Visualization and clinical relevance of the endolymphatic duct and sac in Ménière's disease.

Background: Ménière's disease (MD) is a chronic inner ear disorder with a multifactorial etiology. Decreased visualization of the endolymphatic duct (ED) and sac (ES) is thought to be associated with MD, although controversy exists about whether this finding is specific to MD. Recent literature has revealed that two distinct ES pathologies, developmental hypoplasia and epithelial degeneration, can be distinguished in MD using the angular trajectory of the vestibular aqueduct (ATVA) or ED-ES system as a radiographic surrogate marker. It has been suggested that these two subtypes are associated with distinct phenotypical features. However, the clinical differences between the ATVA subtypes require further validation. Research objective: The objective of this study is to investigate whether (1) non-visualization of the ED-ES system is a discriminative radiological feature for MD in a cohort of vertigo-associated pathologies (VAPs) and whether (2) different angular trajectories of the ED-ES system in MD are associated with distinguishable clinical features. Setting: The study was conducted in the Vertigo Referral Center (Haga Teaching Hospital, The Hague, the Netherlands). Methods: We retrospectively assessed 301 patients (187 definite MD and 114 other VAPs) that underwent 4h-delayed 3D FLAIR MRI. We evaluated (1) the visibility of the ED-ES system between MD and other VAP patients and (2) measured the angular trajectory of the ED-ES system. MD patients were stratified based on the angular measurements into αexit ≤ 120° (MD-120), αexit 120°-140° (MD-intermediate), or αexit ≥ 140° (MD-140). Correlations between ATVA subgroups and clinical parameters were evaluated. Results: Non-visualization of the ED-ES system was more common in definite MD patients compared with other VAPs (P < 0.001). Among definite MD patients, the MD-140 subtype demonstrated a longer history of vertigo (P = 0.006), a higher prevalence of bilateral clinical disease (P = 0.005), and a trend toward a male preponderance (p = 0.053). No significant differences were found between ATVA subgroups regarding the presence or severity of auditory symptoms, or the frequency of vertigo attacks. Conclusion: Non-visualization of the ED-ES system is significantly associated with MD. Among MD patients with a visible ED-ES system, we demonstrated that the MD-140 subtype is associated with a longer disease duration, a higher prevalence of bilateral MD, and a trend toward a male preponderance.

Quality of life after intratympanic steroid injection for Ménière's disease.

Objective: This study explores how treatment with intratympanic steroid injection affects quality of life, as well as several subjective complaints in patients with Ménière's disease. Methods: Patients filled in the Ménière's Disease Outcome Questionnaire (MDOQ) and answered questions about subjective complaints. Scores before and after treatment were compared using paired t tests. Results: Forty-nine patients treated with intratympanic steroid injection were included. Quality of life was improved in 36 (73%) patients, the same in 9 (18%) patients, and lower in 4 (8%) patients. Overall, the mean change in MDOQ was +20.6 points (95% confidence interval +14.5 to +26.7 points, p < 0.001). The improvement was seen in the emotional, physical, and mental domain. Most patients experienced less vertigo and instability but did not notice change in subjective hearing, tinnitus, or aural fullness after treatment. Conclusion: Treatment with intratympanic steroid injection leads to an improvement in quality of life in most patients. Moreover, the procedure is only minimally invasive. Based on the findings in this study, treatment with ITS should be discussed with every patient suffering from vertigo attacks due to active Ménière's disease. Level of evidence: Level 4.

Time to Functional Recovery After Laser Tonsillotomy Performed Under Local Anesthesia vs Conventional Tonsillectomy With General Anesthesia Among Adults: A Randomized Clinical Trial.

