EAONO/JOS classification for acquired cholesteatoma: evaluating the impact of the number of affected sites on treatment and outcomes

PURPOSE

The European and Japanese system for cholesteatoma classification proposed an anatomical differentiation in five sites. In stage I disease, one site would be affected and in stage II, two to five. We tested the significance of this differentiation by analyzing the influence of the number of affected sites on residual disease, hearing ability and surgical complexity.

METHODS

Cases of acquired cholesteatoma treated at a single tertiary referral center between 2010-01-01 and 2019-07-31 were retrospectively analyzed. Residual disease was determined according to the system. The air-bone gap mean of 0.5, 1, 2, 3 kHz (ABG) and its change with surgery served as hearing outcome. The surgical complexity was estimated regarding the Wullstein's tympanoplasty classification and the procedure approach (transcanal, canal up/down).

RESULTS

513 ears (431 patients) were followed-up during 21.6 ± 21.5 months. 107 (20.9%) ears had one site affected, 130 (25.3%) two, 157 (30.6%) three, 72 (14.0%) four and 47 (9.2%) five. An increasing number of affected sites resulted in higher residual rates (9.4-21.3%, p = 0.008) and surgical complexity, as well poorer ABG (preoperative 14.1 to 25.3 dB, postoperative 11.3-16.8 dB, p < 0.001). These differences existed between the means of cases of stage I and II, but also when only considering ears with stage II classification.

CONCLUSION

The data showed statistically significant differences when comparing the averages of ears with two to five affected sites, questioning the pertinence of the differentiation between stages I and II.

Predictive factors for abscessing tonsillitis: a retrospective analysis

OBJECTIVE

In clinical practice, identifying abscesses in tonsillar infections is crucial for early therapeutic management. Diagnosis of a peritonsillar abscess is usually based on clinical symptoms. Complementary examination procedures, such as laboratory parameters and imaging, are available for confirmation.

PATIENTS AND METHODS

A retrospective analysis was carried out of data for 752 patients who presented with acute tonsillar infection and were hospitalized between January 2012 and February 2021. The data analyses involved evaluating the patient's clinical symptoms, inflammatory parameters, and previous medical history in relation to the predictive power of these factors for the presence of an abscess.

RESULTS

Predictor analysis for the presence of an abscess showed significant values for trismus (OR 2.392; 95% CI, 1.305 to 4.383; p=0.005) and palatal arch protrusion (OR 29.679; 95% CI, 17.460 to 50.447; p=0.000). The inflammatory parameter C-reactive protein and the leukocyte count were not statistically significant as predictors.

CONCLUSIONS

The presence of a tonsillar abscess can be diagnosed from the clinical presentation alone if the findings are clear. Further diagnostic procedures are indicated in case of inconclusive findings, and ultrasound should be the primary noninvasive method. Computed tomography is only required in selected cases. Inflammatory parameters can be assessed in order to monitor therapy, but do not predict the presence of an abscess. However, if defined action sequences are being considered, tonsillar abscesses can be differentiated at an early point.

Cellular density and variability in laryngeal and pharyngeal squamous cell carcinoma using confocal laser endomicroscopy

OBJECTIVE

Confocal laser endomicroscopy (CLE) allows the visualization of epithelium in a thousand-fold magnification. This study analyzes the architectural differences at the cellular level of the mucosa and squamous cell carcinoma (SCC).

PATIENTS AND METHODS

A total of 60 CLE sequences recorded in 5 patients with SCC undergoing laryngectomy between October 2020 and February 2021 were analyzed. The corresponding histologic sample derived from H&E staining was assigned to each sequence, capturing CLE images of the tumor and healthy mucosa. In addition, the cellular structure analysis was performed to diagnose SCC by measuring the total number of cells and cell size in 60 sequences in a fixed field of view (FOV) with 240 μm in diameter (45,239 μm2).

