Prognostic factors in cochlear implantation in adults: Determining central process integrity.

The purpose of this study is to examine various preoperative factors that can play a role in the auditory rehabilitation outcome of cochlear implant (CI) recipients. In order to determine the level of integrity of central processing preoperatively, special attention was given to residual hearing, duration of deafness, and cochlear nerve diameter as prognostic factors. A cohort of 232 (272 CI implantations) postlingually deafened adults was evaluated in this study. Hearing results at 1, 2 and up to 3 years postoperatively were compared with various preoperative factors: promontory stimulation testing, residual hearing, duration of deafness, and magnetic resonance imaging of the cochlear nerve. Postoperative hearing performance was measured based on the German Freiburg monosyllabic word test and the Oldenburg sentence test. Postoperative hearing performance showed a significant improvement in each consecutive year after implantation. Duration of deafness showed a negative correlation to word recognition and a positive correlation to increased signal-to-noise-ratio in sentence testing. A significant decline in hearing outcome was shown starting around the second decade of deafness corresponding to 66% of life spent in deafness. MR imaging of cochlear nerve diameter shows a positive correlation of larger nerve diameter to better speech understanding. Promontory stimulation testing did not show any prognostic value. In this retrospective review it could be shown that there is an intricate interaction in the preoperative variables: duration of deafness - as well as the ratio of life spent in deafness; residual hearing; and cochlear nerve diameter.

[Squamous cell carcinoma of the nasal vestibule - Review of literature]. / Das Plattenepithelkarzinom des Naseneingangs ­ Eine Literaturübersicht.

BACKGROUND: Squamous cell carcinoma of the nasal vestibule is a rare entity. In consequence disagreement in etiology, staging system and therapy of primary tumor with or without adjuvant treatment of regional lymph nodes are apparent. METHODS: Pubmed-Recherche of relevant literature concerning: lymphatic drainage, metastases, incidence, risk factors (leather, nickel, nicotine, human papillomavirus, Staging system (UICC, AJCC, Wang's system), therapy of the primary tumor, regional lymph nodes and immunohistochemistry. RESULTS: Fifty-five studies were found and analyzed. Results are inconsistent. CONCLUSION: The Wang-classification is recommended. Radiation and surgery are the treatment of choice for small lesions. Larger lesions (T3-Wang) should be treated with a combined approach. In cT1-cT2cN0-situation after accurate diagnostic, an elective therapy of regional lymph nodes is not necessary.

The difficulty of predicting clinical outcome after intended submaximal resection of large vestibular Schwannomas.

INTRODUCTION: Intended subtotal resection of large vestibular schwannomas (T4a and b according to the Hannover classification system) has been shown to be safe and, in combination with stereotactic radiosurgery, might enable sufficient tumor control. However, risk factors for postoperative neurological deterioration in these surgically challenging lesions are largely unknown. METHODS: Pre- and postoperative symptoms, clinical and radiological data of patients who underwent intended subtotal resection for vestibular schwannoma in our department between 2010 and 2014 were reviewed. Risk factors for postoperative neurological deterioration were analyzed in uni- and multivariate analyses. RESULTS: 63 patients harboring T4a (N = 33, 52%) or T4b (N = 30, 48%) tumors were included. At time of discharge, facial nerve and hearing function had deteriorated from a serviceable to a non-serviceable level (H&B grades I + II vs. >II) in 24% (N = 15/63) and 21% (N = 6/29), respectively. Deterioration of vertigo was more common after near (N = 3/9, 33% vs. 2/38, 5%) than after subtotal resection (<.25 ccm vs. ≥ .25 ccm tumor remnant on the initial postoperative MRI; p = .042). No further correlation with patient age, sex, neurofibromatosis, resection extent and tumor volume, or -cyst volume was found. Patients were reevaluated after a median of 3 months after surgery. At that time, facial nerve function and hearing had both decreased from a preoperative serviceable to a non-serviceable level in 5%. In univariate analyses, risk of deterioration of facial nerve function increased with preoperative tumor volume (p = .037). CONCLUSION: Intended submaximal resection provides satisfactory neurological outcome for patients with large VS. Risk factors for postoperative neurological deterioration remain unclear.

