ENTtoday

Literature Review: A Roundup of Important Recent Studies

Wide Variation in Maximal Medical Therapy for CRS

What is maximal medical therapy for chronic rhinosinusitis?

Background: Even 27 years after the introduction of endoscopic diagnosis and treatment of chronic rhinosinusitis (CRS), “maximal medical therapy” has not been defined. In its clinical indicators, the American Academy of Otolaryngology-Head and Neck Surgery recommends three weeks of an antibiotic with a topical steroid. A recent survey from the American Rhinologic Society indicated that the majority of respondents also used an oral steroid, achieving good results in CRS with polyposis, allergic fungal sinusitis and CRS without polyposis. This current study was designed to shed some light on the topic.

Study design: A survey of 603 otolaryngology consultants in the UK to assess prescription, duration and type of medical therapy for CRS.

Setting: Private and academic practice.

Synopsis: Out of the 603 surveyed, 158 returned questionnaires. Sixty-one percent of the respondents were rhinologists. The results indicated that decongestants, antifungals and immunotherapy were used in a very limited fashion for treatment. Clarithromycin for five weeks or less was the preferred antibiotic choice. Sixty percent of the respondents always prescribed a topical steroid. Oral steroids were used sparingly.

Bottom line: There are few evidence-based studies helping to define maximal medical therapy for CRS. These studies indicate that if antibiotics, topical steroids and decongestant are used for treatment, 50 percent resolve CRS. If oral corticosteroids are added, 75 percent will resolve CRS. This survey on preferences indicates that most respondents use oral antibiotics, steroid nasal sprays and saline douches. Almost predictably, however, “maximal medical” therapy for CRS varies greatly among participants and does not reflect recent evidence or guidelines.

Reference: Sylvester DC, Carr S, Nix P. Maximal medical therapy for chronic rhinosinusitis: a survey of otolaryngology consultants in the United Kingdom. Int Forum Allergy Rhinol. 2013;3:129-132.

—Reviewed by James A. Stankiewicz, MD

“Sinus Headache” Diagnosis and Treatment

How can you distinguish between a true rhinological headache and a migraine headache?

Background: Otolaryngologists see patients who complain of “sinus headaches.” The media has accepted the term. However, literature reviews and practitioner experience agree it is an overused phrase that is often incorrect. While review articles and consensus panels have discussed “sinus headache,” there are currently no evidence-based guidelines available for diagnosis and treatment.

Study design: Systematic literature review for level of evidence about diagnosis and treatment of “sinus headache.”

Setting: Multi-institutional review panel; academic medical centers.

Synopsis: Rhinosinusitis Task Force criteria of diagnosis of chronic sinusitis were reviewed. The International Headache Society criteria for headache attributed to rhinosinusitis and for migraine headache were reviewed, along with supporting literature. Evidence-based studies of level B and higher were reviewed for the diagnosis of sinus headache and for migraine headache. Based on these reviews, a summary of the diagnosis and treatment of “sinus headache” versus migraines was established.

Bottom line: “Sinus headache” requires an adequate workup to determine the true etiology of the headache. Treatment will follow in a more precise and targeted fashion. The workup should include history, physical exam, neurological exam, nasal endoscopy and CT scan with high suspicion for a diagnosis of migraine headache. Findings of sinusitis on CT scan or endoscopy with appropriate history will focus more on a rhinologic cause.

Reference: Patel ZM, Kennedy DW, Setzen M, Poetker DM, DelGaudio JM. “Sinus headache”: rhinogenic headache or migraine? An evidence-based guide to diagnosis and treatment. Int Forum Allergy Rhinol. 2013;3:221-230.

—Reviewed by James A. Stankiewicz, MD

Hospital-Acquired Conditions after HN Cancer Surgery Uncommon but Costly

How rare are hospital-acquired conditions (HACs) after head and neck cancer (HNCA) surgery, and how do they relate to mortality, complications and costs?

Background: In 1999, the Institute of Medicine (IOM) reported that medical errors were a leading cause of death and disability. Only a small number of HACs represent true medical errors. The authors note that there have been no studies that address the incidence of HACs in HNCA surgical patients. This study was set to determine the incidence of HACs in HNCA surgery and its association with in-hospital mortality, complications, hospitalization length and costs.

