Medical malpractice litigation involving otolaryngology residents and fellows: A case-based 30-year review

BACKGROUND

Errors, misdiagnoses, and complications can occur while trainees are involved in patient care. Analysis of such events could reveal areas for improvement by residency and fellowship programs.

AIM

To examine lawsuits tried at the state and federal level involving otolaryngology trainees.

METHODS

The LexisNexis database, an online legal research database containing state and federal case records from across the United States, was retrospectively reviewed for malpractice cases involving otolaryngology residents or fellows from January 1, 1990 to December 31, 2020. Case data collected: Plaintiff/trainee/defendant characteristics, allegations, medical outcomes, and legal outcomes.

RESULTS

Over the study period, 20 malpractice lawsuits involving otolaryngology trainees were identified. Plaintiffs raised numerous allegations including procedural error (n = 12, 25.5%), incorrect diagnosis and/or treatment (n = 8, 17.0%), and lack of knowledge of trainee involvement (n = 6, 12.8%). Nine cases (45%) had verdicts in favor of the plaintiff, whereas 5 cases (25%) had verdicts in favor of the defense. Six cases (30%) ended in a settlement. Awards to plaintiffs were heterogenous, with a median of $617,500 (range $32K-17M) for settled cases and verdicts favoring plaintiffs.

CONCLUSION

The findings enclosed herein represent the first published analysis of trainee involvement in otolaryngology malpractice cases held at the state/federal level. Otolaryngology trainees can be involved in lawsuits for both procedural and nonprocedural events. This study highlights the importance of education specifically in the domains of procedural errors, informed consent, proper diagnosis/management, and clear communication within patient care teams. Training programs should incorporate these study findings into effective simulation courses and didactic sessions. Educating trainees about common pitfalls holds the promise of decreasing healthcare systems costs, reducing trainee burnout, and, most importantly, benefiting patients.

Synovial osteochondromatosis of the temporomandibular joint: A case report

BACKGROUND

Synovial osteochondromatosis is a rare but benign condition that can result in significant impairment of joint functionality. This case report documents an uncommon presentation of this disorder occurring within the temporomandibular joint, causing the patient significant pain, trismus, and difficulty with daily activities such as eating and speaking. A review of the literature including disease mechanisms and previously documented cases is included to provide comprehensive background for clinical decision-making.

CASE SUMMARY

A 48-year-old male patient presented with a 3-mo history of trismus, crepitus with jaw movement and significant pain while chewing. Physical examination revealed a firm mass and tenderness to palpation at the right temporomandibular joint. Further workup revealed a bilobed mass extending into the joint space as well as significant bony erosion of the glenoid fossa. The patient underwent mass excision with joint reconstruction and pathology revealed synovial osteochondromatosis. The patient reported significant improvement in his symptoms postoperatively.

CONCLUSION

This report outlines the investigative approach and treatment course of synovial osteochondromatosis. The positive outcome following surgical intervention in this case emphasizes the importance of interdisciplinary collaboration and the potential for improvement in quality of life of this patient population.

CX3CR1 receptor as a potential therapeutic target in chronic rhinosinusitis and allergic rhinitis

Chronic rhinosinusitis and allergic rhinitis are chronic inflammatory diseases that affect the mucous membrane of the nose and paranasal sinuses. These diseases are characterized by recruitment of inflammatory cells to the upper airway. For this to take place a complex interaction between inflammatory cells and the cytokines/chemokines (ligand) liberated at the site of inflammation is involved in a process termed chemotaxis or directed cell migration against concentration gradient of the ligand. This entails signal transduction through the cell surface receptor resulting in cellular functional response and directed migration. In this editorial the novel role of CX3CR1 receptor in the immunopathology of chronic inflammation of the nose and paranasal sinuses will be explored with its potential role as therapeutic target in chronic nasal inflammation.

Effect of intranasal stents (AlaxoLito, AlaxoLito Plus and AlaxoLito Xtreme) on the nasal airway: A case report

BACKGROUND

The study of intranasal stents on the nasal airway is limited in the medical literature. The authors aim to provide objective measurements on their effects on the nasal airway. The aim is to study the feasibility of three novel intranasal stenting devices, AlaxoLito, AlaxoLito Plus, and AlaxoLito Xtreme, as treatment for nasal obstruction.

CASE SUMMARY

A 58- year-old man, who had right sided nasal obstruction, used stents during sporting activities intermittently for four years and subsequently in addition to intermittent sports use regularly for sleep for another two years. Magnetic resonance imaging (MRI) of the nasal passages and rhinomanometric measurements were taken with and without stents in situ. The stents tested are all braided from thin nitinol wires. The AlaxoLito Nasal Stent has a length of 35 mm. The AlaxoLito Plus and AlaxoLito Xtreme Nasal Stents have a length of 60 mm. Both have a diameter of about 10 mm in unloaded state and comprise a widened, ball-shaped section (which is positioned at the nasal alar) of about 11 and 14 mm, respectively. Rhinomanometric nasal airflow after application of the stents improved 1.11, 1.23, and 1.38 fold, respectively, with application of the AlaxoLito, AlaxoLito Plus and AlaxoLito Xtreme stents. MRI showed that after application of the stents, the nasal passage increased in diameter.

CONCLUSION

Intranasal stenting shows improvement in nasal airflow. Intermittent and regular longterm use had been shown to be safe, with no discomfort and no side effects.

Day case paediatric microlaryngobronchosocopy: A prospective study

AIM

To assess the feasibility and parental acceptance of diagnostic microlaryngobronchoscopy (MLB) as day case surgery.

METHODS

A prospective study was performed over a 26 mo period at a tertiary paediatric ENT centre. Patients were selected in clinic using set criteria. All MLBs were performed using a standardised anaesthetic protocol and patients monitored post-operatively. Six weeks following surgery, parents underwent questionnaire surveys.

RESULTS

Ninety-four out of 101 MLBs was successfully performed as day case surgery over the set period. Seven patients required an overnight stay for further observation. Fifty-seven parents took part in the questionnaire of which 68.4% were highly satisfied with same day discharge.

CONCLUSION

MLB is feasible, safe and acceptable as day case surgery in carefully selected patients.

Meatoplasty: A novel technique and minireview

We describe a modified aural meatoplasty technique. The technique has been mainly used for mastoid surgery but it may also be used to address other causes of meatal stenosis. It involves removing most of the cartilage in the conchal bowl and soft tissue in the external auditory meatus. Cartilage from the helical root may also be sacrificed as part of this procedure. Our technique produces an excellent cosmetic result and an adequate meatoplasty which is easy to monitor in the outpatient setting.

Embryology of the nose: The evo-devo concept

Aim was to gather relevant knowledge in evolution and development to find a rational explanation for the intricate and elaborate anatomy of the nose. According to classic embryology, the philtrum of the upper lip, nasal dorsum, septum and primary palate develop from the intermaxillary process, and the lateral walls of the nasal pyramid from the lateral nasal processes. The palatal shelves, which are outgrowths of the maxillary processes, form the secondary palate. The median nasal septum develops inferiorly from the roof of the nasal cavity. These valuable embryologic data do not explain the complex intricacy of the many anatomical structures comprising the nose. The evo-devo theory offers a rational explanation to this complex anatomy. Phylogenically, the nose develops as an olfactory organ in fish before becoming respiratory in tetrapods. During development, infolding of the olfactory placodes occurs, bringing the medial olfactory processes to form the septolateral cartilage while the lateral olfactory processes form the alar cartilages. The olfactory fascia units these cartilages to the olfactory mucosa, that stays separated from brain by the cartilaginous olfactory capsule (the ethmoid bone forerunner). Phylogenically, the respiratory nose develops between mouth and olfactory nose by rearrangement of the dermal bones of the secondary palate, which appears in early tetrapods. During development, the palatal shelves develop into the palatine processes of the maxillary bones, and with the vomer, palatine, pterygoid and inferior turbinate bones form the walls of the nasal cavity after regression of the transverse lamina. Applying the evolutionary developmental biology (evo-devo) discipline on our present knowledge of development, anatomy and physiology of the nose, significantly expands and places this knowledge in proper perspective. The clinicopathologies of nasal polyposis, for example, occurs specifically in the ethmoid labyrinth or, woodworker’s adenocarcinomas, occurring only in the olfactory cleft can now be explained by employing the evo-devo approach. A full understanding of the evo-devo discipline, as it pertains to head and neck anatomy, has profound implications to the otolaryngologist empowering his skills and abilities, and ultimately translating in improving surgical outcomes and maximizing patient care.

