Management of Palatal Defects after Free-Flap Reconstruction and Radiotherapy.

Palatal fistulas have significant effects on quality of life. Traditional prosthetic rehabilitation and surgical reconstruction of palate defects in radiation-naïve tissues are well described. However, palatal fistulas developing after initial tumor extirpation, free-flap reconstruction, and adjuvant radiation or chemoradiation are associated with challenging secondary tissue effects. In this review, we will discuss the management of palatal fistulas after surgical reconstruction and radiotherapy.

Longitudinal Assessment of Singing Students.

INTRODUCTION: Singers have unique vocal demands, and if the voice is impaired there can be a negative impact on their quality of life. While a variety of options exist to assess vocal health, the utilization of cepstral peak prominence (CPP) has increased due to his reliability in some situations. However, it has not been utilized commonly in the singing population. This study sought to assess vocal health in singing students using noninvasive measures such as singing voice handicap index (SVHI) and consensus auditory perceptual evaluation of voice (CAPE-V) as well as CPP to provide preliminary information on this measure. METHODS: A prospective longitudinal study of singing students independent of year of training enrolled in a 2-credit voice lesson at an undergraduate School of Music was conducted. Non-invasive measures were used to evaluate the voice. All participants recorded the same spoken sentence at four equally spaced intervals throughout the semester using a ZOOM H4n Pro (two cardioid input microphone, Hauppauge, New Year). Participants completed SVHI at the time of each recording, and CAPE-V conducted by two speech language pathologists trained in voice. CPP was determined using running speech samples. RESULTS: A total of 23 singers completed the study (11 male, 12 female). There was a significant difference in SVHI at the first recording compared to the final recording (10.6 ± 4.6 vs 9.3 ± 5.9, P= 0.008). Similarly, there was a significant difference in CPP at the first recording compared to the final recording (9 ± 3 vs 9.4 ± 1.1, P < 0.001). However, no significant difference was seen with CAPE-V. CONCLUSION: Our results are similar to previous studies. There was no evidence in decline in objective and subjective vocal quality utilizing the measure included in our study.

Prognostic factors in the management of pediatric subglottic stenosis.

OBJECTIVE: We report outcomes of endoscopic interventions in the management of pediatric subglottic stenosis (SGS), and factors that lead to open airway reconstruction. METHODS: A retrospective cohort review of all pediatric patients with SGS, treated by a single surgeon, at a tertiary academic medical center from 2012 to 2020 was conducted. Variables recorded included patient demographics, initial grade of stenosis, gestational age, length of intubation, comorbidities as well as total number of interventions. RESULTS: A total of 47 patients were included in the study, of which 51% (n = 24) were female. Laryngotracheal reconstruction (LTR) was performed in 49% (n = 23) of patients. Decannulation was achieved in 25 of 32 tracheostomized patients. Fifteen patients did not have tracheostomy. There was a significant difference in gestational age (28.7 ± 5.36 vs 33.2 ± 6.13), initial grade of stenosis (2.3 ± 0.82 vs 1.6 ± 0.88), and total number of interventions (5.7 ± 2.8 vs 2.3 ± 1.5) when stratifying patients proceeding to LTR versus not (p < 0.05). There was no significant difference, however, in the length of intubation between the two groups. Of the comorbidities recorded, none were found to have a significant impact on the outcome. CONCLUSION: Subglottic stenosis is a challenging condition to treat, often requiring multiple interventions including LTR. We propose a set of risk factors that may assist in the treatment of SGS patients with certain comorbidities to minimize interventions and maximize outcomes.

Relationship between pain-related comorbidities and quality of life in patients with symptoms of chronic rhinosinusitis.

