2018 ENT JOURNAL - MARCH ISSUE

MARCH 2018 • VOL. 97, NO. 3



Post-turbinectomy nasal packing with Merocel versus glove finger Merocel: A prospective, randomized, controlled trial



Comparison of anterior palatoplasty and uvulopalatal flap placement for treating mild and moderate obstructive sleep apnea

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Psoriasis, chronic tonsillitis, and biofilms: Tonsillar pathologic findings supporting a microbial hypothesis

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Quality of life in patients with larynx cancer in Latin America: Comparison between laryngectomy and organ preservation protocols

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EDITORIAL BOARD

Editor-in-Chief

Robert T. Sataloff, MD, DMA, FACS

Professor and Chairman, Department of Otolaryngology–Head and Neck Surgery, and Senior Associate Dean for Clinical Academic Specialties, Drexel University College of Medicine Philadelphia, PA

EDITORIAL BOARD MEMBERS Jean Abitbol, MD Jason L. Acevedo, MD, MAJ, MC, USA Jack B. Anon, MD Gregorio Babighian, MD Peter C. Belafsky, MD, PhD Bruce Benjamin, MD Gerald S. Berke, MD Michael J. Brenner, MD Kenneth H. Brookler, MD Karen H. Calhoun, MD Steven B. Cannady, MD Ricardo Carrau, MD Swapna Chandran, MD Chien Chen, MD Dewey A. Christmas, MD Nicolle T. Clements, MS Daniel H. Coelho, MD, FACS David M. Cognetti, MD Maura Cosetti, MD James V. Crawford, MD David H. Darrow, MD, DDS Rima Abraham DeFatta, MD Robert J. DeFatta, MD, PhD Hamilton Dixon, MD Paul J. Donald, MD, FRCS Mainak Dutta, MS, FACS Russell A. Faust, PhD, MD Ramón E. Figueroa, MD, FACR Charles N. Ford, MD Paul Frake, MD Marvin P. Fried, MD Richard R. Gacek, MD Andrea Gallo, MD Frank Gannon, MD Emilio Garcia-Ibanez, MD Soha Ghossani, MD William P. R. Gibson, MD David Goldenberg, MD Jerome C. Goldstein, MD Richard L. Goode, MD Samuel Gubbels, MD Reena Gupta, MD Joseph Haddad Jr., MD Missak Haigentz, MD Christopher J. Hartnick, MD Mary Hawkshaw, RN, BSN, CORLN Garett D. Herzon, MD Thomas Higgins, MD, MSPH Jun Steve Hou, MD John W. House, MD Glenn Isaacson, MD Steven F. Isenberg, MD 42 www.entjournal.com

Stephanie A. Joe, MD Shruti S. Joglekar, MBBS Raleigh O. Jones, Jr., MD Petros D. Karkos, MD, AFRCS, PhD, MPhil David Kennedy, MD Seungwon Kim, MD Robert Koenigsberg, DO Karen M. Kost, MD, FRCSC Jamie A. Koufman, MD Stilianos E. Kountakis, MD, PhD John Krouse, MD Ronald B. Kuppersmith, MD, MBA, FACS Rande H. Lazar, MD Robert S. Lebovics, MD, FACS Keat-Jin Lee, MD Donald A. Leopold, MD Steve K. Lewis, BSc, MBBS, MRCS Daqing Li, MD Robert R. Lorenz, MD John M. Luckhurst, MS, CCC-A Valerie Lund, FRCS Karen Lyons, MD A.A.S. Rifat Mannan, MD Richard Mattes, PhD Brian McGovern, ScD William A. McIntosh, MD Brian J. McKinnon, MD Oleg A. Melnikov, MD Albert L. Merati, MD, FACS Joseph P. Mirante, MD, MBA, FACS Ron B. Mitchell, MD Steven Ross Mobley, MD Jaime Eaglin Moore, MD Thomas Murry, PhD Ashli K. O’Rourke, MD Ryan F. Osborne, MD, FACS J. David Osguthorpe, MD Robert H. Ossoff, DMD, MD Enrique Palacios, MD, FACR Michael M. Paparella, MD Kourosh Parham, MD, PhD Arthur S. Patchefsky, MD Meghan Pavlick, AuD Spencer C. Payne, MD Kevin D. Pereira, MD, MS (ORL) Nicolay Popnikolov, MD, PhD Didier Portmann, MD Gregory N. Postma, MD Matthew J. Provenzano, MD Hassan H. Ramadan, MD, FACS

Richard T. Ramsden, FRCS Gabor Repassy, MD, PhD Dale H. Rice, MD Ernesto Ried, MD Alessandra Rinaldo, MD, FRSM Joshua D. Rosenberg, MD Allan Maier Rubin, MD, PhD, FACS John S. Rubin, MD, FACS, FRCS Amy L. Rutt, DO Anthony Sclafani, MD, FACS Raja R. Seethala, MD Jamie Segel, MD Moncef Sellami, MD Michael Setzen, MD, FACS, FAAP Stanley Shapshay, MD Douglas M. Sidle, MD Herbert Silverstein, MD Jeffrey P. Simons, MD Raj Sindwani, MD, FACS, FRCS Aristides Sismanis, MD, FACS William H. Slattery III, MD Libby Smith, DO Jessica Somerville, MD Thomas C. Spalla, MD Matthew Spector, MD Paul M. Spring, MD Brendan C. Stack, Jr., MD, FACS James A. Stankiewicz, MD Jun-Ichi Suzuki, MD David Thompson, MD Lester D.R. Thompson, MD, FASCP Helga Toriello, PhD, FACMG Ozlem E. Tulunay-Ugur, MD Galdino Valvassori, MD Emre Vural, MD Donald T. Weed, MD, FACS Neil Weir, FRCS Kenneth R. Whittemore, MD David F. Wilson, MD Ian M. Windmill, PhD Ian J. Witterick, MD,MSc, FRCSC Richard J. Wong, MD Naoaki Yanagihara, MD Eiji Yanagisawa, MD, FACS Ken Yanagisawa, MD, FACS Anthony Yonkers, MD Mark Zacharek, MD Joseph Zenga, MD Liang Zhou, MD

