Tympanoplasty--conchal cavum approach

Reflux Symptom Index (RSI), Videolaryngostroboscopy and Voice Analysis: A Triad of Non-Invasive Tools to Study Treatment Outcomes of Laryngopharyngeal Reflux Disease (LPRD)

Study post treatment improvement of Laryngopharyngeal Reflux Disease (LPRD) using non-invasive tools of Reflux symptom index (RSI), Reflux finding score (RFS) grading of videolaryngostroboscopy (VLS) and voice analysis. This study from December 2020 to April 2022 enrolled 100 adults with complaints suggestive of reflux symptoms and having Reflux Symptom Index (RSI) more than 13. All patients underwent VLS along with voice analysis. VLS findings were graded using Reflux Finding Score (RFS). Patients were advised for lifestyle modifications and proton pump inhibitors for 8 weeks when post treatment RSI, VLS and voice analyses were again documented. The age range was from 18 to 75 years. Males predominated. Lifestyle modification compliance was seen in 85% of the patients. We found a significant association (P = 0.001) for difference in pretreatment and posttreatment for both Reflux Symptom Index (RSI) parameters & Reflux Finding Score Index (RFS) parameters. Voice analysis pre and post treatment showed a significant association (P = 0.001) for fundamental frequency, jitter, shimmer, harmonic-to-noise ratio and maximum phonation time. The gold standard of diagnosis of LPRD is 24 h pH monitoring but has many false negatives and false positives due to intermittent reflux and inaccurate probe placement. This costly, time consuming and invasive procedure is not widely available amongst our speciality. Excellent visualisation of VLS allowed accurate RFS calculation. Voice analysis permitted early diagnosis of LPRD induced hoarseness before it became clinically significant. It also documented the treatment outcome. We conclude that an 8-weeks proton pump inhibitor treatment combined with lifestyle modification resulted in a significant improvement in the parameters of the non-invasive tools of RSI and RFS and voice analysis.

The novel retro-conchal approach for middle ear surgeries: Our experience in 196 patients

BACKGROUND

This study aimed to describe a new proposed retro-conchal approach for middle ear surgery and to evaluate its advantages and postoperative impact.

METHODOLOGY

A retrospective case-series study was held at a tertiary university hospital from March 2008 to April 2022. We included 196 adult patients who were candidates for middle ear surgery because of chronic otitis media. The retro-conchal approach entailed a skin incision on the medial conchal surface 1 cm anterior to the auricular sulcus. It allowed the harvesting of the required size of conchal cartilage and temporalis fascia through the same incision with access into the middle ear and complete exposure to the mastoid process. In addition, we evaluated the use of this approach in tympanoplasty, including cholesteatoma surgeries with at least one-year postoperative follow-up.

RESULT

The long-term follow-up (22.9 ± 6.37 months) revealed that most operated cases (89%) did not develop postoperative sequelae related to this approach. On the other hand, 22 patients (11%) developed adverse outcomes, with a statistically significant difference regarding adverse outcomes as the P-value <0.001.

CONCLUSION

According to our experience with a relatively large number of patients, the retro-conchal technique was practical for various middle ear surgeries. It allowed optimal access to different middle ear areas and obtaining large-sized conchal cartilage and temporalis fascia (if needed) through the same incision without needing extra surgical steps. In addition, it was a safe maneuver without significant adverse outcomes in the long-term follow-up.

Accuracy of magnetic resonance imaging in the assessment of depth of invasion in tongue carcinoma: A systematic review and meta-analysis

Tongue carcinoma constitutes 10.4-46.9% of all oral squamous cell carcinomas (OSCCs) and is notoriously known for invading tissues deeper than the evident gross margins. The deeper the tumor invades, the higher are its chances of future morbidity and mortality due to extensive neck dissection and risk of recurrence. Magnetic resonance imaging (MRI) is a noninvasive diagnostic aid used for measuring a preoperative tumor's depth of invasion (DOI) as it can efficiently outline soft tissue tumors from adjacent normal tissue. To assess various MRI modalities used in measuring DOI in tongue carcinoma and their reliability compared with other DOI measuring modalities. The protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO) database (CRD42022330866), and the following Preferred Reporting Items for a Systematic Review and Meta-Analysis (PRISMA) Diagnostic Test Accuracy guidelines were performed. PubMed electronic database was searched using a combination of keywords for relevant articles in the English language since 2016. Critical appraisal was carried out using the Quality Assessment of Diagnostic Accuracy Studies-Comparative (QUADAS-C) risk-of-bias (RoB) assessment tool. A weighted mean difference (WMD) was calculated between MRI and histopathological DOI along with pooled correlation and subgroup analysis, where possible. A total of 795 records were retrieved of which 17 were included in the final review with 13 included for meta-analysis. A high RoB was found for most studies for all parameters except flow and timing. WMD showed a statistically significant MRI overestimation of 1.90 mm compared with histopathology. Subgroup analysis showed the 1.5 Tesla machine to be superior to the 3.0 Tesla machine, while imaging sequence subgroup analysis could not be performed. MRI is a viable preoperative DOI measurement modality that can help in efficient treatment planning to decrease surgical morbidity and mortality.