Use of Holmium:Yag laser in early stage oropharyngeal squamous cell cancer

AIM: To evaluate the efficacy of Holmium:Yag laser resection for oropharyngeal squamous cell cancer.

METHODS: A prospectively collected case series of all patients with oropharyngeal squamous cell carcinoma undergoing laser resection using the Holmium:Yag laser technique only over a 15 year period at a tertiary referral centre. All patients underwent long term follow up with regular clinical and radiological surveillance, when indicated. All patients were operated on under general anaesthetic with a laser-safe endotracheal tube. Typically laser resection was performed first using an operating microscope, followed by neck dissection. The tumour was held with a Luc’s forceps or Allis clamp. The Holmium:Yag laser was implemented via a fibre delivery system. The Holmium:Yag laser fibre, of 550 micron diameter, was inserted through a Zoellner sucker and attached via steri-strips to a second Zoellner suction to provide smoke evacuation. The settings were 1J/pulse, 15 Hz, 15 W in a continuous delivery modality via a foot pedal control. The procedure is simple, bloodless, effective and quick. All surgeries were performed as day cases.

RESULTS: Twenty-seven oropharyngeal squamous cell cancer patients were identified, at the following subsites: 23 lateral pharyngeal wall/tonsil, 2 anterior faucal and 2 tongue base. Of the 23 tonsil tumours, 19 required no further treatment (83% therefore had negative histopathological margins) and 4 required chemoradiotherapy (17% were incompletely excised or had aggressive histopathological features such as discohesive, perineural spread, vascular invasion). The 2 patients with anterior faucal pillar neoplasia needed no further treatment. Both tongue base cancer cases required further treatment in the form of chemoradiotherapy (due to positive histopathological margins). Postoperatively, patients complained of pain locally, which resolved with regular analgesia. There were no postoperative haemorrhages. Swallowing and speech were normal after healing (10-14 d). There was one case of fistula when neck dissection was carried out simultaneously; this resolved with conservative management. All patients were followed up with serial imaging and clinical examination for a minimum of five years. Median follow up was 84 mo.

CONCLUSION: Holmium:Yag lasers are a safe and effective treatment for Stage 1 and 2 squamous cell carcinoma of the oropharynx, excluding the tongue base.

Word perception in noise at different channels in simulated cochlear implant listeners

AIM: To find out effect of different signal-to-noise ratios (SNRs) on word perception at different number of channels.

METHODS: Thirty participants with normal hearing in the age range of 18-25 years (mean age 23.6 years) were involved in the study. For word perception test, there were 28 key-words embedded in sentences comprises of four lists processed for different channels (4, 8 and 32 channel) using AngelSim program at -5, 0 and +5 SNRs. The recorded stimuli were routed through audiometer connected with computer with CD player and presented in free field condition with speakers kept at 0° azimuth in a sound treated room.

RESULTS: Repeated measure ANOVA showed significant main effect across different SNRs at 4 channel, 8 channel and at 32 channel. Further, Bonferroni multiple pairwise comparisons shows significant differences between all the possible combinations (4, 8 and 32 channel) at +5 dB SNR, 0 dB SNR and -5 dB SNR.

CONCLUSION: Present study highlights the importance of more number of channels and higher signal to noise ratio for better perception of words in noise in simulated cochlear implantees.

Positron-emission tomography/computed tomography imaging in head and neck oncology: An update

Cancers of the head and neck account for more than half a million cases worldwide annually, with a significant majority diagnosed as squamous cell carcinoma (HNSCC). Imaging studies such as contrast-enhanced computed tomography (CT), magnetic resonance imaging (MRI) and ¹⁸F-2-fluoro-2-deoxy-D-glucose positron-emission tomography/computed tomography (¹⁸F-FDG PET/CT) are widely used to determine the presence and extent of tumors and metastatic disease, both before and after treatment. Advances in PET/CT imaging have allowed it to emerge as a superior imaging modality compared to both CT and MRI, especially in detection of carcinoma of unknown primary, cervical lymph node metastasis, distant metastasis, residual/recurrent cancer and second primary tumors, often leading to alteration in management. PET/CT biomarker may further provide an overall assessment of tumor aggressiveness with prognostic implications. As new developments emerged leading to better understanding and use of PET/CT in head and neck oncology, the aim of this article is to review the roles of PET/CT in both pre- and post-treatment management of HNSCC and PET-derived parameters as prognostic indicators.

X-linked deafness: A review of clinical and radiological findings and current management strategies

X-linked deafness is a rare genetic disorder causing a severe mixed hearing loss. This is due to an abnormal connection between the internal auditory meatus (IAM) and the basal turn of the cochlear leading to a “3^rd window effect” and cochlear conductive hearing loss. Patients are traditionally treated with conventional hearing aids however these are often unsatisfactory. Cochlear implantation is a high-risk procedure in such cases due to the risk of inadvertent electrode placement in the IAM. We present three paediatric cases where the hearing loss was managed with a combination of a bone anchored hearing aid in combination with a conventional behind the ear hearing aid. We also present a review of the current literature regarding the management of X-linked deafness.

Management of intratemporal facial nerve schwannomas: The evolution of treatment paradigms from 2000-2015

Intratemporal facial nerve schwannoma (FNS) are rare benign tumors of the skull base. Many of these tumors will be detected during evaluation for symptoms suggestive of vestibular schwannoma. However, there are several signs and symptoms which can suggest the facial nerve as the origin of the tumor. Intratemporal FNS can be multiple, like “beads on a string”, or solitary lesions of the internal auditory canal. This variable tumor morphology necessitates multiple treatment options to allow patients the best chance of preservation of facial nerve function. Historically FNS were managed with resection of the nerve with cable grafting. However this leaves the patient with permanent facial weakness and asymmetry. Currently most patients find this outcome unacceptable, especially when they present with good to normal facial nerve function. Facial paralysis has a significantly negative impact on quality life, so treatment regimens that spare facial nerve function have been used in patients who present with moderate to good facial nerve function. Nerve sparing options include tumor debulking, decompression of the bony facial canal, radiosurgery, and observation. The choice of management depends on the degree of facial nerve dysfunction at presentation, hearing status in the affected ear, medical comorbidities and patient preference. Each treatment option will be discussed in detail and suggestions for patient management will be presented.

It is 2015: What are the best diagnostic and treatment options for Ménière’s disease?

Ménière’s disease (MD) is a common cause of recurrent vertigo. Its pathophysiology is still unclear and controversial. The most common histological finding in postmortem temporal bone studies of patients is endolymphatic hydrops (EH). However, not all cases of hydrops are associated with MD and it may represent the end point of various etiologies. The diagnostic criteria for MD have undergone changes during the past few decades. A recent collaboration among specialty societies in United States, Europe and Japan has given rise to a new set of guidelines for the diagnosis and classification of MD. The aim is to develop international consensus criteria for MD that would help improve the quality of data collected from patients. The diagnosis of MD can be difficult in some cases as there is no gold standard for testing. Previous use of audiometric data and electrocochleography are poorly sensitive as screening tools. Recently magnetic resonance imaging as a diagnostic tool for identifying EH has gained popularity in Asia and Europe. Vestibular evoked myogenic potentials are also used but lack specificity. Finally, the treatment for MD has improved with the introduction of intratympanic treatments with steroids and gentamicin as well as less invasive treatment with the Meniett device.