CLINIC EDITORS Dysphagia Jamie A. Koufman, MD Peter C. Belafsky, MD, PhD Gregory N. Postma, MD Facial Plastic Surgery Anthony P. Sclafani, MD, FACS Geriatric Otolaryngology Kourosh Parham, MD, PhD, FACS Karen M. Kost, MD, FRCSC Head and Neck Ryan F. Osborne, MD, FACS Paul J. Donald, MD, FRCS Reena Gupta, MD Imaging Enrique Palacios, MD, FACR Ramón E. Figueroa, MD, FACR Laryngoscopic Robert T. Sataloff, MD, DMA, FACS Otoscopic John W. House, MD Brian J. McKinnon, MD Pathology Lester D.R. Thompson, MD, FASCP Pediatric Otolaryngology Rande H. Lazar, MD Rhinoscopic Eiji Yanagisawa, MD, FACS Dewey A. Christmas, MD Joseph P. Mirante, MD, MBA, FACS Ken Yanagisawa, MD, FACS Special Topics Robert T. Sataloff, MD, DMA, FACS Thyroid and Parathyroid David Goldenberg, MD

ENT-Ear, Nose & Throat Journal March 2018

Editor-in-Chief Robert T. Sataloff, MD, DMA, FACS 219 N. Broad St., 10th Fl., Philadelphia, PA 19107 entjournal@phillyent.com Ph: 215-732-6100 Managing Editor Linda Zinn Manuscript Editors Martin Stevenson and Wayne Kuznar Associate Editor, Reader Engagement Megan Combs Creative Director Eric Collander National Sales Manager Mark C. Horn mhorn@vendomegrp.com Ph: 480-895-3663 Traffic Manager Judi Zeng Please send IOs to adtraffic@vendomegrp.com All ad materials should be sent electronically to: https://vendome.sendmyad.com Customer Service/Subscriptions www.entjournal.com/subscribe Ph: 888-244-5310 email: VendomeHM@emailpsa.com Reuse Permissions Copyright Clearance Center info@copyright.com Ph: 978-750-8400 Fax: 978-646-8600 Chief Executive Officer Jane Butler Chief Marketing Officer Dan Melore Vice President, Finance Bill Newberry Vice President, Custom Media Jennifer Turney Director, Circulation Rachel Beneventi

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ENT-Ear, Nose & Throat Journal March 2018

CONTENTS ORIGINAL ARTICLES 64

Post-turbinectomy nasal packing with Merocel versus glove finger Merocel: A prospective, randomized, controlled trial Rani Abu Eta, MD; Ephraim Eviatar, MD; Jacob Pitaro, MD; Haim Gavriel, MD

69

Comparison of anterior palatoplasty and uvulopalatal flap placement for treating mild and moderate obstructive sleep apnea Süheyl Hayto lu, MD; Osman Kür at Arikan, MD; Nuray Bayar Muluk, MD; Birgül Tuhanio lu, MD; Mustafa Çörtük, MD

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Psoriasis, chronic tonsillitis, and biofilms: Tonsillar pathologic findings supporting a microbial hypothesis

MARCH 2018 • VOL. 97, NO. 3

E22

Christine M. Clark, MD; Shivani Shah-Becker, MD; Abraham Mathew, MD; Neerav Goyal, MD, MPH

E25

91

E34

E38

E1

Alvaro Sanabria, MD, PhD, FACS; Daniel Sánchez, MD; Andrés Chala, MD; Andres Alvarez, MD

E44

Brandon J. Wang, BA, BBA; Felicia L. Carter, MA, CCC-SLP; Kenneth W. Altman, MD, PhD

E10

Prospective evaluation of the early effects of radiation on the auditory system frequencies of patients with head and neck cancers and brain tumors after radiotherapy Akram Hajisafari, Msc; Mohsen Bakhshandeh, PhD; Seyed Mahmoud Reza Aghamiri, PhD; Mohammad Houshyari, MD; Afshin Rakhsha, MD; Eftekhar Rajab Bolokat, Msc; Abbas Rezazadeh, PhD

E18

Pharyngeal pack placement in minor oral surgery: A prospective, randomized, controlled study

The utility of enlarging symptomatic nasal septal perforations Philip G. Chen, MD; Stephen Floreani, MBBS; Peter-John Wormald, MD

“Split to save”: Accessing mandibular lesions using sagittal split osteotomy with virtual surgical planning

Relationship between dysarthria and oral‑ oropharyngeal dysphagia: The current evidence

Bilateral pyriform sinus parathyroid adenomas Thomas Muelleman, MD; Sreeya Yalamanchali, MD; Yelizaveta Shnayder, MD

E41

ONLINE EXCLUSIVES

CO2-laser–assisted diverticulotomy remains an effective and safe method for treating Zenker diverticulum Mazin Merdad, MD, MPH; Nitin Bhatia, MD; Elie E. Rebeiz, MD, FACS

Quality of life in patients with larynx cancer in Latin America: Comparison between laryngectomy and organ preservation protocols

Stanley Yung-Chuan Liu, MD, DDS; Douglas Sidell, MD; Leh-Kiong Huon, MD; Carlos Torre, MD

Alternative therapies for chronic rhinosinusitis: A review Aaron S. Griffin, MBBS, BSci; Peter Cabot, PhD, BSci; Ben Wallwork, PhD, MBBS, FRACS; Ben Panizza, MBA, MBBS, FRACS

Herbert B. Allen, MD; Saagar Jadeja, BS; Rina M. Allawh, MD; Kavita Goyal, MD

83

Aerophagia and subcutaneous emphysema in a patient with Rett syndrome

Incidence of epistaxis after endoscopic pituitary surgery: Proposed treatment algorithm Lee A. Zimmer, MD, PhD; Norberto Andaluz, MD