RESULTS

Out of 3,600 images, 1,620 (45%) showed benign mucosa and 1,980 (55%) SCC. The automated analysis yielded a difference in cell size, with healthy epithelial cells being 171.9±82.0 μm2 smaller than SCC cells, which were 246.3±171.9 μm2 and showed greater variability in size (p=0.037). In addition, due to the probe's fixed FOV, there was a difference in cell count with a total of 188.7±38.3 and 124.8±38.6 cells in images of normal epithelium and SCC (p<0.001), respectively. Regarding cell density as a criterion for the differentiation of benign/malign, using a cut-off value of 145.5 cells/FOV, we obtained sensitivity and specificity of 88.0% and 71.9%, respectively.

CONCLUSIONS

SCC reveals marked differences at a cellular level compared to the healthy epithelium. Our results further support the importance of this feature for identifying SCC during CLE imaging.

The influence of obstructive sleep apnea and continuous positive airway pressure on the nasal microbiome

OBJECTIVE

The aim of this study was to investigate the influence of obstructive sleep apnea and continuous positive airway pressure on the nasal microbiome.

PATIENTS AND METHODS

Endonasal swabs from the olfactory groove of 22 patients with moderate and severe obstructive sleep apnea (OSA) and a control group of 17 healthy controls were obtained at the Department of Otorhinolaryngology of the Friedrich-Alexander-Universität Erlangen-Nürnberg. 16S rRNA gene sequencing was performed to further evaluate the endonasal microbiome. In a second step, the longitudinal influence of continuous positive airway pressure (CPAP) therapy on the nasal microbiome was investigated (3-6 and 6-9 months).

RESULTS

Analysis of the bacterial load and β-diversity showed no significant differences between the groups, although patients with severe OSA showed increased α-diversity compared to the control group, while those with moderate OSA showed decreased α-diversity. The evaluation of longitudinal changes in the nasal microbiota during CPAP treatment showed no significant difference in α- or β-diversity. However, the number of bacteria for which a significant difference between moderate and severe OSA was found in the linear discriminant analysis decreased during CPAP treatment.

CONCLUSIONS

Long-term CPAP treatment showed an alignment of the composition of the nasal microbiome in patients with moderate and severe OSA as well as an alignment of biodiversity with that of the healthy control group. This change in the composition of the microbiome could be both part of the therapeutic effect in CPAP therapy and a promoting factor of the adverse side effects of the therapy. Further studies are needed to investigate whether the endonasal microbiome is related to CPAP compliance and whether CPAP compliance can be positively influenced in the future by therapeutic modification of the microbiome.

TIMP-1 as a biomarker in obstructive sleep apnea: screening, monitoring, risk stratification, and a step towards precision medicine

OBJECTIVE

The diagnosis of obstructive sleep apnea (OSA) is a complex time- and resource-intensive diagnostic procedure. Since tissue inhibitors of matrix metalloproteinases (TIMP's) are involved in various pathophysiological processes and are correlated with a high cardiovascular risk, TIMP's appear to be a suitable candidate for an OSA-biomarker.

PATIENTS AND METHODS

In a prospective controlled diagnostic study, TIMP-1 serum levels of 273 OSA-patients and controls were analyzed for correlation with OSA severity, BMI, age, sex, cardio-/ cerebrovascular comorbidities. Furthermore, longitudinal medium- and long-term effects of CPAP-treatment (n=15) on TIMP-1-levels were investigated.

RESULTS

TIMP-1 was clearly linked to OSA as well as to disease severity (mild, moderate, severe; each p<0.001) and was not influenced by age, gender, BMI, or cardio-/cerebrovascular comorbidities. ROC curve analysis revealed an AUC of 0.91 ± 0.017 SE (p<0.001), suggesting a TIMP-1 cut-off value of 75 ng/ml (sensitivity 0.78; specificity 0.91) being especially sensitive for patients with severe OSA (sensitivity 0.89; specificity 0.91). The likelihood ratio was 8.88, while the diagnostic odds ratio was 37.14. CPAP-treatment led to a significant decrease of TIMP-1 after 6-8 months (p=0.008).