Diagnosis and management of laryngeal cleft: A single centre experience and a novel endoscopic technique

AIM: To examine the presentation, diagnosis and outcomes of patients with laryngeal cleft.

METHODS: An 18 mo (from mid-2012 to 2013) prospective longitudinal study was performed at the Barts Children’s and Royal London Hospital, a tertiary referral centre. Chart review was performed for all patients including data extraction of demographics, outpatient clinic review documentation, speech therapy findings, medication list, operative findings alongside technique and follow up. A systematic review of contemporary English medical literature was also reviewed to compare series. The study was approved and registered by the hospital clinical governance and audit board. Biostatistician review was not required.

RESULTS: Twenty-two children aged 1 to 72 mo (mean age 23.5 mo) with a 7:4 male-female ratio. Twenty had Benjamin-Evans type 1 clefts and 2 had a type 2 cleft. All were symptomatic despite medical management including anti-reflux therapy. Patients presented with dyspnoea (81%), feeding difficulty (63%), stridor (54%) and recurrent pneumonia (36%). Several patients had concomitant aerodigestive abnormalities including 7 with laryngomalacia, 4 subglottic stenosis, 2 subglottic webs and 1 tracheo-oesophageal fistula. To date, 18 patients have undergone endoscopic repair, all of whom have shown radiological and/or clinical signs of improvement. All endoscopic repairs were performed with the novel use of a Negus knot pusher, with Baby Benjamin rigid suspension, to more reliably and easily suture at depth.

CONCLUSION: This is a significant single unit series demonstrating the strong association of laryngeal cleft with combined aerodigestive symptoms and other laryngeal abnormalities. Endoscopic management of type 1 and 2 laryngeal clefts is successful. We recommend the use of a Negus knot pusher to facilitate endoscopic repair.

Management of post-operative fistula in head and neck surgery: Sweeping it under the carpet?

The most dreaded complication in head and neck surgery is the development of fistula. Fistulas are common and devastating. The prevalence and the risk factors that contribute to fistula formation after head and neck procedures were discussed briefly. The main goal of this manuscript is to discuss current management of head and neck fistula. We believed that the best management strategy for head and neck fistulas is prevention. We recommend a holistic preventive approach during the perioperative period. The roles of different types of wound products and hyperbaric oxygen therapy were also discussed and highlighted. We also discussed the operative repair of fistulas, which relies on the tenet of providing well-vascularized tissue to an area of poor wound healing. Most often, the surgeon’s preference and range of operative skills dictate the timing and the type of repair. We highlighted the use of the pectoralis major, a well-known flap, as well as a novel technique in the surgical repair of complex, difficult-to-heal head and neck fistula.

Morbus Menière: Were the last 50 years of molecular biological research fruitless for Menière’s disease?

After discovering an inner ear hemorrhage, Prosper Menière ascribed disease to the inner ear for the first time. Since that time, a lot of efforts have been made to determine the pathophysiologic causes of the classical symptoms sensorineural hearing loss, vertigo attacks, tinnitus and ear fullness. According to its express pattern Menière’s disease may appear as classical and atypical disease. In the last decades, huge advances have taken place in biochemical and physiological research and in pathophysiological understanding of the inner ear and its diseases. This encloses stimulus perception and conduction, regulation of inner-ear fluid homeostasis and inner ear diseases with underlying genetics. Menière’s disease pathophysiologic correlate is an endolymphatic hydrops which is characterized by changes of inner ear homeostasis with its parameters volume, concentration, osmolarity and pressure of the endolymph. Hormones, autonomous system and the immunsystem together with purinergic, adrenergic and muscarinic receptors, steroids, vasopressin, atrial natriuretic peptide and aquaporin channels regulate inner ear homeostasis. Consequently, general diagnostics comprise a magnetic resonance imaging with gadolinium, vestibular diagnostics and tone audiometry. Standard therapy for acute inner ear symptoms is limited to cortisone infusions together with a rheologic agent or a radical scavenger. For acute vertigo attacks and for the mainstay therapy antivertiginous pharmaceuticals are given. In severe cases destruction of the vestibular hair cells by ototoxic antibiotics, endolymphatic sac surgery or neurectomy of the vestibular nerve might be necessary. Certainly, in research there is a move from simple pharmaceutical therapy forward to nanoparticle-based, genetic-based and stem cell therapy.

Thyroid lymphoma: A case report and literature review

Thyroid lymphoma is an unusual pathology. Different subtypes of lymphoma can present as primary thyroid lymphoma. This review illustrates via imaging, findings and treatment the need for accurate diagnosis and timely treatment. Patients and methods: patient’s chart, pathological findings and radiological images were reviewed in a retrospective analysis. Over several days, this 80 years old woman developed airway obstruction and rapid enlargement of her thyroid secondary to diffuse large B-cell lymphoma. She rapidly responded to her oncological protocol. Primary thyroid lymphoma is a rare disease. It is an important diagnosis to consider in patients presenting with rapidly enlarging neck masses. It is a treatable condition with fairly favorable overall survival even with the most aggressive histological subtypes.

Tongue dysfunction in neurological and neuromuscular disorders: A narrative literature review

Evaluation of oral function is useful for tracking longitudinal changes in swallowing function. Using videofluoroscopic (VF) images, we can evaluate swallowing function, but it is extremely difficult to quantitatively evaluate the oral phase. Recently, several studies have tried to quantitatively assess tongue function by analyzing tongue movement on VF images, to measure tongue thickness by ultrasonography, and to measure tongue pressure as surrogate for tongue strength. In this review article, the current state of quantitative assessments of tongue function for identification and management of dysphagia in patients with neuromuscular and other neurological disorders (NNMD) has been outlined. Disturbed bolus transport in patients with NNMD has been quantitatively measured on VF images by analyzing tongue base movement and bolus transport from the mouth to the pharynx. Enlarged tongue in Duchenne muscular dystrophy patients were observed by measuring the transverse width of the tongue on ultrasound. Tongue pressures that were measured using a handheld probe in NNMD patients were less than half of those in healthy subjects. More studies are needed to develop guidelines what types of tongue dysfunction give an indication of adjusting diet and introducing tube feeding to NNMD patients.

Diagnosis and treatment of sudden sensorineural hearing loss

Nationwide epidemiological surveys of idiopathic sudden sensorineural hearing loss (SSNHL) have been performed five times by the Research Committee of the Ministry of Health and Welfare or the Ministry of Health, Welfare and Labour in Japan. These surveys included patients who had SSNHL in 1972, 1987, 1993, 2001, and 2012. Using the criteria for the grading of hearing loss in SSNHL or the criteria for grading the degree of hearing recovery after SSNHL established by the Research Committee, we compared the outcomes of SSNHL between the five nationwide surveys. The results revealed that the outcomes of SSNHL have not changed in the past 40 years. In 1972, 88% of patients received steroids, but none received prostaglandin E₁ (PGE₁). The use of PGE₁ has increased since the 1980s, but its effect on SSNHL may not be significant. Intratympanic steroid injection has been introduced recently for the treatment of SSNHL, but it does not seem to be used widely in Japan. Intratympanic therapy that can reduce the total amount of steroids administered will be used more frequently if the true effects and indications for this therapy are known. Elucidation of the etiologies of SSNHL and development of treatments specific for these etiologies are expected.

Nasopharyngeal carcinoma: Long term follow-up of 83 patients

AIM: To analyzes the clinical, paraclinical, therapeutical and evolutive features of nasopharyngeal carcinoma (NPC).

METHODS: All the patients treated for a nasopharyngeal carcinoma between 2000 and 2013 in the Ear-Nose-Throat Department of the Military Hospital of Tunis, Tunisia were collected in this study. Eighty-three patients signed a written consent prior to study enrollment. The gender ratio (M/W) was 6.5 with a median age of 49 years (range 16-85). The median follow up time was 37 mo (18 to 108 mo). The evolution, during and after the end of therapy, was assessed on clinical biological and radiological exams. Different parameters were analyzed and compared to other series: complications of chemo and radiotherapy, recurrence of the disease, metastasis and overall survival rate.

