Meta-analysis of imaging techniques for the diagnosis of complex regional pain syndrome type I.

PURPOSE: To compare the effectiveness of imaging techniques in aiding and confirming the diagnosis of complex regional pain syndrome (CRPS) type I. METHODS: We conducted a meta-analysis of randomized controlled studies that evaluated the effectiveness of 3 different imaging techniques in aiding the diagnosis of CRPS type I. A systematic search in bibliographical databases resulted in 24 studies with 1,916 participants. RESULTS: To determine the effectiveness of each imaging technique, we determined the average specificity, sensitivity, negative predictive value, and positive predictive value and then statistically compared them using the analysis of variance statistical test, which indicated that compared with magnetic resonance imaging and plain film radiography, triple-phase bone scan had a significantly better sensitivity and negative predictive values. However, there appeared to be no statistical significance between imaging techniques when we evaluated specificity and positive predictive value using the analysis of variance test. CONCLUSIONS: The findings of this meta-analysis support the use of triple-phase bone scan in ruling out CRPS type I, owing to its greater sensitivity and higher negative predictive value than both magnetic resonance imaging and plain film radiography. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic I.

Using the Middle Turbinate to Protect the Skull Base in Endoscopic Transsphenoidal Surgery: A Cadaver Study.

OBJECTIVES: Inadvertent intracranial injury from nasogastric tube (NGT) placement is a described and potentially fatal complication following endoscopic transsphenoidal hypophysectomy (TSH). This cadaver study assessed the role of middle turbinate (MT) preservation and medialization in preventing accidental skull base injury from NGT insertion after TSH. Methods: Standard approach for TSH was performed on 3 human cadavers. MTs were placed into neutral position (MTN), then medialized via suture pexy to the septum (MTP), and subsequently resected (MTR). After each stage, 3 blinded individuals passed a 10 F Dobhoff and a 16 F NGT on each side of each cadaver (5 passes per side). Using endoscopic visualization, each pass was scored by a blinded reviewer based on the first contact point of the tube (0 = nasopharynx, 1 = inferior sphenoid face, 2 = sphenoid sinus), with higher scores suggestive of increased risk of intracranial injury. Results: There were 270 Dobhoff and 270 NGT passes scored. Data was divided into 3 groups based on presence and position of the MT. Significant differences were demonstrated between all three groups [one-way ANOVA: Dobhoff F(2,267) = 6.981, p = 0.001], [NGT F(2,267) = 17.582, p < 0.001]. There were significant differences between means for MTN versus MTP groups [Dobhoff (0.43 vs 0.22, p = 0.007), NGT (0.73 vs 0.28, p < 0.001)] and MTP versus MTR groups [Dobhoff (0.22 vs 0.55, p < 0.001), NGT (0.28 vs 0.81, p < 0.001)], indicating that the presence and position of the MT can significantly affect the accessibility of the sphenoid sinus interior after TSH. There was a trend toward lower means in the MTN group compared to the MTR group. Conclusion: MT preservation and deliberate medialization against the septum may reduce risk of inadvertent intracranial NGT injury in postop TSH patients. This simple maneuver should be considered in all routine TSH procedures.

Prevalence and Clinical Significance of Radiographic Sinus Disease on Preoperative Computed Tomography Imaging in the Endoscopic Skull Base Surgery Population.

INTRODUCTION: Endoscopic skull base surgery (ESBS) provides a safe, minimally invasive approach to treat benign and malignant skull base lesions. The significance of concomitant sinonasal pathology on imaging in patients undergoing ESBS and its effect on perioperative management is not well described. We sought to identify the prevalence and clinical significance of incidentally found radiographic sinus disease on preoperative imaging in patients undergoing ESBS and provide a protocol for management of these patients. DESIGN: A retrospective chart review was performed of consecutive patients who underwent ESBS from January 1, 2016 to June 30, 2018. Preoperative computed tomography (CT) scans were reviewed and scored using the Lund-Mackay (LM) staging system. Preoperative nasal endoscopy findings were analyzed. Any preoperative treatment based on these findings and changes in intraoperative management were examined. RESULTS: A total of 156 patients (81 women, 74 men) who underwent ESBS were reviewed. The average LM score was 2 ± 2.7 (range: 0-12). A total of 94 patients (60.3%) had evidence of radiographic sinus disease (LM score > 0) and 23 patients (14.7%) had presence of sphenoid sinus disease. Seven patients (4.5%) were treated preoperatively based on CT and/or nasal endoscopy findings. All patients who received preoperative treatment had evidence of sinus disease on imaging with an average score of 4.7 and were evaluated and treated within 1-2 weeks prior to ESBS. One patient had ESBS postponed until endoscopic sinus surgery was performed for extensive chronic rhinosinusitis (CRS) findings on imaging. CONCLUSION: A review of preoperative imaging in patients undergoing ESBS can help identify concurrent sinonasal disease, which has the potential to alter preoperative as well as intraoperative management in these patients. We report a diligent but conservative approach for the treatment of concomitant CRS in the ESBS population with decision for preoperative treatment guided by various factors.

Predictors of eustachian tube dysfunction improvement and normalization after endoscopic sinus surgery.