CONCLUSIONS

TIMP-1 seems to fulfill the preconditions for a circulating OSA-biomarker: disease-specific with a mandatory presence in affected patients, reversible on treatment, reflects disease severity and provides a cutoff value between the healthy state and disease. In the clinical routine, TIMP 1 may help to stratify the individual OSA-associated cardiovascular risk and to monitor the treatment response to CPAP-therapy as a further step towards providing a personalized therapy.

F18-FDG PET/CT imaging early predicts pathologic complete response to induction chemoimmunotherapy of locally advanced head and neck cancer: preliminary single-center analysis of the checkrad-cd8 trial

Aim

In the CheckRad-CD8 trial patients with locally advanced head and neck squamous cell cancer are treated with a single cycle of induction chemo-immunotherapy (ICIT). Patients with pathological complete response (pCR) in the re-biopsy enter radioimmunotherapy. Our goal was to study the value of F-18-FDG PET/CT in the prediction of pCR after induction therapy.

Methods

Patients treated within the CheckRad-CD8 trial that additionally received FDG- PET/CT imaging at the following two time points were included: 3–14 days before (pre-ICIT) and 21–28 days after (post-ICIT) receiving ICIT. Tracer uptake in primary tumors (PT) and suspicious cervical lymph nodes (LN +) was measured using different quantitative parameters on EANM Research Ltd (EARL) accredited PET reconstructions. In addition, mean FDG uptake levels in lymphatic and hematopoietic organs were examined. Percent decrease (Δ) in FDG uptake was calculated for all parameters. Biopsy of the PT post-ICIT acquired after FDG-PET/CT served as reference. The cohort was divided in patients with pCR and residual tumor (ReTu).

Results

Thirty-one patients were included. In ROC analysis, ΔSUVmax PT performed best (AUC = 0.89) in predicting pCR (n = 17), with a decline of at least 60% (sensitivity, 0.77; specificity, 0.93). Residual SUVmax PT post-ICIT performed best in predicting ReTu (n = 14), at a cutpoint of 6.0 (AUC = 0.91; sensitivity, 0.86; specificity, 0.88). Combining two quantitative parameters (ΔSUVmax ≥ 50% and SUVmax PT post-ICIT ≤ 6.0) conferred a sensitivity of 0.81 and a specificity of 0.93 for determining pCR. Background activity in lymphatic organs or uptake in suspected cervical lymph node metastases lacked significant predictive value.

Conclusion

FDG-PET/CT can identify patients with pCR after ICIT via residual FDG uptake levels in primary tumors and the related changes compared to baseline. FDG-uptake in LN + had no predictive value.

Trial registry

ClinicalTrials.gov identifier: NCT03426657.

Predictive Value of Multiparametric MRI for Response to Single-Cycle Induction Chemo-Immunotherapy in Locally Advanced Head and Neck Squamous Cell Carcinoma

Objectives

To assess the predictive value of multiparametric MRI for treatment response evaluation of induction chemo-immunotherapy in locally advanced head and neck squamous cell carcinoma.

Methods

Twenty-two patients with locally advanced, histologically confirmed head and neck squamous cell carcinoma who were enrolled in the prospective multicenter phase II CheckRad-CD8 trial were included in the current analysis. In this unplanned secondary single-center analysis, all patients who received contrast-enhanced MRI at baseline and in week 4 after single-cycle induction therapy with cisplatin/docetaxel combined with the immune checkpoint inhibitors tremelimumab and durvalumab were included. In week 4, endoscopy with representative re-biopsy was performed to assess tumor response. All lesions were segmented in the baseline and restaging multiparametric MRI, including the primary tumor and lymph node metastases. The volume of interest of the respective lesions was volumetrically measured, and time-resolved mean intensities of the golden-angle radial sparse parallel-volume-interpolated gradient-echo perfusion (GRASP-VIBE) sequence were extracted. Additional quantitative parameters including the T1 ratio, short-TI inversion recovery ratio, apparent diffusion coefficient, and dynamic contrast-enhanced (DCE) values were measured. A model based on parallel random forests incorporating the MRI parameters from the baseline MRI was used to predict tumor response to therapy. Receiver operating characteristic (ROC) curves were used to evaluate the prognostic performance.

