Clinical management and outcome of head and neck paragangliomas (HNPGLs): A single centre retrospective study.

CONTEXT: Head and neck paragangliomas (HNPGLs) are rare, usually benign, slow-growing tumours arising from neural crest-derived tissue. Definitive management pathways for HNPGLs have yet to be clearly defined. OBJECTIVE: To review our experience of the clinical features and management of these tumours and to analyse outcomes of different treatment modalities. METHODS: Demographic and clinical data were obtained from The Northern Ireland Electronic Care Record (NIECR) as well from a prospectively maintained HNPGL database between January 2011 through December 2023. RESULTS: There were 87 patients; 50 females: 37 males with a mean age of 52.3 ± 14.2 years old (range 17-91 years old). 58.6% (n = 51) of patients had carotid body tumours, 25.2% (n = 22) glomus vagal tumours, 6.8% (n = 6) tumours in the middle ear, 2.2% (n = 2) in the parapharyngeal space and 1.1% (n = 1) in the sphenoid sinus. 5.7% (n = 5) of patients had multifocal disease. The mean tumour size at presentation was 3.2 ± 1.4 cm (range 0.5-6.9 cm). Pathogenic SDHD mutations were identified in 41.3% (n = 36), SDHB in 12.6% (n = 11), SDHC in 2.2% (n = 2) and SDHA in 1.1% (n = 1) of the patients. Overall treatment modalities included surgery alone in 51.7% (n = 45) of patients, radiotherapy in 14.9% (n = 13), observation in 28.7% (n = 25), and somatostatin analogue therapy with octreotide in 4.5% (n = 4) of patients. Factors associated with a significantly higher risk of recurrence included age over 60 years (p = .04), tumour size exceeding 2 cm (p = .03), positive SDHx variants (p = .01), and vagal and jugular tumours (p = .04). CONCLUSION: The majority of our patients underwent initial surgical intervention and achieved disease stability. Our results suggest that carefully selected asymptomatic or medically unfit patients can be safely observed provided lifelong surveillance is maintained. We advocate for the establishment of a UK and Ireland national HNPGL registry, to delineate optimal management strategies for these rare tumours and improve long term outcomes.

A Multicenter Retrospective Case Review of Outcomes and Complications of S53P4 Bioactive Glass.

OBJECTIVE: The objective of this multicenter retrospective case review was to assess the natural clinical course, efficacy, and safety of mastoid obliteration with S53P4 Bioactive Glass (bioactive glass). METHODS: Retrospective case note review in a regional Tertiary Referral Centre and District General Hospital. Patients undergoing mastoid cavity obliteration as part of primary or secondary procedure with bioactive glass between 2012 and 2018. Outcome measures were assessed from a prospectively collated database and case note review. Primary outcomes were the common morbidities of a mastoid cavity; dry or discharging ear (Merchant's scale), vertigo in cold air, and a watertight middle ear. Patients were also assessed for audiological outcomes and recidivism. RESULTS: Ninety patients were included. During the follow-up period, (mean, 22 months; range, 6-59 months) cholesteatoma recidivism was observed in 2% of ears (2 patients). An acceptably dry (Merchant Grade 0-1) ear was achieved in 91% of all ears (95% primary cases, 80% secondary cases). Delayed healing of the graft in the external ear canal retaining the S53P4BAG Bioactive Glass (BonAlive Ò (BonAlive Ò Biomaterials Ltd., Turku, Finland)) within the mastoid occurred in 13% (12 ears). However, in all cases, conservative management resulted in complete healing. CONCLUSIONS: Bioactive glass provides a safe and effective means of mastoid obliteration. Complications including overlay graft failure and slow epithelialization, resulting in prolonged postoperative discharge (up to 2 months) and dehiscence into the external ear canal, do not preclude full recovery and may be successfully managed conservatively.

Tympanic membrane retraction: An endoscopic evaluation of staging systems.

OBJECTIVES/HYPOTHESIS: The objectives of this work were to assess inter- and intraobserver variability of different staging systems for tympanic membrane (TM) retraction using otoendoscopy in children at risk of retraction from cleft palate, to compare hearing level with stage of retraction, and to propose optimum characteristics for monitoring TM retraction with endoscopy. STUDY DESIGN: Cross-sectional study. METHODS: Endoscopic images of 245 TMs of children with cleft palate (mean age, 13.0 years) were assessed on two separate occasions by six observers using the Sade and Erasmus staging systems for pars tensa retraction and Tos system for pars flaccida retraction. Intra- and interobserver agreements were calculated. Extent of TM retraction was compared with hearing threshold. TMs with middle ear effusion, tympanostomy tubes, or perforation were excluded. RESULTS: A total of 108 ear drums (44%) were rated as having pars tensa and/or flaccida retraction. Intraobserver agreement was fair to moderate (kappa = 0.3-0.37, P < .001) for the different staging systems and interobserver agreement slight to moderate (0.18-0.41 P < .001). Conductive hearing loss (four-tone average air-bone gap >25 dB HL) was present in 11 ears (15%). No correlation between hearing threshold and retraction stage was found. Isolated tensa retraction onto the promontory increased hearing threshold more than retraction involving the incus (P = .02; analysis of variance). CONCLUSIONS: Endoscopic image capture may provide a clear objective record of TM retraction, but current staging systems have unsatisfactory reliability when applied to such images, and retraction stage correlates poorly with hearing threshold. Modification of retraction assessment to improve validity and clinical relevance is proposed.

