ENTtoday

Literature Review: A roundup of important recent studies

Gentamicin vs. Dexamethasone in Meniere’s Disease

Does intratympanic gentamicin or dexamethasone control vertigo in patients with intractable, unilateral Meniere’s disease?

Background: Intratympanic gentamicin demonstrates good control of vertigo but significant incidence of hearing loss and prolonged imbalance associated with higher dosing protocols. Intratympanic steroids have varied control rates of vertigo with a low risk of side effects.

Study design: Prospective, randomized, controlled study.

Setting: Tertiary referral center.

Synopsis: Sixty patients with at least six months of unilateral definite Meniere’s disease (AAO-HNS 1995) refractory to medical management were randomized to two treatment groups: low-dose intratympanic gentamicin (ITG) or intratympanic dexamethasone (ITD). Low-dose ITG treatment was defined as 2 mL of 27.6 mg/mL (40 mg/mL buffered). A second treatment was given 20 days later if there were no signs of vestibular dysfunction or significant reduction in calorics. Nineteen patients received one ITG treatment and 13 received the second treatment. Intratympanic administration of dexamethasone was defined as 4 mg/mL once every three days for a total of three injections. Four patients received one retreatment and five patients received two retreatments for uncontrolled vertigo.

Vertigo control was calculated using AAO-HNS 1995 (classes A through F). Two-year follow-up for the ITG group revealed 81 percent complete control (class A) and 12 percent substantial control (class B). In the ITD group, 43 percent obtained complete control (class A) and 18 percent substantial control (class B).

Hearing loss in the ITD group was strictly related to the progression of Meniere’s disease, that is, only in patients who had poor control of vertigo. For the ITG group, 12 percent had increased hearing loss likely attributable to gentamicin.

Bottom line: In patients with refractory, unilateral Meniere’s disease, low-dose intratympanic gentamicin is relatively effective in controlling vertigo and has a low incidence (12 percent) of hearing loss. Intratympanic dexamethasone 4 mg/mL is less effective in controlling vertigo, similar to placebo, and did not influence hearing loss.

Reference: Casani AP, Piaggi P, Cerchiai N, et al. Intratympanic treatment of intractable unilateral Meniere’s disease: gentamicin or dexamethasone? A randomized controlled trial. Otolaryngol Head Neck Surg. 2012;146(3):430-437.

—Reviewed by Larry Lundy, MD

 

Flying after Tympanoplasty

Does early commercial air travel after tympanoplasty affect graft take rates?

Background: Patients are typically advised to avoid flying after tympanoplasty due to the potential for graft displacement with altitude changes. However, financial and personal reasons often necessitate flying home immediately after surgery.

Study design: Retrospective, controlled study.

Setting: Quaternary referral center.

Synopsis: A retrospective chart review identified 69 patients who flew on the first post-operative day after a tympanoplasty. They were compared with 100 patients matched for age, sex, side of operation, size of perforation, surgical approach, graft material and grafting technique. All patients had middle ear and ear canal packing with absorbable gelatin sponge as part of the standard tympanoplasty technique, and all followed the same post-operative protocol of oral antibiotics and ototopical drops. All patients were evaluated at 30 days. Of the flight group, six (13 percent) had graft failure. Of the non-flight group, 12 (12 percent) had graft failure.

Bottom line: Early commercial air travel after tympanoplasty can be considered a relatively safe option. Packing of the middle ear and ear canal likely adds sufficient stability to the tympanic membrane graft.

Reference: Konishi M, Sivalingam S, Shin SH, et al. Effects of early commercial air travel on graft healing rates after tympanoplasty. Ann Otol Rhinol Laryngol. 2012;121(2):110-112.

—Reviewed by Larry Lundy, MD

 

Patients with PVCM Aren’t Homogeneous

Is paradoxical vocal cord motion (PVCM) strictly a psychological disorder, or is it multifactorial?

Background: PVCM is descriptive for inappropriate adduction of the larynx during respiration. The etiology is unclear but has long been hypothesized to be psychological or a psychological conversion reaction. Because of similarity in presentation, PVCM is frequently misdiagnosed as refractory asthma.

Study design: Prospective study and psychological testing of subset.

Setting: Department of Otolaryngology, Ohio State University College of Medicine, Columbus, Ohio; Department of Social Sciences and Humanities, Spokane Community College, and Spokane Valley Ear, Nose and Throat, Spokane, Washington.

Synopsis: Of 170 patients older than 18 years, 117 were shown in the prospective study to be diagnosed by video laryngoscopy with PVCM.

A subset of 47 newly diagnosed PVCM patients underwent psychological analysis, which showed that PVCM demonstrated a conversion disorder pattern but not an anxiety disorder or a correlation with stress.

Noting that the etiology of PVCM appears to be multifactorial, the authors said that while PVCM is a classic conversion disorder for the majority of patients, there appears to be a subset of 25 percent of the patients with normal psychological testing. They said comorbid factors such as asthma, reflux and laryngeal sicca can exacerbate the symptoms.

Bottom line: The etiology of PVCM can be separated into primary PVCM (75 percent psychologically based) and secondary PVCM (25 percent divided into laryngeal hyperactivity disorders and neurological).

Reference: Forrest LA, Husein T, Husein O. Paradoxical vocal cord motion: classification and treatment. Laryngoscope. 2012;122(4):844-853.

—Reviewed by Sue Pondrom

 

CND in Differentiated Thyroid Carcinoma

Is total thyroidectomy with central neck dissection (CND) superior to total thyroidectomy alone in decreasing regional recurrence without increasing surgical morbidity in differentiated thyroid carcinoma?

