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Histologic correlation of VEGF and COX-2 expression with tumor size in squamous cell carcinoma of the larynx and hypopharynx

April 30, 2017     Rodrigo Gonzalez Bonhin, MD; Guilherme Machado de Carvalho, MD; Alexandre Caixeta Guimaraes, MD; Vanessa Brito Campoy Rocha, MD; Carlos Takahiro Chone, MD, PhD; Agrício Nubiato Crespo, MD, PhD; Eliane Maria Ingrid Amstalden, MD, PhD


The prognosis and survival of patients with laryngeal and hypopharyngeal squamous cell carcinoma (SCC) are related to the clinical staging. Tumor growth and metastasis are closely related to angiogenesis. Vascular endothelial growth factor (VEGF) and cyclooxygenase 2 (COX-2) are intimately related to the angiogenic process in which the blood supply required for neoplastic evolution is ensured. Considering the contributions of VEGF and COX-2 to the formation, growth, and progression of primary tumors, as well as their metastasis, it has been thought that the expression of these two factors might be related to the size and/or aggressiveness of laryngeal and hypopharyngeal cancer. To test that theory, we conducted a retrospective study to evaluate the expression of VEGF and COX-2 markers in archived specimens of SCC of the larynx and hypopharynx to correlate their expression with tumor size. These specimens had been obtained from 35 patients-31 men and 4 women, aged 37 to 75 years (mean: 57)-who had been treated for laryngeal or hypopharyngeal SCC at our tertiary care university hospital over a period of 15 years. Immunohistochemical analyses were performed with avidin-biotin-peroxidase staining for VEGF and COX-2 antibodies. The degree of VEGF and COX-2 expression was based on the German scale of immunoreactivity. Specimens were separated into groups based on the intensity of expression (none/low and moderate/strong) and tumor size (TNM categories T1/T2 and T3/T4). A total of 7 patients exhibited moderate or strong VEGF expression (3 from the T1/T2 group and 4 from the T3/T4 group), and 17 patients demonstrated moderate or strong COX-2 expression (8 from the T1/T2 group and 9 from the T3/T4 group). We found no statistically significant relationship between tumor size and either VEGF or COX-2 expression. Our study demonstrated that despite the intrinsic connection between and VEGF and COX-2, neither appears to be related to the size of the SCCs of the larynx or hypopharynx. Other factors must be involved in the pathogenesis and progression of this disease, and further studies are needed to identify them.

Role of intraoperative ropivacaine in adult post-tonsillectomy pain control: A randomized controlled trial

April 30, 2017     William C. Yao, MD; Christian A. Corbitt, MD; Masayoshi Takashima, MD


We sought to evaluate the efficacy of ropivacaine in post-tonsillectomy pain management in adults and evaluate the timing of intraoperative ropivacaine administration for this purpose. A prospective, double-blinded, randomized, controlled trial with a paired design was performed in 25 consecutive adults undergoing tonsillectomy. To date, no studies examining the efficacy of local anesthetics in post-tonsillectomy pain control have used a paired design to account for the variability in pain difference between individuals. Patients were prerandomized into those receiving tonsillar fossa injections before or after the tonsillectomy. All surgeries were performed by the senior author. The tonsil on 1 side was injected with saline and the tonsil on the other side with ropivacaine. Patient responses were obtained via written questionnaire. Three of 25 patients were excluded from the study. Sixteen of 22 patients had lateralization of pain to 1 side during recovery. No statistically significant difference in pain control was observed between ropivacaine and normal saline. Local anesthetic decreased pain in 7 of 22 patients, and increased pain was experienced on the side with local anesthetic in 9 of 22 patients. Six of 22 patients had no difference in pain from one side to the other. The time to equalization of pain based on laterality was 8.8 and 6.8 days, respectively, in the patients injected before or immediately after the tonsillectomy. Administration of the local anesthetic ropivacaine does not affect post-tonsillectomy pain. Moreover, timing of injection does not affect postoperative pain. We recommend against the use of intraoperative ropivacaine for pain control in patients undergoing tonsillectomy.