Study design: Retrospective cross-sectional study of discharge data for 123,662 adult patients who underwent an ablative procedure for a malignant oral cavity, laryngeal, hypopharyngeal or oropharyngeal neoplasm during 2001–2008.

Setting: Discharge data from the Nationwide Inpatient Sample, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality.

Synopsis: HACs were uncommon (<1 percent of all cases), and the majority experienced only one. Vascular catheter-associated infection was the most common, followed by falls and trauma, central line-associated bloodstream infection and foreign objects retained after surgery. Individual analysis revealed vascular catheter-associated infection was associated with major surgical procedures, flap reconstruction and a comorbidity score ≥ 2; central line-associated bloodstream infection was associated with urgent/emergency admission, flap reconstruction and a comorbidity score ≥ 2. Patients with HACs were significantly more likely to be admitted through urgent or emergency care, have advanced comorbidity, undergo major surgical procedures, have pedicled or free flap reconstruction, suffer an acute post-operative complication and die in hospital. Flap reconstruction was more common in patients who developed HACs (30.5 percent) than in those who did not (9.1 percent). There were no significant differences between hospital characteristics and HAC incidence. Study limitations included not being able to derive a meaningful analysis of long-term outcomes; a lack of data on readmission, previous surgical procedures or prior chemotherapy; a limited ability to adequately control for case mix; and a possible under-reporting of complications.

Bottom line: HACs are uncommon in HNCA surgical patients but are significantly associated with increased in-hospital mortality, morbidity and hospital-related costs.

Citation: Kochhar A, Pronovost PJ, Gourin CG. Hospital-acquired conditions in head and neck cancer surgery. Laryngoscope. 2013;123:1660-1669.

—Reviewed by Amy Eckner

Tympanoplasty Plus Mastoidectomy in Perforations

How effective is the use of mastoidectomy performed with tympanoplasty in bettering outcomes for tympanic membrane perforations?

Background: The role of mastoidectomy performed with tympanoplasty for tympanic membrane perforations in the absence of cholesteatoma continues to be debated. According to the authors, well-designed studies to address this issue are lacking in current literature. Arguments for mastoidectomy with tympanoplasty are largely based on theoretical grounds, anecdotal evidence and limited case series.

Study design: Review of 26 peer-reviewed publications on tympanoplasty and mastoidectomy (articles were classified as either randomized controlled trials, prospective cohort, retrospective cohort, retrospective case control or case series).

Setting: MEDLINE search using PubMed to identify English-language articles.

Synopsis: Three primary outcome measures were identified and analyzed: tympanic membrane repair success rate, otorrhea and infection improvement, and hearing outcomes. There was no evidence of improved outcomes following mastoidectomy compared with tympanoplasty alone. No randomized controlled trials supported mastoidectomy for improving outcomes. The majority of the literature came from retrospective reviews comparing outcomes between patients who underwent tympanoplasty with and without mastoidectomy. The retrospective review had a large potential bias based on the criteria with which patients were selected to undergo mastoidectomy.

Collectively, mastoidectomies were generally performed in conjunction with worse disease. Success rates were generally good (>80 percent) for all studies, regardless of whether a mastoidectomy was performed or not. Results were universally favorable for rates of persistent infection and drainage, with >90 percent control in most cases. Rates of persistent otorrhea were similar regardless of whether a mastoidectomy was performed or not. Only two studies showed improved hearing rates for patients undergoing mastoidectomy, and seven showed worse hearing rates. Results suggest worse overall outcomes for patients with prominent mucosal inflammatory disease, but no definitive benefit from undergoing mastoidectomy was demonstrated. MRSA patients might benefit from mastoidectomy with a tympanoplasty to eradicate hidden infection reservoirs.

Bottom line: The available literature shows no additional benefit to performing mastoidectomy with tympanoplasty for uncomplicated tympanic membrane perforations. There is not enough evidence to make recommendations for those with more complicated perforations.

Citation: Eliades SJ, Limb CJ. The role of mastoidectomy in outcomes following tympanic membrane repair: a review. Laryngoscope. 2013;123:1787-1802.

—Reviewed by Amy Eckner

Transoral BOT Resection Effective for OSA

How effective is base of tongue (BOT) resection by transoral robotic surgery (TORS) in obstructive sleep apnea/hypopnea syndrome (OSAHS)?

