Editor’s note: Due to the COVID-19 pandemic, the 2021 Triological Society Combined Sections Meeting was held virtually on Jan. 29-30. The physical distance didn’t stop otolaryngologists in every specialty area from discussing the latest treatments, techniques, and issues in otolaryngology research and clinical practice.
The Best Practices session, an extension of the popular “Best Practices” feature that runs frequently in The Laryngoscope, was designed to point to evidence found in the literature in a way that clinicians and surgeons can put to use. Here are the questions they tackled:
Should all vocal fold leukoplakia undergo biopsy and resection?
Dinesh Chhetri, MD, a professor of head and neck surgery at the University of California, Los Angeles, said that these lesions pose some uncertainty. “We have essentially two ways of managing. One is to say, ‘I’m going to biopsy and treat everything,’” he said. “The other is to say, ‘I’m going to biopsy and treat only those that look concerning to me.’”
The leukoplakia referred to here are mostly white lesions in patients with normal vocal fold mobility. The bottom line from the literature, Dr. Chhetri said, is that clinicians should consider the look, the voice, and the expectations of patient follow-up (Laryngoscope. 2019;129:429-434).
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He noted that lesions that should be most strongly considered for biopsy and treatment are those that are red, raised, and ragged, or that have vascular stippling; those in which the patient has hoarseness that’s out of proportion to the lesion’s appearance or who have poor mucosal waves; patients expected to have poor follow-up; and patients with poor progress, with worsening of the lesion’s size and appearance over time.
In one study, researchers grouped leukoplakia into six types based on narrow-band imaging, with the worst types having large brown spots (abnormal vascularity) within or on the outside of the lesions. Three types were considered benign, and three were considered malignant; the diagnostic accuracy was 91%.
Do antivirals improve congenital cytomegalovirus (CMV)-related hearing loss outcomes?
Sanjay Parikh, MD, professor of otolaryngology–head and neck surgery at the University of Washington in Seattle, said that antiviral treatment is associated with improved hearing outcomes in newborns who have CMV and symptomatic central nervous system involvement, or who have moderate to severe CMV.
In one of the largest trials to study this condition, 96 patients were randomized within 30 days of birth and given six weeks or six months of oral ganciclovir. At 12 and 24 months, the six-month treatment group had a higher rate of hearing preservation (N Engl J Med. 2015;372:933-943).
For isolated sensorineural hearing loss with no CNS involvement, the data are more limited, Dr. Parikh said. But early studies suggest that antiviral treatment is associated with hearing improvement or preservation.
We have essentially two ways of managing. One is to say, ‘I’m going to biopsy and treat everything.’ The other is to say, ‘I’m going to biopsy and treat only those that look concerning to me. —Dinesh Chhetri, MD
Is sublingual immunotherapy (SLIT) effective for allergic rhinitis?
Andrew Lane, MD, director of the Johns Hopkins Sinus Center in Maryland, said that yes, SLIT is an effective treatment in adults and children who have severe allergic rhinitis symptoms that aren’t responsive to traditional pharmacotherapy, reducing symptoms and improving quality of life. It also helps reduce the use of anti-allergic medications and is self-administered easily, Dr. Lane said. Studies show that results from SLIT therapy are best when the treatment is given for at least 12 months, but he cautioned that the clinical effect size might be small.
One of the highest quality data sources mentioned by Dr. Lane was a meta-analysis of 49 randomized, double-blind, placebo-controlled clinical trials of the therapy for allergic rhinitis (Allergy. 2011;66:740-752). Patients treated with SLIT showed significantly improved symptom and medication scores when compared to patients receiving a placebo, with a trend toward more reduction if SLIT was given for more than 12 months. All doses and preparations of SLIT were equally effective.
Dr. Lane noted that more study is needed to determine the most effective starting point and the optimal dosing for SLIT. Researchers should also report sensitization status uniformly so that the therapy can be assessed across patients who are mono- and poly-sensitized, he said.
Should patients receive five days of antibiotics following clean-contaminated head and neck surgery?
Peri-operative antibiotics are given for many common clean-contaminated procedures in head and neck surgery, but the length of time they should be given has remained a question. Samir Khariwala, MD, MS, professor and vice chair of otolaryngology–head and neck surgery at the University of Minnesota, presented data showing that a 24- to 48-hour course appears to do just as well as a longer course.
In one of the studies he cited—a 2016 retrospective review—147 patients undergoing free flap reconstruction received an antibiotic course of two days or fewer, or a long course of more than two days (Surg Infect (Larchmt). 2016;17:100-105). Surgical site infection, flap dehiscence, flap loss, and length of stay were no different for the two groups.
Some evidence, though limited, suggests that a 48-hour course of ampicillin/sulbactam is superior to just 24 hours.
Ampicillin sulbactam should be the preferred antibiotic, according to the data, said Dr. Khariwala. Some evidence, though limited, suggests that a 48-hour course of ampicillin/sulbactam is superior to just 24 hours, however. And clindamycin, which consistently results in higher rates of infections in clean-contaminated surgery, should probably be avoided.
Should the contralateral tonsil be removed in cases of HPV-positive squamous cell carcinoma (SCC) of the tonsil?
Maie St. John, MD, PhD, chair of head and neck surgery at the University of California, Los Angeles, said that, based on literature review, in cases of HPV-positive SCC of one of the tonsils, it’s unknown just how often there’s also a tumor on the other tonsil. Routinely removing the contralateral tonsil brings concerns of pain, increased bleeding risk, or scarring. Missing occult disease in the contralateral tonsil, however, could be fatal.
The published evidence, Dr. St. John said, recommends that the contralateral tonsil should be removed routinely in cases of HPV-positive tonsillar SCC, since it doesn’t appear to increase rates of morbidity or complications, and identifying contralateral disease can “dramatically alter treatment and prognosis.”
In one retrospective review of 211 cases, seven of the patients (3.3%) had synchronous bilateral tonsillar HPV-positive SCC (SBTC), and another two patients had moderate to severe dysplasia on the contralateral tonsil, with no preoperative clinical or radiographic evidence of contralateral disease (Clin Otolaryngol. 2018;43:1-6).
Future studies, said Dr. St. John, should make attempts to identify “clinical disparities or differences” in tumor traits that could improve preoperative identification of patients with SBTC.
Thomas R. Collins is a freelance medical writer based in Florida.