Background: Although differentiated thyroid carcinoma is the fastest growing malignancy worldwide, considerable debate surrounds the question of whether CND is a preferred option with total thyroidectomy. Proponents claim that CND not only decreases regional recurrence and the surgical morbidity of reoperation but also provides information on nodal metastasis. Those who challenge the use of CND argue that total thyroidectomy alone offers an equal survival benefit and that CND is associated with risks.

Study design: Systematic review and meta-analysis.

Setting: Department of General Surgery, Chang Zheng Hospital, affiliated with Second Military Medical University, Shanghai, People’s Republic of China.

Synopsis: Sixteen trials with 3,558 patients were analyzed for surgical morbidities and locoregional recurrence after total thyroidectomy with CND versus total thyroidectomy alone. There was no increased risk of recurrent laryngeal nerve injury (temporary or permanent) or permanent hypocalcemia or locoregional recurrence when CND was performed. (Locoregional recurrence was slightly higher after total thyroidectomy alone.) Post-operative temporary hypocalcemia was more common after total thyroidectomy with CND than after total thyroidectomy alone. The retrospective nature of the study prevented researchers from analyzing the role of radioiodine therapy. An additional limitation was that cohorts were divided into groups based upon surgeon preference or expertise rather than randomization, which would have increased heterogeneity between groups.

Bottom line: The surgical morbidity in patients who received total thyroidectomy with CND was no greater in patients undergoing total thyroidectomy alone. There was a higher risk of temporary hypocalcemia from subsequent CND with additional dissection in the central cervical compartment.

Reference: Shan CX, Zhang W, Jiang DZ, et al. Routine central neck dissection in differentiated thyroid carcinoma: a systemic review and meta-analysis. Laryngoscope. 2012;122(4):797-804.

—Reviewed by Sue Pondrom

 

Clonazepam for Pain in Burning Mouth Syndrome

Is clonazepam, a GABA agonist, effective in treating pain associated with burning mouth syndrome (BMS)?

Background: Treatment has been problematic for burning mouth syndrome (BMS), a complex disorder characterized by painful burning sensations of the oral cavity. Treatments used have included antidepressants, analgesic mouth rinse, alpha-lipoic acid and hormone therapy. No specific therapy has been found. Although clonazepam has been cited as effective in treating BMS patients, there have been no double-blinded, randomized, controlled studies.

Study design: Randomized clinical trial.

Setting: School of Dental Medicine, University of Erlangen-Nuremberg, Erlangen, Germany; Department of Surgery, William Osler Health Center Etobicoke Campus, Toronto, Canada; Smell and Taste Clinic, Department of Otorhinolaryngology, Technical University of Dresden Medical School, Germany.

Synopsis: Twenty patients with idiopathic BMS were randomly assigned to receive clonazepam (0.5 mg/day, n = 10) or placebo (lactose, n = 10) for a nine-week period. The drugs were well tolerated by all participants, and the medication had no significant effect on either Zerssen Mood Scale or Beck Depression Inventory (BDI) scores, indicating that clonazepam produced no major change in psychological states. The taste test score increased in both groups over time, but there was no difference in increase between the two groups. Similar findings were made for salivary flow. Importantly, there was significant improvement in pain ratings over sessions and the improvement was more pronounced in patients receiving clonazepam compared with those receiving placebo. Neither maximal effect nor compliance appeared to be dose related; both were observed at the lower dose range. Nothing is known regarding long-term benefits beyond the nine-week length of the trial.

Bottom line: Clonazepam has a positive effect on pain in BMS patients.

Reference: Heckmann SM, Kirchner E, Grushka M, et al. A double-blind study on clonazepam in patients with burning mouth syndrome. Laryngoscope. 2012;122(4):813-816.

—Reviewed by Sue Pondrom

 

Ultrasonic Bone Aspirator for Removal of Frontal Sinus Osteoma

Can the ultrasonic bone aspirator (UBA) be successfully employed to remove exostotic skull osteomas without injury to adjacent vital structures?

Most osteomas, bony outgrowths of skeletal structures that develop through intramembranous ossification, arise in the skull. They affect the cranial vault, facial skeleton, paranasal sinuses and, most frequently, the skull base.

Background: Most osteomas, bony outgrowths of skeletal structures that develop through intramembranous ossification, arise in the skull. They affect the cranial vault, facial skeleton, paranasal sinuses and, most frequently, the skull base. Rarely malignant, osteomas grow slowly, blocking or compressing adjacent structures and frequently causing aesthetic deformity. Additionally, they may obstruct mucosal outflow, resulting in orbital compression or auditory dysfunction. Open forehead ostectomy is performed under direct visualization with a chisel or burr, although this procedure may be associated with complications. The UBA uses ultrasonic waves to emulsify bone without damaging surrounding soft tissue.

Study design: “How I Do It” case study.

Setting: Department of Otolaryngology-Head and Neck surgery, Jefferson Medical College, Thomas Jefferson University, Philadelphia; Ursinus College, Collegeville, Pennsylvania.

Synopsis: Osteoma was diagnosed in a 34-year-old man with a history of trauma to his right frontal region and a slow-growing mass over the right frontal sinus, associated with right-sided supraorbital pain. Using UBA, a direct suprabrow incision was made and the supraorbital neurovascular trunk was identified and preserved. Equipped with the Spetzler Claw tip, the UBA was used to remove the osteomas and contour the bone to match the contralateral side. At a four-week follow-up, the patient denied supraorbital hypesthesia, pain or discomfort and was pleased with his cosmetic outcome. The authors note that a disadvantage of using UBA may be the expense of acquiring the instrumentation.

Bottom line: UBA can be successfully employed to remove skull osteomas without injury to adjacent vital structures.

Reference: Ehieli E, Chu J, Gordin E, et al. Frontal sinus osteoma removal with the ultrasonic bone aspirator. Laryngoscope. 2012;122(4):736-737.

—Reviewed by Sue Pondrom