Oral Squamous Cell Carcinoma Clinico-pathological features in relation to Tumor Stage; AJCC 2018 perspective

Objective

To investigate the association between clinicopathological findings and tumor stage according to AJCC 2018 guidelines in patients suffering from Oral squamous cell carcinoma (OSCC).

Methods

A descriptive study was conducted from January 2019 to January 2020 at King Edward Medical University and University of Health Sciences on a total of 49 patients enrolled after obtaining written informed consent. Clinical and radiographic findings were recorded. Pathological reporting was done using AJCC 2018 cancer staging guidelines. Association between clinicopathological features with tumor stage and grade was assessed using Chi-square and Kruskal-Wallis test.

Result

Mean age of the patients was 46.1 ± 10.6 years. Most of the tumors were of well differentiated type (49%) and moderately differentiated (40.8%) with predominant clinical stage III in 42.9% & IV in 44.9 % and primary tumor stage pT2 28.6% & pT3 36.7%. Significant difference was seen for primary tumor stage in relation to age, gender, depth of invasion, primary site, and size of tumor (p < 0.01). For clinical stages, significant difference was observed in the age, gender, size of tumor, nodal metastasis, and anatomical tumor site (p < 0.01).

Conclusion

Application of 8th Edition AJCC guidelines identifies the importance of the latest classification with strong association of latest stage criteria with age, gender, site of primary tumor, tumor thickness, depth of invasion, nodal metastasis and size of largest lymph node involved, and Level of Lymph node involved (level III & V) in a subset of patients from a developing country.

Palisade Cartilage Tympanoplasty, an Alternative Surgical Approach for CSOM

INTRODUCTION

The hearing outcome and graft take in patients of CSOM with sclerotic mastoids were studied using the novel technique of palisade cartilage tympanoplasty. Besides, it was compared with tympanoplasty type-1 above and over the cortical mastoidectomy in both groups.

MATERIALS AND METHODS

Out of 313 patients of CSOM, 125 had sclerotic mastoid and were included in the study. Palisade cartilage group patients were subjected to palisade cartilage tympanoplasty type-1. While as in the Temporalis fascia group patients, type-1 tympanoplasty was done using temporalis fascia as graft material. These procedures were performed in addition to cortical mastoidectomy done in all cases.

RESULTS

Statistically significant (P<0.001) mean postoperative hearing gain was achieved (> 20 dB) in both the groups with a reduction of AB gap to 13.3 & 11.79 dB, respectively. However, the post-surgery hearing outcomes achieved were similar in both groups (P=0.09). The overall graft take rate of 86% was seen in the Palisade cartilage group. The remaining 14% had graft take failure. The primary graft failure rate was 10% (5/50), and the secondary failure rate within six months of follow-up was 4% (2/50). The Temporalis fascia group graft take rate was higher (92%) than the Palisade cartilage group, with only 4 % (3/75) of cases having a primary graft failure rate. However, these findings (92% vs. 86%) were not statistically significant (P=0.2830).

CONCLUSIONS

As the hearing outcomes and graft take rates were comparable in the two groups, the present study highlighted the use of palisade cartilage tympanoplasty in patients of CSOM with sclerotic mastoids as an alternative method to tympanoplasty.

A telemonitoring system to support CPAP therapy in patients with obstructive sleep apnea: a participatory approach in analysis, design, and evaluation

Background

Continues positive airway pressure (CPAP) therapy is a gold standard treatment for moderate to severe cases of OSA (obstructive sleep apnea). The present research aimed to describe the analysis, design, and evaluation of a telemonitoring system to improve CPAP adherence in patients afflicted with OSA.