RESULTS: Of the 83 patients of our study, 15% had T1 tumors, 20% had T2, 23% had T3 and 41% had T4 disease. At the time of diagnosis, 14% of the patients had a cranial nerve deficit. Only 12 patients had exclusive radiotherapy and the remaining of our patients had concomitant radio chemotherapy. Iatrogenic complications were diagnosed in 53% of the cases: radioepithelitis (28%), radiodermatitis (9%), xerostomia (17%), osteoradionecrosis (3%), cerebral radionecrosis (1%) and a pancytopenia (17%). The follow-up period varied from 18 to 108 mo (average: 37 mo). During the first six months after treatment, a persistence of the disease was found in 11% of patients, while a recurrence of the cancer was diagnosed in 6% and distant metastasis developed in 14% of the patients. Fifteen patients needed remedial chemotherapy for a relapse or metastasis and five had palliative chemotherapy for very advanced cases. We report 3 cases of death during the follow-up.

CONCLUSION: Despite its excellent radio-chemotherapy response, and general good prognosis, a careful follow-up of patients with NPC is necessary to detect and manage any iatrogenic complication, locoregional recurrence or metastasis of the disease.

Synchronous carcinoma of head and neck: 2 cases report

Multiple primary cancers are becoming an increasingly frequent situation and are often the source of many diagnostic and therapeutic difficulties. We report the case of two patients diagnosed with head and neck synchronous carcinomas. The first case is a 33-year-old man with a history of a keratinizing squamous cell carcinoma of the eye lid and who was operated 4 mo later from a mucoepidermoid carcinoma of the submandibular salivary gland. The second case is a 71-year-old woman who underwent a total parotidectomy for a mucoepidermoïd carcinoma of the left parotid gland and who consulted 2 mo later for epistaxis. The explorations concluded to a squamous cell carcinoma of the nasopharynx. The patient had a complementary radiotherapy. No local neither distant recurrence of the two tumors has been detected after a follow-up of 36 mo in the first case and 24 mo in the second one.

Relationship between chronic rhinosinusitis and lower airway diseases: An extensive review

Significant links between allergic rhinitis and asthma have been reported, and the united airway disease hypothesis is supported by numerous findings in epidemiologic, physiologic, pathologic, and immunologic studies. The impact of allergic rhinitis on asthma has been established. On the other hand, the relationship between chronic rhinosinusitis and lung diseases has been under investigation. Chronic rhinosinusitis is a common disease, and the high prevalence of chronic rhinosinusitis in some kinds of lung diseases has been reported. Recent studies suggest that the treatment of chronic rhinosinusitis has beneficial effects in the management of asthma. Here, we present an overview of the current research on the relationship between chronic rhinosinusitis and lower airway diseases including asthma, chronic obstructive pulmonary disease, cystic fibrosis, diffuse panbronchiolitis, primary ciliary dyskinesia, idiopathic bronchiectasis, and allergic bronchopulmonary aspergillosis.

Infrathyroidian hydatid cyst: Diagnostic difficulties and therapeutic management, a case report

Hydatidosis is a cosmopolitan anthropozoonose common to humans and many mammals. The cervical localization is rare even in endemic countries. We report a case of cervical hydatidosis located in the infra-thyroidian region. The diagnosis was suspected on clinical and radiological examinations (Ultrasonography, computed tomography-scan). The surgical removal of the cyst was difficult because of the inflammatory tissue around the mass. The confirmation of the diagnosis was obtained by the histopathological examination. During the follow-up, a local recurrence of the disease was diagnosed after 9 mo treated successfully by surgery.

Why use tympanometry in general practice: A review

Otitis media is a frequent problem in preschool children and one of the most common reasons for treatment with antibiotics in children. The exact diagnosis is important for proper management. The diagnosis of otitis media is often difficult. Pneumatic otoscopy, otomicroscopy, and tympanometry can improve the diagnostic quality by indicating fluid or no fluid in the middle ear and thus improve the quality of treatment. The aim of this review is to explain why and how tympanometry can improve the diagnostic quality in otitis media, and to identify some barriers and difficulties encountered when using tympanometry in daily practice. The current literature on tympanometry and own experiences during 38 years are used to elucidate the aim. Tympanometry is difficult to understand and use, when the procedure is not properly trained. The problems are both of a technical nature, and it is difficult to understand and use the information from the curve and the figures on the display. If the use of tympanometry in general practice is increased, the diagnostic quality will improve and hopefully antibiotics will be prescribed on more appropriate indications and less frequently. More demand on tympanometry will hopefully reduce the price of the tympanometer, making it more accessible for GPs. First in that situation the use will be nearly as common as the use of the otoscope.

Deafblindness and dual sensory loss research: Current status and future directions

Deafblindness is more than the addition of hearing impairment plus vision impairment. The absence or impairment of both distance senses gives a condition which is more disabling than the sum of each. Deafblindness is rare among young people but becomes frequent at higher ages. Deafblindness can be either congenital or acquired. The heterogeneity of the population has been reported to be huge. Different levels of vision and hearing loss, different use of language modality, different kinds and severity of additional disabilities, and different medical aetiology are some of the variables splitting the group. Research in deafblindness is still in it is advent due to a number of limitations and a lack of current scientific interest. Some of the challenges in deafblindness research are: lack of consensus on the definition of deafblindness; rareness of the condition which makes it difficult to even gather just a small group to study; heterogeneity of the population; difficulties with using traditional functional assessment procedures; communication barriers; and the difficulties of interpretation of deafblind behavior. This editorial calls for more interest in deafblindness in general and for more international cooperation and innovative studies to overcome existing barriers: Cooperation on data collection to form big enough sample sizes; development of reliable and valid tests and assessment tools; development of new research methods and approaches.

Rare complication: Tapia’s syndrome following shoulder surgery under endotracheal general anesthesia

Tapia’s syndrome is a rare disorder, characterized with paralysis of extracranial part of Nervus Vagus and Nervus Hypoglossus, effecting the ipsilateral vocal cord and the tongue. This complication is usually related to intubation and head positioning during surgery. In this study, we report a case with Tapia’s syndrome under general anesthesia, following arthroscopic shoulder instability surgery. Patient recovered as short as 3 mo, following complication.

Vessel selection and free flap monitoring in head and neck microvascular reconstruction

Microvascular free flap surgery has become a successful and reliable method of reconstruction following head and neck cancer resection. The effectiveness of free flap reconstruction has increased with improved surgical technique as well as technological refinement in vessel selection and flap monitoring. Few papers have studied the factors that influence success or failure rates of free flap reconstructions, particularly with an eye towards the technologic advancements that have refined the procedure in the last several decades. Here we present a comprehensive review of perioperative and intraoperative considerations that influence free flap outcomes as well methods of vessel selection and flap monitoring important during microvascular reconstruction of the head and neck.

Obstructive sleep apnea: An interdisciplinary challenge for otorhinolaryngologists

Otolaryngologists play a pivotal role in the diagnosis and management of sleep-related breathing disorders (SRBD) in both adults and children. Otolaryngologists are often the first medical specialists to be contacted by patients with complaints as snoring, episodic sleep apnea observed by the bed partners with or without reported excessive daytime sleepiness and therefore emerge as important gatekeepers of the general health of an individual by means of an active preventive, and in many cases therapeutic, role. Comprehensive diagnosis and treatment of SRBD requires a team approach and hence building interdisciplinary teams with other involved relevant specialties is necessary from the patients’ perspective.

