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Literature Review: A Roundup of Important Recent Studies

Simulator Training Can Accelerate Resident Learning

Does use of an endoscopic sinus surgery simulator improve performance of surgical trainees?

Background: Surgical training has traditionally been based upon the tenets of “watch one, do one, teach one,” in which residents learn through participation in the management of patients. This study was undertaken to determine whether use of a simulator could accelerate learning.

Study design: A group of 14 otolaryngology residents and six attending surgeons participated. Trainees performing a limited number of sinus surgery procedures in patients were compared with those using the simulator. The surgical tasks that were completed were videotaped. The control group assisted in two additional endoscopic sinus surgery cases, while the experimental group worked with a simulator.

Setting: This research was undertaken through collaboration of two university-based residency programs in New York City.

Synopsis: The authors report that simulator-trained residents can at least match the surgical performance of residents trained traditionally in the operating room. Simulator training can propel a novice resident forward in his technical skills. Further, the authors report that significant disparity existed among the participating residents regarding the number of trials needed to obtain proficiency.

Bottom line: The study demonstrates that simulator training can contribute to and potentially accelerate resident skills. These findings will impact the future of surgical training.

Reference: Fried MP, Kaye RJ, Gibber MJ, et al. Criterion-based (proficiency) training to improve surgical performance. Arch Otolaryngol Head Neck Surg. 2012;138:1024-1029.

—Reviewed by Jonas Johnson, MD

FDG-PET Indicative of Hypoxic Status

Does assessment of maximum standardized uptake values (SUVmax) predict outcome in patients with T2 tongue cancer?

Background: Two-[(18)F]fluoro-2-deoxy-D-glucose positron emission tomography (FDG-PET) is widely employed for pre-clinical staging in head and neck oncology. Prior studies have suggested that high-level FDG uptake is associated with poor prognosis. This study was undertaken to determine whether FDG-PET could be used as a marker predicting tumor hypoxia.

Study design: Patients treated for T2 oral tongue cancer who had undergone pre-treatment FDG-PET were enrolled. All patients were treated with primary surgery. Adjuvant radiation was used as needed. Immunohistochemical evaluation of paraffin-embedded specimens was undertaken for markers of hypoxia including HIF-1α, CA-9 and GLUT-1.

Setting: Department of Otolaryngology, Asan Medical Center, Seoul, Republic of Korea.

Synopsis: The authors demonstrated that

SUVmax obtained by FDG-PET was an independent predictor of survival and was indicative of hypoxic status. In this study, hypermetabolic lesions were not detected on FDG-PET. The authors suggest this may be because these cases had shallow depth (< 3 mm). SUV higher than 5.05 and a high SUVmax were strongly associated with reduced disease-free survival and overall survival by multivariate analysis. In multivariate analysis that included SUVmax, HIF-1α was a significant predictor of disease-free survival.

Bottom line: High SUV on FDG-PET may correlate with poor prognosis.

Reference: Han MW, Lee HJ, Cho KJ, et al. Role of FDG-PET as a biological marker for predicting the hypoxic status of tongue cancer. Head Neck. 2012;34:1395-1402.

—Reviewed by Jonas Johnson, MD

Laryngeal Visualization in Dysphonic Patients Superior to HPE Alone

Are history and/or physical examination sufficient to guide clinical decision making regarding the timing of examinations for dysphonic patients?

Background: Not all tests achieve the same diagnostic accuracy. Traditionally, laryngeal visualization has been the gold standard for determining the best treatment for hoarseness. However, recently published clinical guidelines suggest that visualization may be delayed in the absence of serious underlying conditions or prolonged symptoms, implying that history is integral in risk stratification and determination of the timing of laryngoscopy.

Study design: Expert survey.

Setting: NYU Voice Center, Department of Otolaryngology and Division of Biostatistics, New York University School of Medicine, New York City.

Synopsis: Six laryngologists were presented with eight patient vignettes that included history and physical examination (HPE), laryngoscopy and stroboscopy. Questions were posed regarding diagnosis and management plans, with operative findings via direct laryngoscopy employed as a comparator. The diagnostic accuracy of HPE was 5 percent, while the accuracy following both flexible laryngoscopy and stroboscopy was 68.3 percent. Taking a specific diagnosis (cancer), HPE alone identified only 33 percent of cases, while both laryngoscopy and stroboscopy identified 100 percent of cases. The authors noted that one of the main complaints about the recently published guidelines is that in patients with no concerning comorbidity identified via HPE, there is a three-month allowance for observation prior to visualization.

Bottom line: Laryngeal visualization through flexible laryngoscopy and stroboscopy in dysphonic patients is more accurate than HPE alone in determining the diagnosis of patients with hoarseness.

Reference: Paul BC, Chen S, Sridharan S, Fang Y, Amin MR, Branski RC. Diagnostic accuracy of history, laryngoscopy, and stroboscopy. Laryngoscope. 2013;123:215-219.

—Reviewed by Sue Pondrom

Pillar Implant Improves Snoring and Some OSA

What is the efficacy of the Pillar implant in the treatment of snoring and mild-to-moderate obstructive sleep apnea?

Background: Various treatment modalities have been introduced and evaluated for patients with snoring or obstructive sleep apnea (OSA). Although positive airway pressure therapy has repeatedly proven successful, there is low adherence. Various surgical procedures have been attempted. Laser-assisted uvulopalatoplasty failed to show any clinical efficacy and is no longer recommended. Uvulopalatopharyngoplasty does not reliably normalize the apnea-hypopnea index (AHI). Maxillomandibular advancement is considered to be the only surgical procedure, with the exception of tracheotomy, to reduce AHI. There has not been a meta-analysis of the Pillar implant.