Results of stapedotomy in otosclerosis with severe and profound hearing loss.

OBJECTIVE: To evaluate the technical and functional results of 144 stapedotomies in patients with severe to profound hearing loss (SPHL) and to compare the success rate in this group with that of 1001 primary stapedotomies for mild to moderate hearing loss (MMHL). STUDY DESIGN: Retrospective chart review. SETTING: Tertiary referral centre. METHODS: The charts of 1369 consecutive stapedotomy cases were reviewed. One hundred twenty-seven patients (144 stapedotomies) with SPHL were included. The outcomes were analyzed according to the 1995 American Academy of Otolaryngology-Head and Neck Surgery Committee on Hearing and Equilibrium guidelines and evaluated with the Amsterdam Hearing Evaluating Plots and the Glasgow Benefit Plot. RESULTS: The magnitude of hearing improvement was greater in patients with SPHL compared with patients with MMHL. The mean gain in air conduction in patients with SPHL was 32 (+/- 13) dB compared with 23 (+/- 11) dB in the series of 1001 primary stapedotomies for MMHL. Air-bone gap closure < or = 10 dB was achieved in 63% of cases and < or = 20 dB in 90% of patients with SPHL, compared with 82% and 97%, respectively, in patients with MMHL. CONCLUSIONS: SPHL in otosclerosis is not infrequent, comprising 13% of all primary stapedotomies in this series. The magnitude of hearing improvement poststapedotomy is greater in SPHL compared with MMHL. Symmetric hearing could be achieved in two-thirds of patients, and normal hearing can be achieved in selected cases.

Functional results of 394 bilateral stapedotomies evaluated with the Glasgow Benefit Plot.

This study aimed to evaluate the results of 394 bilateral stapedotomies according to the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) guidelines and with the Glasgow Benefit Plot (GBP) and also analyze the benefit of a second-ear stapedotomy in achievement of normal and symmetrical hearing using retrospective chart review. The charts of 1,369 stapedotomies performed by senior author (J.H.) from 1991 to 2006 were reviewed. Results of 394 bilateral stapedotomies were included. The hearing results were evaluated according to the 1995 AAO-HNS Committee on Hearing and Equilibrium (CHE) guidelines and the GBP criteria. Success rates after the first and second ear surgeries were separately analysed. ABG closure < or =20 dB was demonstrated in 98% of cases after both first and second procedures. Postoperative AC gain was higher in the first ear surgery compared with the second ear surgery in all groups of preoperative hearing impairment. As a result of first ear surgery, 142 (72%) patients changed into the category of unilateral hearing loss. As a result of second ear surgery, 125 (64%) patients changed into the category of normal and symmetric hearing. In this study the largest group of 394 primary bilateral stapedotomies was simultaneously evaluated according to AAO-HNS guidelines and GBP criteria. The results showed that the first ear surgery was more successful in achievement of normal hearing in the operated ear. Second ear surgery was more beneficial in providing symmetric hearing.

The Markham-Stouffville hospital experience with malleovestibulopexy.

OBJECTIVE: To analyze the hearing results of malleovestibulopexy (MVP) technique in the special situations encountered in revision stapedotomies and congenital middle ear malformations. DESIGN: Retrospective chart review. SETTING: Tertiary referral stapes surgery center, community hospital. METHODS: Audiometric results of 1369 stapedotomies performed in Markham-Stouffville Hospital during a period from 1991 to 2006 were reviewed. The results of 24 MVP procedures employed for revision stapedotomy or for congenital conductive hearing loss were included. MAIN OUTCOME MEASURES: Air-bone gap (ABG) closure, air conduction (AC) gain, speech reception threshold (SRT) improvement. RESULTS: Significant improvement in AC, ABG and SRT was demonstrated postoperatively. ABG closure within 20 dB was achieved in 61% of cases. One patient had transient postoperative vertigo. None of patients developed sensori neural hearing loss (SNHL) due to the surgery. CONCLUSION: When surgical options for middle ear reconstruction are limited due to stapes immobility combined with absent or eroded incus, MVP offers a useful alternative enabling good hearing results. In our experience, the laser-assisted MVP technique is associated with low risk of postoperative SNHL and vestibular symptoms. This method offers a valuable adjunct to standard middle ear reconstruction techniques.