Revision surgery for otosclerosis: An overview

Stapes surgery for otosclerosis has been proved to be a very satisfying procedure. However, the condition is difficult for the patients with no or little hearing gain after surgery and for those who had sudden or gradual hearing loss after a successful air-bone gap closure in the follow-up period. The issue of re-exploring the middle ear is challenging. A general review of this subject from several points of view remains lacking. In this study, articles related with the revision surgery for otosclerosis have been reviewed after a PubMed research and common and/or contradictory points were documented. The aim of this study is to give an insight to diagnostic and therapeutic approaches for the clinicians in patients who need a revision surgery. In conclusion, prosthesis problems, loose prosthesis in stapedotomy and migrated prosthesis in stapedectomy are the most common causes for revision surgery. Most important indicators which effect better hearing outcome following revision surgery are those ears with the presence of incus, with no obliteration of oval window, with small fenestra stapedotomy and the experience of surgeon. The risk of neurosensorial hearing loss in revision cases is not high but the hearing gain is limited as compared to primary cases. The rate of 10 dB air-bone gap closure is around 60%-70% at most and even less promising results have been reported. Patient’s demands and expectations have to be clarified in a realistic way.

Complicated sinusitis in children: 18 cases report

AIM: To precise the clinical characteristics of rhinosinusitis in pediatric population, their complications and therapeutic approaches.

METHODS: All infants younger than 15 years admitted to the Ear, Nose and Throat Department of the Military Hospital of Tunis, Tunisia for a complicated rhinosinusitis between 2006 and 2013 were evaluated. Data related to patients and the disease were collected and analyzed: past medical history, complaints, clinical examination, radiologic findings, therapeutic management and evolution.

RESULTS: Eighteen cases were identified with a mean age of 5.1 years (5 mo to 13 years) (SD ± 3.1). A male preponderance was noted in 72% of the cases. Rhinorrhea and fever were the most common presenting symptoms. Radiological explorations (computed tomography-scan ± magnetic resonance imaging) have been practiced for all of our patients. Orbital involvement was found in 77% of the cases associated with meningitis in 2 cases. Antibiotherapy was prescribed to all our patients. Surgical procedures were performed in 8 cases: endoscopic sinus surgery and/or external drainage of orbital abscess. After an average follow-up period of 2.5 years, 3 of our patients were lost. The ophthalmic sequelae noted in 3 cases (16%) were permanent and caused important functional and social problems. A favourable outcome has been noted in the rest of our patients.

CONCLUSION: Rhinosinusitis can be extremely severe in children requiring urgent radiological imaging and aggressive treatment to avoid orbital and intracranial complications.

Exostoses of the external auditory canal

Ear canal exostoses are bilateral, usually symmetric multiple bony growths occurring in the medial portion of the external auditory canal. Also known as surfer’s ear, exostosis is thought to be a reactive process from repeated stimulation by cold water and is much more common than external auditory osteoma. Exostoses are usually asymptomatic and discovered on routine otoscopy. Indications for surgical treatment are recurrent otitis externa, hearing loss, otalgia and other conditions in which access medial to the exostoses is required. Surgery is not risk-free and postoperative complications are the most important factor for negative impact on the patient’s health-related quality of life. This review offers an overview of the recent advances in the understanding of this condition, with a special focus on the etiology and physiopathology of this condition, the different surgical procedures and their outcomes, the risk factors for recurrence and the results of preventive measures. Finally, this review suggests the need for the otological surgeon to acquire a great deal of experience before undertaking surgical treatment of exostoses as it is a challenging operation and, besides expertise, demands great patience and extreme care in order to achieve good results.

Clinical anatomy of the tympanic nerve: A review

The tympanic (Jacobson’s) nerve is a useful anatomical structure in the middle ear with both practical and physiological functions extending beyond its origin. The paper reviews its clinical anatomy in adults and its surgical significance. English language articles from 5 major databases and Google scholar search engine were used to identify papers outlining the anatomy of the tympanic nerve, associated pathology and surgical relevance. In the majority of cases the tympanic nerve arises from the inferior ganglion of the glossopharyngeal nerve traversing through the tympanic canaliculus into the middle ear. On the promontory it coalesces with sympathetic fibres from the carotid chain forming the tympanic plexus which has individual variability. Functionally, as well as giving off parasympathetic fibres to the parotid gland via the lesser petrosal nerve, it is a useful anatomical landmark for cochlear implantation. The surgical importance of the tympanic nerve is not only restricted to middle ear surgery; it also extends to salivary gland disorders. The tympanic nerve remains clinically relevant to the modern otolaryngologist and as such a detailed understanding of its anatomy is crucial.

Experimental models of cholesteatoma: A review

Cholesteatoma describes the keratinized, stratified squamous epithelium in the middle ear and mastoid, which has osteoclastic activity and is capable of bone resorption. Its origin is unknown and remains a topic of current investigation. In addition, ongoing studies are investigating new molecules for treatment. This review summarizes the various experimental models of cholesteatoma.

Prenatal diagnosis and management of nasal glioma

Advances in foetal imaging have increased our detection rate of craniofacial abnormalities in utero. Nasal glioma is a rare, benign, congenital facial defect. Once detected, further imaging is required to assess for intracranial communication, the presence of additional defects, determine the patency of the aerodigestive tract and decide on timing of delivery. The authors review the current literature on diagnosis and management of nasal glioma in this rapidly advancing field of craniofacial anomalies detected in utero. Literature search of EMBASE and MEDLINE databases yielded 594 articles, which were screened by 2 independent reviewers. A total of 7 papers were selected after exclusion. There have been seven cases of prenatally diagnosed nasal glioma. The earliest of these was detected at 20 wk gestation. The majority were investigated with foetal magnetic resonance imaging (MRI) to establish any intracranial communication or bony defects. Ultrasound monitoring, doppler waveform and 3D rendered images were utilised to delineate the lesion, monitor growth and differentiate potential diagnosis. Postnatal MRI is favoured by most to re-evaluate the lesion and aid surgical planning. Surgical resection was performed within the first few months of life. Diagnostic uncertainty was seen in all cases, until formal histology was obtained, emphasising the challenges, and need for early appropriate specialist input. Whilst the prenatal detection of craniofacial abnormalities increases, there remain diagnostic challenges in differentiating prenatal congenital midfacial defects in utero. These defects are best investigated and monitored using prenatal ultrasound and MRI, to narrow the differential diagnosis, guide timing of delivery and allow for appropriate surgical planning. Prenatally detected nasal glioma, may only be confirmed on histology and families must be counselled appropriately to prepare them for the possible alternative diagnoses. Early surgical resection was undertaken to achieve more favourable aesthetic outcomes, reduce complications of ocular development and provide definitive histological diagnosis.

Vestibular evoked myogenic potential

Vestibular evoked myogenic potential (VEMP), is an electromyographic response of vestibular origin evoked by sound, vibration or electrical stimulation. VEMP is widely used as a clinical test of the otolith organs. Nowadays, two kinds of VEMP, cervical VEMP (cVEMP) and ocular VEMP (oVEMP) are clinically used. cVEMP is a test of sacculo-collic reflex while oVEMP is a test of utriculo-ocular reflex. Absence of responses, large interaural asymmetry of amplitudes, prolonged peak latencies, and abnormal thresholds of responses are regarded as abnormal responses. Clinical application to various diseases of the vestibular system was performed. Using VEMP, a new type of vestibular neuritis, inferior vestibular neuritis was established. A prominent feature of VEMP in Meniere’s disease is a shift of a preferred frequency in cVEMP. The whole aspects of VEMP findings in patients with benign paroxysmal positional vertigo are not clarified yet. Sensitivity of cVEMP to vestibular schwannoma was 80.0%, while specificity was 52.7%. Concerning diagnosis of superior canal dehiscence syndrome (SCDS), oVEMP to air-conducted sound is the most helpful. Augmentation of oVEMP responses is a prominent feature in SCDS. I also presented “idiopathic otolithic vertigo”, which I proposed as a new clinical entity based on VEMP findings. Some patients complained of lateral tilting sensation in the roll plane, or tilting or translational sensation in the pitch plane without rotatory vertigo. Majority of patients with these symptoms had absent or decreased responses of oVEMP and/or cVEMP. I proposed that these patients could be diagnosed as having “idiopathic otolithic vertigo”.

