with multiple tumors or those
with a family history.
Background: As otolaryngologists, we occasionally encounter paragangliomas. These relatively unusual
tumors can be associated with some known mutations and named syndromes. Those of us who have studied
for board exams relatively recently will remember these syndromes as von Hippel-Lindau disease, multiple
endocrine neoplasia type 2 (MEN2), and neurofibromatosis type 1 (NF1). Our knowledge of human genetics is
rapidly evolving. When we encounter one of these tumors, what kind of genetic tests should be ordered, and
do we need to do a work-up on the patient or their family members for related tumors?
Objective: To describe the incidence of genetic markers in a registry of patients with head and neck
paragangliomas.
Design: Review of tumor registry with genetic testing.
Participants: This study included patients in the European Australian American Head and Neck
Paraganglioma registry as well as 3 European registries; 809 patients were included in the study.
Methods: All registrants provided 10 mL of blood that was used for genetic analyses. Patients were screened
for SDHx disorders, and those with these disorders were excluded. A diagnosis of MEN2, von Hippel-Lindau
disease, and NF1 were based on clinical as well as genetic criteria.
Results: A total of 11 patients with head and neck paragangliomas had mutations suggestive of von HippelLindau disease, which the authors estimate to be 0.5% of the von Hippel-Lindau population. The authors
further estimate that, of those with von Hippel-Lindau disease, 0.8% will have a head and neck paraganglioma.
In addition, there was one case involving the RET gene that suggested MEN2. These patients included 8
women and 4 men, who were diagnosed at a mean age of 28 years. All but one of the von Hippel-Lindau
patients had carotid body tumors, and the RET patient had a jugular paraganglioma. All patients with von
Hippel-Lindau disease had either clinical manifestations or a family history suggestive of this disorder.
Conclusions: These data suggest that genetic testing for von Hippel-Lindau disease, as well as for MEN2 and
NF1, should not be ordered in patients found to have paragangliomas of the head and neck—the reason being
that only a very small percentage of the paraganglioma population will have one of these disorders. Genetic
testing should be ordered only if there is a red flag such as multiple tumors or a family history.
Reviewer's Comments: In the past 7 years, several studies have reported that approximately one third of
pheochromocytoma presentations are caused by germline mutations. The most common susceptibility gene is
von Hippel-Lindau, which is followed by succinate dehydrogenase mutations. There were 31 patients in this
study who had features suggestive of an inherited disorder, but no mutations were found to explain their
tumors. It is likely that there are some still genetic sources of these tumors that are yet to be described.
(Reviewer-Benjamin T. Crane, MD).
© 2010, Oakstone Medical Publishing
Keywords: Paragangliomas, Carotid Body Tumor, Genetic Testing, Von Hippel-Lindau, Multiple Endocrine Neoplasia Type 2
Print Tag: Refer to original journal article
Magnet Retention Problems in CI--Is It More Than an Issue of Flap Thickness?
External Magnet Displacement in Cochlear Implants: Causes and Management.
Posner D, Scott A, et al:
Otol Neurotol 2010; 31 (January): 88-93
Cochlear implant patients with magnet retention difficulty tend to have higher body mass index and
thicker flaps, but flap thinning is not always successful.
Background: For a cochlear implant (CI) to work properly, the head piece magnet must be held against the
magnet in the implant to prevent the head piece from falling off. Magnet retention difficultly (MRD) is defined as
the head piece falling off repeatedly with slight or minor head movements. This problem may also be manifest
as poor communication with the implanted device. This complication has not previously been systematically
reported in the literature.
Objective: To report on a series of CI patients with MRD and to suggest appropriate management.
Design: Retrospective review.
Participants: 11 patients with MRD lasting > 6 weeks after surgery.
Methods: Patients were initially given conservative treatment. After these techniques failed, the flap over the
implant was measured using a 27-gauge needle to puncture the skin and touch the implant. In some patients,
surgical flap thinning was performed through an incision posterior to the site of the internal magnet.
Interventions: Increasing magnet strength, wearing a head band, shaving the hair over the magnet site, and
flap thinning were the interventions used.
Results: MRD lasting >6 weeks occurred in 3% of patients. Average age was 55 years. Body mass index
(BMI) was >30 in 4 patients, and 25 to 30 in an additional 6 patients. These data suggested being overweight
was a risk factor for MRD. Ten of 11 patients had MRD during initial device programming. In 3 cases, scalp
thickness was anticipated to be a problem, and thinned was performed during the implantation surgery.
Patients were initially given stronger magnets, and headbands were recommended, although only 5 patients
used them. Hair was shaved on 3 patients. The skin flap was measured in 8 patients and found to average
6.75 mm (range, 4 to 12 mm). Four patients had surgical flap thinning. Post-revision flap thickness was 4.3 mm
(range, 3.5 to 5 mm). After thinning, 2 patients had significant improvement, and 2 noted only slight
improvement. One patient who underwent flap thinning to 6 mm had a flap 12 mm thick 3 months later. A
disproportionate 45% of the MRD group was African American, and the authors believe thick, wiry hair may
play a role.
Conclusions: MRD may be related to BMI, but other factors such as hair type also may play a role.
Reviewer's Comments: This is the first formal report of a CI complication that is relatively common. Although
increased flap thickness and BMI put patients at risk for MRD, other factors are likely involved as well, such as
the type of hair. I would like to have known the BMI and flap thickness in the non-MRD CI population to be able
to interpret these results. Surgical thinning of the flap is not always definitive as the problem sometimes
continues with a thinner flap, and flaps could thicken after surgery. It is possible that other treatments (such as
steroid injections) that were not discussed may also have a role in MRD treatment. (Reviewer-Benjamin T.
Crane, MD).
© 2010, Oakstone Medical Publishing
Keywords: Cochlear Implant, Hearing Loss, Obesity
Print Tag: Refer to original journal article
Consider Observation for Vestibular Schwannomas
Long-Term Hearing Preservation in Vestibular Schwannoma.