Importance: Carbon dioxide laser tonsillotomy performed under local anesthesia may be an effective and less invasive alternative than dissection tonsillectomy for treatment of tonsil-related afflictions. Objective: To compare functional recovery and symptom relief among adults undergoing tonsillectomy or tonsillotomy. Design, Setting, and Participants: This randomized clinical trial was conducted at 5 secondary and tertiary hospitals in the Netherlands from January 2018 to December 2019. Participants were 199 adult patients with an indication for surgical tonsil removal randomly assigned to either the tonsillectomy or tonsillotomy group. Interventions: For tonsillotomy, the crypts of the palatine tonsil were evaporated using a carbon dioxide laser under local anesthesia, whereas tonsillectomy consisted of total tonsil removal performed under general anesthesia. Main Outcomes and Measures: The primary outcome was time to functional recovery measured within 2 weeks after surgery assessed for a modified intention-to-treat population. Secondary outcomes were time to return to work after surgery, resolution of primary symptoms, severity of remaining symptoms, surgical complications, postoperative pain and analgesics use, and overall patient satisfaction assessed for the intention-to-treat population. Results: Of 199 patients (139 [70%] female; mean [SD] age, 29 [9] years), 98 were randomly assigned to tonsillotomy and 101 were randomly assigned to tonsillectomy. Recovery within 2 weeks after surgery was significantly shorter after tonsillotomy than after tonsillectomy (hazard ratio for recovery after tonsillectomy vs tonsillotomy, 0.3; 95% CI, 0.2-0.5). Two weeks after surgery, 72 (77%) patients in the tonsillotomy group were fully recovered compared with 26 (57%) patients in the tonsillectomy group. Time until return to work within 2 weeks was also shorter after tonsillotomy (median [IQR], 4.5 [3.0-7.0] days vs 12.0 [9.0-14.0] days; hazard ratio for return after tonsillectomy vs tonsillotomy, 0.3; 95% CI, 0.2-0.4.). Postoperative hemorrhage occurred in 2 patients (2%) in the tonsillotomy group and 8 patients (12%) in the tonsillectomy group. At 6 months after surgery, fewer patients in the tonsillectomy group (25; 35%) than in the tonsillotomy group (54; 57%) experienced persistent symptoms (difference of 22%; 95% CI, 7%-37%). Most patients with persistent symptoms in both the tonsillotomy (32 of 54; 59%) and tonsillectomy (16 of 25; 64%) groups reported mild symptoms 6 months after surgery. Conclusions and Relevance: This randomized clinical trial found that compared with tonsillectomy performed under general anesthesia, laser tonsillotomy performed under local anesthesia had a significantly shorter and less painful recovery period. A higher percentage of patients had persistent symptoms after tonsillotomy, although the intensity of these symptoms was lower than before surgery. These results suggest that laser tonsillotomy performed under local anesthesia may be a feasible alternative to conventional tonsillectomy in this population. Trial Registration: Netherlands Trial Register Identifier: NL6866 (NTR7044).

[Laser treatment of the tonsils in adults on an outpatient basis]. / Poliklinische lasertonsillotomie bij volwassenen.

Tonsil complaints in adults are common. If conservative treatment fails, there is an indication for surgical removal of the tonsils. The current standard procedure, tonsillectomy under anaesthesia, is invasive, painful, and relatively often leads to complications including postoperative bleeding. There is an alternative procedure: the CO2 laser tonsillotomy under local anaesthesia. In this procedure, only the lymphatic tissue is removed. As a result, this procedure is associated with significantly less pain, shorter recovery, less postoperative bleeding, and a significant reduction in tonsil complaints.

Hydropic Ear Disease: Correlation Between Audiovestibular Symptoms, Endolymphatic Hydrops and Blood-Labyrinth Barrier Impairment.