Classic clamp-and-tie total thyroidectomy for large goiters in the modern era: To drain or not to drain

AIM: To evaluate the role of drains in clamp-and-tie total thyroidectomy (cTT) for large goiters.

METHODS: A hundred patients were randomized into group D (drains maintained for 24 h) and ND (no drains). We recorded epidemiological characteristics, thyroid pathology, hemostatic material, intraoperative events, operative time and difficulty, blood loss, biochemical and hematological data, postoperative vocal alteration and pain, discomfort, complications, blood in drains, and hospitalization.

RESULTS: The groups had comparable preoperative characteristics, pathology, intraoperative and postoperative data. Hemostatic material was used in all patients of group ND. Forty patients in group D and 9 in ND felt discomfort (P < 0.001).

CONCLUSION: Drains in cTT for large goiters give no advantage or disadvantage to the surgeon. The only “major disadvantage” is the discomfort for the patient. Inversely, drains probably influence surgeons’ serenity, especially when cTT is performed in nonspecialized departments.

Nanoparticle based inner ear therapy

Synthetic nanoparticles can be used to carry drugs, genes, small interfering RNA (siRNA) and growth factors into the inner ear, to repair, restore and induce cellular regeneration. Nanoparticles (NPs) have been developed which are targetable to selected tissue, traceable in vivo, and equipped with controlled drug/gene release. The NPs are coated with a ‘stealth’ layer, and decorated with targeting ligands, markers, transfection agents and endosomal escape peptides. As payloads, genes such as the BDNF-gene, Math1-gene and Prestin-gene have been constructed and delivered in vitro. Short-hairpin RNA has been used in vitro to silence the negative regulator of Math1, the inhibitors of differentiation and DNA binding. In order to facilitate the passage of cargo from the middle ear to the inner ear, the oval window transports gadolinium chelate more efficiently than the round window and is the key element in introducing therapeutic agents into the vestibule and cochlea. Depending upon the type of NPs, different migration and cellular internalization pathways are employed, and optimal carriers should be designed depending on the cargo. The use of NPs as drug/gene/siRNA carriers is fascinating and can also be used as an intraoperative adjunct to cochlear implantation to attract the peripheral processes of the cochlear nerve.

Noise-induced hearing loss in the 21st century: A research and translational update

Millions of people worldwide are exposed to harmful levels of noise daily in their work and leisure environment. This makes noise-induced hearing loss (NIHL) a major occupational health risk globally. NIHL is the second most common form of acquired hearing loss after age-related hearing loss and is itself a major contributing factor to presbycusis. Temporary threshold shifts, once thought to be relatively harmless and recoverable, are now known to cause permanent cochlear injury leading to permanent loss of hearing sensitivity. This article reviews the current understanding of the cellular and molecular pathophysiology of NIHL with latest findings from animal models. Therapeutic approaches to protect against or to mitigate NIHL are discussed based on their proposed action against these known mechanisms of cochlear injury. Successes in identifying genes that predispose individuals to NIHL by candidate gene association studies are discussed with matched gene knockout animal models. This links to exciting developments in experimental gene therapy to replace and regenerate lost hair cells and post-noise otoprotective therapies currently being investigated in clinical trials. The aim is to provide new insights into current and projected future strategies to manage NIHL; bench to bedside treatment is foreseeable in the next 5 to 10 years.

Cause of idiopathic sudden sensorineural hearing loss: The stress response theory

The stress response theory is a relatively new concept about the cause of idiopathic sudden sensorineural hearing loss (ISHL). A number of possible etiologies have been proposed in the literature, as discussed in this paper, but each proposed etiology has been both supported and refuted in the literature. However, the stress response theory can integrate hypotheses that have been advocated so far. The word “stress” refers to a constellation of physical and psychological stimuli including systemic viral and bacterial illness, systemic inflammatory disorders, and physical, mental or metabolic stress. Numerous studies have demonstrated adverse effects of systemic stress on health. Stress causes changes in the immune system and cytokine network through activation of the hypothalamus-pituitary-adrenal axis and the sympathetic nervous system. Several types of catecholamine and cytokine receptors are in the cochlea cells other than capillary cells, and then they can respond to systemic stressors. However, there are few studies examining how systemic stress is associated with cochlear dysfunction. The stress response theory addresses this question. In the theory, a variety of stressors and risk factors contribute to the onset of ISHL in varying degrees. The lateral wall of the cochlea has very unique responses to systemic stressors. It plays a critical role in causing ISHL. Systemic stressors converge at the lateral wall and trigger pathological activation of nuclear factor κ-light-chain-enhancer of activated B cells, a transcriptional factor known as a stress sensor. This activation enhances local expression of genes associated with immune and inflammatory system, resulting in cochlear dysfunction. We review the original stress response theory advocated by Adams et al and the integrative stress response theory that integrates our knowledge about the etiologies of ISHL so far.

Systematic review of animal models of middle ear surgery

Animal models of middle ear surgery help us to explore disease processes and intervention outcomes in a manner not possible in patients. This review begins with an overview of animal models of middle ear surgery which outlines the advantages and limitations of such models. Procedures of interest include myringoplasty/tympanoplasty, mastoidectomy, ossiculoplasty, stapedectomy, and active middle ear implants. The most important issue is how well the model reflects the human response to surgery. Primates are most similar to humans with respect to anatomy; however, such studies are uncommon now due to expense and ethical issues. Conversely, small animals are easily obtained and housed, but experimental findings may not accurately represent what happens in humans. We then present a systematic review of animal models of middle ear surgery. Particular attention is paid to any distinctive anatomical features of the middle ear, the method of accessing the middle ear and the chosen outcomes. These outcomes are classified as either physiological in live animals, (e.g., behavioural or electrophysiological responses), or anatomical in cadaveric animals, (e.g., light or electron microscopy). Evoked physiological measures are limited by the disruption of the evoking air-conducted sound across the manipulated middle ear. The eleven identified species suitable as animal models are mouse, rat, gerbil, chinchilla, guinea pig, rabbit, cat, dog, sheep, pig and primate. Advantages and disadvantages of each species as a middle ear surgical model are outlined, and a suggested framework to aid in choosing a particular model is presented.

Adenosine amine congener ameliorates cisplatin-induced hearing loss

AIM: To investigate a novel pharmacological intervention to mitigate cisplatin ototoxicity using a selective adenosine A₁ receptor agonist adenosine amine congener (ADAC).

METHODS: Male Wistar rats (8-10 wk) were exposed to a two-cycle cisplatin treatment similar to clinical course of cancer chemotherapy. Each cycle comprised 4 d of intraperitoneal cisplatin injections (1 mg/kg twice daily) separated by 10 d of rest. ADAC (100 μg/kg) or drug vehicle solution (control) was administered intraperitoneally for 5 d at 24 h intervals during the second cisplatin cycle (Regime 1), or upon completion of the cisplatin treatment (Regime 2). Hearing thresholds were measured using auditory brainstem responses (ABR) before cisplatin administration (baseline) and 7 d after the end of cisplatin treatment. Histological analysis of cochlear tissues included hair cell counting and qualitative assessment of apoptosis using terminal deoxynucleotidyl transferase mediated dUTP nick end labelling (TUNEL) staining.

RESULTS: ABR threshold shifts in cisplatin-treated Wistar rats ranged from 5-29 dB across the frequency range used in the study (4-24 kHz). Higher frequencies (16-24 kHz) were mostly affected by cisplatin ototoxicity (mean threshold shift 25-29 dB). ADAC treatment during the second cisplatin cycle reduced cisplatin-induced threshold shifts by 12-16 dB (P < 0.01) at higher frequencies compared to control vehicle-treated rats. However, the treatment was ineffective if ADAC administration was delayed until after the completion of the cisplatin regime. Functional recovery was supported by increased survival of hair cells in the cochlea. Qualitative analysis using TUNEL staining demonstrated reduced apoptosis of the outer hair cells and marginal cells in the stria vascularis in animals treated with ADAC during the second cisplatin cycle.