Stangerup S-E, Thomsen J, et al:
Otol Neurotol 2009; October 31 (): epub ahead of print
Observation of vestibular schwannomas with excellent speech discrimination yields hearing preservation
results comparable to the best surgical results.
Background: It has now become standard care in many communities to order an MRI with gadolinium
contrast for patients presenting with asymmetric hearing loss. As a result of these studies, we identify tumors
at an early stage, and many of these small tumors will never experience significant growth. However, it is often
difficult to predict a tumor's future capacity for growth. This leaves us with a dilemma—do we do offer surgery
immediately and take the risk of hearing loss all at once, or do we watch the tumor over time? If we observe,
the hearing might slowly decline, and we could lose the chance for hearing-preservation surgery.
Objective: To report the long-term hearing preservation rate in observed vestibular schwannomas.
Design: Retrospective review.
Participants: 932 Danish patients with unilateral vestibular schwannomas.
Methods: To be included, patients had to have 2 audiograms during the study period. In 97% of patients, the
observation period lasted a year; in 40%, it lasted at least 5 years; and in 11%, it lasted >10 years. Patients
were classified using the modified Word Recognition Scoring (WRS) classification system: Class 0, 100%
discrimination; Class I, 70% to 99%; Class II, 50% to 69%; Class III, 1% to 49%; and Class IV, 0%. Good
hearing was defined as a discrimination of 70% or better. Hearing was also classified using the American
Academy of Otolaryngology–Head and Neck Surgery guidelines. These guidelines rated class A as pure tone
average <30 dB and speech discrimination ≥70%; Class B was <50 dB and at least 50% discrimination; Class
C was >50 dB but <50% discrimination; and Class D was discrimination ≤50%.
Results: Of the 19% of patients with Class A hearing, 51% maintained Class A hearing during the observation
period. Using the WRS classification system of those in class 0 or I, 20% lost Class I after a year; after 5 years,
41% lost Class I speech discrimination; and 48% lost Class I hearing after a decade. Overall, patients starting
with Class I hearing lost 6.6% of their speech discrimination each year. The best prognosis was for those in
Class 0, who had a 69% chance of maintaining class I hearing after 10 years.
Conclusions: Hearing preservation results with observation compare favorably with the expected results after
surgery and radiation.
Reviewer's Comments: This paper provides a convincing argument for observing patients with excellent
speech discrimination and small vestibular schwannomas. These results demonstrate that the hearing
preservation compares favorably with the best surgical hearing preservation results. However, the authors
point out that there are currently no studies that follow hearing >5 years after acoustic neuroma surgery; thus,
the long-term results are difficult to compare. (Reviewer-Benjamin T. Crane, MD).
© 2010, Oakstone Medical Publishing
Keywords: Hearing Loss, Acoustic Neuroma, Vestibular Schwannoma, Surgery, Radiation
Print Tag: Refer to original journal article
Vestibular Symptoms Can Be a Blast
Blast Exposure: Vestibular Consequences and Associated Characteristics.
Hoffer ME, Balaban C, et al:
Otol Neurotol 2009; December 8 (): epub ahead of print
Blast injury can produce persistent dizziness symptoms. It differs from blunt trauma in that headache
symptoms and more constant disequilibrium are more common.
Background: Blast injury is quickly becoming recognized as a source of head trauma. Blast is an event in
which individuals experience a pressure wave prior to hearing the noise. This occurs because the blast is
caused by a supersonic pressure wave that, by definition, travels faster than the speed of sound. The usual
cause of these injuries is explosions in which solid matter does not directly affect the individual.
Objective: To define the vestibular consequences of blast injury.
Design: Retrospective review.
Participants: Inclusion criteria for the study were isolated blast injury with no significant blunt trauma, no open
head injury, and a definitive diagnosis of mild traumatic brain injury. The 146 patients in this study were divided
into acute (≤3 days), subacute (4 to 30 days), and chronic (1 to 12 months) groups.
Methods: All patients underwent a complete physical examination and had a detailed history. Patients
underwent testing, which included an audiogram, rotational chair testing, dynamic posturography, and head
thrust testing. Several standardized questionnaires and cognitive tests were also performed.
Results: Acute group symptoms included dizziness in 98%, but only 4% of subjects had vertigo. One third of
patients had hearing loss, and 72% had headache similar to migraine. Cognitive complaints were reported in
78% of this group. Unlike in blunt trauma, benign positional vertigo (BPV) was uncommon after blast trauma. In
the longer latency presentations, the incidence of dizziness was lower (averaging near 80%), and vertigo was
more common (around 40%). The 3 groups were similar in the prevalence of both headache and hearing loss.
The dizziness was classified into 4 types. (1) Post-blast BPV was similar to clinical BPV. (2) Post-blast
exercise-induced dizziness included unsteadiness, vertigo, and headache elicited by physical exertion. (3)
Post-blast dizziness (PBD) included constant unsteadiness that was worse with challenging conditions such as
optic flow and moving environments, but no vertigo. (4) Post-blast dizziness with vertigo (PBDV) included
constant unsteadiness accompanied by episodic vertigo. Headache was common in both PBD and PBDV.
Post-traumatic stress disorder was rare in the acute setting (2%) but was common in subacute (20%) and
chronic (44%) patients.
Conclusions: Blast trauma differs from blunt trauma in that headache symptoms and more constant
disequilibrium are more common.
Reviewer's Comments: It is unclear if these are really separate patient populations or if these results are
simply due to the progression of blast injury over time. In reading the description of this disorder, it seems that
the symptoms many of these patients complained of (chronic dizziness and headache) are very similar to
those of migraine-associated vertigo (MAV). In fact, I believe many of these patients would meet the
Neuhauser criteria for MAV. It would be interesting to explore the possibility that blast trauma may be a trigger
for MAV. (Reviewer-Benjamin T. Crane, MD).