Results

Fifteen patients (68.2%) showed pathologic complete response in the re-biopsy, while seven patients had a residual tumor (31.8%). In all patients, the MRI-based primary tumor volume was significantly lower after treatment. The baseline DCE parameters of time to peak and wash-out were significantly different between the pathologic complete response group and the residual tumor group (p < 0.05). The developed model, based on parallel random forests and DCE parameters, was able to predict therapy response with a sensitivity of 78.7% (95% CI 71.24–84.93) and a specificity of 78.6% (95% CI 67.13–87.48). The model had an area under the ROC curve of 0.866 (95% CI 0.819–0.914).

Conclusions

DCE parameters indicated treatment response at follow-up, and a random forest machine learning algorithm based on DCE parameters was able to predict treatment response to induction chemo-immunotherapy.

Influence of p16 status on indication and outcome of salvage neck dissection in oropharyngeal cancer

BACKGROUND

Human papillomavirus (HPV)+ and HPV- oropharyngeal squamous cell carcinomas (OPSCC) are separate tumor entities.

AIMS/OBJECTIVES

The aim of this study was to examine if the p16 status influences the need and outcome of a salvage neck dissection (SND) after primary radiochemotherapy (pRCT).

MATERIAL AND METHODS

Retrospective study of 164 patients (n = 108 p16-, n = 56 p16+) who underwent pRCT for OPSCC between 2009 and 2016. HPV status was defined via p16 immunohistochemical staining. Clinical nodal status was assessed using ultrasound and computed tomography of the neck with contrast.

RESULTS

Of the 56 p16+ patients, 17 (30.4%) patients were given an indication for a SND after pRCT with 4 (23.5%) patients showing persistent malignant nodes. Of the 108 p16- patients, 24 (22.2%) patients underwent a SND with 8 (33.3%) patients showing persistent malignant nodes. There was no significant association of the p16 status and neither the indication for SND (p(Chi²(two-sided)-Test) = 0.25, ϕ = 0.34) nor the occurrence of positive nodes (p(Chi²(two-sided)-Test) = 0.74, ϕ = 0.50). The probability for persistence of the ypN + nodal status independent of HPV-status was 29.2%(12/41).

CONCLUSIONS AND SIGNIFICANCE

There was neither a significant association between the p16 status and the indication for a SND nor for persistent malignant nodal disease after pRCT.

Safety and efficacy of single cycle induction treatment with cisplatin/docetaxel/ durvalumab/tremelimumab in locally advanced HNSCC: first results of CheckRad-CD8

Background

To determine safety and efficacy of single cycle induction treatment with cisplatin/docetaxel and durvalumab/tremelimumab in stage III-IVB head and neck cancer.

Methods

Patients received a single cycle of cisplatin 30 mg/m² on days 1–3 and docetaxel 75 mg/m² on day 1 combined with durvalumab 1500 mg fix dose on day 5 and tremelimumab 75 mg fix dose on day 5. Patients with pathologic complete response (pCR) in the rebiopsy after induction treatment or at least 20% increase of intratumoral CD8+ cell density in the rebiopsy compared with baseline entered radioimmunotherapy with concomitant durvalumab/tremelimumab. The objective of this interim analysis was to analyze safety and efficacy of the chemoimmunotherapy-induction treatment before radioimmunotherapy.

Results

A total of 57 patients were enrolled, 56 were treated. Median pretreatment intratumoral CD8+ cell density was 342 cells/mm². After induction treatment, 27 patients (48%) had a pCR in the rebiopsy and further 25 patients (45%) had a relevant increase of intratumoral CD8+ cells (median increase by a factor of 3.0). Adverse event (AE) grade 3–4 appeared in 38 patients (68%) and mainly consisted of leukopenia (43%) and infections (29%). Six patients (11%) developed grade 3–4 immune-related AE. Univariate analysis computed p16 positivity, programmed death ligand 1 immune cell area and intratumoral CD8+ cell density as predictors of pCR. On multivariable analysis, intratumoral CD8+ cell density predicted pCR independently (OR 1.0012 per cell/mm², 95% CI 1.0001 to 1.0022, p=0.016). In peripheral blood CD8+ cells, the coexpression of programmed death protein 1 significantly increased especially in patients with pCR.