DEPARTMENTS 44

Advertiser Index

48

ENT Journal Online

50

Editorial

54

Otoscopic Clinic

55

Imaging Clinic

57

Pathology Clinic

58

Thyroid and Parathyroid Clinic

62

Special Topics Clinic

E49

Laryngoscopic Clinic

E51

Rhinoscopic Clinic

Badr A. Al-Jandan, FRCD(C); Faiyaz Ahmed Syed, MDS; Ahed Zeidan, MD; Hesham Fathi Marei, MSc, MFDS (RCS Eng), PhD; Imran Farooq, MSc EDITORIAL OFFICE

Robert T. Sataloff, MD, DMA, FACS, Editor-in-Chief • 219 N. Broad St., 10th Fl. • Philadelphia, PA 19107

46 www.entjournal.com

ENT-Ear, Nose & Throat Journal March 2018

JOURNAL ONLINE

www.entjournal.com

Ear, Nose & Throat Journal's website is easy to navigate and provides readers with more editorial content each month than ever before. Access to everything on the site is free of charge to physicians and allied ENT professionals. To take advantage of all our site has to offer, go to www.entjournal. com and click on the "Registration" link. Once you have filled out the brief registration form, you will have full access. Explore and enjoy!

ONLINE EXCLUSIVES Relationship between dysarthria and oraloropharyngeal dysphagia: The current evidence

Aerophagia and subcutaneous emphysema in a patient with Rett syndrome

There is a high prevalence of dysphagia among patients with neuromuscular diseases and cerebrovascular diseases, and its consequences can be profound. However, the correlation between dysarthria and oral-oropharyngeal dysphagia remains unclear. We conducted a literature review to define the clinical presentation of both dysarthria and dysphagia in patients with neuromuscular and cerebrovascular diseases. We performed a systematic PubMed search of the English-language literature since 1995. Objective and subjective outcomes instruments were identified for both dysarthria and dysphagia. Studies that included....

A patient with Rett syndrome presented to our Emergency Department with extensive subcutaneous emphysema in the cervical region, chest wall, upper extremities, and back.

Diagnostic evaluation revealed a mucosal tear in the posterior pharyngeal wall and an abscessed retropharyngeal lymph node, but she had no known history of trauma to account for these findings. This report discusses the occurrence of subcutaneous emphysema in the context of a rare neurodevelopmental disorder and proposes accentuated aerophagia, a sequela of Rett syndrome, as the most likely underlying mechanism.

Brandon J. Wang, BA, BBA; Felicia L. Carter, MA, CCC-SLP; Kenneth W. Altman, MD, PhD

Prospective evaluation of the early effects of radiation on the auditory system frequencies of patients with head and neck cancers and brain tumors after radiotherapy

Akram Hajisafari, Msc; Mohsen Bakhshandeh, PhD; Seyed Mahmoud Reza Aghamiri, PhD; Mohammad Houshyari, MD; Afshin Rakhsha, MD; Eftekhar Rajab Bolokat, Msc; Abbas Rezazadeh, PhD

Patients with head and neck cancer after radiotherapy often suffer disability such as hearing disorders. In this study, the effect of radiotherapy (RT) on hearing function of patients with head and neck cancer after RT was determined according to the total dose delivered to specific parts of the auditory system. A total of 66 patients treated with primary or postoperative radiation therapy for various cancers....

Pharyngeal pack placement in minor oral surgery: A prospective, randomized, controlled study

Badr A. Al-Jandan, FRCD(C); Faiyaz Ahmed Syed, MDS; Ahed Zeidan, MD; Hesham Fathi Marei, MSc, MFDS (RCS Eng), PhD; Imran Farooq, MSc

We conducted a prospective, randomized, controlled study to investigate the influence of pharyngeal pack placement on postoperative nausea, vomiting, and throat pain after minor oral surgery. Our study group was made up of 80 patients—45 men and 35 women, aged 19 to 52 years (mean: 27.3)—who underwent a minor oral surgical procedure under general anesthesia. Patients were randomly assigned to one of three groups: 20 patients who received a pharyngeal pack under videolaryngoscopic guidance....

48 www.entjournal.com

Christine M. Clark, MD; Shivani Shah-Becker, MD; Abraham Mathew, MD; Neerav Goyal, MD, MPH

Alternative therapies for chronic rhinosinusitis: A review

Aaron S. Griffin, MBBS, BSci; Peter Cabot, PhD, BSci; Ben Wallwork, PhD, MBBS, FRACS; Ben Panizza, MBA, MBBS, FRACS

The use of alternative medicine in chronic rhinosinusitis (CRS) continues to increase in popularity, for the most part without meeting the burden of being based on sound clinical evidence. New and emerging treatments, both natural and developed, are numerous, and it remains a challenge for otolaryngologists as well as general practitioners to keep up to date with these therapies and their efficacy. In this systematic review, we discuss a number of alternative therapies for CRS, their proposed physiologic mechanisms, and evidence supporting their use. This analysis is based on....

CO2-laser–assisted diverticulotomy remains an effective and safe method for treating Zenker diverticulum

Mazin Merdad, MD, MPH; Nitin Bhatia, MD; Elie E. Rebeiz, MD, FACS

Our objectives were to review our experience with laserassisted diverticulotomy (LAD) in the treatment of Zenker diverticulum (ZD) and compare our results with those in published literature on other endoscopic and surgical techniques. We conducted a retrospective chart review of 57 patients who underwent LAD treatment of ZD in a single tertiary care institution. Data on surgical complications, length of stay, and follow-up were collected.

Age ranged from 56 to 89 years. Endoscopic exposure of the diverticulum was not possible in 2 patients. All 55....

ENT-Ear, Nose & Throat Journal March 2018

ENT JOURNAL ONLINE

Bilateral pyriform sinus parathyroid adenomas

Thomas Muelleman, MD; Sreeya Yalamanchali, MD; Yelizaveta Shnayder, MD

Parathyroid glands undergo a variable descent during embryologic development and can be found anywhere in the neck from the level of the mandible to the mediastinum.