Regent: An invaluable new offering from the American Academy of Otolaryngology-Head and Neck Surgery

April 30, 2017     Robert T. Sataloff, MD, DMA, FACS, Editor-in-Chief

Atypical presentation of vocal fold granulomas

April 30, 2017     Raj B. Patel, MD; Aaron Jaworek, MD; Robert T. Sataloff, MD, DMA, FACS

Vocal fold granulomas usually form near the vocal process or on the mucosa covering the medial surface of the arytenoid cartilage. These lesions are not true granulomas and consist of fibroblasts, collagen, leukocytes, and proliferating capillaries.

A huge parapharyngeal space tumor in a child

April 30, 2017     Yuntsung Hung, MD; Chi-Shiun Huang, MD; Liang-You Yang, MD

Most clinicians will see only a small number of cases of parapharyngeal space tumors during their careers.

Facial nerve mimicking the fibrocartilaginous annulus of the tympanic membrane

April 30, 2017     Hande Senem Deveci, MD; Tülay Erden Habeşoğlu, MD; Cem Karataş, MD; Selami Uzun, MD

In this case, the mastoid segment of the facial nerve was mobilized with a microelevetor at the posterior quadrant, but the facial nerve was preserved.

Endoscopic view of long-term patency of the sphenoid ostium following balloon dilation

April 30, 2017     Joseph P. Mirante, MD, MBA, FACS; Dewey A. Christmas, MD; Eiji Yanagisawa, MD, FACS

In this case a 32-year-old patient with a history of recurrent sphenoid sinusitis had undergone balloon dilation of the sphenoid sinus ostium approximately 7 years earlier.

Therapeutic effect of hyaluronic acid in reducing nasal mucosa recovery time after septoplasty

April 30, 2017     Francesco Klinger, MD; Fabio Caviggioli, MD; Andrea Vittorio Emanuele Lisa, MD; Luca Maione, MD; Valeriano Vinci, MD; Mattia Siliprandi, MD; Federico Barbera, MD; Marco Klinger, MD; Luca Malvezzi, MD


Mucociliary clearance represents a host defense mechanism of airways that can be compromised by various pathologic conditions, such as nasal septal deviation. Although septoplasty can resolve obstruction, it impairs mucociliary clearance in the immediate postoperative period. Clinical studies have demonstrated how hyaluronic acid can interfere with this function. Our study aims to provide evidence of a therapeutic effect of hyaluronic acid on nasal mucosa recovery after septoplasy. Sixty-five patients underwent septoplasty. On postoperative day 1, patients were randomized to a control arm that was treated with mupirocin ointment or an experimental arm that received additional treatment with sodium hyaluronate solution. Pre- and postoperatively, anterior rhinoscopy was performed to analyze mucosal status, and mucociliary clearance was measured by using the saccharin transit time (STT) method. The t test was used for independent groups. During the preoperative evaluation, we observed a significant difference in STT between the convex and concave side in both groups. Fifteen days after surgery, we observed a significant difference preoperatively to postoperatively for both the convex and the concave side (p < 0.02 and p < 0.008, respectively). One month after surgery, we observed a reduction of STT when comparing preoperative control group values and, after 1 month, postoperative values in both sides (p < 0.015 and p < 0.005, convex and concave side, respectively). Our results show a significant reduction of the STT for both nasal sides as soon as 15 days after septoplasty in patients randomized to additional treatment. Our experience provides further evidence for the therapeutic effect of hyaluronic acid in accelerating nasal mucosa recovery after septoplasty.