Research Objective: To investigate the correlation between clinical features and MRI-confirmed endolymphatic hydrops (EH) and blood-labyrinth barrier (BLB) impairment. Study Design: Retrospective cross-sectional study. Setting: Vertigo referral center (Haga Teaching Hospital, The Hague, the Netherlands). Methods: We retrospectively analyzed all patients that underwent 4 h-delayed Gd-enhanced 3D FLAIR MRI at our institution from February 2017 to March 2019. Perilymphatic enhancement and the degree of cochlear and vestibular hydrops were assessed. The signal intensity ratio (SIR) was calculated by region of interest analysis. Correlations between MRI findings and clinical features were evaluated. Results: Two hundred and fifteen patients with MRI-proven endolymphatic hydrops (EH) were included (179 unilateral, 36 bilateral) with a mean age of 55.9 yrs and median disease duration of 4.3 yrs. Hydrops grade is significantly correlated with disease duration (P < 0.001), the severity of low- and high-frequency hearing loss (both P < 0.001), and the incidence of drop attacks (P = 0.001). Visually increased perilymphatic enhancement was present in 157 (87.7%) subjects with unilateral EH. SIR increases in correlation with hydrops grade (P < 0.001), but is not significantly correlated with the low or high Fletcher index (P = 0.344 and P = 0.178 respectively). No significant differences were found between the degree of EH or BLB impairment and vertigo, tinnitus or aural fullness. Conclusion: The degree of EH positively correlates with disease duration, hearing loss and the incidence of drop attacks. The BLB is impaired in association with EH grade, but without clear contribution to the severity of audiovestibular symptoms.

[Adenotonsillectomy with or without intubation? Safety of the adenotonsillectomy without endotracheal tube in children]. / Wel of geen intubatie bij adenotonsillectomie volgens Sluder?Resultaten.

OBJECTIVE: To determine the safety of the non-intubated and intubated adenotonsillectomy by the Sluder method in children DESIGN: Retrospective database study METHOD: We compared the data of adenotonsillectomy by the Sluder method in children until thirteen years of two teaching hospitals from 2014 until 2017. In the Amphia Hospital the procedure was performed without endotracheal tube placement and without perioperative opioids, in the Haga Hospital the patients were intubated and received perioperative opioids. Primary outcome was reoperation for postoperative haemorrhage. Secondary outcomes included desaturation (saturation ≤ 90% > 1 min), severe hypoxemia (saturation ≤ 85% for ≥ 5 min), airway complications, bradycardia, total postoperative haemorrhages, use of rescue medication, hospital readmission and 30-day mortality. RESULTS: A total of 1370 patients were analysed: 1267 adenotonsillectomies and 103 tonsillectomies. Median operation time was 7 minutes in the non-intubated group versus 12 minutes in the intubated group. The primary outcome occurred in thirteen patients in the group without intubation (2.2%) and eleven times in the group with intubation (1.4%). There was one case of severe hypoxemia in the group without intubation. Desaturation occurred mostly in the group without intubation (26.4%) for a short time (median 0 min, interquartile range 0-1). Bradycardia was seen more in the group with intubation (4.1% vs 2.2%). CONCLUSION: The incidence of postoperative haemorrhage and severe airway complications after adenotonsillectomy by the Sluder method with and without endotracheal tube placement in both groups was comparable.

Effectiveness of endolymphatic duct blockage versus endolymphatic sac decompression in patients with intractable Ménière's disease: study protocol for a double-blinded, randomised controlled trial.

INTRODUCTION: Outcomes of surgery for Ménière's disease (MD) remain discordant. Recently, a new surgical procedure in which the endolymphatic duct is clipped was proposed. To date, only one prospective trial assessing this technique was published, yielding promising results. This protocol describes a prospective, double-blinded, randomised controlled trial that will be carried out to assess the effectiveness of this surgical intervention. METHODS: Eighty-four patients with intractable MD will be recruited from 13 hospitals in the Netherlands. Intraoperatively, randomisation will determine whether endolymphatic duct blockage (EDB) or endolymphatic sac decompression (ESD) will be performed. Randomisation will be 1:1 stratified for gender and duration of MD (recent-onset versus mature MD). All participants receive vestibular rehabilitation after surgery. Patients are followed up during 1 year after surgery. Follow-up visits will take place at 1 week, 3 months, 6 months and 12 months after surgery. The main study endpoint is proportion of patients who are free of vertigo spells at 12 months postoperatively. Secondary parameters include cumulative number of vertigo bouts, co-intervention, tinnitus, hearing, quality of life, cost effectiveness and a budget impact analysis. Total duration of the study is 4 years. ANALYSIS: The primary analysis will follow the intention-to-treat principle. For the primary outcome, a χ2 test will be performed. Secondary outcomes will be analysed using a linear mixed model (EDB versus decompression group) at the different time measurement point. ETHICS AND DISSEMINATION: This study was reviewed and approved by a board of specialists before funding was obtained, as well as by the Medical Research Ethics Committee Leiden-The Hague-Delft and the boards of all participating centres. Results of this study will be published in international peer-reviewed scientific journals and will be presented on (inter)national scientific conferences and meetings. TRIAL REGISTRATION NUMBERS: NL9095 and ISRCTN12074571; Pre-Results.