To the best of our knowledge, we present the first report of a patient who was found to have bilateral parathyroid adenomas in her pyriform sinuses. A middle-aged woman with renal failure and secondary hyperparathyroidism presented with dysphagia and was found to have bilateral....

The utility of enlarging symptomatic nasal septal perforations

Philip G. Chen, MD; Stephen Floreani, MBBS; Peter-John Wormald, MD

Nasal septal perforations cause a subset of patients to suffer with significant impairments in quality of life. While smaller perforations can often be surgically repaired, perforations exceeding 2 cm are challenging to close. These repairs are highly technical, and there is a lack of consensus regarding the most effective means to do so. The authors performed a retrospective chart review of patients with....

Volume 97, Number 3

Incidence of epistaxis after endoscopic pituitary surgery: Proposed treatment algorithm

Lee A. Zimmer, MD, PhD; Norberto Andaluz, MD

Endoscopic transsphenoidal surgery for pituitary tumors is an increasingly common practice. Little has been reported on the incidence and treatment of postoperative epistaxis in this population. The aim of this study was to analyze the incidence of postoperative epistaxis and formulate a treatment algorithm based on our experience. We performed a case series with chart review. A total of 434 consecutive patients who had endoscopic transsphenoidal pituitary surgery were identified between April 2006 and November 2013. The incidence, clinical management, and outcomes were recorded. Based on the data, a treatment algorithm....

ONLINE DEPARTMENTS Laryngoscopic Clinic: Reinke edema

Jessie C. Everaert, BS; Jonathan J. Romak, MD; Robert T. Sataloff, MD, DMA, FACS Rhinoscopic Clinic: Endoscopic findings of bilateral fungal balls

Jong Seung Kim, MD; Sam Hyun Kwon, MD, PhD

www.entjournal.com 49

EDITORIAL

Geriatric surgery in otolaryngology More than one-third of all inpatient surgical procedures are performed on patients age 65 and over.1 This is not surprising. In 2015, people ≥65 years constituted 15% of the U.S. population, and this percentage is expected to grow to 24% by 2060.2 In 2010, nearly 40% of hospital discharges (including short-stay hospitals) involved patients ≥65 years of age.3 This means that approximately 200 million operations a year are performed on elderly (≥65 years) patients. While these data are not specific to otolaryngology, it is likely that the age profile of our patients is similar; and, with changing population demographics, it is certain that the percentage of otolaryngology patients who are elderly will increase.

We have been trained to understand that pediatric patients are not just “small adults.” Similarly, geriatric patients are not just “old adults.” They have special problems and require knowledgeable diagnostic and therapeutic intervention.

The American Academy of Otolaryngology–Head and Neck Surgery acknowledged the importance of geriatric otolaryngology by publishing with Thieme a multidisciplinary textbook of geriatric otolaryngology–head and neck surgery in 2015.4 That text makes it clear that special knowledge of geriatric otolaryngology is important in all subspecialties except pediatric otolaryngology, and such knowledge is especially important in surgical decision making.

On one hand, surgery should not be denied to patients simply because they are “old.” Moreover, “old” is hard to define. More and more people are living beyond 100 years, so denying surgery to an 80-year-old and condemning him/her to suffer from a potentially correctable problem for another 15 to 20 years is not right. We need to be concerned about quality of life. On the other hand, surgery that is unlikely to improve quality of life, or that presents a high risk of ending life without a concomitant benefit (such as some surgery for advanced head and neck cancer), might not be appropriate in this population.

Numerous articles on surgery in the elderly have been published—far too many to reference in an editorial. Discussions of this topic appear regularly in publications of the American College of Surgeons, for example. The underlying theme of most of these articles is the need to improve preoperative assessment. Surgical decision making must focus on more than surgical mortality and morbidity. We must consider maintenance of independence, quality of life, return to at least preoperative functional activity levels, the likely consequences of each person’s physiologic reserve, the cognitive effects associated with general anesthesia in the elderly, and the patient’s desires regarding quality of life and longevity.

Ideally, with the help of a healthcare team, the surgeon needs to consciously assess cognitive function, nutrition, risk of falls, geriatric syndromes, and other special healthcare issues in all elderly patients for whom surgery is contemplated.

Such preoperative assessments help not only in surgical decision making, but also in perioperative care of elderly patients.

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ENT-Ear, Nose & Throat Journal March 2018

Editorial

Elderly patients have increased risk of postoperative morbidity, sometimes after even relatively short general anesthesia. Problems may include long-term cognitive impairment, delirium, deep vein thrombosis, myocardial ischemia, infection, and others. It is essential for the physician, patient, and family to review these risks and make sure everyone agrees that they are justified and weighed against potential benefits. Physician and patient education are required, but much of the necessary knowledge is still being developed.

While there is no specific measure that will guide us in decisions about whether to perform surgery, assessments of frailty can be helpful and enlightening. This topic, as well as other tools for clinical assessment that predict adverse outcomes in geriatric patients, is covered in other literature.4-10 Interesting studies in geriatric trauma patients have shown the value of frailty assessment. For example, Joseph et al looked at elderly trauma patients (a particularly vulnerable population) and found that a 50-variable frailty index predicted unfavorable discharge disposition in geriatric patients.11 In a follow-up paper published during the same year, they validated a 15-variable trauma-specific frailty index (TSFI).12 The TSFI proved to be an effective instrument for predicting discharge disposition in geriatric trauma patients.

Similar studies in otolaryngology patients have not been performed. Other frailty instruments have been used to predict surgical survival and outcomes, although most otolaryngologists are not using frailty assessment routinely and knowledgably. There are exceptions, such as the University of Pittsburgh Medical Center, where targeted assessments of elderly patients have shown great value.

Nearly all otolaryngologists care for elderly patients, and the percentage of elderly patients in our practices will continue to increase. As a field, it is past time for us to study otolaryngology-specific implications of advanced age, to apply and study assessment tools that have proven useful in other specialties, and to develop assessments and guidelines of our own to assist our trainees and our patients in providing optimal care for patients 65 and older.