© 2010, Oakstone Medical Publishing
Keywords: Blast Injury, Migraine, Vestibular, Vertigo, Dizziness, Headache
Print Tag: Refer to original journal article
Bilateral BAHA Significantly Improves Quality of Life
Bilateral Bone-Anchored Hearing Aid: Impact on Quality of Life Measured With the Glasgow Benefit Inventory.
Ho EC, Monksfield P, et al:
Otol Neurotol 2009; 30 (August 19): 891-896
The Glasgow Benefit Inventory demonstrates a clear benefit of bilateral bone-anchored hearing aid
devices.
Background: The Bone-anchored Hearing Aid (BAHA) device was first proposed in the late 1970s but has
really only caught on in the United States during the past decade. At the authors’ institution, University Hospital
Birmingham (United Kingdom), the first bilateral BAHA was used in 1995, and there are now >100 bilateral
BAHA users. To measure the benefit in these patients, the Glasgow Benefit Inventory (GBI) was used.
Objective: To describe a quality of life (QOL) benefit in BAHA users.
Design: Retrospective review.
Participants: 93 patients who had been using their bilateral BAHA for at least 6 months. In these patients, the
indication for BAHA was variable but was most primarily a chronically draining mastoid cavity (41%).
Methods: A GBI was sent out, and the total scores for these patients fell between 18 and 90. However, these
scores were transposed to a scale of ±100, with 0 corresponding to no change in QOL.
Results: QOL improved in 92%; 3% reported no change; and 5% felt a deteriorating QOL. However, of the 4
patients who had a deteriorating QOL, 3 of these continued to use their BAHA every day. Overall, the average
benefit was +38. This value is slightly higher than others have reported for single-sided BAHA use. When
examined in different domains, the general domain had +50 improvement, physical health had +18
improvement, and social support was +14. These results are in the range of unilateral BAHA, bilateral cochlear
implantation.
Conclusions: Bilateral BAHA offers improved QOL.
Reviewer's Comments: I believe there is a clear benefit to binaural hearing whether it is achieved with a
cochlear implant, BAHA, or unaided hearing after stapes surgery. I would not hesitate to offer bilateral BAHA to
appropriate patients. However, based on the results presented here, it is difficult to see a clear quality of life
benefit over a single-sided BAHA device. A more ideal study would have been to use a single-sided BAHA in
patients who would be candidates for a bilateral device. The GBI could be measured after the first device, and
then measured again after the second device to quantify the added benefit of the second binaural device.
However, to my knowledge, studies of this type have not yet been conducted. (Reviewer-Benjamin T. Crane,
MD).
© 2010, Oakstone Medical Publishing
Keywords: Hearing Loss, Binaural Hearing, Conductive Hearing Loss
Print Tag: Refer to original journal article
How Effective Are Transtympanic Steroids for Meniere's?
Transtympanic Steroids for Ménière’s Disease.
Herraiz C, Plaza G, et al:
Otol Neurotol 2010; 31 (January): 162-167
Transtympanic steroids improve tinnitus, hearing loss, and vertigo symptoms in patients with Ménière’s
disease.
Background: Ménière’s disease is an idiopathic disorder that is characterized by spontaneous vertigo spells,
fluctuating sensorineural hearing loss, low frequency tinnitus, and aural fullness. Although both systemic and
locally applied steroids have previously been reported to be successful treatments of Ménière’s disease, the
mechanism of action remains unknown.
Objective: This paper seeks to describe the efficacy of transtympanic steroids (TTS) in controlling Ménière’s
symptoms at 12 and 24 months.
Design: Descriptive prospective study.
Participants: A total of 34 patients were included, 70% of whom were women; 18% of patients had bilateral
disease. Patients had to have probable or definitive Ménière’s disease according to the American Academy of
Otolaryngology 1995 criteria.
Methods: Patients were initially treated with 6 months of medical therapy including betahistine, salt restriction,
and increased water intake. Many of these patients had previously had oral steroids. If patients did not have
their symptoms controlled, they were offered TTS if their pure tone hearing was better than 70 dB; otherwise,
they were offered transtympanic gentamicin.
Interventions: 3 TTS injections 1 week apart using methylprednisolone 40 mg/mL with 1% lidocaine.
Results: Interestingly, the most troublesome symptom was tinnitus in 37% of patients, vertigo in 33%, and
hearing loss in 30%. One month after the injection, slightly more than half the patients experienced a hearing
improvement of ≥10 dB; this hearing remained stable over subsequent audiograms. At 6 months, the number
of vertigo spells decreased from 4.0 to 1.2, with 41% of patients having had no vertigo attacks 6 months after
treatment. When examined at 6-month intervals, the control of vertigo improved with time. At the 2-year mark,
96% of patients had only one vertigo episode in the previous 6 months. Thirty-five percent of patients required
1 or 2 additional injections during the 2-year period. Three fourths of patients had some tinnitus improvement,
and 6 patients reported that tinnitus was controlled after 2 years.
Conclusions: These results demonstrate decreased frequency of vertigo, improved hearing, and improvement
in tinnitus after the use of TTS for Ménière’s disease.
Reviewer's Comments: These results add to the mounting evidence that intratympanic steroids are beneficial
for Ménière’s disease. However, this study includes a relatively small number of patients, and it is surprising
that only one third had vertigo as their primary complaint. The final piece of evidence that is needed to cement
the role of steroids in Ménière’s disease treatment is a placebo-controlled trial, which has yet to be published.
(Reviewer-Benjamin T. Crane, MD).
© 2010, Oakstone Medical Publishing
Keywords: Ménière’s Disease, Tinnitus, Vertigo, Hearing Loss
Print Tag: Refer to original journal article
Salivary Gland Cancers Difficult to Treat
Outcomes of Postoperative Concurrent Chemoradiotherapy for Locally Advanced Major Salivary Gland Carcinoma.
