Pre-operative high resolution computed tomography scans for cholesteatoma: has anything changed?

OBJECTIVE: CT temporal bone scans are often performed to aid in surgical planning and management of cholesteatomas. With improvements in the resolution of CT scans today, it is now possible to obtain more information from these scans than before. The aim of this study is to compare findings on high resolution CT (HRCT) temporal bone scans to intra-operative findings, so as to determine how well various middle ear structures are assessed by HRCT scanning. STUDY DESIGN: Retrospective study. SETTING: Otology clinic of a tertiary otolaryngology centre. SUBJECTS AND METHODS: 32 mastoidectomies performed by a single otologist for clinically confirmed cholesteatoma were included. Correlation of CT and intra-operative findings on the status of structures including the ossicles, semicircular canals, facial canal and tegmen was analysed using kappa and AC1 statistics. RESULTS: In all patients, a soft tissue mass with bony erosion in keeping with a cholesteatoma was seen on CT. Radiosurgical agreement was excellent for the presence of semicircular canal erosion (k=0.89, AC1=0.96), facial canal dehiscence (k=0.74, AC1=0.76), tegmen erosion (k=0.76, AC1=0.92) and malleus erosion (k=0.76, AC1=0.85). It was good for incus erosion (k=0.71, AC1=0.92) and stapes erosion (k=0.63, AC1=0.73). CONCLUSION: There was good to excellent radiosurgical agreement in the assessment of the status of various middle ear structures. Improvement in radiosurgical agreement from existing studies in the literature was noted. This was especially true for features such as facial canal dehiscence. With technological advancements, CT temporal bone scans appear even more valuable for evaluation of patients prior to cholesteatoma surgery.

Botolinum toxin in rhinitis: Literature review and posterior nasal injection in allergic rhinitis.

BACKGROUND: Current pharmacological management of allergic rhinitis (AR) varies in onset, duration, symptom control, and requires frequent administration. Single-dose botulinum toxin (BTX) has been documented in various trials as a treatment option in rhinitis. OBJECTIVE: We review the current literature on the use of BTX in rhinitis and investigate the efficacy and safety profile of a novel intranasal injection site for AR control. STUDY DESIGN: Single-arm pilot study. METHODS: Ten adult patients having moderate to severe AR with proven house dust-mite allergy were recruited. Each patient received 12.5 units of Botox injected to the posterior lateral wall of each side of the nose under endoscopic guidance. Immediate postprocedural discomfort and Total Nasal Symptom Score (TNSS) at 2 and 4 weeks were used as primary outcome measures. Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ) was used as secondary outcome measure. RESULTS: Overall TNSS (minimum = 0; maximum = 20) showed an improvement from a mean of 15.1 (preinjection) to 7.6 (2 weeks) and 7.7 (4 weeks). Greatest effect was seen in subscales of rhinorrhea (4.0-1.7) followed by sneeze, nasal congestion, and itch. Mean discomfort of the procedure was scored 5.7 over 10. RQLQ scores similarly showed an improvement in all domains of quality of life. Two subjects complained of mild headache not requiring any medical intervention. CONCLUSION: Based on our review of current literature, BTX shows clear efficacy on symptoms of both intrinsic and allergic rhinitis, with a good safety profile. Single-dose posterior nasal injection demonstrates good efficacy and duration of action, with moderate discomfort. LEVEL OF EVIDENCE: 4. Laryngoscope, 127:2447-2454, 2017.

Correlating voice handicap index and quantitative videostroboscopy following injection laryngoplasty for unilateral vocal paralysis.

OBJECTIVE: 1) Determine the correlation between voice handicap index and quantitative videostroboscopy for patients undergoing injection laryngoplasty for unilateral vocal paralysis; 2) assess which videostroboscopy measurements correlate best with voice handicap index in patients demonstrating progressive improvement beyond six months following injection laryngoplasty. STUDY DESIGN: Case series with chart review. SETTING: Patients undergoing outpatient injection laryngoplasty with hyaluronic acid between 2005 and 2007. SUBJECTS AND METHODS: Twenty-eight patients were assessed preoperatively and postoperatively using voice handicap index and videostroboscopy. Various videostroboscopy measurements were quantified: glottic open area (ratio of open to total glottic area during closed phase of phonation), glottic closed phase (frame ratio of closed phase to total glottic cycle), supraglottic compression (percent encroachment of supraglottis onto best-fit ellipse around glottis), wave amplitude (difference in glottic open area between open and closed phases), and wave duration (number of frames per glottic cycle). Correlation coefficients were calculated using Spearman's r. RESULTS: One hundred seventeen separate recordings were analyzed. Correlation coefficients between voice handicap index (normalized to preoperative values) and glottic closed phase showed moderate-strong correlation (r = -0.733, P < 0.001), while glottic open area and wave duration showed weak-moderate correlation (r = 0.465, P < 0.001 and r = -0.404, P < 0.001 respectively). Other parameters showed poor correlation. A subset of 25 recordings from eight patients with progressive voice handicap index improvement beyond six months showed highest correlation with supraglottic compression (r = 0.504, P < 0.05). CONCLUSION: Voice handicap index correlates best with glottic closed phase, suggesting duration of vocal fold closure during the glottic cycle best represents patients' subjective outcome post-procedure. Progressive improvement in voice handicap index beyond six months may relate to gradual reduction in compensatory supraglottic compression, with moderate correlation.