Predictors of hearing recovery in patients with severe sudden sensorineural hearing loss.

BACKGROUND: Sudden sensorineural hearing loss (SSHL) is a disease, which severely affects the patient's social and relational life. The underlying pathomechanisms have not been finally clarified yet and outcome is not predictable. METHODS: We conducted a retrospective study in order to identify parameters that influence hearing recovery. The data base contains results of basic otoneurological tests and clinical parameters of 198 patients with idiopathic SSHL of at least 60 dB in at least four frequencies, diagnosed and treated at the University Hospital of Münster, Germany, between 1999 and 2015. Hearing recovery was measured by pure tone audiometry. RESULTS: Multivariate linear and logistic regression analyses indicate that the chance as well as the magnitude of hearing recovery is higher for patients with normal caloric testing than for patients with pathological caloric testing. However, for the subgroup of patients who attained a hearing recovery, the caloric testing result was not found to influence the magnitude. Instead, the magnitude was noticeably lower for patients within this subgroup who had a previous hearing loss. Furthermore, we found indications that the magnitude is higher for men than for women and that receiving a high-dose steroid therapy is associated with a higher chance and magnitude of a hearing recovery. CONCLUSIONS: We conclude that SSHL associated with disorders of the vestibular system or previous hearing loss represent special sub-entities of SSHL that may be caused by unique pathophysiological mechanisms and are associated with worse outcome. Furthermore, our data support the importance of elevated dosage of steroids in SSHL therapy.

Measuring the nose in septorhinoplasty patients: ultrasonographic standard values and clinical correlations.

Although septorhinoplasty is the most commonly performed operation in plastic surgery, and the surgical plan as well as its outcome is directly related to the configuration of the anatomical structures in the nose, these are not routinely assessed preoperatively. The aim of our study was to evaluate the nasal soft tissue and cartilaginous structures by means of high-resolution ultrasonography to set up clinical correlations and standard values. We examined 44 patients before septorhinoplasty by high-resolution ultrasonography in noncontact mode. All pictures were quantitatively evaluated by measuring 13 lengths and 4 ratios. All patients underwent a rhinomanometry measuring the nasal air flow. Besides others, men as well as older patients have a significantly thicker alar cartilage. Patients with thinner alar cartilages have a significantly smaller interdomal distance as well as significantly thinner upper lateral cartilages. The soft tissue above the bony dorsum was significantly thicker in older patients. Younger patients have significantly thicker soft tissue in relation to their cartilage. Patients with thicker soft tissue and thinner cartilage have a smaller tip. The interdomal distance and the thickness of the cartilaginous septum significantly correlated with the nasal air flow. We set up standard values of nasal structures in septorhinoplasty patients which can be used as reference values. By judging cartilage and soft tissue characteristics preoperatively, relevant factors for distinct procedures could be analyzed and the surgical steps can be better planned. Visualization by ultrasonography enables the surgeon to achieve treatment goals in a more predictable fashion.

Cochlear Implantation in the Elderly: Does Age Matter?

OBJECTIVE: To compare the outcome of hearing rehabilitation in younger versus older adult cochlear implant recipients. Analysis of surgical and postoperative complications, as well as the number of auditory therapy sessions in the two age groups. STUDY DESIGN: Individual retrospective cohort study. METHODS: A cohort of 145 postlingually deafened adults was evaluated in this study. The patients were divided into two age groups based on the age at implantation: Group I, 18 to 69 years; and Group II, 70 and older. Postoperative hearing performance was measured based on the German Freiburg monosyllabic word test (FM) and the Oldenburg sentence test (OLSA). RESULTS: Postoperative hearing evaluation results in both groups plateaued and remained constant after 12 months of implantation. The results remained constant at the 2 and 3-year time intervals. There was a significant difference in complications arising after cochlear implantation. Group II showed more cases of vertigo and dysgeusia. The number of auditory therapy sessions in both groups was similar. CONCLUSION: Cochlear implantation in the elderly is highly effective; the postoperative hearing performance is at the same level as younger adult recipients. Complex hearing tasks, such as hearing in background noise, requires an equally long time for comprehension. The recovery period of vestibular dysfunction after surgery may be longer in the elderly. Auditory therapy rehabilitation is not more time consuming in the elderly compared with the younger counterparts.