OBJECTIVE: Studies have demonstrated improvement in Eustachian tube dysfunction (ETD) symptomatology after functional endoscopic sinus surgery (FESS); however, factors associated with ETD symptom alteration have not been elucidated. This study evaluated factors associated with improvement and normalization of ETD symptoms after FESS. METHODS: A case-control study was performed of FESS patients who had clinically significant ETD symptoms based on the Eustachian Tube Dysfunction Questionnaire-7 (ETDQ-7 ≥ 2.1) without middle ear effusion (MEE) preoperatively. Study patients were identified as those with a normalized ETDQ-7 at 2 months postoperatively. Controls were patients whose ETDQ-7 did not normalize at 2 months. Demographics, surgery characteristics, chronic rhinosinusitis phenotype, Lund-Mackay score, temporomandibular joint dysfunction (TMJD), preoperative ETDQ-7 and SNOT-22 scores, and tympanograms were analyzed. Univariate and multivariate analyses were performed comparing study cases and controls. RESULTS: Data were collected on 165 patients, with 46% patients having clinically significant preoperative ETD and 60 patients meeting final study inclusion/exclusion criteria. FESS was associated with both SNOT-22 and ETDQ-7 improvement (P < 0.001). Nasal polyposis was associated with a higher probability of ETDQ-7 normalization (OR 4.429, P = 0.035). Factors associated with failure of ETDQ-7 normalization included TMJD (OR 0.086, P < 0.001, 95% CI 0.019-0.391) and high preoperative ETDQ-7 (OR 0.140, P = 0.006, 95% CI 0.032-0.613). CONCLUSION: In patients with clinically significant ETD symptoms without MEE, FESS was associated with ETDQ-7 improvement. Nasal polyposis was associated with an increased probability of normalization of ETD symptoms postoperatively, whereas TMJD had a negative association. LEVEL OF EVIDENCE: 3b Laryngoscope, 2019.

Surgical Management of Recurrent Tracheocarotid Fistula following Endovascular Stent Placement.

We report the case of a 25-year-old woman who developed a tracheocarotid fistula secondary to an infected endovascular stent placed in the right carotid artery after the patient experienced hemorrhage on her first tracheostomy change. The patient originally had the tracheostomy placed at an outside hospital in September 2014, due to prolonged intubation after a motor vehicle accident. The patient presented to the otolaryngology service with an acute tracheal hemorrhage. This necessitated a neck exploration, median sternotomy, right carotid stent removal with subclavian to carotid bypass, and sternocleidomastoid flap reconstruction. This paper addresses the epidemiology and anatomy of a tracheocarotid fistula and discusses methods to treat such a complication.

Sentinel lymph node status is the most important prognostic factor in patients with melanoma of the scalp.

OBJECTIVES/HYPOTHESIS: To compare clinicopathologic and prognostic factors associated with scalp melanomas and nonscalp melanomas of the head and neck (H&N). STUDY DESIGN: Post hoc analysis of the database from a multi-institutional, prospective, randomized study. METHODS: Clinicopathologic factors were assessed and correlated with survival and recurrence. Univariate and multivariate analysis of prognostic factors affecting disease-free survival and overall survival were performed. RESULTS: Of 405 patients with H&N melanomas ≥1.0 mm Breslow thickness, 109 patients had melanoma of the scalp. All were Caucasian (100%), with most being male (79.5%) with a mean age of 49.8 years. The mean Breslow thickness was 2.4 mm; 25% had signs of ulceration. Sentinel lymph node (SLN) positivity was seen in 20.9% of scalp melanoma patients, and was more likely in younger patients (44.7 vs. 50.8 years, P = .04) and in those with a Breslow thickness of 2 to 4 mm (P = .005). The incidence of locoregional and distant recurrence were similar. Overall survival for scalp melanoma patients was significantly impacted by SLN positivity (P = .03), whereas Breslow thickness and ulceration status predicted poorer survival in nonscalp melanoma patients (P = .005, P < .0001, respectively). CONCLUSIONS: In the Sunbelt Melanoma Trial, SLN status was the strongest predictor of overall survival in scalp melanoma. Tumor thickness and ulceration correlated with poorer overall survival in nonscalp H&N melanoma. The prognostic significance of SLN status in the H&N may vary with the melanoma site.

Treatment outcome in the residually positive neck after definitive chemotherapy and irradiation.

OBJECTIVE: Determine prevalence of viable malignancy in patients undergoing neck dissection (ND) for residual neck disease following concomitant chemotherapy and irradiation (chemo/xrt) for upper aerodigestive squamous carcinoma. To determine survival in groups with a neck complete response to those who had residual disease requiring neck dissection. STUDY DESIGN: Retrospective chart review. METHODS: Retrospective chart review of 230 patients who underwent definitive chemo/xrt for primary squamous cell carcinoma cancer (SCCa) of the head and neck from 2005 to 2009 in one institution. RESULTS: Thirty-nine (17%) patients underwent ND for residual neck mass within 4 months posttreatment. Forty-nine percent (19/39) were pathologically positive for malignancy and 51% (20/39) were negative. The probability of a +ND based on original N-stage was not statistically significant (P = .368). Primary site did not yield significant probability of having +ND, except in the oral cavity (P = .02). Patients had similar overall 5-year survival, among those with a delayed complete response in the neck (66%), ND for residual disease (71%), or those with initial complete response (71%). Lower initial N-stage demonstrated improved survival in all outcome groups. Tonsil SCCa patients who underwent ND had improved survival compared to those with delayed complete response (87.5 vs. 75.8%), both of which had increased survival compared to initial complete responders (65%). CONCLUSIONS: This study supports the use of ND in the postchemo/xrt positive neck regardless of primary site or initial N-stage. ND in this setting conveys survival equal to patients with complete response in the neck after chemo/xrt. These survivorship implications of postchemo/xrt neck dissection extend to all sites, including tonsils.