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References 1. Hall MJ, DeFrances CJ, Williams SN, et al. National Hospital Discharge Survey: 2007 summary. National Health Statistics Reports. U.S. Department of Health and Human Services.

October 26, 2010. www.cdc.gov/nchs/data/nhsr/nhsr029.pdf.

Accessed Jan. 26, 2018.

2. U.S. Census Bureau. 2014 national population projections summary tables. Table 6: Percent distribution of the projected population by sex and selected age groups for the U.S.: 2015 to 2060. www. census.gov/data/tables/2014/demo/popproj/2014-summarytables.html. Accessed Jan. 26, 2018.

3. Centers for Disease Control and Prevention. Number of discharges from short-stay hospitals, by first-listed diagnosis and age: United States, 2010. www.cdc.gov/nchs/data/nhds/3firstlisted/2010first3_ numberage.pdf. Accessed Jan. 26, 2018.

4. Sataloff RT, Johns MM, Kost KM (eds.) Geriatric Otolaryngology.

New York: Thieme Medical Publishers and the American Academy of Otolaryngology–Head and Neck Surgery; 2015.

5. Boyd CM, Darer J, Boult C, et al. Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: Implications for pay for performance. JAMA 2005;294(6):716-24.

6. Woods NF, LaCroix AZ, Gray SL, et al. Frailty: Emergence and consequences in women aged 65 and older in the Women’s Health Initiative Observational Study. J Am Geriatr Soc 2005;53(8): 1321-30.

7. Fried LP, Kronmal RA, Newman AB, et al. Risk factors for 5-year mortality in older adults: The Cardiovascular Health Study.

JAMA 1998;279(8):585-92.

8. Zafonte RD, Hammond FM, Mann NR, et al. Relationship bet­ween Glasgow Coma scale and functional outcome. Am J Phys Med Rehabil 1996;75(5):364-9.

9. Foreman BP, Caesar RR, Parks J, et al. Usefulness of the abbre­ viated injury score and the injury severity score in comparison to the Glasgow Coma Scale in predicting outcome after traumatic brain injury. J Trauma 2007;62(4):946-50.

10. Shah MK, Al-Adawi S, Burke DT. Age as predictor of functional outcome in anoxic brain injury. J Appl Res 2004;4(3):380-4.

11. Joseph B, Pandit V, Rhee P, et al. Predicting hospital discharge disposition in geriatric trauma patients: Is frailty the answer? J Trauma Acute Care Surgery 2014;76(1):196-200.

12. Joseph B, Pandit V, Zangbar B, et al. Validating trauma-specific frailty index for geriatric trauma patients: A prospective analysis.

J Am Coll Surg 2014;219(1):10-17.

Robert T. Sataloff, MD, DMA, FACS Editor-in-Chief Ear, Nose & Throat Journal

ENT-Ear, Nose & Throat Journal March 2018

OTOSCOPIC CLINIC

Schwartze sign Kevin A. Peng, MD; John W. House, MD

Figure 1. Otoscopy of the right tympanic membrane demonstrates a reddish blush on the cochlear promontory.

Figure 2. CT demonstrates demineralization at the fissula ante fenestram on the right, which is present bilaterally.

A 34-year-old man presented to the otology clinic complaining of right progressive hearing loss over the previous 4 years. Otoscopic examination revealed a reddish blush visible on the cochlear promontory beyond an intact right tympanic membrane (figure 1). Both 512- and 1024-Hz tuning forks lateralized to the right ear, and bone conduction was greater than air conduction on the right using both tuning forks.

Audiometry revealed a moderate conductive hearing loss on the right with absent reflexes.

Computed tomography (CT) was performed, revealing demineralization at the fissula ante fenestram bilaterally (figure 2). At the time of surgery, a fixed stapes was noted, confirming the clinical diagnosis of otosclerosis.

Hermann Schwartze (1837-1910) was a German otologist at the University of Halle. In 1878, he published The Pathological Anatomy of the Ear, a comprehensive

text cataloging diseases of the outer, middle, and inner ear.1 Although ankylosis of the stapes was discussed in his book, several years would pass before Politzer coined the term otosclerosis in 1893.2 It remains unclear when Schwartze first noted the red discoloration of the cochlear promontory now associated with his name, but by 1960, the Schwartze sign had become common parlance in otolaryngology publications. It is estimated to affect fewer than 10% of patients with otosclerosis, and it reflects the increased vascularity of otospongiotic bone in the otic capsule.

References

1. Schwartze H, Green JO. The Pathological Anatomy of the Ear. Boston: Houghton, Osgood and Co.; 1878.

2. Mudry A. Adam Politzer (1835-1920) and the description of otosclerosis. Otol Neurotol 2006;27(2):276-81.

From House Clinic, Los Angeles, Calif.

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ENT-Ear, Nose & Throat Journal March 2018

IMAGING CLINIC

An atypical presentation of hemifacial spasm secondary to neurovascular compression Enrique Palacios, MD, FACR; Radia Ksayer, MD; Jeremy Nguyen, MD Hemifacial spasm, also called tic convulsive, is a painless, involuntary contraction of the muscles innervated by the ipsilateral facial nerve, although less commonly it can present with weakness.1,2 As is the case in its trigeminal counterpart, tic douloureux, hemifacial spasm has a diverse array of potential etiologies. The most widely accepted of these is neurovascular compression, first proposed by Schultze.3 Other documented causes include space-occupying lesions, traumatic injury, and Bell palsy.1 Our case involved a 57-year-old man presenting with weakness of the left face for the previous 18 months with acute worsening over the course of that day. Transient ischemic attack was ruled out, although a vascular loop of the ipsilateral vertebral artery was observed on magnetic resonance angiogram (MRA) of the brain to be impinging on the facial nerve (figure). The patient was treated with muscle relaxants with some relief of the symptoms, and he was discharged to be followed for further evaluation of the symptoms.