CONCLUSION: A₁ adenosine receptor agonist ADAC mitigates cisplatin-induced cochlear injury and hearing loss, however its potential interference with antineoplastic effects of cisplatin needs to be established.

Noise-induced cochlear inflammation

Hearing loss is the most common sensory disability with considerable social and economic implications. According to recent World Health Organization estimates, 360 million people worldwide suffer from moderate to profound hearing loss. Exposure to excessive noise is one of the major causes of sensorineural hearing loss, secondary only to age-related hearing loss (presbyacusis). Since cochlear tissues have limited abilities of repair and regeneration, this damage can be irreversible, leading to cochlear dysfunction and permanent hearing loss. Recent studies have shown that cochlear inflammation can be induced by noise exposure and contribute to the overall pathogenesis of cochlear injury and hearing loss. The cochlea is separated from the systemic circulation by the blood-labyrinth barrier, which is physiologically similar to the blood-brain barrier of the central nervous system. Because of this feature, the cochlea was originally considered an immunologically privileged organ. However, this postulate has been challenged by the evidence of an inflammatory response in the cochlea in the presence of bacterial or viral pathogens or antigens that can cause labyrinthitis. Although the main purpose of the inflammatory reaction is to protect against invading pathogens, the inflammatory response can also cause significant bystander injury to the delicate structures of the cochlea. The cochlear inflammatory response is characterised by the generation of proinflammatory mediators (cytokines, chemokines and adhesion molecules), and the recruitment of inflammatory cells (leukocytes). Here, we present an overview of the current research on cochlear inflammation, with particular emphasis on noise-induced cochlear inflammation. We also discuss treatment strategies aimed at the suppression of inflammation, which may potentially lead to mitigation of hearing loss.

Extended pectoralis major myocutaneous flap in head and neck reconstruction

Although the pectoralis major myocutaneous flap is often used in head and neck reconstruction, the extension of the skin paddle beyond the inferior limits of the muscle has not been well described. We aim to clarify the design and application of this extended flap in head and neck reconstruction. In this retrospective study, consecutive cases of extended pectoralis major myocutaneous flap reconstruction of post-ablative head and neck defects at a single tertiary referral center were included for analysis. In 7 cases an extended pectoralis major flap was utilized, in which the skin paddle was extended beyond the inferior border of the pectoralis major to include the rectus sheath. Skin and soft tissue as well as composite defects of the oral cavity, parotid/temporal region and neck were reconstructed. All flaps healed satisfactorily with no loss of skin viability. The extended pectoralis major myocutaneous flap is robust and has versatile applications for reconstruction of large, high and three dimensionally complex defects in the head and neck region.

Surface electromyography for diagnosing dysphagia in patients with cerebral palsy

AIM: To determine the accuracy of 2-channel surface electromyography (sEMG) for diagnosing oropharyngeal dysphagia (OPD) in patients with cerebral palsy.

METHODS: Participants with cerebral palsy and OPD between 5 and 30 years of age and age- and sex-matched healthy individuals received sEMG testing during swallowing. Electrodes were placed over the submental and infrahyoid muscles, and sEMG recordings were made during stepwise (starting at 3 mL) determination of maximum swallowing volume. Outcome measures included submental muscle group maximum amplitude, infrahyoid muscle group maximum amplitude (IMGMA), time lag between the peak amplitudes of 2 muscle groups, and amplitude difference between the 2 muscle groups.

RESULTS: A total of 20 participants with cerebral palsy and OPD (OPD group) and 60 age- and sex-matched healthy volunteers (control group) were recruited. Among 20 patients with OPD, 19 had Dysphagia Outcome and Severity Scale records. Of them, 8 were classified as severe dysphagia (level 1), 1 was moderate dysphagia (level 3), 4 were mild to moderate dysphagia (level 4), 3 were mild dysphagia (level 5), and 3 were within functional limits (level 6). Although the groups were matched for age and sex, participants in the OPD group were significantly shorter, weighed less and had lower body mass index than their counterparts in the control group (both, P < 0.001). All sEMG parameter values were significantly higher in the OPD group compared with the control group (P < 0.05). Differences were most pronounced at the 3 mL swallowing volume. IMGMA at the 3 mL volume was the best predictor of OPD with a sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 85.0%, 90.0%, 73.9%, 94.7% and 88.8%, respectively.

CONCLUSION: Two-channel sEMG may be useful in the diagnosis of OPD in patients with cerebral palsy.

SLC26A4 mutation testing for hearing loss associated with enlargement of the vestibular aqueduct

Pendred syndrome (PS) is characterized by autosomal recessive inheritance of goiter associated with a defect of iodide organification, hearing loss, enlargement of the vestibular aqueduct (EVA), and mutations of the SLC26A4 gene. However, not all EVA patients have PS or SLC26A4 mutations. Two mutant alleles of SLC26A4 are detected in 1/4 of North American or European EVA populations, one mutant allele is detected in another 1/4 of patient populations, and no mutations are detected in the other 1/2. The presence of two mutant alleles of SLC26A4 is associated with abnormal iodide organification, increased thyroid gland volume, increased severity of hearing loss, and bilateral EVA. The presence of a single mutant allele of SLC26A4 is associated with normal iodide organification, normal thyroid gland volume, less severe hearing loss and either bilateral or unilateral EVA. When other underlying correlations are accounted for, the presence of a cochlear malformation or the size of EVA does not have an effect on hearing thresholds. This is consistent with observations of an Slc26a4 mutant mouse model of EVA in which hearing loss is independent of endolymphatic hydrops or inner ear malformations. Segregation analyses of EVA in families suggest that the patients carrying one mutant allele of SLC26A4 have a second, undetected mutant allele of SLC26A4, and the probability of a sibling having EVA is consistent with its segregation as an autosomal recessive trait. Patients without any mutations are an etiologically heterogeneous group in which siblings have a lower probability of having EVA. SLC26A4 mutation testing can provide prognostic information to guide clinical surveillance and management, as well as the probability of EVA affecting a sibling.

Experimental study of transient cochlear ischemia as a cause of sudden deafness

The etiology of sudden deafness or idiopathic sudden sensorineural hearing loss (ISSHL) remains unclear. Over the past 15 years, we have investigated the mechanisms of ischemic-induced hearing loss using a gerbil model of transient cochlear ischemia. In the gerbil, cochlear ischemia can be induced by occluding the bilateral vertebral arteries simultaneously at the neck, because the posterior communicating arteries of the Circle of Willis close spontaneously around 1 mo after birth. When 15 min ischemia was loaded on this animal, permanent hearing loss of about 25 dB and the death of hair cells, especially inner hair cells were induced. These pathological changes were mainly due to lack of an energy source, glutamate excitotoxicity, and the production of free radicals, especially superoxide and nitrous oxide species. Ischemic damage could be prevented by various procedures, such as cooling the cochlea, intratympanic administration of insulin-like growth factor 1 or AM-111 (an anti-apoptotic agent), and systemic administration of prednisolone (steroid), edarabone (free radical scavenger), ginsenoside Rb1 (Kanpo), hematopoietic stem cells, glia-cell derived neurotrophic factor, and liposome-encapsulated hemoglobin (artificial red blood cells). We also found that the cochlea was protected by the ischemic tolerance, indicating that minor cochlear ischemia alleviates or prevents inner ear damage in subsequent severe cochlear ischemia. As ISSHL usually occurs suddenly, with no preceding sign or symptom, we suggest that most ISSHL cases are caused by circulatory disturbance, probably at the stria vascularis.

Elective regional lymphadenectomy for advanced auricular squamous cell carcinoma

AIM: To investigate the rate of occult lymph node disease in elective parotidectomy and neck dissection specimens in patients with advanced auricular cutaneous squamous cell carcinoma (cSCC).

