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Literature Review: A Roundup of Important Recent Studies

Newer Surgical Procedures Not Necessarily Better

How far should we as surgeons develop procedures that may be more costly—and perhaps more dangerous—than those we already have available?

Background: We, as surgeons, often manipulate, change adapt, and revise surgical procedures we perform in otolaryngology-head and neck surgery for the patient’s benefit. However, there are recent instances in which some procedures that have been developed are costly, take longer and present a high risk of complications in the name of cosmesis.

Study design: Guest editorial.

Setting: Department of Otolaryngology-Head and Neck Surgery, Arthur G. James Cancer Hospital, Ohio State University Medical Center, Columbus.

Synopsis: Recently, highly respected journals have published articles describing endoscopic surgery for the thyroid via the axilla and the removal of benign neck masses in children using an endoscopic axillo-breast approach. These articles describe procedures with increased operative time, risks, complications and cost compared with standard approaches to the thyroid or neck mass biopsy. With health care often considred to be too costly, it is unclear how procedures such as these will be supported in today’s health care world and in the future. The question is, are these procedures developed in the same way as endoscopic skull base surgery and pituitary surgery, procedures that have completely changed health care for the better in terms of cost, safety, recovery and outcomes?

Bottom line: Perhaps we need to rethink some surgical developments that are more costly, less safe and more prone to complication—especially in cases where standard surgeries have stood the test of time. Meanwhile, it is hoped that surgeons using these procedures to treat patients describe to patients all factors involved, including cost, safety issues and the increased risk of complications.

Reference: Schuller DE. Why are more costly and more dangerous surgical procedures being developed? Arch Otolaryngol Head Neck Surg. 2012;138(6):539-540.

—Reviewed by James A. Stankiewicz, MD

Primary Frontal Sinus Endoscopic Surgery Relieves Frontal Sinus Symptoms in Most

Over the long term, what factors are most important for successful frontal sinus surgery?

Background: Unfortunately, primary frontal endoscopic sinus surgery is not always successful, especially over the long term. Frontal sinus stenosis, a risk of surgery, can result in recurrence of symptoms. It is important to look at the factors responsible for success and failure to help improve outcomes.

Study design: Retrospective chart review with prospective patient-reported symptoms.

Setting: Department of Otolaryngology-Head and Neck Surgery, University of Adelaide, Adelaide, Australia.

Synopsis: A total of 109 patients who underwent primary frontal sinus endoscopic surgery were evaluated from January 2003 through December 2009. The overall patency rate was 92 percent. Complete resolution of symptoms occurred in 85 patients (78 percent). Clinically significant post-operative stenosis correlated well with return or persistence of symptoms, infection or polyp recurrence, along with actual size of the frontal ostia. Other factors such as asthma, smoking and fungal mucin polyposis in general did not provide a significant correlation.

Bottom line: Primary frontal sinus endoscopic surgery in experienced hands is successful in relieving frontal sinus symptoms in at least 75 percent of patients. Even though a frontal ostia is patent post-operatively (92 percent), some patients still have symptoms or infection requiring revision surgery (9 percent of cases or higher). Surgeons must exercise great care in order to avoide mucosal injury leading to stenosis, which can occur even in experienced hands.

Reference: Naidoo Y, Wen D, Bassiouni A, Keen M, Wormald PJ. Long-term results after primary frontal sinus surgery. Int Forum Allergy Rhinol. 2012;2(3):185-190.

—Reviewed by James A. Stankiewicz, MD

Success Following Surgery to Correct Obstructive Sleep Apnea Dependent Upon Scoring Measures

Are the success rates of surgical treatments for obstructive sleep apnea (OSA) dependent upon the polysomnographic (PSG) scoring system and metrics used?

Background: OSA diagnosis is confirmed by an elevated apnea-hypopnea index (AHI), and surgery can be considered a second-line treatment when continuous positive airway pressure (CPAP) therapy is inadequate or is not tolerated by the patient. Different criteria for cure or improvement are frequently used to determine success thresholds, and some metrics can emphasize statistical over clinical outcomes.

Study design: Retrospective case series with reanalysis of PSG data.

Setting: None specified.

Synopsis: Forty patients (32 males, eight females) with moderate to severe OSA undergoing multi-level pharyngeal surgery were given a preoperative questionnaire, along with pre-operative and post-operative PSGs; post-operative PSGs were scored for both the AHIChicago and AHIRec apnea/hypopnea indices. Surgery was classified as successful in patients with a post-operative

AHIRec ≤ 20 with a 50 percent reduction in AHI from baseline. Thirty-one of the patients had a complete PSG data set; using AHI < 20, 83.3 percent of the cohort had a successful outcome. However, success rates ranged from 38.9 percent to 91.7 percent as criteria and metrics changed (AHI < 30, AHI < 20; AHI reduced by 50 percent; AHI < 20 and reduced by 50 percent) and varied according to the AHI scoring system used.

Bottom line: The definition of OSA surgical treatment success is dependent on the PSG scoring system and metrics used.

Citation: Hobson JC, Robinson S, Antic NA, et al. What is “success” following surgery for obstructive sleep apnea? The effect of different polysomnographic scoring systems. Laryngoscope. 2012;122(8):1878-1880.

—Reviewed by Amy E. Hamaker

Intranasal Splint Use after Surgery Increases Patient Pain, Provides Few Offsetting Benefits

Do the benefits of using intranasal splints following nasal septal surgery outweigh the risks?