Methods

The telemonitoring system was developed in five phases. In the exploratory phase, the body of related literature was reviewed. Then a need analysis was conducted through a focus group discussion with sleep medicine specialists and sales company representatives and an interview with patients. The third phase involved data integration. Then the content and system development were done based on the previous phases. Finally, usability and functionality tests were used to evaluate the system.

Results

The exploratory phase and the needs analysis were conducted by four sleep medicine specialists, two medical informatics specialists, six key figures of the sales companies, two system developers, and 46 patients in different phases. Based on the results obtained from the data integration phase, the telemonitoring system involved three main parts: a patient’s application, a doctor’s portal, a selling companies’ portal (operator’s portal) along with facilitating software for patients to send the CPAP data. Usability and functionality tests were given to 7 and 10 patients, respectively. The total number of usability issues reported by users in the evaluation process was 18, with an average of 2.5 issues per user. The installation problems, disrupted links and improper playing of videos were the main functionalities problems that were solved.

Conclusion

The telemonitoring system, as a means of communication between patients, doctors, and selling companies, can be used to support patients clinically and technically. It has the potential to improve CPAP adherence in patients with OSA.

Long Term Versus Short Term Hearing Results in Endoscopic Sandwich Myringoplasty

INTRODUCTION

The use of the endoscope in otological surgeries has both diagnostic and therapeutic values. It provides an excellent view in difficult nooks and corners. The use of endoscopic sandwich myringoplasty using cartilage and perichondrium has its benefit in hearing outcome and graft uptake in long-term follow-up. The main objective was to compare the long-term with short- term hearing outcomes in those who have undergone endoscopic sandwich myringoplasty with Dhulikhel hospital (D‑HOS) technique.

MATERIALS AND METHODS

Forty-two patients who underwent endoscopic sandwich myringoplasty with D-HOS technique using tragal cartilage perichondrium were enrolled in the study. The hearing outcome was analyzed by comparing the pre-operative findings with post-operative findings and amongst post-operative patients, long-term with short-term air bone gap (ABG) and ABG closure in speech frequencies (0.5kHz, 1kHz, 2kHz, 4kHz) were compared.

RESULTS

Amongst forty-two patients, 40 (95.2%) had graft uptake in both short-term (6.08 months) and in long-term (20 months) follow-up. The mean pre-operative ABG was 28.1±9.3dB whereas the mean short-term post-operative ABG was 14.5±7.2dB, it showed statistical significance (P=0.001). Likewise, while comparing pre-operative with long-term post-operative ABG (13.4±4.8 dB), it showed statistical significance of P=0.000. While comparing short-term with long-term post-operative ABG, it did not show any statistical significance (P=0.065).The mean closure in ABG in both short-term and long-term hearing assessment was not statistically significant (P=0.077).

CONCLUSION

Endoscopic sandwich myringoplasty with D-HOS technique is a reliable procedure with good hearing outcome and graft uptake in both short and long-term follow-up.

Role of transpalatal advancement pharyngoplasty in management of lateral pharyngeal wall collapse in OSA

INTRODUCTION

Non-response to palatal surgery for OSA is a problem. Residual lateral wall hypopharyngeal collapse is the proposed mechanism of failure.

OBJECTIVE

This study aims to evaluate the role of transpalatal advancement pharyngoplasty in non-responders to primary palatal surgery with residual lateral wall hypopharyngeal collapse.

METHODS

This is a retrospective study that was conducted on patients who underwent transpalatal advancement pharyngoplasty for residual lateral wall hypopharyngeal. Inclusion criteria were age greater than 18-years, OSA proved by the polysomnography with apnea hypopnea index >15, lateral wall collapse at the level of hypopharynx as proved by drug-induced sleep endoscopy and had a previous tonsillectomy or previous palatal surgery for OSA. Exclusion criteria were those with no history of tonsillectomy or any other surgery for OSA and those with a missed followup. Data of included patients were collected and included gender, age, polysomnographic data like the apnea hypopnea index, oxygen desaturation and the calculated preoperative Epworth sleepiness scale. The early outcome included symptom improvement as measured by Epworth sleepiness scale score and lateral pharyngeal wall evaluation by nasopharyngoscopic examination in the first postoperative month. Late outcome measurement was performed by the 6-month postoperative polysomnography. Data were analyzed using SPSS program.