Tanvetyanon T, Qin D, et al:
Arch Otolaryngol Head Neck Surg 2009; 135 (July): 687-692
Salivary gland carcinomas remain a difficult group of tumors to treat, although chemotherapy may prove
to be beneficial.
Objective: To evaluate the results of postoperative chemoradiation (CRT) in patients with high-risk salivary
gland cancers.
Design: Case-control study with retrospective data.
Participants: 12 patients with major salivary gland carcinoma treated with postoperative CRT and a control
group of 12 patients treated with postoperative radiotherapy (RT) alone.
Methods: Patients who received postoperative CRT were selected during 1998 to 2007. Those with gross
residual disease or recurrent disease at the time of radiation were excluded. A matched group was generated
with patients who received RT alone and had similar histologic characteristics and disease stage.
Results: Of the 12 patients in the CRT group, 11 had stage III or IV disease. Five patients had
mucoepidermoid carcinoma, 3 had salivary duct carcinoma, 2 had expleomorphic carcinoma, 1 had adenoid
cystic carcinoma, and 1 had undifferentiated carcinoma. The type of chemotherapy used was cisplatin in 8
patients, carboplatin in 3, and cisplatin with 5-fluorouracil in 1 patient. Overall, patients were well matched
between groups, although there was a slightly higher proportion of patients with N2 disease and positive
margins in the CRT group. Locoregional recurrence occurred in 3 patients in the CRT group and 2 in the RT
group. Distant metastasis occurred in 4 patients in the CRT group and 3 in the RT group. The median time to
progression was not statistically different. There appeared to be an advantage in progression-free survival and
locoregional progression-free survival for the CRT group, but neither finding was statistically significant.
Conclusions: CRT may be promising and improve long term survival in patients with advanced salivary gland
carcinomas.
Reviewer's Comments: I found this study to be a bit too disjointed. With a sample size of only 12 patients and
with 5 different salivary gland carcinoma histologies, it is difficult to draw any hard conclusions on what to
believe. Additionally, the type of chemotherapy varied, so it is not clear what type of chemotherapy is beneficial
in what type of cancer. More focused studies need to be performed to really answer this question. (ReviewerPatrick K. Ha, MD).
© 2010, Oakstone Medical Publishing
Keywords: Salivary Gland Cancer, Chemotherapy
Print Tag: Refer to original journal article
Alar Rim Grafting Is Simple, Versatile Technique in Rhinoplasty
Alar Rim Grafting in Rhinoplasty: Indications, Technique, and Outcomes.
Boahene KD, Hilger PA:
Arch Facial Plast Surg 2009; 11 (September-October): 285-289
Alar rim grafting can be used to correct cephalic malposition of the lower lateral cartilage, alar flare, and
alar collapse.
Objective: To evaluate the indications and clinical outcomes of the use of alar rim cartilage grafts in
septorhinoplasty.
Design/Methods: Retrospective analysis of 150 patients who underwent septorhinoplasty over a 15-month
period in a private facial plastic surgery practice and an academic medical center. Those who received alar rim
grafts were identified. The alar rim graft measured 2 to 3 mm wide and 15 to 25 mm long. The grafts were
placed in a precise and tight soft tissue pocket within the nasal ala. Indications for graft placement as well as
clinical outcomes were assessed.
Results: Among the 150 patients who underwent septorhinoplasty, 31 patients received alar rim grafting.
Cephalic malposition of the lower lateral cartilage (9 patients [29%]) as well as alar flare (9 patients [29%]) was
the most common indications for alar rim graft placement. Correction of alar margin collapse (8 patients [26%])
was the next most common indication. Mean duration of follow-up was 26 months, and no complications were
noted.
Conclusions: The use of alar rim grafting is a useful technique in achieving external nasal valve support as
well as improving contour of the nasal base.
Reviewer's Comments: Alar rim grafting is an important adjunct technique in structural grafting rhinoplasty.
The amount of cartilage material required is minimal, and the grafts can be easily placed into a precise softtissue pocket within the nasal ala. In this article, the authors utilized alar rim grafting for lower lateral cartilage
malposition, mild alar retraction, alar contour abnormality, and alar collapse. Palpability of the graft can be
minimized by beveling the edges of the graft as well as crushing the medial edge of the graft. (Reviewer-Tang
Ho, MD).
© 2010, Oakstone Medical Publishing
Keywords: Alar Rim Grafting, Rhinoplasty
Print Tag: Refer to original journal article
PDT Viable Alternative to RT or Surgery for Premalignant Disease
Photodynamic Therapy for Head and Neck Dysplasia and Cancer.
Rigual NR, Thankappan K, et al:
Arch Otolaryngol Head Neck Surg 2009; 135 (August): 784-788
Photodynamic therapy with porfimer sodium may be an option for premalignant lesions and early cancers
of the oral cavity and larynx.
Objective: To determine the effects of photodynamic therapy (PDT) on premalignant and malignant squamous
cell carcinomas of the oral cavity and larynx.
Design: Prospective series.
Participants: 30 patients with primary or recurrent severe dysplasia, carcinoma in situ (CIS), or T1 squamous
cell carcinoma of the oral cavity or larynx.
Methods: Patients were treated with a photosensitizer, porfimer sodium, 2 mg/kg injected 48 hours before light
treatment. The light was a 630 nm wavelength laser, with a dose of 30 J/cm2 for dysplasia and CIS and 75
J/cm2 for carcinoma. Most anterior oral lesions were treated in the clinic, whereas posterior oral and laryngeal
lesions were treated in the operating department. Disease response was evaluated by physical exam at 1
week, 1 month, and then at 3-month intervals.
Results: Of the 30 patients enrolled, 26 were evaluable. One patient withdrew, and 3 were lost to follow-up.