Study design: Meta-analysis.

Setting: Department of Otorhinolaryngology-Head and Neck Surgery, College of Medicine, Korea University; Department of Obstetrics and Gynecology, Department of Otorhinolaryngology-Head and Neck Surgery, College of Medicine, Konkuk University, Seoul, Republic of Korea.

Synopsis: Seven studies, all conducted between January 2002 and March 2011, were analyzed for snoring and mild-to-moderate OSA. The Pillar implant reduced snoring sound significantly and, for mild-to-moderate OSA patients, significantly reduced the Epworth Sleepiness Scale and AHI. The mean extrusion rate was 9.3 percent. The authors noted that there have been significant complications with other types of surgery, including pain, dryness and foreign-body sensation. Therefore, the Pillar implant is a new alternative, with effects that are long lasting due to its biologically compatible structure. Study limitations included the relevant studies not being placebo controlled, the short follow-up period and the co-existing OSA, because polysomnography was not mandatory for diagnosis of snoring in the studies.

Bottom line: The Pillar implant has a moderate effect on snoring and mild-to-moderate OSA.

Reference: Choi JH, Kim SN, Cho JH. Efficacy of the Pillar implant in the treatment of snoring and mild-to-moderate obstructive sleep apnea: a meta-analysis. Laryngoscope. 2013;123:269-276.

—Reviewed by Sue Pondrom

Role of Frontal Sinus Surgery in Nasal Polyp Recurrence

What are the patterns of polyp recurrence and the effect of frontal sinus surgery on polyp recurrence?

Background: One of the most important causes of surgical failure in chronic rhinosinusitis with nasal polyposis (CRSwNP) is polyp recurrence. The rate can be as high as 60 percent. There is some contradictory evidence for higher recurrence rates reported in asthmatic patients, and the role of bacteria and/or fungus is still not clearly elucidated.

Study design: Retrospective cohort study.

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

Synopsis: The study surveyed 338 consecutive operations done for 299 CRSwNP patients. No patients were excluded from the consecutive sampling. Patients received either standard endoscopic sinus surgery or a Draf 3 opening of their frontal sinuses. The authors made a distinction between a polyp that occurred and then resolved on medical treatment and a polyp that persisted despite medical treatment. The polyp recurrence rate in patients with follow-up longer than six months was 40 percent, but only half of them had persisting recurrence lasting longer than three months. The most common site of recurrence of nasal polyps was the frontal sinus region. Aspirin-tolerant asthmatic patients had a 1.7 times higher risk of recurrence at any time after the operation. A multivariate analysis failed to show any significant effect on polyp recurrence of fungal allergy, presence of fungus and staphylococcal superantigens.

Although Draf 3 did not completely prevent polyp recurrence, it was a significant factor in reducing persistence of polyps and in reducing the need for revision surgery. It also had a positive economic implication by decreasing the rate of hospitalization and reoperation. One of the difficulties encountered when comparing results was the absence of a definition of polyp recurrence. The authors defined polyp recurrence as the first recorded appearance of a polyp structure during post-operative follow-up anterior endoscopy.

Bottom line: Nasal polyposis is characterized by a high rate of recurrence. The presence of asthma or aspirin intolerance leads to more aggressive recurrence and, in these patients, the Draf 3 drillout procedure becomes a good option for improved long-term outcomes and reduced need for revision surgery.

Reference: Bassiouni A, Wormald PJ. Role of frontal sinus surgery in nasal polyp recurrence. Laryngoscope. 2013;123:36-41.

—Reviewed by Sue Pondrom

Aging Population Changes Frequency, Disease Types Seen by Otolaryngology

What are the effects of an aging population in the U.S. on the general practice of otolaryngologists?

Background: By 2030, the geriatric population (those aged 65 years and older) will comprise almost 20 percent of the population, compared with 12.4 percent in 2000 and 9 percent in 1960. The geriatric population uses a greater relative amount of health care resources, and it is acknowledged that care of the geriatric ear, nose and throat patient will play an increasing role in the practice of otolaryngology. However, there is relatively little literature addressing the effect the aging population will have on the specialty.

Study design: Retrospective analysis of new patient visits.

Setting: Department of Otolaryngology-Head and Neck Surgery, Emory Voice Center, Emory University School of Medicine; ENT Associates of Georgia, Atlanta.

Synopsis: For the period of 2004 through 2010, the authors reviewed 131,070 consecutive new patient visits at a large private practice otolaryngology group. The pediatric population comprised 14.3 percent of visits, patients aged 18 to 45 years comprised 29.9 percent, those aged 45 to 65 comprised 40.9 percent, and those aged 66 and older comprised 14.9 percent. As patient age increased, otologic diagnoses became more common, while rhinologic and head and neck diagnoses decreased. The No. 1 diagnosis for patients aged 45 to 65, as well as for those 66 and older, was hearing loss. Geriatric patients showed a statistically significant increase, from 14.3 percent in 2004 to 17.9 percent in 2010. Extrapolating these six-year trends out to the year 2030 results in an estimate of 29.8 percent of ENT patients older than age 65 at that time.

The authors noted that the increased proportion of geriatric patients has implications for the type and frequency of disease that general otolaryngologists see in their practice. This should be taken into account in shaping both resident training and otolaryngology board licensing and recertification exams.

Bottom line: The changing population is causing the frequency and type of disease seen by general otolaryngologists to change.

Reference: Creighton FX II, Poliashenko SM, Statham MM, Abramson P, Johns MM III. The growing geriatric otolaryngology patient population: a study of 131,700 new patient encounters. Laryngoscope. 2013;123:97-102.

—Reviewed by Sue Pondrom