RESULTS

The study included 37 patients with a mean age of (40.43 ± 6.51). The study included 26 men and 11 women. There was a statistically significant improvement of apnea hypopnea index from 37.8 ± 9.93 to 9.9 ± 2.55. In addition, a statistically significant improvement of lowest oxygen saturation from 78.9 ± 3.39 to 83.3 ± 3.31 was encountered. The patients improved clinically, and this improvement was measured by statistically significant improvement of Epworth sleepiness scale score and snoring visual analogue scale.

CONCLUSION

Transpalatal advancement pharyngoplasty widens the retropalatal airway and has a great role in the management of the vertical palate phenotype. In addition, it can have a role in the management of lateral walls, especially lateral wall hypopharyngeal collapse.

To Compare Short and Long-Term Graft Uptake and Hearing Outcome of Type I Cartilage Tympanoplasty Between Small, Medium and Large Perforations Using Reinforced Sliced Conchal Cartilage

To compare short and long-term graft uptake and hearing outcome of type I cartilage tympanoplasty between small, medium and large perforations using reinforced sliced conchal cartilage. A retrospective study conducted in a tertiary center. Fifty patients who under went type I tympanoplasty were enrolled. Their mean age was 29.30 years and follow-up time was 6 and 18 months. The preoperative, postoperative short-term and long-term hearing and graft uptake results were analyzed. Graft uptake rate was 96% in short-term and 98% in long-term with one residual perforation in medium size, but 100% in small and large perforations (P < 0.01). Short and long-term ABG closure was identical in small and medium size perforation (P = 0.978) (P = 0.734), but, large perforation showed significant improvement in long-term (P = 0.012). Sliced conchal cartilage reinforced with temporalis fascia is a reliable technique for tympanoplasty. In long-term, large perforations have better graft uptake rate and continuous hearing improvement and ABG closure than small and medium perforations.

Vascular anatomy is a determining factor of successful submental flap raising: a retrospective study of 70 clinical cases

The vascular anatomy of submental flaps (SFs) represents a determining factor in successful SF raising. However, little attention has been focused on the venous return of SFs. Thus, the present study aimed to investigate SF venous return. This study enrolled patients who underwent SF reconstructive surgery in a tertiary referral center between November 2009 and October 2016. The drainage pathway of the SF venous return was routinely identified during the course of our operations to prevent damage during head and neck surgery. The venous return data of 70 patients were reviewed. The size of the flaps ranged from 15 to 84 cm², and total flap loss was not observed in the case series. All of the submental arteries originated from the facial artery; however, the submental veins of 70 patients returned to either the internal jugular vein (IJV, 72.9%) or the external jugular vein (EJV, 27.1%). Our data suggest that drainage of the submental vein into the EJV, which has been previously overlooked, should receive greater attention during SF surgeries. The results support mandatory preservation of the EJV and IJV and indicate that vascular anatomy is a determining factor for successful SF raising.

The palisade cartilage tympanoplasty technique: a systematic review and meta-analysis

Background

Tympanoplasty is a common procedure performed by Otolaryngologists. Many types of autologous grafts have been used with variations of techniques with varying results. This is the first systematic review of the literature and meta-analysis with the aim to evaluate the effectiveness of one of the techniques which is gaining popularity, the palisade cartilage tympanoplasty. PubMed, EMBASE, and Cochrane databases were searched for "palisade", “cartilage”, “tympanoplasty”, "perforation" and their synonyms.

Main body of abstract

In total, 199 articles reporting results of palisade cartilage tympanoplasty were identified. Five articles satisfied the following inclusion criteria: adult patients, minimum 6 months follow-up, hearing and surgical outcomes reported. Studies with patients undergoing combined mastoidectomy, ossicular chain reconstruction, and/or other middle ear surgery were excluded. Perforation closure, rate of complications, and post-operative pure-tone average change were extracted for pooled analysis. Study failure and complication proportions that were used to generate odds ratios were pooled. Fixed effects and random effects weightings were generated. The resulting pooled odds ratios are reported. Palisade cartilage tympanoplasty has an overall take rate of 96% at beyond 6 months and has similar odds of complications compared to temporalis fascia (OR 0.89, 95% CI 0.62, 1.30). The air-bone gap closure is statistically similar to reported results from temporalis fascia tympanoplasty.

Conclusions

Cartilage palisade tympanoplasty offers excellent graft take rates and good postoperative hearing outcomes for perforations of various sizes and for both primary and revision cases. This technique has predictable, long-term results with low complication rates, similar to temporalis fascia tympanoplasty.