Twelve patients (46%) had previous treatment and 14 had primary disease. Twelve patients had dysplasia or
CIS, and 14 patients had T1 cancers. The mean surface area treated was 7.03 cm2, with a mean number of
lesions treated of 1.77. Overall, 24 patients (92.3%) had a complete response, 1 (4.2%) had a partial response,
and 1 did not respond. Three patients with oral dysplasia had recurrence within 90 days after an initial
complete response, and 1 patient developed a second primary cancer outside the treatment field. With respect
to morbidity, there were no reports of severe pain, though 2 patients with oral cavity lesions had severe edema
that resolved within 2 weeks. Only 1 patient had a severe phototoxic reaction due to noncompliance.
Conclusions: PDT with porfimer sodium is a viable alternative to radiotherapy or surgery in patients with
premalignant or early malignant disease of the oral cavity and larynx.
Reviewer's Comments: I think the use of PDT is an intriguing alternative to surgery or radiation therapy,
particular for premalignant disease. The durable response is reasonable, and as the authors point out, it can
always be repeated. Because of the sparing of normal tissue, the side effects are minimal, and one can
reserve the use of radiation or surgery for more extensive disease. However, one should be cautious in using
this as a sole modality especially in oral cavity cancers, as even the T1 lesions may have the propensity for
nodal spread. In addition, longer term follow-up would be required, as well as other demographic information
such as smoking status, to really focus on which patient population is ideal for PDT therapy. (Reviewer-Patrick
K. Ha, MD).
© 2010, Oakstone Medical Publishing
Keywords: Premalignant, Squamous Cell Carcinoma, Photodynamic Therapy
Print Tag: Refer to original journal article
What Is Best Method to Detect Thyroid, Head and Neck Cancers?
Comparison of Positron Emission Tomography/Computed Tomography Imaging and Ultrasound in Staging and
Surveillance of Head and Neck and Thyroid Cancer.
Hwang HS, Perez DA, Orloff LA:
Laryngoscope 2009; 119 (October): 1958-1965
PET-CT and US are complementary tools for the detection of thyroid and head and neck cancers.
Background: Currently, several different modalities are used for the detection, staging, and surveillance of
head and neck and thyroid malignancies. Recently, PET-CT has gained in popularity due to its ability to identify
metabolically active neck disease with the precision of a CT scan. Its use has been advocated by many,
though most studies have showed a low positive predictive value for this modality. Ultrasonography (US) has
also been used by many clinicians for the diagnosis of thyroid and other head and neck malignancies. This
modality has a low false negative rate and also, when combined with fine-needle aspiration (FNA) biopsy, has
the ability to provide additional diagnostic information.
Objective: To evaluate the use of these modalities in cancer detection.
Design/Methods: This is a retrospective review of patient data from a large, tertiary, university-based hospital.
Forty-two patients underwent both US and PET-CT for a thyroid or head and neck malignancy during a 3-year
period between 2004 and 2007. Diagnostic accuracy rates were compared for the 2 modalities based on the
findings of histologically confirmed cancer in US-FNA or surgical specimens.
Results: 14 patients had a primary diagnosis of squamous cell carcinoma, 12 had a diagnosis of papillary
thyroid carcinoma, and the remaining patients had a variety of other cancer diagnoses. The sensitivity and
specificity of US in predicting malignancy was 96.8% and 93.3%, respectively. Positive predictive value (PPV)
and negative predictive value (NPV) was 96% and 93%, respectively. For PET-CT, sensitivity and specificity
was 90.3% and 20%, and PPV and NPV was 70% and 50%.
Conclusions: PET/CT and US, especially when combined with US-guided fine-needle biopsy, are
complementary tools in the detection of cancers of the head and neck. The highly sensitive and specific nature
of US, combined with its low cost, low morbidity, availability as an in-office examination, and ability to guide
biopsies, warrant consideration of its routine use in the management of head and neck and thyroid cancer
patients.
Reviewer's Comments: The current study shows that US is both highly sensitive and specific for the detection
of cervical lymph node metastasis. US avoids radiation exposure and is generally inexpensive and welltolerated by patients. It also allows for concurrent FNA with US-guidance for lymph node sampling. As noted in
previous studies, however, accuracy of US is highly operator-dependent. In contrast, PET-CT was highly
sensitive in detecting malignancy, but had low specificity, PPV, and NPV. These data suggest that PET-CT is
quite capable of confirming the absence of malignancy. Though it has limited specificity, PET-CT has the
added benefit of being able to detect second primary malignant lesions and distant metastatic disease. This
study is limited by its retrospective design and small sample sizes. Furthermore, there is clearly a selection
bias in that US examinations were often performed after results of PET-CT were already known. Nonetheless,
the study suggests that PET-CT and US, in combination with US-guided FNA biopsy can be complementary
tools for the staging and surveillance of thyroid and head and neck cancers. (Reviewer-Justin H. Turner, MD,
PhD).
© 2010, Oakstone Medical Publishing
Keywords: PET/CT, Ultrasonography, Thyroid Cancer, Head & Neck Cancer
Print Tag: Refer to original journal article
Patients With Primary Middle Ear Cancer Have Relatively Poor Prognosis
Middle Ear Cancer: A Population-Based Study.
Gurgel RK, Karnell LH, Hansen MR:
Laryngoscope 2009; 119 (October): 1913-1917
Surgery alone for the treatment of primary middle ear carcinoma had significantly better survival than the
other treatment groups in this study, presumably due to less advanced disease in this group
Background: Primary carcinoma of the middle ear is a rare clinical entity. Data pertaining to the incidence,
treatment, and course of this subset of temporal bone carcinomas are very limited, with few published studies
in the literature.
Objective: To utilize population-based data from the National Cancer Institute's Surveillance, Epidemiology,
and End Results (SEER) database to explore this rare disorder.