In-office vs. operating room procedures for recurrent respiratory papillomatosis

April 30, 2017     Anya J. Miller, MD; Glendon M. Gardner, MD


We conducted a study to analyze hospital and patient costs, outcomes, and patient satisfaction among adults undergoing in-office and operating room procedures for the treatment of recurrent respiratory papillomatosis. Our final study population was made up of 17 patients-1 man and 16 women, aged 30 to 86 years (mean: 62). The mean number of in-office laser procedures per patient was 4.2, and the mean interval between procedures was 5.4 months (although 10 patients underwent only 1 office procedure); the mean number of operating room procedures was 13.5, and the mean interval between procedures was 14.3 months. An equal number of patients reported complications or adverse events with the two types of procedures-5 each. The difference in cost between the office procedure (mean: $3,413.00) and the operating room procedure (mean: $12,382.59) was almost $9,000, but these savings were offset by the fact that the office procedures needed to be performed three times as often. Patients reported slightly more anxiety and discomfort during the office procedures and, overall, they appeared to prefer the operating room procedure. We conclude that office procedures are significantly more cost-effective than operating room procedures, but their use may be limited by patient tolerance and the increased frequency of the procedure.

Nasal, pharyngeal, and laryngeal pemphigus vulgaris successfully treated with rituximab

April 30, 2017     Naveed Sami, MD


Pemphigus vulgaris is a potentially fatal autoimmune blistering disease that can involve the nasopharyngeal and laryngeal tissues. The disease can be recalcitrant to conventional oral treatments, and treatment alternatives are limited. This retrospective study evaluated the efficacy of rituximab as a rescue agent in 5 patients with recalcitrant pemphigus vulgaris involving nasopharyngeal and laryngeal mucosa. All 5 patients were unresponsive to systemic steroids and at least one conventional oral immunosuppressive agent. The patients received rituximab infusions as a rescue agent because of recalcitrant disease. All 5 patients had a complete clinical response to rituximab and could discontinue systemic steroids and reduce the dosage of their initial immunosuppressive agent. No major adverse reactions were observed or reported with rituximab. Rituximab can be used as an effective rescue agent in the treatment of severe pemphigus vulgaris with nasopharyngeal and laryngeal involvement.


April 30, 2017     Lester D. Thompson, MD

Imaging findings of elastofibromas show poorly circumscribed, heterogenous soft-tissue masses that have contrast enhancement, quite frequently bilateral.

Long-term follow-up of KTP laser turbinate reduction for the treatment of obstructive rhinopathy

April 30, 2017     Hemal Raja, FRCS, ORL-HNS; Scott Mitchell, MBChB, MRCS, DOHNS; George Barrett, MRCS, DOHNS; Ashish Sharma, MBBS, MA, MRCS, MRCP; Derek W. Skinner, FRCS, ORL-HNS


We investigated the subjective, long-term, patient-reported symptom control after endoscopic potassium titanyl phosphate (KTP) laser reduction of the inferior turbinates. Symptoms were listed preoperatively and patients were asked, via telephone interview, the status of their symptoms. Chi-square analysis was used to assess statistical significance of the surgical intervention. Thirty-six patients (male:female ratio: 5:4) aged 13 to 80 years (mean: 37.2) were available for follow-up. The mean follow-up time was 68.47 months (range: 44 to 92). The principal symptom patients experienced was nasal obstruction (94.4%); postoperative improvement in this symptom at 44 months and beyond was reported by 85.3% of patients (chi-square 16.94, p < 0.001). Other symptoms, such as rhinorrhea and sneezing, showed no significant improvement at long-term follow-up. This study adds evidence to the long-term improvements in obstructive nasal symptoms using KTP laser reduction of the turbinates.

The role of hypertonic saline in monopolar tonsillectomy in adult patients

April 30, 2017     Jian Ma, MD; Mei Zheng, MS; Jun-Wei Mu, MD; Peng Cui, MD


This study's objective was to look for a simple and inexpensive method to reduce patients' pain during tonsillectomy. Bilateral tonsillectomy patients were enrolled and placed into different groups based on their admission numbers. Patients with odd numbers had electrical tonsillectomy on the right side with hypertonic saline injection into the tonsillar capsule (group A) or electrical tonsillectomy on the left side with normal saline injection (group B). Those with even numbers had electrical tonsillectomy on the left side with hypertonic saline injection into the tonsillar capsule (group A) or electrical tonsillectomy on the right side with normal saline injection (group B). Pain, operative bleeding, postoperative bleeding, and operation time were evaluated. Injecting hypertonic saline into the tonsillar capsule reduced pain caused by electrical tonsillectomy but did not impact the operative or postoperative bleeding and operation time. While simple and economic, monopolar electrical tonsillectomy with the help of hypertonic saline injected into the tonsillar capsule can effectively relieve patients' pain when compared to surgeries with normal saline injection.

