Trio Sections Meeting: Experts Address Clinical Topics

SCOTTSDALE—In Triological Society Best Practices articles, published regularly in the Laryngoscope, experts answer clinical questions in just 800 to 1,100 words and are allowed only five references. The idea is to give readers practical clinical guidance in a concise way. The questions are chosen and answered by members of a committee covering all subspecialty areas. During the Triological Society Combined Sections Meeting, held earlier this year, experts brought this popular item to a session room, addressing clinical topics in a manner similar to the journal’s “TRIO Best Practices” feature.

Do All Inferior Turbinate Reduction Techniques Yield Long-Term Results?

Ashutosh Kacker, MD, professor of clinical otolaryngology at Weill Cornell Medical College in New York City, said that the conventional surgical treatments for turbinate reduction—partial or total turbinectomy, turbinoplasty, electrocautery, submucosal resection, and submucosal resection with lateral displacement—all are associated with varying success rates and postoperative issues, including bleeding, crusting, and nasal dryness.

“At this point, either submucosal resection using a debrider or the conventional submucosal resection with lateral displacement have the best long-term results for turbinate reduction,” he said.

In the turbinoplasty category, microdebrider-assisted and ultrasound turbinate reduction have been shown to be most effective at yielding good long-term results, but there is minimal research on the ultrasound approach, so the microdebrider approach has the advantage of familiarity, Dr. Kacker said. “More research needs to be done on (the ultrasound) technique.”

Do All Vocal Fold Polyps Require Surgery?

David Francis, MD, assistant professor of otolaryngology-head and neck surgery at the University of Wisconsin in Madison, said that while it’s accepted that voice therapy is the first-line treatment for vocal fold nodules, “there’s less consensus regarding vocal fold polyps,” which are rare in the larger landscape of voice problems. But the evidence—and only retrospective case studies are available—suggests that surgery isn’t needed in all cases, he said.

In one study of 42 consecutive patients with translucent, hemorrhagic, or hyaline polyps who underwent voice therapy, 45% improved and didn’t need surgery after eight months of follow-up. The polyps either resolved or became small enough that they weren’t symptomatic anymore. The only predictor of success was whether the polyps were translucent.

Other studies also support the idea that patients’ symptoms often resolve without surgery, indicating that polyps either became smaller or resolved. “Surgery is not necessary for all vocal polyps,” Dr. Francis said. “Small polyps that are more sessile and translucent tend to do better. And a high percentage resolve or shrink due to either voice therapy, vocal hygiene, or time.” But, he added, “Current data do not provide definitive answers because voice therapy is not applied the same across people.” He also pointed out that speech language pathologists specializing in voice are typically concentrated at tertiary academic medical centers and might not be available to all patients.

A remaining question is whether time alone can help in some cases. “Instead of just these single-institution studies,” Dr. Francis said, “we need to start performing multicenter comparative studies with sufficient sample sizes to help inform treatment decisions.”

Does the Frontal Sinus Need to Be Obliterated Following Fracture with Frontal Sinus Outflow?

Alexander Chiu, MD, chair of otolaryngology-head and neck surgery at the University of Kansas in Kansas City and

ENTtoday physician editor, said the approach to this injury involves aesthetics, maintaining normal sinus function, and—most importantly, he said—consideration of short- and long-term complications. “Traditional teachings will tell you that any frontal sinus outflow tract fracture should be acutely treated with a frontal sinus obliteration,” he added.

But is that always the case? Not necessarily, he said. The most relevant literature on the subject, he said, is a systematic review covering seven studies and 350 of 515 patients managed with frontal sinus preservation rather than traditional management. Those managed with preservation had a complication rate that was not statistically different from the others (Craniomaxillofac Trauma Reconstr. 2010;3:141–149).

This is solid evidence that sinus preservation can be a good approach in the right hands, Dr. Chiu said. “You do need to acutely manage frontal sinus outflow tract injuries. The question is whether you need to obliterate and cranialize. The short-term evidence points to the fact that you can follow these patients and treat them endoscopically if they maintain an obstruction—if you have the skill set to treat those patients.”

Is Dexamethasone Effective in Preventing Nausea and Vomiting After Common Otolaryngology Procedures?

Parwane Pagano, MD, assistant professor of anesthesiology at Columbia University Medical Center in New York City, said risk factors for postoperative nausea and vomiting (PONV) include female gender, age younger than 50, the duration of the anesthesia, and the need for opioids. PONV can delay discharge and lead to unplanned hospitalizations after procedures that were planned as outpatient.

Dexamethasone is thought to work for PONV by central nervous system binding, lowering inflammatory mediators, and possibly by killing pain. Hyperglycemia can occur in patients with impaired glucose tolerance, she noted.

In one of the more recent studies, a meta-analysis of seven randomized controlled trials, including 611 patients undergoing thyroidectomy, IV dexamethasone at 5 to 10 mg, given intraoperatively with one other antiemetic drug or antacid, was associated with a lower incidence and decreased severity of PONV (Med Sci Monit. 2014;20:2837-2845). Other studies and analyses have found similar efficacy, Dr. Pagano said.

“The literature surveyed supports the administration of dexamethasone as a very effective agent for prevention of postoperative nausea and vomiting in these frequently performed procedures,” she said. An area for future research involves patients who go on to suffer nausea and vomiting in the first one to three days, even after discharge.

“An important question is, what is the incidence of such post-discharge nausea and vomiting, and which longer-acting additional medications might be most optimal to prevent this complication?” she said.

Are Water Precautions Necessary After Tympanoplasty Tube Placement?

After the commonly performed tympanostomy tube insertion, the traditional recommendation is that children avoid water exposure to reduce the risk of postoperative otorrhea, said Richard Goode, MD, professor of otolaryngology, emeritus, at Stanford University in Palo Alto, Calif.

But is this precaution really necessary? Not really, Dr. Goode said. He pointed to studies such as a meta-analysis that included five controlled studies with a pooled analysis of 619 patients who had undergone tube placement. None of the studies found a statistically significant difference between children who swam without ear protection and non-swimmers (Laryngoscope. 1999;109:536-540).

In another study, researchers found no differences in the overall incidence of otorrhea between swimmers and non-swimmers. They also found that a child would have to wear ear plugs for 2.8 years to prevent one episode of otorrhea.

Dr. Goode pointed out that there is extensive literature on this question, and there is room to debate about whether he focused on the right studies. But he said he has changed his mind after thinking for years that “of course” ear plugs should be worn after the procedure. “Water precautions should not be routinely advised after tube placement,” Dr. Goode said.

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Thomas Collins is a freelance medical writer based in Florida.