Design/Methods: This is an analysis of records from the SEER database derived from patients diagnosed
with middle ear carcinoma between 1973 and 2004. Middle ear lymphomas and rhabdomyosarcomas were
excluded from the study. Demographic and tumor-specific data were extracted from the database and overall
survival was determined. Data regarding lymph node involvement were not reported as this information was
not recorded for a majority of patients in the database.
Results: The 5-year observed survival rate for all patients (n=215) was 36.4% with a median duration of
follow-up of 48 months. Histologic subtypes included squamous cell carcinoma (62.4%), adenocarcinoma
(18.2%), other carcinoma (13.0%), and noncarcinoma (6.0%). Subtype-specific 5-year survivals were 23.9%,
65.0%, 60.0%, and 38.6%, respectively. The difference in survival rate between squamous cell carcinoma and
adenocarcinoma was statistically significant. Of the 123 patients with known stage, 23.6% had local disease,
69.1% had regional disease by extension, and 7.3% had distant disease. Respective 5-year survivals for these
groups were 64.9%, 34.2%, and 0%, respectively. Patients were treated with either surgery alone (31.2%),
radiation therapy alone (16.3%), surgery and radiation therapy (38.6%), or no surgery or radiation (8.4%). The
5-year observed survivals for these treatment modalities were 69.2%, 14.6%, 26.4%, and 0%, respectively.
Conclusions: Patients with primary middle ear carcinoma have a relatively poor prognosis. Survival among
patients treated with surgery alone was significantly higher than that from the other 3 groups.
Reviewer's Comments: Middle ear carcinoma is very rare, and many clinicians are unfamiliar with its
incidence, treatment, and course. This study uses pooled data from the National Cancer Institute's SEER
database to outline the historical characteristics of this disease process. The majority of patients presented
with advanced local disease and overall survival was poor. Patients with squamous cell carcinoma had a much
poorer prognosis than those with adenocarcinoma or other carcinomas. A majority of patients were treated with
either surgery alone or surgery plus radiation therapy. This study does have some limitations. First, there is no
established staging system for middle ear carcinoma, meaning that patients had to be grouped according to
generic codes. Furthermore, few patients had any recorded data for lymph node involvement. Finally,
information as to why patients underwent specific treatments was not recorded in the database, limiting the
ability to make conclusions as to the most appropriate and successful therapies. Nonetheless, this study
should assist physicians in understanding this rare disease process and in counseling their patients.
(Reviewer-Justin H. Turner, MD, PhD).
© 2010, Oakstone Medical Publishing
Keywords: Temporal Bone Resection, SEER Database, Radiation Therapy
Print Tag: Refer to original journal article
Thread-Lift No Longer Recommended for Facial Rejuvenation
Thread-Lift for Facial Rejuvenation: Assessment of Long-Term Results.
Abraham RF, DeFatta RJ, Williams EF III:
Arch Facial Plast Surg 2009; 11 (May-June): 178-183
The thread-lift procedure offers only limited short-term cosmetic improvement and has poor long-term
results.
Objective: To determine the clinical efficacy of the thread-lift procedure for facial rejuvenation compared to the
more traditional methods.
Methods: 3 groups of patients were enrolled in the study. Ten patients received thread-lifts only to the brow,
midface, jowl, or neck area. Twenty-three patients received a combination of thread-lifts with other additional
facial rejuvenation procedures. Ten patients received non-thread-lift facial rejuvenation procedures and were
designated as control subjects. Follow-up period ranged from 12 to 31 months (mean, 21 months). Four
independent facial plastic surgeons who were blinded to the groups graded the results on a numerical scale.
Results: Aesthetic improvement was noted in all groups at 1 month post-procedure. However, the result with
the thread-lift only group did not persist. Compared to the other 2 groups, the thread-lift only group also had the
lowest aesthetic improvement score for all the evaluators. The difference was statistically significant (P <0.1).
Conclusions: The thread-lift procedure offers only limited short-term cosmetic improvement and has poor
long-term results. The authors do not recommend continued use of this procedure.
Reviewer's Comments: The thread-lift procedure was popular at one time given the demand for a minimally
invasive type of facial rejuvenation technique. However, it offers only short-term benefit and it is believed that
this benefit may be due to mostly the postoperative edema. This is not so surprising given that the technique
does not address the issue of volume depletion in the aging face and repositions the soft tissue only in the
superficial layer. The original Contour ThreadliftTM system has since then lost its FDA approval and is no
longer available in the U.S. However, variations of the barbed sutures are still available in different packaging.
(Reviewer-Tang Ho, MD).
© 2010, Oakstone Medical Publishing
Keywords: Thread-Lift, Aging Face, Facial Rejuvenation
Print Tag: Refer to original journal article
Lower Lateral Crural Cartilage ‘Recycled’
Lower Lateral Crural Turnover Flap in Open Rhinoplasty.
Janis JE, Trussler A, et al:
Plast Reconstr Surg 2009; 123 (June): 1830-1841
Lower lateral crural turnover flap is useful in open rhinoplasty as a technique to correct lower lateral crural
deformity and strengthen the external nasal valve.
Background: Deformities of the lower lateral crura can compromise esthetic alar contour as well as alar arch
strength and external valve function. The ideal alar basal view represents an equilateral triangle with a slight
alar flaring toward the alar base.
Objective: To review the senior authors' experience with the use of lower lateral crural turnover flap to correct
lower crural deformity and improve external nasal valve function.
Design/Methods: This study is a retrospective review of the authors' experience with lateral crural turnover
flap in 24 consecutive open rhinoplasties. The majority of these (n=21) are primary rhinoplasties. The cases
are evaluated for indications, contraindications, and long-term (>12 months) outcomes of using this technique.