Practical applicability of the STAMCO and ChOLE classification in cholesteatoma care.

BACKGROUND: To compare cholesteatoma care internationally and to evaluate outcomes, ear surgeons must use the same terminology. However, a clear universal definition on how to describe the extension, destruction and accompanying morbidity caused by the cholesteatoma is lacking. The practical applicability by means of interrater agreement is assessed for the STAMCO and the ChOLE classification. METHODS: A total of 134 adult patients derived from the nationwide multicentre study in the Netherlands, entitled Dutch Cholesteatoma Data (DCD) were included. Retrospective analysis of 134 surgical reports according to the STAMCO and ChOLE classification for localisation/extension of the cholesteatoma, complication status and ossicular chain status. Both the percentage agreement and the interrater agreement were determined for each item of the classifications and interrater agreement was compared between the classifications as a whole. RESULTS: Differences in interrater agreement were found for both the localisation/extension of the cholesteatoma and ossicular chain status. STAMCO classification derived from the surgical report scored better on the localisation/extension of the cholesteatoma, whereas the ChOLE classification derived from the surgical report scored better on the status of the ossicular chain. In both classifications, complication status had a low agreement level but was also poorly registered in the surgical reports. CONCLUSION: Both STAMCO and ChOLE will be beneficial in uniform registration of cholesteatoma pathology in practice. Modifications proposed for both classifications may make them even more practical applicable in the future. A common denominator obtained from these two classifications may be incorporated in a standardised surgical report to facilitate evaluation which make outcomes transferable towards both classifications.

CO2-Lasertonsillotomy Under Local Anesthesia in Adults.

Tonsil-related complaints are very common among the adult population. Tonsillectomy under general anesthesia is currently the most performed surgical treatment in adults for such complaints. Unfortunately, tonsillectomy is an invasive treatment associated with a high complication rate and a long recovery time. Complications and a long recovery time are mostly related to removing the vascular and densely innervated capsule of the tonsils. Recently, CO2-lasertonsillotomy under local anesthesia has been demonstrated to be a viable alternative treatment for tonsil-related disease with a significantly shorter and less painful recovery period. The milder side-effect profile of CO2-lasertonsillotomy is likely related to leaving the tonsil capsule intact. The aim of the current report is to present a concise protocol detailing the execution of CO2-lasertonsillotomy under local anesthesia. This intervention has been performed successfully in our hospital in more than 1,000 patients and has been found to be safe and to be associated with a steep learning curve.

Tonsillotomy versus tonsillectomy in adults suffering from tonsil-related afflictions: a systematic review.