Hemifacial spasm affects 0.8/100,000 people.1 It presents most often in the fifth to sixth decades of life and is nearly twice as common in females.4,5 Symptoms typically manifest initially in the orbicularis oculi and progress downward, although 4% progress in the opposite direction.1 With its nonspecific symptomatology, the differential diagnosis for hemifacial spasm is wide and includes facial tic, myokymia, blepharospasm, and tardive dyskinesia.6 Diagnostic workup for hemifacial spasm consists of a complete neurologic exam, electromyography, mag-

A

B

C

D

Figure. Noncontrast MR examination at the level of the cerebellopontine angle reveals a vascular loop corresponding to the distal portion of the left vertebral artery, compressing the area at the origin of the left facial nerve at the pontomedullary junction (A and B). In the axial (C) and coronal (D) T2W images, the arrows point to the flow void of the vessel. In the axial image of the source angiogram (C) and in the coronal view of the time-of-flight image (D), the arrows identify the vessel to better advantage than in A and B. The thin arrow in panel C identifies the left anterior inferior cerebellar artery.

netic resonance (MR) imaging, and MRA.3 Botulinum toxin injection and microvascular decompression are the mainstays of treatment.4 Symptoms are controlled

From the Department of Radiology, Head and Neck Section, Tulane University Medical Center, New Orleans.

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Imaging Clinic

acutely with anticonvulsants, muscle relaxants, and benzodiazepines.7 Visualization of the vascular structure and the nerve is best achieved in oblique sagittal gradient MR imaging, which is reported to have a 75.9% sensitivity for identification of facial nerve compression by the anterior inferior cerebellar artery or the posterior inferior cerebellar artery, the first and second most common offending vessels, respectively.8 Neurovascular compression involving the vertebral artery, which accounts for a minority of cases (17%), can be evaluated with 100% sensitivity due to the vessel’s larger caliber.8,9 MRA and computed tomography angiography have demonstrated similar utility in identification of pathologic vessels.10 References 1. Samii M, Günther T, Iaconetta G, et.al. Microvascular decom­ pression to treat hemifacial spasm: Long-term results for a consecutive series of 143 patients. Neurosurgery 2002;50(4):71218; discussion 718-19.

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2. Mauriello JA Jr., Leone T, Dhillon S, et al. Treatment choices of 119 patients with hemifacial spasm over 11 years. Clin Neurol Neurosur 1996;98(3):213-16.

3. Zappia JJ, Wiet RJ, Chouhan A, Zhao JC. Pitfalls in the diagnosis of hemifacial spasm. Laryngoscope 1997;107(4):461-5.

4. Lorentz I. Treatment of hemifacial spasm with botulinum toxin.

J Clin Neurosci 1995;2(2):132-5.

5. Auger RG, Whisnant JP. Hemifacial spasm in Rochester and Olmsted County, Minnesota, 1960 to 1984. Arch Neurol 1990; 47(11):1233-4.

6. Palacios E, Breaux J, Alvernia JE. Hemifacial spasm. Ear Nose Throat J 2008;87(7):368-70.

7. Wang A, Jankovic J. Hemifacial spasm: Clinical findings and treatment. Muscle Nerve 1998;21(12):1740-7.

8. Nagaseki Y, Omata T, Ueno T, et al. Prediction of vertebral artery compression in patients with hemifacial spasm using oblique sagittal MR imaging. Acta Neurochir (Wien) 1998;140(6):565-71.

9. Payner TD, Tew JM Jr. Recurrence of hemifacial spasm after microvascular decompression. Neurosurgery 1996;38(4):686–90; discussion 690-1.

10. El Refaee E, Langner S, Baldauf J, et al. Value of 3-dimensional highresolution magnetic resonance imaging in detecting the offending vessel in hemifacial spasm: Comparison with intraoperative high definition endoscopic visualization. Neurosurgery 2013;73(1):58-67.

ENT-Ear, Nose & Throat Journal March 2018

PATHOLOGY CLINIC

Dentigerous cyst Lester D.R. Thompson, MD

Figure 1. A unilocular radiolucency around tooth #32 (arrow) shows a crown-root junction of the cyst in this orthopantomograph.

Figure 2. Left: A few layers of epithelium are noted, lacking a palisading of the nuclei and showing an abrupt junction with the surrounding fibrous tissue. Right: Inflammation is noted in the adjacent stroma, with several projections of the epithelium into the stroma.

A dentigerous cyst is a development cyst that surrounds and envelops the crown of an unerupted tooth, attached at the crown-root (cemento-enamel or cervical) junction. Dentigerous cysts account for about 20% of all odontogenic cysts, developing during a peak age of 10 to 30 years, with a male predilection (3:2). The lesion presents in the mandible (3rd molar region) about twice as often as the maxilla (near maxillary canines).

Patients are usually asymptomatic, so these cysts are incidentally discovered during routine dental imaging.

However, pain may be experienced with bone expansion or resorption of adjacent teeth. Imaging studies (orthopantomographs) usually show a unilocular radiolucency surrounding the crown of the affected tooth (figure 1), with a well-defined sclerotic border. Cyst enucleation or extraction is generally employed, although marsupialization is sometimes used for larger lesions.

Histologically, there is a difference in findings depending on whether the lesion is inflamed. The noninflamed cyst shows 2 to 3 cell layers of cuboidal to squamoid

cells adjacent to fibrous connective tissue (figure 2), rarely showing ciliated, mucous, or sebaceous cells. The inflamed cyst shows a much thicker, proliferative epithelium, with hyperplastic rete, chronic inflammation (figure 2), and sometimes hyalinized keratin (Rushton bodies). Cholesterol clefts are common.

The differential diagnosis includes a dental follicle, an eruption cyst (a soft-tissue cyst overlying the erupting tooth), a glandular odontogenic cyst, and a unicystic ameloblastoma, while an odontogenic keratocyst may also be considered.

Suggested reading

Johnson NR, Gannon OM, Savage NW, Batstone MD. Frequency of odontogenic cysts and tumors: A systematic review. J Investig Clin Dent 2014;5(1):9-14.