Thyroid cartilage invasion in laryngeal and hypopharyngeal squamous cell carcinoma treated with total laryngectomy.

The objective of this study is to analyze the accuracy of computed tomography in detecting malignant thyroid cartilage invasion. In a retrospective chart review, 120 patients with carcinoma of the larynx and hypopharynx underwent computed tomography before total laryngectomy. These data were compared with the histological specimens. Multidetector computed tomography (MDCT) scan had a positive predictive value (PPV) of 76 % and a negative predictive value (NPV) of 69 %. The specificity of MDCT was 89 % and sensitivity was 46 %. Comparison between radiologic suspected cartilage invasion and histologic results showed a significant correlation (p < 0.02). We found no significant impact of cartilage invasion concerning survival rates (5-year overall survival p = 0.683; 5-year disease-free survival p = 0.711). Preoperative CT scan is an important instrument in detecting neoplastic cartilage invasion.

Association Between Facial Nerve Monitoring With Postoperative Facial Paralysis in Parotidectomy.

IMPORTANCE: Electrophysiologic facial nerve monitoring is becoming an established intraoperative aid to assist the surgeon in facial nerve trunk or branch location and dissection. Limited studies have addressed the postoperative outcomes of parotid surgery with and without monitoring. OBJECTIVE: To examine the influence of intraoperative facial nerve monitoring on postoperative facial nerve function and procedure duration in parotid surgery. DESIGN, SETTING, AND PARTICIPANTS: An 8-year retrospective review of parotidectomies performed at the Department of Otorhinolaryngology-Head and Neck Surgery, University of Münster. The study analyzed 120 patients undergoing parotidectomy without monitoring from January 1, 1988, to December 31, 1991, and 147 patients undergoing parotidectomy with monitoring from January 1, 2003, to December 31, 2006. The patients were further subdivided in partial parotidectomy (PP) (n = 222) and total parotidectomy (TP) (n = 45) groups. An evaluation of operative time was performed to test the hypothesis of shorter duration of surgery with facial nerve monitoring. Final follow-up was completed on December 31, 2008, and data were analyzed from June 1 to December 31, 2013. MAIN OUTCOMES AND MEASURES: Comparison of the incidence of facial nerve dysfunction and operative time between the PP and TP subgroups with and without monitoring. RESULTS: A total of 267 patients (127 men [47.6%] and 140 women [52.4%]; mean [SD] age, 51.3 [17.6] years; range, 3-90 years) were included in the analysis. A significant reduction in postoperative facial nerve dysfunction with the use of nerve monitoring could be seen in the PP group (46 of 99 without monitoring [46.5%] vs 18 of 123 with monitoring [14.6%]; P = .001). A similar finding was evident in the TP group when comparing moderate and severe nerve dysfunction (9 of 21 without monitoring [42.9%] vs 2 of 24 with monitoring [8.3%]; P = .01). The mean (SD) operative time in the PP subgroup without nerve monitoring was 115.3 (37.8) minutes; with nerve monitoring, 110.1 (33.6) minutes. The mean (SD) operative time in the TP subgroup without nerve monitoring was 134.5 (50.4) minutes; with nerve monitoring, 158.3 (56.3) minutes. There was no statistical difference between these groups. CONCLUSIONS AND RELEVANCE: Facial nerve monitoring in primary parotid surgery for benign and malignant disease does not necessarily reduce the operative time, but the rate of transient postoperative facial nerve dysfunction or the grade of palsy is reduced.

Exploratory study of long-term health-related quality of life in patients with surgically treated primary parotid gland cancer.