Background: OSAHS surgical treatment can be challenging and even controversial. According to the authors, there is a critical need to improve surgical treatment of OSAHS patients through either a shift in treatment paradigm or technological advances. Reports have described the use of TORS-assisted BOT resection with other concomitant upper airway procedures, but the authors note that there are no previous studies on TORS-assisted BOT resection without any other concomitant surgical alterations at other levels of upper airway.

Study design: Case series of 27 patients (12 with clinical and polysomnographic data) who received BOT resection via TORS between June 2010 and May 2012. Patients were excluded if other concomitant upper airway procedures were performed, or if post-operative polysomnograms (PSGs) were not available.

Setting: Wayne State University; Barbara Ann Karmanos Cancer Institute, Detroit, Mich.

Synopsis: A single surgeon performed all of the cases. The primary efficacy endpoint was changes in apnea-hypopnea index (AHI), with secondary efficacy endpoints of changes in LO2sat, Epworth Sleepiness Scale (ESS), BMI and snoring intensity. Surgical response was achieved when post-operative PSG showed >50 percent reduction in AHI with a final AHI <20. The majority of patients had previously undergone other types of upper airway procedures. No intra-operative difficulty or complication was encountered. Median total operative time was 75 minutes, median blood loss was 20 ml, the median total volume of BOT tissue removed was 22.1 mL and the median hospital stay was three days. Mean AHI was 43.9 ± 41.1 pre-operatively and 17.6 ± 16.2 post-operatively for an average AHI reduction of 28.3 percent. There was a significant reduction in ESS and snoring intensity but no significant difference between pre-operative and post-operative BMI or LO2sat. Six of 12 patients achieved surgical response, and all had post-operative AHI of less than 10. Surgical outcomes appeared similar to those patients who underwent the BOT procedure in addition to other upper airway surgeries.

Bottom line: There was a statistically significant improvement in ESS, AHI and snoring intensity for patients who received a BOT resection via TORS for the treatment of OSAHS.

Citation: Lin HS, Rowley JA, Badr MS, et al. Transoral robotic surgery for treatment of obstructive sleep apnea-hypopnea syndrome. Laryngoscope. 2013;123:1811-1816.

—Reviewed by Amy Eckner

Type I GPT Improves Vocal Outcomes in GI

How effective is type I Gore-Tex thyroplasty (GTP), when used by itself, on patients with nonparalytic glottic incompetence (GI)?

Background: GI encompasses a variety of laryngeal pathologies. Type I (medialization) thyroplasty has long been considered the procedure of choice for surgical treatment of GI resulting from vocal fold paralysis/immobility. Although both injection laryngoplasty and type I thyroplasty have been used to treat GI in patients with mobile folds, reliable, comparable vocal outcomes data in this varied patient population remain limited.

Study design: Retrospective review consisting of a subgroup analysis of validated, subjective and perceptual voice outcome measures (voice-related quality of life [VRQOL], Glottal Function Index [GFI] and GRBAS [grade, roughness, breathiness, asthenia, and strain]) after GTP in patients with vocal fold paresis (VFP), hypomobility, scar and atrophy.

Setting: University of North Carolina Voice Center, Chapel Hill.

Synopsis: Forty-eight patients with nonparalytic GI treated with GTP were reviewed. Patients were grouped according to primary diagnosis: VFP (12), hypomobility (20), scar (7) and atrophy (9). Twenty patients underwent bilateral type I GTP, and 28 were unilateral. Median follow-up time was 11 months. The median post-GTP increase in VRQOL for the entire surgical cohort was 30 points and was significant for each subgroup as well. The median decrease in GFI for the entire surgical cohort was seven points. Several subgroups also showed significantly improved post-operative GFI scores, including hypomobility and VFP. The median decrease in GRBAS was two points for the entire group. All subgroups (except scar) showed significant improvements in perceptual scoring. Post-thyroplasty increases in VRQOL had a moderate correlation with post-thyroplasty decreases in GFI.

Bottom line: Patients with nonparalytic GI, particularly those with vocal fold hypomobility, showed improved subjective and perceptual measures following GTP.

Citation: Shah RN, Deal AM, Buckmire RA. Multidimensional voice outcomes after type I Gore-Tex thyroplasty in patients with nonparalytic glottic incompetence: a subgroup analysis. Laryngoscope. 2013;123:1742-1745.

—Reviewed by Amy Eckner