Lin HP, Wang YP, Chen HM, et al. A clinicopathological study of 338 dentigerous cysts. J Oral Pathol Med 2013;42(6):462-7.

From the Department of Pathology, Southern California Permanente Medical Group, Woodland Hills Medical Center, Woodland Hills, Calif.

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THYROID AND PARATHYROID CLINIC

A midline mediastinal parathyroid cyst Guy Slonimsky, MD; Aaron Baker, MD; Henry Crist, MD; David Goldenberg, MD

A

B

Figure 1. A: Axial CT with contrast of the neck and chest demonstrates a homogeneous cystic lesion overlying the inferior border of the thyroid gland, anterior border of the trachea, and the great mediastinal vessels. B: Coronal CT of the cyst demonstrates its cervical and mediastinal components with splaying of the innominate veins.

A 49-year-old woman presented with progressive dysphagia of several months’ duration accompanied by a pressure sensation at the lower anterior base of her neck. Her medical history was significant for type II diabetes, hypertension, hypertriglyceridemia, obesity, anxiety, and depression. Lab values were unremarkable.

Physical examination revealed no neck mass. The remainder of her head and neck examination was within normal limits. On ultrasound, a cystic lesion measuring 4.0 × 2.7 × 3.6 cm was seen, abutting and immediately caudal to the thyroid isthmus. There were no pathologic findings within the thyroid gland and no neck lymphadenopathy.

Computed tomography (CT) of the neck with intravenous contrast revealed a cystic mass of similar dimensions adhering to the anterior tracheal surface

and occupying the space between the thyroid isthmus and the aortic arch. Because of mass effect, there was splaying of the inferior poles of the thyroid lobes and the left and right innominate veins (figure 1).

The cytologic findings of an ultrasound-guided fine-needle aspiration biopsy were of rare macrophages, inflammatory cells, and proteinaceous debris, consistent with cystic contents; there was no evidence of malignant cells.

The patient underwent exploration of the lower neck and upper anterior mediastinum by a cervical approach.

A cystic lesion at the superior anterior mediastinum was identified. It was meticulously dissected and entirely removed. Histopathology revealed a unilocular cystic cavity containing parathyroid cells in rare residual groups on an otherwise flat lining and in focal nests

From the Department of Surgery, Division of Otolaryngology–Head and Neck Surgery (Dr. Slonimsky, Dr. Baker, and Dr. Goldenberg) and the Department of Pathology (Dr. Crist), The Pennsylvania State University, College of Medicine, Hershey.

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Thyroid and Parathyroid Clinic

parathyroid carcinoma presenting as a cystic neck or mediastinal mass.13,14 The location and size of the parathyroid cyst will dictate the appropriate surgical approach. The cervical approach will enable the resection of lesions in the neck and upper mediastinum, whereas large mediastinal lesions and lower or posterior mediastinal lesions will require thoracotomy, median sternotomy, or thoracoscopy.15 References

Figure 2. Nests of parathyroid cells are seen within the wall of the cyst with residual foci lining the cyst wall (arrow) (hematoxylin and eosin stain, original magnification ×100).

within its fibrous wall, indicative of a parathyroid cyst (figure 2).

Parathyroid cysts are rare lesions of the neck and mediastinum with a peak incidence in the fourth and fifth decades of life.1-3 These cysts are generally divided into nonfunctional or functional, based on their hormonal activity, and can rarely lead to hypercalcemic crisis.3-5 There are several theories for the pathogenesis of these cysts, including remnants of branchial clefts, retention cysts, coalescence of numerous minute cystic lesions, or degeneration of an adenoma.3 The clinical presentation is varied and ranges from an incidental finding on imaging or physical examination in the asymptomatic patient to a neck mass with compressive symptoms, recurrent laryngeal nerve palsy, and sometimes hyperparathyroidism.2-4,6 The mainstay of diagnosis includes neck ultrasonography, CT, or magnetic resonance imaging, with nonspecific findings of a benign-appearing homogeneous cystic lesion.7 Detection of parathyroid hormone in fine-needle aspiration can facilitate the diagnosis, as parathyroid cysts can be easily misdiagnosed as thyroid cysts or other cystic lesions of the neck.8 Histopathology will reveal a smooth cystic lesion lined with cuboidal epithelium and nests of parathyroid cells within its wall.9 Nonfunctioning asymptomatic cysts can be observed with routine follow-up. Symptomatic nonfunctioning cysts can be treated with fluid aspiration2 or sclerotherapy in recurrent cases with the risk of fibrosis.10,11 Although needle aspiration may lead to definitive resolution in some cases,12 surgical resection is warranted in many cases as a diagnostic procedure, for the treatment of hyperparathyroidism (in cases of functional cysts), and because of the rare possibility of 60 www.entjournal.com

1. Cappelli C, Rotondi M, Pirola I, et al. Prevalence of parathyroid cysts by neck ultrasound scan in unselected patients. J Endocrinol Invest 2009;32(4):357–9.

2. Ippolito G, Palazzo FF, Sebag F, et al. A single-institution 25-year review of true parathyroid cysts. Langenbecks Arch Surg 2006; 391(1):13–18.

3. Shields TW, Immerman SC. Mediastinal parathyroid cysts re­ visited. Ann Thorac Surg 1999;67(2):581–90.

4. Suzuki K, Sakuta A, Aoki C, Aso Y. Hyperparathyroidism caused by a functional parathyroid cyst. BMJ Case Rep 2013 June 21;2013. pii: bcr2012008290 5. Khan A, Khan Y, Raza S, et al. Functional parathyroid cyst: A rare cause of malignant hypercalcemia with primary hyper­ parathyroidism—a case report and review of the literature. Case Rep Med 2012;2012:851941.

6. Jarnagin WR, Clark OH. Mediastinal parathyroid cyst causing persistent hyperparathyroidism: Case report and review of the literature. Surgery 1998;123(6):709–11.

7. Kato H, Kanematsu M, Kiryu T, et al. Nonfunctional mediastinal parathyroid cyst: Imaging findings in two cases. Clin Imaging 2008;32(4):310–13.