OBJECTIVE: Tonsillotomy has emerged as an alternative for tonsillectomy in treating patients with tonsil-related afflictions. Tonsillotomy provides favourable outcomes in children, but treatment of choice in adults remains unclear. This systematic review sought to evaluate the current literature on the efficacy and adverse events of tonsillotomy compared to tonsillectomy in adults. METHODS: A Medline and Cochrane search was conducted for randomized clinical trials (RCTs) and cohort studies comparing tonsillotomy to tonsillectomy in adults. Risk of bias was assessed. Outcome measures were efficacy of the procedure in resolving the initial tonsil-related symptoms (tonsillitis, obstructive sleep apnoea, tonsil stones, halitosis, dysphagia), procedure-related complications, recovery time, post-operative use of analgesics, patient satisfaction, and operating time. RESULTS: In total nine papers were included. These trials had a high risk of bias and the inter-comparability of results was poor. The reported studies found generally a similar efficacy for both interventions. With regard to pain, the use of analgesics, patient satisfaction and operation time, the results were generally in favour of tonsillotomy. Post-operative haemorrhages were more frequent after tonsillectomy. CONCLUSION: Current evidence suggests an equal efficacy of tonsillotomy and tonsillectomy in adults and a preference for tonsillotomy in terms of pain, analgesics use, patient-satisfaction, operation time and post-operative complications.

Post-operative morbidity and 1-year outcomes in CO2-laser tonsillotomy versus dissection tonsillectomy.

OBJECTIVE: In this study a type of partial tonsil surgery, CO2-laser tonsillotomy, was compared to regular tonsillectomy. The effectiveness and post-operative recovery rate of both interventions in adult patients was assessed by using a questionnaire. STUDY DESIGN: Prospective follow-up non-randomized cohort study. METHOD: One hundred and seven adults were included; 46 tonsillectomies and 61 tonsillotomies were performed. Patients in the tonsillectomy group underwent general anaesthesia, while tonsillotomy was performed in an ambulatory setting with local anaesthesia. Post-operative questionnaires were administered by mail after 2 weeks, 6 months, and 1 year to assess recovery rate and symptom recurrence. RESULTS: In total, 72.5% of patients were cured from their initial symptoms after tonsillotomy. Three patients (7.5%) required re-surgery for their initial complaints. After tonsillectomy, 97.2% of patients were cured. Both groups showed equally high satisfaction scores after treatment. Post-operative evaluation after 2 weeks showed a mean pain-intensity score of 5.4 (Visual Analogue Scale 0-10) after tonsillotomy and a mean pain-intensity score of 7.7 after tonsillectomy. The post-operative use of analgesics was twice as long in the tonsillectomy group compared to the tonsillotomy group and the tonsillectomy group required twice as many days for full recovery. After tonsillectomy a higher rate of major post-operative haemorrhage was seen. CONCLUSION: CO2-laser tonsillotomy is associated with a shorter and less painful recovery period. Both surgical methods are equal in terms of long-term satisfaction, although tonsillotomy comes with a higher recurrence rate of mild symptoms. A strict pre-operative patient selection for CO2-laser tonsillotomy is necessary.

Novel head and neck cancer survival analysis approach: random survival forests versus Cox proportional hazards regression.

BACKGROUND: Electronic patient files generate an enormous amount of medical data. These data can be used for research, such as prognostic modeling. Automatization of statistical prognostication processes allows automatic updating of models when new data is gathered. The increase of power behind an automated prognostic model makes its predictive capability more reliable. Cox proportional hazard regression is most frequently used in prognostication. Automatization of a Cox model is possible, but we expect the updating process to be time-consuming. A possible solution lies in an alternative modeling technique called random survival forests (RSFs). RSF is easily automated and is known to handle the proportionality assumption coherently and automatically. Performance of RSF has not yet been tested on a large head and neck oncological dataset. This study investigates performance of head and neck overall survival of RSF models. Performances are compared to a Cox model as the "gold standard." RSF might be an interesting alternative modeling approach for automatization when performances are similar. METHODS: RSF models were created in R (Cox also in SPSS). Four RSF splitting rules were used: log-rank, conservation of events, log-rank score, and log-rank approximation. Models were based on historical data of 1371 patients with primary head-and-neck cancer, diagnosed between 1981 and 1998. Models contain 8 covariates: tumor site, T classification, N classification, M classification, age, sex, prior malignancies, and comorbidity. Model performances were determined by Harrell's concordance error rate, in which 33% of the original data served as a validation sample. RESULTS: RSF and Cox models delivered similar error rates. The Cox model performed slightly better (error rate, 0.2826). The log-rank splitting approach gave the best RSF performance (error rate, 0.2873). In accord with Cox and RSF models, high T classification, high N classification, and severe comorbidity are very important covariates in the model, whereas sex, mild comorbidity, and a supraglottic larynx tumor are less important. A discrepancy arose regarding the importance of M1 classification (see Discussion). CONCLUSION: Both approaches delivered similar error rates. The Cox model gives a clinically understandable output on covariate impact, whereas RSF becomes more of a "black box." RSF complements the Cox model by giving more insight and confidence toward relative importance of model covariates. RSF can be recommended as the approach of choice in automating survival analyses.