Hearing results of stapedotomy and malleo-vestibulopexy in congenital hearing loss.

AIMS: To analyze hearing results of surgical treatment of hearing loss associated with the congenital stapes ankylosis with or without malformations of ossicular chain. STUDY DESIGN: Retrospective chart review. METHODS: The charts of 1369 stapedotomies performed by senior author (JH) from 1991 to 2006 were reviewed. In 40 cases operative findings were consistent with isolated congenital stapes fixation or associated with middle ear malformations. The modified stapedotomy technique was employed in 33 cases and malleo-vestibulopexy was used in 7 cases. Operative findings were standardized according to Cremers' classification. The outcomes of 40 surgeries were analyzed according to the 1995 AAO-HNS Committee on Hearing and Equilibrium guidelines. High frequency hearing results on 4, 8 and 12kHz were reported in addition to standard frequencies. Results of stapedotomies and malleo-vestibulopexies were calculated separately. Surgical complications were described. RESULTS: The mean post-operative air conduction (AC) was 33 dB, bone conduction (BC) 22 dB and speech reception thresholds (SRT) 31 dB. Closure of the air-bone gap (ABG) to within 10 dB was achieved in 24/40 (60%) of cases. Lack of improvement was observed in 3/40 (8%) patients. In 26/32 (81%) of cases with potential for bilaterally serviceable hearing it was achieved. In 24/40 (60%) of cases symmetrical hearing with interaural difference of less than 10 dB was demonstrated. CONCLUSION: Significant hearing gain in patients with congenital stapes ankylosis makes surgical treatment a valuable adjunct or an alternative to hearing aids in selected cases.

A model of airflow in the nasal cavities: Implications for nasal air conditioning and epistaxis.

BACKGROUND: A friction force is generated when moving air contacts the nasal walls, referred to as wall shear stress. This interaction facilitates heat and mass transfer between the mucosa and air, i.e., air-conditioning. The objective of this research was to study the distribution of wall shear stress within the nasal cavity to identify areas that contribute significantly to air-conditioning within the nasal cavity. METHODS: Three-dimensional computational models of the nasal airways of five healthy subjects (three male and two female subjects) were constructed from nasal CT scans. Numerical simulations of nasal airflow were conducted using the commercial computational fluid dynamics code Fluent 6 (Ansys, Inc., Canonsburg, PA). Wall shear stress was derived from the numerical simulation. Air-conditioning was simulated to confirm the relationship with wall shear stress. RESULTS: Nasal airflow simulations predicted high wall shear stress along the anterior aspect of the inferior turbinate, the anteroinferior aspect of the middle turbinate, and within Little's area. CONCLUSION: The airflow simulations indicate that the inferior and middle turbinates and Little's area on the anterior nasal septum contribute significantly to nasal air-conditioning. The concentration of wall shear stress within Little's area indicates a desiccating and potentially traumatic effect of inhaled air that may explain the predilection for spontaneous epistaxis at this site.

Lessons learned from the surgical management of benign paroxysmal positional vertigo: the University Health Network experience with posterior semicircular canal occlusion surgery (1988-2006).

OBJECTIVE: To assess the long-term efficacy and safety of posterior semicircular canal (PSCC) occlusion for intractable and incapacitating benign paroxysmal positional vertigo (BPPV) and identify lessons that may be learned from our experience. STUDY DESIGN: Retrospective review. SETTING: Tertiary referral centre. METHODS: Clinical records and results of audiometric and vestibular testing were reviewed on a series of patients who underwent occlusion of the PSCC for intractable BPPV between 1988 and 2006. OUTCOME MEASURES: Postoperative neurotologic examination, audiometry, and vestibular testing were assessed. RESULTS: Thirty-two PSCC occlusion procedures were performed (24 females, 8 males; mean age 46 years). The average follow-up was 63 months. All patients had complete resolution of their PSCC positional vertigo, which has been maintained long term. Thirteen patients (40%) have experienced other forms of dizziness postoperatively (contralateral BPPV in four, continued Meniere disease attacks in three, ipsilateral lateral or superior canal BPPV in two, otolithic symptoms in two, continued oscillopsia in one, and subsequent cerebellar degeneration in one). Postoperative audiometry demonstrated an average reduction in pure-tone threshold of 6.1, 6.3, and 6.9 dB at 0.5 to 3, 4, and 8 kHz, respectively. Five patients had a mild to moderate reduction in caloric activity in the operated ear postoperatively. Two patients with Meniere disease had a significant postoperative caloric reduction. No patient had postoperative facial weakness. CONCLUSIONS: PSCC occlusion is a safe and highly effective treatment for intractable BPPV. However, other forms of vertigo may persist or arise subsequently in approximately 40% of cases. Patients with Meniere disease may be susceptible to increased caloric reduction postoperatively.