Conclusions

Single cycle induction treatment with cisplatin/docetaxel and durvalumab/tremelimumab is feasible and achieves a high biopsy-proven pCR rate.

Pain after External and Endonasal Septorhinoplasty-A Propensity Score Matching Analysis

Guidelines for pain management following septorhinoplasty are lacking, leading to a wide range of therapy regimes even including opioid medication. Thus, the presented study strived to investigate and compare postoperative pain intensities after external and endonasal septorhinoplasty and evaluate whether pain perception is potentially related to patient satisfaction with the aesthetic result. In addition, the effectiveness of an escalating pain treatment protocol was evaluated sparing the necessity of opioid medication. This retrospective study performed at a tertiary referral medical center includes two well-balanced groups of 54 patients each created by propensity score matching out of a total of 161 patients following external or endonasal functional septorhinoplasty performed by a single surgeon between October 1, 2011 and March 31, 2017. Pain intensity was assessed using the visual analogue scale (0-10) on the first three postoperative days (PODs) alongside with the evaluation of the analgesic score. Patients' self-reported outcome was measured with the Utrecht questionnaire, preoperatively, and 3 and 12 months, postoperatively. Postoperative mean pain sensations were similarly high following the external and endonasal approach (F _(2;190) = 2.166, p = 0.118) followed by a linear decrease over the first three PODs (F _(2;190) = 16.84, p < 0.001). Pain sensations were not related to the duration of surgery, gender, patients' age, revision surgery, and the preoperative and postoperative assessment of the nasal appearance. The consumption of metamizole (F _{(1,76;172,15)} = 2.83, p = 0.065) and ibuprofen (F _(2;196) = 1.037, p = 0.356) were similarly high regardless of the surgical approach. Accordingly, both the endonasal and the external approaches led to comparable postoperative pain intensities and analgesic scores. Pain was treated effectively using a standardized escalating pain treatment protocol sparing the administration of opioids. Pain was not related to patient satisfaction with the nasal appearance pre- and postsurgery.

Titanium ball joint total ossicular replacement prosthesis--experimental evaluation and midterm clinical results

During reconstruction of the ossicular chain, there is a need to address the forces and loads caused by the ambient atmospheric pressure variations and the resulting tympanic membrane movements. It is understood that when a rigid middle ear prosthesis is inserted the malleoincudal joint, a keyfactor in controlling pressure variations in the middle ear space is bypassed. In this paper we describe a modified total titanium ossicular replacement prosthesis with an innovative micro ball joint in the headplate which is designed to compensate for tympanic membrane movements caused by atmospheric pressure variations. The characteristics of this modified prosthesis were examined in temporal bone experiments and compared to the standard titanium total ossicular reconstruction prosthesis. Sound-induced stapes footplate movements were investigated by means of a Laser vibrometer and revealed no significant differences between the two prostheses in vitro. Intraoperatively, the insertion of the modified prosthesis required more delicate handling. The angle between the shaft and the headplate was variable and ranged from 60 to 90° as estimated by the surgeon. Twelve consecutive patients were eligible for clinical evaluation. The pure tone average (PTA) air-bone gap after a mean follow up period of 32 months was 18.8 dB. Furthermore, no extrusion, dislocation or other adverse events were observed. We conclude that the modified total ossicular replacement prosthesis with integrated micro ball joint yields similar volume velocities of the stapes footplate in the laboratory experiments compared to the standard rigid prosthesis. The audiological and morphological results are encouraging and show that the mobile prosthesis headplate adjusting to the level of the tympanic membrane is a further step in the development of a physiological middle ear implant. This article is part of a special issue entitled "MEMRO 2012".