BACKGROUND: Health-related quality of life (HRQOL) has received more and more attention as an outcome in cancer therapy. In this exploratory study, we assessed the long-term HRQOL among 77 surgically treated patients with parotid gland cancer. METHODS: The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30-questions (EORTC-QLQ-C30) and European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 Head and Neck 35-questions (EORTC-QLQ-C30-H&N35) questionnaires were used in a cross-sectional design. The mean time-lag between initial diagnosis and completion of the questionnaire was 89.7 months. RESULTS: The HRQOL significantly increased with the time-lag to surgery and decreased with the patients' age. Factors with clinically significant effects in several areas of long-term HRQOL (ie, more than 4 scores) were age, type of neck dissection, preoperative facial nerve palsy, and postoperative radiation therapy. CONCLUSION: In parotid gland cancer surgery, factors, such as sex, age, type of surgery, facial nerve palsy, and radiation therapy, seem to be associated with clinically meaningful differences in long-term HRQOL scores.

Surgical margins and oncologic results after carcinoma of the external auditory canal.

OBJECTIVES/HYPOTHESIS: External auditory canal cancer is rare and carries a poor prognosis. To date, only a few studies provide evidence for clinical decision making in multimodal treatment. METHODS: Retrospective chart review of 36 cases in three tertiary referral centers. RESULTS: Thirteen patients were treated by surgery alone, 18 by surgery with adjuvant chemoradiotherapy (CRT) and five by primary CRT. Clear surgical margins (R0) were obtained in 19 patients and positive margins (R1) in 12. The 5-year overall survival and local control rates were 59.4% and 74.2% with R0 status versus 56.6% and 26.3% with R1 status. The 5-year overall survival and local control rates were 46.2% and 70.7% with surgery alone, 78.1% and 43.2% with surgery and adjuvant CRT, and 25.0% and 80.0% with primary CRT. CONCLUSION: Surgery is integral to the management of external auditory canal cancer, whereas CRT is necessary as an adjuvant or primary treatment, depending on tumor stage. LEVEL OF EVIDENCE: 4.

Outcome measures in stapes surgery: postoperative results are independent from preoperative parameters.

The aim of this study was to compare audiometric results before and after stapes surgery and identify potential prognostic factors to appropriately select patients with otosclerosis who will most likely benefit from surgery. We enrolled 126 patients with otosclerosis (162 consecutive ears) in our study who underwent stapes surgery between 2007 and 2012 at our institution. Preoperative and postoperative data including pure-tone audiometry, speech audiometry, stapedial reflex audiometry and surgical data were analyzed. The average preoperative air-bone gap (ABG) was 28.9 ± 8.6 dB. Male patients and patients older than 45 years of age had greater preoperative ABGs in comparison to females and younger patients. Postoperative ABGs were 11.2 ± 7.4 dB. The average ABG gain was 17.7 ± 11.1 dB. Preoperative audiometric data, age, gender and type of surgery did not influence the postoperative results. Stapes surgery offers predictable results independent from disease progression or patient-related factors. While absolute values of hearing improvement are instrumental in reflecting audiometric results of a cohort, relative values better reflect individual's audiometric data resembling the patient's benefit.

Clinicopathological characteristics of carcinoma from unknown primary in cervical lymph nodes.

Carcinoma in cervical lymph nodes of unknown origin represents a rare clinical entity where optimal diagnostic and therapeutic management is still a widely debated issue. Molecular classification of these metastases is thus of utmost importance. We analyzed the expression of eight basic molecular markers in 26 metastases from unknown primaries, 31 metastases from overt primaries and their associated primaries. Medical records of the respective patients were reviewed for main clinicopathological parameters. The expression rates showed no significant differences between the two tumor entities, neither in absolute terms nor in comparison among the parameters. Surprisingly, patients with metastases from unknown primary demonstrated improved progression-free survival (p = 0.046) despite advanced age (p = 0.029), advanced nodal stage (p = 0.006) and higher incidence of extracapsular spread (p = 0.045) compared to patients with metastases from overt primaries. Presence of extracapsular spread was associated with increased expression of epidermal growth factor receptor in metastases from overt primaries (p = 0.035) and reduced expression of matrix metalloproteinase-2 in metastases from unknown primary (p = 0.031). We thus conclude that cervical metastases from unknown and overt primaries show similarities in their molecular profile, but fundamental differences in clinical parameter.