METHODS: At a single institution, from 2000 to 2010, 17 patients with advanced auricular cSCC were considered high risk for occult regional parotid and/or neck nodal metastases and, thus, underwent an auriculectomy and elective regional lymphadenectomy (parotidectomy and/or neck dissection). Indications for elective regional lymphadenectomy were large tumor size, locally invasive tumors, post-surgical and post-radiation recurrence, and being an immunosuppressed patient. We determined the presence of microscopic disease in the regional (parotid and neck dissection) pathology specimens.

RESULTS: There were 17 advanced auricular cSCC patients analyzed for this study. Fifteen (88%) patients were men. The average age was 69 (range: 33 to 86). Ten (59%) patients presented with post-surgical recurrence. Five (29%) patients presented with post-radiation recurrence. Four (24%) patients presented with both post-surgical and post-radiation recurrence. Four (24%) patients were immunosuppressed (2 (12%) were liver transplant patients, 2 (12%) were chronic lymphocytic leukemia patients, and 1 (6%) was both). The subsite distribution of cSCC included helix (3, 18%), antihelix (2, 12%), conchal bowl (7, 41%), tragus (2, 12%), and postauricular sulcus (3, 18%). Four (24%) patients presented with multifocal auricular cSCC. No patients had bilateral disease. All patients were confirmed to have cSCC on final pathology. The tumors were well (5, 29%), moderately (10, 59%), and poorly (2, 12%) differentiated SCC. The average size of the cSCC tumor was 2.9 cm (range: 1.7 to 7 cm). Twelve (70%) tumors were greater than 2 cm. Six (35%) patients underwent partial auriculectomy. Eleven (65%) patients underwent total auriculectomy. Eight (47%) patients underwent elective parotidectomy and elective neck dissections; 3 (18%) underwent only elective parotidectomy; 3 (18%) underwent only an elective neck dissection; 2 (12%) underwent an elective parotidectomy and therapeutic neck dissection; and 1 (6%) underwent a therapeutic parotidectomy and an elective neck dissection. None of the elective parotidectomy or neck dissection specimens were found to contain any malignant disease. All therapeutic parotidectomy and neck dissection specimens contained metastatic SCC. Fourteen (82%) underwent parotidectomy. Of these, 10 (71%) underwent superficial parotidectomy whereas 4 (29%) underwent total parotidectomy. Fourteen (82%) underwent neck dissections [levels II/Va (1, 7%), levels II/III/Va (2, 14%), levels I/II/III/Va (2, 14%), and complete levels I-V (9, 64%)]. Three (18%) underwent concurrent temporal bone resections for tumor extension from the auricle. The average follow-up for our patients was 44 mo (range: 4 to 123 mo). At the time of the review, 6 (35%) patients were alive and 11 (65%) had passed away.

CONCLUSION: This study suggests that, in patients with advanced auricular cutaneous SCC, elective regional lymphadenectomy is not necessary. However, furtherprospective studies are necessary to assess the necessity.

Endolymphatic hydrops in Meniere’s disease secondary to otitis media and visualized by gadolinium-enhanced magnetic resonance imaging

Aimed to test the hypothesis that endolymphatic hydrops in Meniere’s disease (MD) may be secondary to otitis media, history of a patient who developed MD as a complication of otitis media was reviewed. The inner ear was imaged using a 3.0 Tesla MR system post-intravenous injection of gadolinium-tetraazacyclododecane-tetraacetic acid (Gd-DOTA) in a standard single dosage (0.1 mmol/kg). Both t2-spc-rst-tra-iso (T2-weighted) and heavily T2-weighted 3-dimensional fluid-attenuated inversion recovery magnetic resonance imaging [hT(2)W-3D-FLAIR] sequences were applied. As a result, in the T2-weighted images, the perilymph and endolymph, cerebrospinal fluid surrounding the eighth nerve (N8), and middle ear granulation tissue showed intense signals. In the hT(2)W-3D-FLAIR images, evident enhancement by Gd-DOTA was observed in the middle ear cavity and the perilymphatic compartments of the cochlea. Cochlear endolymphatic hydrops was implicated by the enlarged scala media in the basal turn. In general, the Gd-DOTA uptake in the vestibule was weak, and signs of vestibular endolymphatic hydrops were obvious. The N8 on the diseased side was also significantly enhanced. To conclude, endolymphatic hydrops in MD may be induced by otitis media. Cochlear endolymphatic hydrops in MD secondary to otitis media may not follow the classical pattern.

Antimicrobial potential of Terminalia chebula Retz. fruit extracts against ear pathogens

AIM: To evaluate the antimicrobial potential of Terminalia chebula (T. chebula) extracts against pathogens causing otitis externa and compare it with ear drops.

METHODS: Four different extracts, methanol, ethanol, acetone and aqueous (hot and cold) extracts, from the T. chebula were tested for their antimicrobial activity through the agar well diffusion method and minimum inhibitory concentration (MIC)/minimum bactericidal concentration (MBC) values were determined through the macrodilution broth method against six different microorganism, five bacterial (one gram positive and four gram negative) and one yeast.

RESULTS: Organic and aqueous fruit extracts displayed activity against all five tested bacterial ear pathogens with a maximum zone of inhibition of 31.6 mm against Staphylococcus aureus, followed by Acinetobacter sp. (24.6 mm), Pseudomonas aeruginosa (23.6 mm), Proteus mirabilis (21 mm) and Escherichia coli (19.3 mm). Of the four solvents evaluated, acetonic fruit extract of T. chebula was found to be best. The MIC values ranged between 0.78 mg/mL and 50 mg/mL for the different bacterial ear pathogens and MBC values ranged between 1.56 mg/mL and 50 mg/mL. The acetonic fruit extract showed larger inhibition zones compared to the herbal ear drops, Kan pip with lowest MIC of 0.78 mg/mL and MBC of 1.56 mg/mL.

CONCLUSION: Acetonic extract of T. chebula fruit may be used to treat otitis externa. However, more detailed studies, such as in vivo testing and pharmacokinetics properties, are needed to determine its therapeutic potential.

Effects of p27Kip1- and p53- shRNAs on kanamycin damaged mouse cochlea

AIM: To study the effects of adeno-associated virus (AAV) delivered short hairpin RNAs (shRNAs) on adult CD-1 mouse cochlea damaged by aminoglycoside antibiotic kanamycin.

METHODS: Three different shRNAs were designed (p27 ^Kip1, p53 and p27 ^Kip1+p53) and tested in COS cells. A total of 20 adult CD-1 mice were used in the experiment. Mice were divided into five different groups (four animals/group) depending on the AAV-shRNA construct they received and whether they received kanamycin or not. Saline and AAV-EGFP injected animals were used as controls. All constructs were injected through the round window membrane (RWM) into the cochlea. Cochleae were harvested after 1 mo. Apoptosis was detected with Tunel labeling from paraffin-embedded cochlear tissue sections.

RESULTS: AAV2/2-p27 ^Kip1-shRNA and AAV2/2-p53-shRNA were tested in COS cells. Western blotting analysis confirmed that both constructs silenced their target genes effectively in the cell culture. AAV2/2-shRNA constructs were injected into the cochlea of CD-1 mice through the intact RWM. Cotransduction of individual AAV2/2-shRNAs with AAV2/2-EGFP resulted in EGFP expression in the organ of Corti. Kanamycin treatment had no effect on the expression pattern of the EGFP. AAV2/2-shRNA treated mice (either with p53 or p27^Kip1and p53 together) showed fewer apoptotic hair cells in the cochlea than the control group (P < 0.05; AAV2/2-p53-shRNA vs saline P = 0.00014; AAV2/2-p27+p53-shRNA vs saline P = 0.0011). AAV2/2-p27-shRNA injected cochleae showed no significant difference in the number of apoptotic cells when compared to the saline injected cochleae.

CONCLUSION: Silencing of p53 protein in the kanamycin treated ears may decrease cell death in the organ of Corti.