Quality-of-life outcomes in Graves disease patients after total thyroidectomy

April 30, 2017     Lukas H. Kus, MD; Wilma M. Hopman, MA; Ian J. Witterick, MD; Jeremy L. Freeman, MD


Historically, research into surgical treatment of Graves disease has assessed subtotal rather than total thyroidectomy. Most clinicians now recommend total thyroidectomy, but little information is available regarding quality-of-life (QOL) outcomes for this procedure. Our aim was to assess QOL after total thyroidectomy. This is a retrospective, pilot study of patients with Graves disease who underwent total thyroidectomy from 1991 to 2007 at a high-volume tertiary referral center in Toronto, Canada. Questionnaires addressing disease-specific symptoms and global QOL concerns were sent to 54 patients. Analyses included parametric and nonparametric tests to assess the differences between perception of symptoms and global QOL before and after surgery. Forty patients responded (response rate: 74%) at a median of 4.8 years postoperatively. On a 10-point scale, overall wellness improved from 4.1 preoperatively to 8.7 postoperatively (p < 0.001). Patients recalled missing less work or school after surgery (7.8 vs. 1.1 days/year; p = 0.001). Overall satisfaction with the procedure was high. On average, symptoms improved within 32 days of surgery, and all symptoms showed substantial improvement. This is the first North American study to assess QOL outcomes of patients with Graves disease after total thyroidectomy. Patients experienced marked and rapid improvement in QOL postoperatively. These findings suggest that total thyroidectomy is a safe and effective treatment.

Large pediatric maxillary dentigerous cysts presenting with sinonasal and orbital symptoms: A case series

April 30, 2017     Shakil Ahmed Nagori, MDS; Anson Jose, MDS; Ongkila Bhutia, MDS; Ajoy Roychoudhury, MDS


Dentigerous cysts are benign odontogenic cysts associated with the crowns of unerupted, embedded, or impacted teeth. Most of them are associated with mandibular third molars, followed by maxillary third molars and canines. They are usually asymptomatic, and rarely do they grow extensively and compress the adjacent anatomic structures. We report 5 cases of extensive maxillary dentigerous cysts presenting with sinonasal and orbital symptoms. A literature review for similar presentations of dentigerous cysts has demonstrated 21 cases. Recognition of the extensive growth potential of the dentigerous cyst, diagnosing it with its unusual presentation, and appropriate management are discussed in this article.

Medially displaced common and internal carotid arteries presenting as a pulsatile mass: Clinicoradiologic analysis of 62 cases

April 30, 2017     Ilker Burak Arslan, MD; Yildiz Arslan, MD; Erhan Demirhan, MD; Selahattin Genc, MD; Yeliz Pekcevik, MD; Levent Altin, MD; Zahide Yilmaz, MD; Ibrahim Cukurova, MD