Squamous cell carcinoma of the larynx arising in multifocal pharyngolaryngeal oncocytic papillary cystadenoma: a case report and review of the literature.

We report on a rare case of a laryngeal carcinoma arising in a multifocal pharyngolaryngeal oncocytic papillary cystadenoma (OPC). The disease of a 63-year-old man is well documented by computed and positron emission tomography, histology, and electron microscopy. We could show that an OPC can even develop in the pharynx. The coexistence of both tumors makes this a challenging diagnosis for pathologists. Treated by surgery and radiotherapy, both lesions dissolved. Based on the literature available, we discuss the theory that the laryngeal carcinoma might be the result of a true metaplasia facilitated by chronic irritation and recommend a regular follow-up for OPC too. As in benign oncocytic lesions, we could show that the detection of numerous mitochondria is a diagnostic indicator for malignant variants as well.

Cyclin A1 shows age-related expression in benign tonsils, HPV16-dependent overexpression in HNSCC and predicts lower recurrence rate in HNSCC independently of HPV16.

BACKGROUND: Promoter methylation of the tumor suppressor gene Cyclin A1 could be associated with Human Papillomavirus 16 (HPV16) induced Head and Neck Squamous Cell Carcinoma (HNSCC) and Cervical Carcinoma. There is disagreement about the impact of this epigenetic event on protein expression of Cyclin A1 in malignant and non-malignant tissue and there hardly exists any information about possible relationships between Cyclin A1 expression and clinicopathological characteristics in HNSCC. METHODS: We analyzed protein expression of Cyclin A1 in 81 HNSCC and 74 benign tonsils by immunohistochemistry and correlated it to Cyclin A1 methylation status, presence of HPV16 infection and other clinicopathological characteristics. RESULTS: Overexpression of Cyclin A1 was more present in HNSCC than in tonsils (p < 0.001). In both entities, HNSCC and benign tonsils, expression of Cyclin A1 significantly correlated with the expression of Cyclin-dependent kinase-inhibitor p16 (p = 0.000672 and 0.00495). In tonsils, expression of Cyclin A1 was inversely proportional to age (p = 0.00000396), and further correlated with expression of tumor suppressor gene p53 (p = 0.000228). In HNSCC Cyclin A1 expression was associated with the presence of HPV16 DNA (p = 0.0014) and a lower recurrence rate in univariate and multivariate analysis (p = 0.002 and 0.013). Neither in HNSCC nor in tonsils Cyclin A1 expression correlated with promoter methylation. CONCLUSIONS: Cyclin A1 is an important cell cycle regulator with age-related increased expression in tonsils of children. HPV16 induces overexpression of Cyclin A1 in HNSCC despite promoter methylation. Overexpression of Cyclin A1 predicts a lower recurrence rate in HNSCC independently of HPV16.

Prevalence and impact on clinicopathological characteristics of human papillomavirus-16 DNA in cervical lymph node metastases of head and neck squamous cell carcinoma.

BACKGROUND: Human papillomavirus (HPV) is a basic risk factor for head and neck squamous cell carcinoma (HNSCC). Little knowledge exists about the impact of HPV on clinical diagnostic and therapy of patients with HNSCC. METHODS: We evaluated the evidence of HPV16 in 131 retrospectively collected HNSCC and associated cervical lymph node metastases by HPV16 real-time polymerase chain reaction (PCR) and p16 immunohistochemistry and its impact on clinicopathological characteristics. RESULTS: HPV16-DNA and p16 overexpression were present in 27% of HNSCCs. All cervical lymph node metastases of HPV16-positive HNSCC showed HPV16-DNA. HPV16 was strongly associated with tumors arising from the oropharyngeal site (p < .000001), favorable outcome after standard therapy in univariate (p = .001) and multivariate (p = .0004) analysis, and cervical lymph node metastases before primary detection. CONCLUSION: HPV16-diagnostic in cervical lymph node metastases can predict the site of tumor origin in case of carcinoma of unknown primary (CUP) and favorable outcome and should, therefore, be included in routine diagnostic workup.