INTRODUCTION: Facial pain is a common manifestation of sinonasal disease but may be due to a variety of other conditions. Misattribution of pain to chronic rhinosinusitis may result in worse quality of life in populations both with and without objective evidence of sinonasal disease. The purpose of this study was to determine if there is an association between pain-related comorbidities and worse chronic rhinosinusitis specific quality of life in patients with and without objective evidence of sinonasal inflammation. METHODS: Retrospective cohort study of 299 patients meeting diagnostic criteria for sinusitis evaluated at a tertiary academic medical center from 2017 to 2018. Objective evidence was measured using the Lund-Kennedy and Lund-MacKay scoring systems; for the purposes of this study a score >3 on either scale was considered indicative of disease. Quality of life was determined by the rhinosinusitis disability index. RESULTS: A total of 191 patients were included in the study, with an average age of 52.7. (SD=15.3). The average Lund-Kennedy and Lund-MacKay scores were 4.7 and 8.3, respectively. The average rhinosinusitis disability index was 32.1. When stratified by the presence of pain-related comorbidities, there was no significant difference in Lund-Kennedy (p = 0.203), Lund-MacKay (p = 0.101), or rhinosinusitis disability index (p = 0.421). CONCLUSION: Although prior studies have suggested a correlation between the presence of pain-related comorbidities and worse chronic rhinosinusitis specific quality of life, this relationship was not evident within the current cohort of patients. The relationship between pain and sinusitis specific quality of life is likely complex and requires further research to fully elucidate.

Pain Catastrophizing and Quality of Life in Adults With Chronic Rhinosinusitis.

OBJECTIVES/HYPOTHESIS: Psychological comorbidity is common in patients with chronic rhinosinusitis (CRS) and is correlated with decreased overall and disease-specific quality of life (QoL). Prior research reported that anxiety and depression, as measured by the hospital anxiety and depression scale (HADS), are associated with worse CRS-specific QoL, as assessed via the Rhinosinusitis Disability Index (RSDI). Furthermore, patients prone to anxiety/depression may display an exaggerated response to real or anticipated discomfort; the pain catastrophizing scale (PCS) is a validated instrument designed to measure this phenomenon. This study is intended to explore the role of pain catastrophizing in relation to anxiety, depression, and disease-specific QoL in patients with facial pain attributed to CRS. STUDY DESIGN: Prospective cohort study. METHODS: Diagnosis of presumed CRS was based upon current American Academy of Otolaryngology - Head & Neck Surgery (AAO-HNS) guidelines; all participants reported facial pain as a component of their CRS symptomatology. RSDI, HADS, and PCS questionnaires were administered upon presentation prior to intervention, and objective measurements of sinonasal inflammation were obtained via nasal endoscopy and computed tomography (CT). RESULTS: Seventy-five patients were enrolled in the study. Significant positive correlations were found between PCS and HADS, total RSDI, and RSDI emotional sub-scores (P < .05). The incidence of objective evidence of disease, as measured via nasal endoscopy and CT, was not significantly different in catastrophizing patients. CONCLUSIONS: Pain catastrophizing correlates with anxiety/depression and worse disease-specific QoL in patients meeting symptomatic criteria for CRS. Otolaryngologists should be aware that catastrophic thinking can intensify a patient's perception of sinonasal symptoms, and clinicians may consider management of psychological comorbidity to optimize rhinologic outcomes. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:1939-1945, 2021.

Intradiploic Epidermoid of the Tegmen Tympani With Cochlear Invasion.

Intradiploic epidermoid cysts are benign tumors that account for ∼1% of all intracranial space occupying lesions. Because of the indolent growth, symptoms are usually gradual in onset with a prolonged duration. While they can originate from any part of the skull, temporal bone epidermoids are rare. We describe a case of an unusual presentation of a temporal bone epidermoid cyst. A 64-year-old male presented with sudden right-sided hearing loss and worsening right eyelid ptosis was found to have a nonenhancing lobulated mass above the right tegmen tympani with complex signal and possible communication with the apical turn of the cochlea on magnetic resonance imaging (MRI). He underwent subtemporal craniotomy with excision of the cyst lining and matrix without any complications and was discharged home on postoperative day 1. Complete excision was not possible given that the facial nerve and cochlea were improved. He had subjective improvement in his hearing immediately after surgery. Intradiploic epidermoid cysts are benign tumors that can present anywhere in the skull with variable presentation. While complete excision is the goal, neurovascular involvement may make this challenging. The use of computed tomography scan and MRI can prove to be invaluable in determining accurate diagnosis and size for surgical planning.