Results: The lower lateral crural turnover flap represents a bilaminate construct where a 5-mm to 7-mm total
width of lower lateral crural cartilage is turned over after the vestibular skin is undermined off the cephalic
border of the cartilage and full-thickness incisions made in the medial and lateral margins of the cartilage. At
least 6 mm of caudal rim strip is preserved. The cartilage flap is turned over and flattened with Adson Brown
forceps and sutured in place with simple 5-0 Vicryl sutures. Indications noted by the authors for lower lateral
crural turnover flap include crural concavity or convexity, weakness of the lateral crura, and external valve
collapse. The technique is contraindicated when there is insufficient width of the lower lateral crura (<1.2 cm).
The flap can be used to complement other alar grafting techniques including batten and crural strut grafts. One
patient required revision secondary to iatrogenic unilateral alar asymmetry. The authors found that the effects
of lateral crural turnover flap are stable 1 year after the rhinoplasty procedure.
Conclusions: Lower lateral crural turnover flap is a useful adjunct technique in open rhinoplasty for the
correction of lower lateral crura contour deformity and structural weakness.
Reviewer's Comments: The lower lateral crural turnover flap as described in this article represents a
modification of the technique previously described by McCollough and Fedok for the endonasal approach. The
technique adds to the surgeon's armamentarium of methods available for correcting and strengthening the
lower lateral crura. Compared to other structural grafting techniques, it is unique in that it allows the use of
adjacent expendable cartilage without the need to resort to distant cartilage graft site such as the concha.
(Reviewer-Tang Ho, MD).
© 2010, Oakstone Medical Publishing
Keywords: Rhinoplasty, External Nasal Valve, Cartilage Grafts
Print Tag: Refer to original journal article
Does Prophylactic Central Neck Dissection Decrease Nodal Recurrence?
Prophylactic Central Neck Dissection in Stage N0 Papillary Thyroid Carcinoma.
Zuniga S, Sanabria A:
Arch Otolaryngol Head Neck Surg 2009; 135 (November): 1087-1091
Prophylactic central neck dissection for N0 papillary thyroid carcinoma does not decrease the rate of
nodal recurrence.
Background: The management of the central neck compartment is still controversial in thyroid cancer. Drs.
Douglas Evans and Maisie Shindo have advocated elective central neck dissection for well-differentiated
thyroid malignancies. The most recent American Thyroid Association guideline, based on level 2 evidence,
suggested a similar protocol. However, the clinical evidence for elective central compartment dissection is still
far from clear. This is particularly important given improved capability to stage metastatic disease with high
resolution ultrasonography.
Objective: To assess the disease-free survival of patients who are treated with central neck dissection for N0
papillary thyroid carcinoma.
Design/Methods: This is a retrospective cohort study at a single tertiary institution. Included were papillary
thyroid carcinoma patients staged clinically to be N0 without any previous oncologic treatment. The test group
consisted of those treated with central neck dissection with curative intent, while the control group did not
undergo the neck dissection. Those deemed to be high risk for recurrence were treated with postop I-131.
Power analysis was based on the assumption that recurrence rate was 15% overall and that the central neck
dissection would reduce recurrence by 2-fold. Disease-free survival and neck recurrence rate were collected in
the 2 cohorts.
Results: 266 patients were included in the study with a mean follow-up time of nearly 7 years. In total, 51.3%
of patients underwent central neck dissection. There were no differences between the 2 groups in terms of 5year disease-free survival (88.2% in the dissection group and 85.6% in the control group). Accounting for the
selection bias, a Cox multivariate analysis was performed to assess neck recurrence. No differences were
found in the neck dissection group compared to the control group. Interestingly, among those who did undergo
central neck dissection, 82.3% had neck disease and 16.9% had neck recurrence.
Conclusions: Prophylactic central neck dissection did not improve the rate of neck recurrence in N0 papillary
thyroid patients.
Reviewer's Comments: In the management of well-differentiated thyroid cancer, the field is still waiting for
any form of good clinical study to direct the management of the central neck for N0 disease. Unfortunately, this
study adds to the confusion. Any randomized study for this question may not be feasible. The weakness is that
this is a retrospective cohort study with a selection bias built in; the candidates for the central neck dissection
were chosen by the surgeon without any clear guidelines. This study, like most of the retrospective studies on
this topic, has the limitations of selection bias—those with more aggressive disease would more likely be
treated with neck dissection and with higher and repeated doses of I-131. (Reviewer-Young J. Kim, MD).
© 2010, Oakstone Medical Publishing
Keywords: Thyroid Malignancy, Papillary Thyroid Malignancy, Central Neck Dissection, Nodal Recurrence
Print Tag: Refer to original journal article
Level 1 and 2 Regions of the Neck Can Be Approached With Facelift Incisions
Facelift Approach to Upper Cervical Surgery.
Hughes J, Stephens J, et al:
Otolaryngol Head Neck Surg 2009; 141 (December): 783-785
Supra-SMAS facelift incision is appropriate for access to level 1 and 2a.
Background: Neck incision within neck crease line can be cosmetically pleasing for cervical excisional
biopsies, but avoidance of neck incision may further improve cosmesis. Facelift incision has replaced Blair
incision for parotidectomy for many surgeons. Facelift incision has been used for mandibular fracture repair as
well as sentinel node biopsies.
Objective: To investigate facelift incision for upper cervical neck mass excisions.
Methods: This is a feasibility study of a supra-SMAS approach to excision of upper cervical neck masses. The
skin flaps are elevated superficial to the SMAS/platysma layer, and the platysma is entered 2 fingerbreadths
below the mandible. Five cases are reported here: 3 cases of submandibular gland excision, 1 excision of
upper cervical lymph node, and 1 branchial cleft cyst.
Results: Of the 5 cases, 1 patient had postop hematoma that required an operative intervention. The authors
report improved surgical access for level 1 and level 2a.
Conclusions: Supra-SMAS facelift incision is appropriate for access to level 1 and 2a.