[A woman with sinusitis]. / Een vrouw met sinusitis.

A 52-year-old woman was referred because of maxillary sinusitis. CT-scan showed two migrated dental implants in both maxillary sinuses.

A visual analog scale can assess the effect of surgical treatment in children with chronic otitis media with effusion.

BACKGROUND: The OM-6 survey is a validated and multinationally accepted instrument to measure the treatment effect of otitis media in children. Routine use of the OM-6 in a busy general practice is not always possible and can lead to incomplete returned surveys. A simplified method is favoured when the aim is a continuous process of complete treatment-outcome-data collection. This study tests if a VAS can quantify how much a child suffers from chronic otitis media and how much this changes due to surgical treatment. The change in overall OM-6 scores due to surgical treatment, functions as the gold reference standard. Furthermore, this study tests if the VAS is faster to use than the OM-6 and if it leads to an improvement in complete data collection. METHODS: Prospective cohort follow-up study of 175 consecutive children with chronic otitis media in a paediatric otolaryngology practice in a metropolitan area. Data collected included patient's age, gender, clinical presentation, type of surgical procedure performed, overall OM-6 score and VAS score (at initial presentation and at follow-up), time needed to complete an OM-6 survey and VAS separately and number of incorrect OM-6 surveys and VAS questions returned. RESULTS: The VAS scores and overall OM-6 scores show a good, positive correlation at baseline (Spearman's rho=0.71). This correlation improves at follow-up, one and 6 months after intervention (rho=0.73 and rho=0.80, respectively). The change in VAS scores and overall OM-6 scores, interpreted as change due to surgical intervention, show a good positive correlation at follow-up (rho=0.70 and rho=0.77, respectively). The VAS is almost three times faster than the OM-6 (28s versus 81s). More than 13% of OM-6 surveys were returned incomplete. All VAS questions were returned correct. CONCLUSIONS: The VAS can be used as a simplified method for routine surgical treatment effect analysis in children with chronic otitis media.

Laser myringotomy versus ventilation tubes in children with otitis media with effusion: a randomized trial.

OBJECTIVES: Insertion of ventilation tubes in children with otitis media with effusion (OME) is an accepted and common treatment procedure. The majority of patients require general anesthesia. Although laser myringotomy can be performed in local anesthesia, evidence is lacking that this treatment modality is an alternative for tubes, and outcome predictors for laser myringotomy are not available. STUDY DESIGN: Prospective randomized trial. METHODS: We screened 1,403 children with chronic OME that were indicated for placement of ventilation tubes. In the eligible patients, we performed laser myringotomy in one ear and placed a tube in the other ear, both within the same patient. Follow-up was scheduled each month for 6 months. Success was defined as absence of effusion or aural discharge. A logistic regression model was used with success of the therapy as binary outcome. This model was based on base-line variables, asked for in a parent's questionnaire. RESULTS: Two hundred eight children received the allocated intervention, and no complications occurred. The mean closure time of the laser perforation was 2.4 weeks, and the mean patency time of the ventilation tube was 4.0 months. The mean success rate was 40% for laser and 78% for tubes. Ten known variables were found to predict middle ear status after therapy. CONCLUSION: Laser myringotomy is a safe but less-effective procedure than insertion of a ventilation tube in the treatment of chronic OME. The prognostic model enables the otolaryngologist to choose the surgical treatment for the child that benefits most: laser myringotomy or ventilation tube.