Epithelioid Sarcoma of the Tongue: An Unusual Tumor Mimic for Squamous Cell Carcinoma.

INTRODUCTION: Epithelioid sarcoma is a rare soft tissue malignancy that usually presents in the distal extremities along fascial planes, aponeuroses or tendon sheaths. Very rarely, it presents as a primary or metastatic lesion of the head neck. METHODS: Chart review and comprehensive literature review using PubMed and Google Scholar. RESULTS: A 17-year-old non-smoker was referred for evaluation of an ulcerative lesion of the right anterior-lateral tongue, progressing over several months. Incisional biopsy was concerning for squamous cell carcinoma. He underwent partial glossectomy and bilateral selective neck dissections, with reconstruction using a radial forearm free flap. Final pathology was consistent with epithelioid sarcoma, proximal type, demonstrating perineural invasion and close margins. Post-operative PET scan showed no persistent nor metastatic disease. He underwent post-operative radiation therapy to a total dose of 56 Gy to the primary site. CONCLUSION: Epithelioid sarcoma is a rare malignancy usually presenting in the extremities of young adults, which uncommonly presents in the head and neck as a primary or metastatic lesion. The infrequency of these lesions has prevented development of evidence-based treatment recommendations. As with most sarcomas, surgery is the mainstay of therapy for epithelioid sarcoma, while radiation has been used in an adjunctive role. Although a rare lesion, epithelioid sarcoma should be considered in the differential diagnosis for atypical epithelioid lesions of the tongue and oral cavity when patient demographics, gross lesion characteristics, or histopathology are not entirely consistent with more common lesions, such as squamous cell carcinoma.

Does quality of research in otolaryngology correlate with academic impact?

OBJECTIVE: To determine if the quality of otolaryngology-related journal articles correlates with traditional measures of article impact. METHODS: All articles published by Laryngoscope in 2011 were categorized according to level of evidence (LOE) according to the Oxford Center for Evidence Based Medicine rubric. Articles without a level of evidence assigned were alphabetically subcategorized type with letters A-D corresponding to Contemporary Reports, Case Reports, Basic Science or Animal Studies, and Other respectively. Citations per article were then recorded per article each year from 2012 to 2018. RESULTS: A total of 494 articles were included for analysis, 315 had numerical LOE and 179 had alphabetical LOE. There was a strong negative correlation between numerical LOE and median and interquartile number of citations (R = -.9014, P = .037). Overall, numerical LOE had a significantly higher median number of citations per article compared with the non-number/alphabetical group (14 vs 6, P < .001). CONCLUSIONS: Higher quality research as determined by level of evidence is in fact being cited more frequently than lower quality articles. Although the scope of this study was relatively limited, these data suggest that better designed studies may exhibit greater impact by traditional measures. Such findings should serve as an impetus for (and validation of) continued pursuit of high LOE research. LEVEL OF EVIDENCE: NA.

Do Postoperative Antibiotics Improve Skin Reactivity Following Percutaneous Auditory Osseointegrated Implant Placement?

OBJECTIVE: To determine if the routine use of postoperative antibiotics following percutaneous auditory osseointegrated implant placement reduces skin reactivity. STUDY DESIGN: Retrospective matched case-controlled series. SETTINGS: Tertiary academic medical center. SUBJECT AND METHODS: A total of 44 patients who underwent percutaneous auditory osseointegrated implant placement were divided into those who received 5 days of postoperative antibiotics (AB) and those who received no antibiotics (NAB). All surgery was performed using the same surgical technique (Minimally Invasive Ponto Surgery). Variables recorded included patient demographics, Holgers skin reaction score, complications, and need for further intervention. RESULTS: A total of 23 patients received prophylactic postoperative antibiotics (AB) while 21 patients did not (NAB). At the first postoperative visit (AB 12.7 d versus NAB 12.3 d, p = 0.9) there were no differences in average Holgers score (AB 0.3 ±â€Š0.7 versus NAB 0.2 ±â€Š0.5, p = 0.27). The odds ratio for skin reactivity at the first visit was 0.11 (95% CI 0.01-2.32). There were also no statistical differences in Holgers score (AB 0.05 ±â€Š0.2 versus NAB 0.1 ±â€Š0.3, p = 0.25) at most recent followup visit (AB mean 97.5 d versus NAB 102.8 d, p = 0.84). The odds ratio for skin reactivity at the most recent visit was 0.16 (95% CI 0.01-3.64). CONCLUSIONS: The use of postoperative antibiotics does not appear to confer significant difference in skin reactivity in patients receiving percutaneous osseointegrated auditory implants. Such findings support the theory that skin reactivity, when it does occur, may not be an infectious-mediated process.