We conducted a prospective study to analyze the medially displaced courses of the common carotid artery (CCA) and the cervical segment of the internal carotid artery (ICA) in patients who were diagnosed with a pulsatile mass on nasopharyngolaryngoscopy and by clinicoradiologic findings. Our study group was made up of 62 patients-40 women and 22 men, aged 30 to 88 years (mean: 63.7)-who presented with a submucosal pseudomass or a bulging mass on the pharyngeal wall with obvious pulsation. For comparison purposes, we recruited a control group of 62 consecutively presenting patients who had been admitted to our Neurology Department with acute severe headache and who had undergone CT angiography based on a suspicion of an aneurysm or a vertebral or carotid artery dissection. A medially displaced carotid artery was identified in all patients in the study group. Two main course abnormalities were observed: (1) a pharyngeal superficial placement (PSP), consisting of a bulging or placement immediately adjacent to the naso-orohypopharyngeal lumen, and (2) a retropharyngeal midline placement (RMP), which entailed medialization of the carotid arteries to the midline. A PSP was observed in 11 patients, an RMP was found in 17 patients, and both were seen in 34 patients. The distance from the aberrant carotid artery to the pharyngeal wall and to the retropharyngeal midline of the retropharynx was measured at four levels: nasopharyngeal, retropalatal, retroglossal, and retroepiglottic in both groups. The mean distance was significantly shorter in the study group than in the control group at all four levels (p < 0.002). We conclude that the most likely diagnosis of a pulsatile mass detected on nasopharyngolaryngoscopy is an aberrant CCA or cervical ICA.

Linear IgA dermatosis limited to the mucosal membranes as a rare cause of dysphagia

April 30, 2017     Victoria M. Bones, MD; Lyndsay L. Madden, DO

Stapes-pyramidal fixation by a bony bar

April 30, 2017     N. Wendell Todd Jr., MD, MPH; Kai-Chieh Chan, MD

The treatment of otorrhea in children with cleft palate: An institutional review

April 30, 2017     Stephen Nogan, MD; Katie Phillips, MD; Jonathan Grischkan, MD


We conducted a retrospective observational chart review to characterize otorrhea in patients with cleft palate (CP) after tympanostomy tube placement in terms of the bacteria profile, treatment effectiveness, and overall disease burden. A total of 157 patients over 6 years were reviewed. Fifty of the 157 patients (31.8%) experienced postoperative otorrhea. Of the 50 patients with otorrhea, all received topical antibiotics, 30 received oral antibiotics, and 12 received povidone-iodine irrigations. The average duration of otorrhea was 5.2 months for patients with povidone-iodine irrigations and 8.5 months for those without povidone-iodine irrigations. Methicillin-resistant Staphylococcus aureus was the most commonly cultured microorganism. The average number of total healthcare visits over a 12-month period was 13.6 per patient. We conclude that postoperative otorrhea is a common problem after tympanostomy tube placement in children with CP and places a significant burden on these patients and the healthcare system. The bacteriologic profile may be different in this population compared with the non-CP population with otorrhea after tympanostomy, and a search for more effective treatment options is warranted, including further investigation into povidone-iodine irrigations.

Speech perception and auditory performance following cochlear implantation in elderly Koreans

March 24, 2017     Sungsu Lee, MD, PhD; Hyong-Joo Park, MD; Hyong-Ho Cho, MD, PhD; Yong-Beom Cho, MD, PhD


The benefits of cochlear implantation (CI) in the elderly remain debatable in terms of sound and speech perception. Moreover, the results of CI may be affected by the intensity and pitch of spoken language. We conducted a retrospective study to evaluate surgical and hospitalization times, postoperative complications, and hearing outcomes after CI in elderly Koreans. Our study population was made up of 55 postlingually deafened adults who underwent unilateral CI. They were divided into two groups based on age; an older group consisted of 21 patients aged 65 years or older (mean 71.8) at the time of CI, and a comparison group was made up of 34 patients aged 18 to 64 years (mean: 47.5). The mean surgical and hospitalization times and the mean number of postoperative complications in the two groups were comparable. Auditory outcomes were quantified by the speech reception threshold (SRT), the speech discrimination test (SDT), scores on the Korean version of the Glendonald Auditory Screening Procedure (GASP-K), and categories of auditory performance (CAP) scores. The SDT and GASP-K values were significantly lower in the older group at 3 months, 1 year, and 2 years; there were no significant differences in mean SRT and CAP values. We conclude that elderly patients may obtain appreciable benefits from CI without experiencing serious surgical complications. Nevertheless, difficulties in speech perception should be taken into consideration in older patients.