Reviewer's Comments: This is one of those "how I do it" papers. As far as quantitative analysis goes, there is
no mention of operative time or any analysis of patient satisfaction. The obvious thing to note is that this
cosmetically pleasing approach is associated with hematoma that required operative intervention. However,
given that only 5 cases were followed, it is difficult to place a value to this complication. There were no nerve
injuries in this series, but once again, this would require more cases to be followed. Overall, this is a feasibility
study, and I would wait for further follow-ups in the author's series to recommend this approach for others.
(Reviewer-Young J. Kim, MD).
© 2010, Oakstone Medical Publishing
Keywords: Neck Mass, Facelift Incision, Supra-SMAS Approach
Print Tag: Refer to original journal article
OK-432 Sclerotherapy Can Be Effective for Branchial Cleft Cysts
Sclerotherapy of Branchial Cleft Cysts Using OK-432.
Kim MG, Lee NH, et al:
Otolaryngol Head Neck Surg 2009; 141 (September): 329-334
OK-432 sclerotherapy may be effective for uniloculated branchial cleft cyst, and its use is not associated
with difficult surgical excision after failed sclerotherapy.
Background: Branchial cleft cyst is typically treated with surgical excision, but recently, sclerotherapy has
been introduced to treat these benign congenital lesions. OK-432 is a sclerosing agent and a TLR4 agonist
that induces an acute inflammatory response locally at the sight of injection. It has been used in lymphangioma
and ranula, but its use in branchial cleft cysts has been limited.
Objective: To determine whether sclerotherapy with OK-432 is effective for branchial cleft cyst.
Design/Methods: This is a non-controlled case series of patients with branchial cleft cysts treated with OK-432
at a single institution over 3 years. Twenty-three patients with untreated branchial cleft cysts were treated with
OK-432. Some patients required multiple injections. The responses were measured radiographically and
clinically every 3 months for 1 year. Those who failed sclerotherapy were treated with surgical excision.
Results: Of 23 subjects, 61% showed complete regression. In total, 94% of uniloculated lesions had complete
or marked response that did not require surgical intervention. Most of the failures occurred with the
multiloculated lesions. All 5 patients with multiloculated lesions had either only partial responses or no
responses. All of these patients were treated successfully with surgical excisions. The side effects of this
treatment were pain and fever, which occurred in 56.5% of patients.
Conclusions: Sclerotherapy with OK-432 for branchial cleft cyst is an effective treatment for uniloculated
lesions and should be considered as an alternative to surgical excision.
Reviewer's Comments: It should be noted that surgical excision is the standard of care for branchial cleft cyst
given its low morbidity of surgery. However, this report is useful for those situations in which surgery is not a
good option. The authors provide some critical experience in their series. First, malignancy has to be ruled out.
Second, sclerotherapy may be effective for only uniloculated lesions. Third, even the uniloculated lesions may
require multiple rounds of sclerotherapy for substantial response. Lastly, it appears that sclerotherapy OK-432
does not render the surgical excision more difficult. This last point is important since sclerotherapy would be
considered for those who are not good surgical candidates. (Reviewer-Young J. Kim, MD).
© 2010, Oakstone Medical Publishing
Keywords: Branchial Cleft Cyst, Sclerotherapy, OK-432
Print Tag: Refer to original journal article
Pain Should Be Appropriately Followed in Head-Neck Cancer Population
The Role of Pain in Head and Neck Cancer Recurrence and Survivorship.
Scharpf J, Karnell LH, et al:
Arch Otolaryngol Head Neck Surg 2009; 135 (August): 789-794
Post-treatment pain within the first year of treatment among patients with head and neck cancer is
associated with higher recurrence rate and lower survival rate.
Background: Pain is a common occurrence in head and neck carcinoma, but the difficulty in objectively
quantitating pain as it relates to prognosis has prevented clear studies to demonstrate its clinical significance.
The use of PET-CT scans has been expanded without any clear efficacy, while clinical history has sometimes
taken a back seat to technological advances.
Objective: To examine post-treatment pain and its relationship to recurrence and survival. Design/Methods:
This was a prospective observational study on 339 patients with head and neck carcinomas treated at a single
tertiary institution from 1998 to 2001. Quality of life data were collected at 3, 6, 9, and 12 months after
diagnosis. A validated pain score that rated pain from 1 to 10 was used, and the relationship between selfreported pain, recurrence, 5-year disease-specific survival, and quality of life was analyzed with both univariate
and multivariate analyses.
Results: Post-treatment pain in the first year was statistically associated with recurrence and 5-year diseasespecific survival. Those with high post-treatment pain (7 to 10) had a 5-year disease-specific survival rate of
65.1% while those with low pain had a survival rate of 81.8%. In this series, post-treatment pain was an
independent predictor of both recurrence and 5-year survival.
Conclusions: The authors advocate that pain be quantitated throughout the management of head and neck
carcinoma.
Reviewer's Comments: Given the recent reports on the uncertainties of PET-CT to appropriately follow head
and neck carcinoma patients as well as the spiraling costs of health care, otolaryngologists should resort to
sound clinical judgment to provide standard of care. The authors acknowledge that post-treatment pain may be
due to occult persistence disease, so they compared those with high level of pain without any recurrence to
those with high level of pain with recurrence. The survival rate of this first group was 64.0%, and this was
comparable to the 69.7% survival rate among those with low pain and no recurrence. Those with high pain and
recurrence had a survival rate of 19%. This report did not find a temporal worsening of pain in this population in
the course of a year, and the authors did not incorporate other medical comorbidities in their analysis. Overall,
this report reminds us that pain should be appropriately followed among the head-neck cancer population.
(Reviewer-Young J. Kim, MD).
© 2010, Oakstone Medical Publishing
Keywords: Squamous Cell Carcinoma, Pain, Recurrence
Print Tag: Refer to original journal article