The Role of External Fixation in Trauma and Reconstruction of the Mandible in the Age of Rigid Fixation.

Internal rigid fixation is the gold-standard treatment for facial fractures, but there are some specific cases that are more amenable to external fixation (ex-fix) application. Herein, we discuss advantages and disadvantages to ex-fix in the modern treatment of comminuted mandible fractures, infected mandible fractures, fractures of the condylar region, oncologic mandibular resection, pediatric mandible fractures, and fractures in the edentulous patient.

The effect of smoking on quality of life following sinus surgery: 10-year follow-up.

OBJECTIVES: The purpose of this study is to investigate the 10-year postoperative quality of life outcomes in smokers and nonsmokers with chronic rhinosinusitis. STUDY DESIGN: This is a single-institution prospective cohort study. METHODS: 235 patients who have previously been enrolled in a 4-year follow-up study were identified and contacted for a telephone interview. Rates of revision surgery, smoking status and 20-item sinonasal outcomes test (SNOT-20) scores were obtained. Preoperative SNOT-20 scores were compared with those obtained at the 10-year follow-up. RESULTS: Of the patients enrolled in the initial 4-year study, 22.5% were available for a telephone interview, including 43 out of 185 nonsmokers (23.2%) and 9 out of 50 smokers (18%). Demographic data including age, sex and race were analyzed and found to be similar between the two groups. Preoperative SNOT-20 scores were similar between nonsmokers and smokers (28.9 vs. 25.8, p = 0.89). There was no significant difference in long-term SNOT-20 scores (10 years postoperatively) between nonsmokers and smokers (31.5 vs. 28.2, p = 0.629). CONCLUSIONS: While cigarette smoke may have long-term adverse effects on the sinonasal mucosa, we found no difference in quality of life outcomes between smokers and nonsmokers 10 years after functional endoscopic sinus surgery.

Ethical issues in laryngology: tracheal stenting as palliative care.

OBJECTIVES/HYPOTHESIS: To improve understanding of aspects of end-of-life care that may not be intuitive to the otolaryngology community. DATA SOURCES AND REVIEW METHODS: A comprehensive review of the literature was performed by searching Medline, Embase, and Google Scholar databases. Primary manuscripts' bibliographies were reviewed to identify any nonindexed references. Prospective consultation by means of one-on-one interviews was sought from nonotolaryngology key stakeholders in the areas of hospice nursing care and patient advocacy in order to identify pertinent issues. RESULTS: We identified over 1,000 articles published from 1965 to 2013 on the topic of tracheal stents, as well as over 40,000 on hospice/end-of-life care. Three articles focusing specifically on palliative care and airway stenting were identified, of which three were case reports and none were definitive reviews. There are a number of significant issues and concepts unique to hospice care. These are likely unfamiliar to all except for head and neck oncology-specialized otolaryngologists. An example is that hospice care focuses on quality of life rather than prolongation of life (such as curative surgery). Patients with nonoperable tracheal obstruction from malignancy face an unpleasant demise from suffocation. For those patients, stenting can relieve suffering by restoring airway patency. CONCLUSIONS: Airway stenting can be a valid palliative care option, even for terminal patients receiving hospice care, when performed to relieve airway obstruction and improve quality of life. End-of-life ethics is an underdeveloped area of otolaryngology that should be explored.