Atrophic rhinitis: a CFD study of air conditioning in the nasal cavity.

Atrophic rhinitis is a chronic disease of the nasal mucosa. The disease is characterized by abnormally wide nasal cavities, and its main symptoms are dryness, crusting, atrophy, fetor, and a paradoxical sensation of nasal congestion. The etiology of the disease remains unknown. Here, we propose that excessive evaporation of the mucous layer is the basis for the relentless nature of this disease. Airflow and water and heat transport were simulated using computational fluid dynamics (CFD) techniques. The nasal geometry of an atrophic rhinitis patient was acquired from computed tomography scans before and after a procedure to narrow the nasal cavity. Simulations of air conditioning in the atrophic nose were compared with similar computations performed within the nasal geometries of four healthy humans. The excessively wide cavity of the patient generated abnormal flow patterns, which led to abnormal patterns of water fluxes across the wall. Geometrically, the atrophic nose had a much lower surface area than the healthy nasal passages, which increased water fluxes per unit area. Nevertheless, the simulations indicated that the atrophic nose did not condition inspired air as effectively as the healthy geometries. These simulations of water transport in the nasal cavity are consistent with the hypothesis that excessive evaporation of mucus plays a key role in the pathophysiology of atrophic rhinitis. We conclude that the main goals of a surgery to treat atrophic rhinitis should be 1) to restore the original surface area of the nose, 2) to restore the physiological airflow distribution, and 3) to create symmetric cavities.

An overview of numerical modelling of nasal airflow.

Computer modelling of fluid flows is a mature technology used widely in engineering. The process, known as computational fluid dynamics (CFD), allows accurate prediction of fluid flow and associated phenomena based on the mathematical laws governing fluid behaviour. A fluid may be defined as any substance that can flow and thus both liquids and gases behave as fluids. The mathematical predictions of CFD can therefore be applied to nasal airflow. In current clinical practice, it is only possible to perform a few limited measurements of nasal airflow, and the clinical relevance of these measurements is questionable. Computer models are not limited by the anatomical inaccessibility of the nasal cavities, and a detailed objective characterisation of airflow can therefore be provided in all areas of an individual nose. In addition, the ability to remodel computer simulations offers a potential predictive tool for planning nasal surgery. This article provides an overview of the basic concepts of computational fluid dynamics, and a summary of the current capabilities of this technology in the characterisation of nasal airflow. The objective is to give otorhinolaryngologists a basic understanding of the computer modelling of nasal airflow, and the background information with which to evaluate CFD-based rhinology literature.

Numerical model of a nasal septal perforation.

This paper describes numerical simulation of airflow in a nose with a nasal septal perforation. Diseased airflow is compared to airflow in a healthy nasal model. The healthy model has been generated from CT scans from the Antrim Area Hospital ENT clinic and is close to being anatomically accurate. The nasal septal perforation has been superimposed on the healthy geometry using image manipulation software. The flow is modeled as laminar, steady state, with the flow rates corresponding to quiet breathing at rest approximately 165 ml/sec. Healthy flow patterns show that the majority of the flow travels close to nasal septum, in the region close to the middle turbinate. In the diseased case, high shear stresses concentrated at the posterior region of the perforation explain bleeding associated with nasal perforations.

Noise exposure in orthopaedic practice: potential health risk.

Noise exposure is one of the major causes of permanent hearing loss in society. Exposure of health service staff to intense levels of noise in the workplace is a potential risk for the development of temporary and permanent hearing loss. In this prospective study, 18 members of the orthopaedic staff underwent hearing assessment by pure tone audiometry and speech discrimination prior to noise exposure at the workplace and immediately following cessation of work. The number of hours of exposure and noise levels in the workplace was also analysed. Only minimal temporary sensorineural threshold shifts were detected post-noise exposure. There was no change in speech discrimination scores and no individuals complained of tinnitus. The number of hours of exposure ranged from 1.5 to 8.5 hours (mean 5.2 hours). Recorded sound levels for instruments ranged from 119.6 dB at source to 73.1 decibels at 3 metres. Although high sound levels are recorded in the orthopaedic operating theatre, the intermittent nature exposure to the intense noise may protect staff against hearing loss, speech discrimination difficulties and tinnitus.