Background: Intranasal splints are often used following nasal septal surgery for adhesion prevention and septal position support. However, these splints have been shown to cause significant discomfort in patients. Evidence from previous studies on the use of intranasal splints compared with controls and other prevention and support methods may suggest benefits and risks of use.

Study design: Literature review.

Synopsis: Data from six randomized controlled trials (RCT) performed over the previous 20 years that compared outcomes of septal surgery with and without intranasal splints were examined. Three RCTs consisted of patients randomized to receive a splint post-surgery or not to receive a splint. In these trials there was generally little statistical difference in intranasal adhesion prevention, but those patients with splints experienced more post-surgical pain than those who did not have post-surgical splints.

The other three RCTs compared the use of post-surgical splints to a variety of methods. In a comparison of randomized splints and antibiotic meshes versus placement of transseptal horizontal mattress sutures, mucosal adhesion rates and post-operative pain were statistically the same. An RCT of patients undergoing septoplasty alone with a splint inserted on one side only showed no statistical difference in pain between the splint side and control side but better mucosal scores in the splint side. One RCT that used silicone splints with integral airway showed improved mucosal status.

Bottom line: Traditional splints cause a significant increase in pain without sufficient evidence of decreased adhesion prevention; however, newer, thinner splints may offer better treatment options with less pain.

Citation: Tang S, Kacker A. Should intranasal splints be used after nasal septal surgery? Laryngoscope. 2012;122(8):1647-1648.

—Reviewed by Amy E. Hamaker

New Reprocessing Guidelines for ENT Endoscopes Stress High-Level Disinfection Techniques

What are the guidelines for disinfection specific to flexible ear/nose/throat endoscopes?

Background: Endoscopes have become indispensible tools in ENT departments, but poor cleaning and disinfection procedures can lead to patient infections. Although reprocessing guidelines are available for digestive and respiratory endoscopes, specific references to ENT endoscopes do not currently exist. Non-channeled ENT

endoscopes require high-level disinfection but cannot be autoclaved, and ENT departments often require a quick turnaround time for disinfection due to frequent, often outpatient, use.

Study design: Literature review plus guideline development.

Synopsis: Flexible ENT endoscopes should be reprocessed immediately after use, and the entire endoscope must be cleaned and disinfected.

The authors examined both traditional and emerging disinfection methods and recommended specific seven-step protocols for manual disinfection by immersion, automatic disinfection, manual disinfection with wipes containing chlorine dioxide (ClO2) and immersion disinfection with ClO2 electronically controlled by a microprocessor. Reprocessing time ranged from two to 30 minutes and varied by disinfection method used. Some specific protocol recommendations were made, including rinsing with sterile water and using an enzymatic cleaning solution.

Sterile protective sheaths were also examined, although these must be used in conjunction with cleaning and medium-level disinfection methods to guarantee high-level disinfection. Microbiological tests on endoscopic surfaces were not recommended except in the case of epidemics, and tracking for disinfection protocols, equipment testing and maintenance, and action/intervention logs were recommended for all sites.

Bottom line: ENT endoscopes can be safely and quickly reprocessed if high-level disinfection protocols are maintained. Thorough tracking of reprocessing methods and equipment use and maintenance are recommended, but routine culture tests on endoscopic surfaces are not.

Citation: Cavaliere M, Iemma M. Guidelines for reprocessing nonlumened heat-sensitive ear/nose/throat endoscopes. Laryngoscope. 2012;22(8):1708-1718

—Reviewed by Amy E. Hamaker

Multicenter Study Shows Feasibility and Safety of Transoral Robotic Surgery

Is transoral robotic surgery (TORS) a safe, feasible method for head and neck cancer surgery?

Background: The role of TORS as a multidisciplinary treatment for head and neck cancer is expanding. Although several single-institution studies on TORS have been conducted, multicenter data on its effectiveness and safety are limited.

Study design: Review of pooled early data from independent institutional review board-approved prospective clinical trials.

Setting: University of Pennsylvania, Philadelphia; University of Alabama at Birmingham; and Mayo Clinic, Rochester, Minn.

Synopsis: For this study, 179 patients who presented with benign and malignant lesions of the oropharynx, supraglottic larynx, hypopharynx and oral cavity between May 2005 and December 2008 were evaluated. Centers followed similar protocols for data collection. Feasibility was measured by the ability to utilize TORS without reverting to traditional surgery, while safety was measured by the incidence of peri-operative complications and functional outcomes. Surgical margin adequacy was measured by the presence of any positive margin after the procedure.

Positive surgical margins were detected in seven of the 179 patients. Estimated blood loss for all patients was 82.8 ± 130 mL, with no transfusions required. The average hospital stay was 4.2 ± 2.7 days. Patients who underwent TORS without previous radiation therapy had a percutaneous endoscopic gastrostomy tube dependency rate of 5.0 percent.

There were no intra-operative or peri-operative deaths; 29 patients experienced serious adverse events requiring hospitalization, although no serious adverse events were directly related to the robotic device. In total, there was a 98.9 percent success rate based on this study’s criteria; surgical margin rates were comparable with those resulting from other transoral approaches.

Bottom line: Per this study’s criteria, TORS is a feasible, effective, safe procedure for resection of certain types of benign and malignant head and neck tumors.

Citation: Weinstein GS, O’Malley BW II, Magnuson JS, et al. Transoral robotic surgery: a multicenter study to assess feasibility, safety, and surgical margins. Laryngoscope. 2012;122(8):1701-1707.

—Reviewed by Amy E. Hamaker