8. Ujiki MB, Nayar R, Sturgeon C, Angelos P. Parathyroid cyst: Often mistaken for a thyroid cyst. World J Surg 2007;31(1):60–4.

9. Fortson JK, Patel VG, Henderson VJ. Parathyroid cysts: A case report and review of the literature. Laryngoscope 2001;111(10): 1726–8.

10. Kaplanoglu V, Kaplanoglu H, Ciliz DS, Duran S. A rare cystic lesion of the neck: Parathyroid cyst. BMJ Case Rep 2013 Oct 11;2013. pii: bcr2013200813 11. Kim JH. Ultrasound-guided sclerotherapy for benign non-thyroid cystic mass in the neck. Ultrasonography 2014;33(2):83–90.

12. Prinz RA, Peters JR, Kane JM, Wood J. Needle aspiration of nonfunctioning parathyroid cysts. Am Surg 1990;56(7):420–22.

13. Vazquez FJ, Aparicio LS, Gallo CG, Diehl M. Parathyroid carcinoma presenting as a giant mediastinal retrotracheal functioning cyst. Singapore Med J 2007;48(11):e304-7.

14. Pirundini P, Zarif A, Wihbey JG. A rare manifestation of para­ thyroid carcinoma presenting as a cystic neck mass. Conn Med 1998;62(4):195–7.

15. Dell’Amore A, Asadi N, Bartalena T, et al. Thoracoscopic re­ section of a giant mediastinal parathyroid cyst. Gen Thorac Cardiovasc Surg 2014;62(7):444–50.

ENT-Ear, Nose & Throat Journal March 2018

SPECIAL TOPICS CLINIC

Complete resolution of guttate psoriasis after tonsillectomy Jason E. Cohn, DO; Michael Pfeiffer, DO; Gerard Vernose, MD

Figure 1. Photo shows the guttate psoriasis on the patient’s hands before tonsillectomy.

Figure 2. This photo shows the patient’s hands 2 months after tonsillectomy. The psoriasis has resolved completely.

Psoriasis is a chronic, inflammatory, immunemediated disease that affects 3.2% of adults in the United States.1 Streptococcal infections have been associated with several systemic disease processes including glomerulonephritis and rheumatic heart disease. A well-established link between psoriasis and streptococcal infection also has been reported in the literature.1,2 Specifically, this association appears to be with both guttate and plaque psoriasis.

Although the exact etiology is unclear, it is believed that a streptococcal trigger residing in the palatine tonsils might activate T cells in the skin through molecular mimicry.1 HLA-Cw*0602 homozygosity has been linked to streptococcal-associated psoriasis.3 Several studies have reported improvement or complete resolution of psoriasis after tonsillectomy.1,2,4-8 A 26-year-old man presented to our office with a history of recurrent streptococcal tonsillitis. One episode of tonsillitis was treated with oral levofloxacin by his primary care physician. However, because the patient

developed joint pain after several days of treatment, it was discontinued.

Two weeks later, the patient began to develop a rash over his hands (figure 1), trunk, back, and extremities.

The patient was evaluated by a dermatologist and was subsequently diagnosed with guttate psoriasis. It was further described as a salmon-pink, teardrop-shaped papular rash with a fine scale. This rash was treated with topical steroids.

Several months later the rash resolved, but it returned with another episode of tonsillitis. Given the recurrent episodes of tonsillitis, the patient underwent tonsillectomy 2 months later. After surgery, the rash completely resolved (figure 2). On his back, some hypopigmented lesions from scarring remained, but these are expected to improve over time. The patient currently does not require treatment for psoriasis; his rash has not returned to date.

Several studies have demonstrated the efficacy of tonsillectomy for the treatment of streptococcal-associated

From the Department of Otolaryngology–Head and Neck Surgery, Philadelphia College of Osteopathic Medicine (Dr. Cohn and Dr. Pfeiffer); and the Department of Otolaryngology–Head and Neck Surgery, Jefferson Health–Methodist Hospital (Dr. Vernose), Philadelphia.

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Special Topics Clinic

psoriasis. One meta-analysis revealed that 290 of 410 (70.7%) patients with psoriasis who underwent tonsillectomy experienced improvement of their psoriasis.1 The authors concluded that evidence is insufficient to support tonsillectomy in most patients with psoriasis.

However, a tonsillectomy might be beneficial when psoriasis exacerbations are closely associated with recurrent tonsillitis.1 A randomized, controlled trial demonstrated that patients with plaque psoriasis undergoing tonsillectomy had significantly improved health-related quality of life and psoriasis-related stress.5 A Cochrane database protocol states that adult tonsillectomy for psoriasis is beneficial, but the evidence for this is not robust.6 It has been shown, especially with guttate psoriasis, that tonsillectomy has a potential benefit in psoriasis disease burden.1,5,7,8 Our patient demonstrated complete recovery after tonsillectomy. The decision to perform a tonsillectomy in this case was appropriate because the patient’s psoriasis flares corresponded with episodes of tonsillitis. It is important to highlight this case because it involved an adult, although tonsillitis-associated guttate psoriasis is typically reported in the pediatric population.4,7,8 Additionally, we demonstrated a significant improvement in this disease process with photographic evidence. Future prospective studies looking at the efficacy of tonsillectomy on psoriasis are encouraged.

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References

1. Rachakonda TD, Dillon JS, Florek AG, Armstrong AW. Effect of tonsillectomy on psoriasis: A systematic review. J Am Acad Dermatol 2015;72(2):261-75.

2. Sigurdardottir SL, Thorleifsdottir RH, Valdimarsson H, Johnston A. The role of the palatine tonsils in the pathogenesis and treatment of psoriasis. Br J Dermatol 2013;168(2):237-42.

3. Thorleifsdottir RH, Sigurdardottir SL, Sigurgeirsson B, et al.

HLA-Cw6 homozygosity in plaque psoriasis is associated with streptococcal throat infections and pronounced improvement after tonsillectomy: A prospective case series. J Am Acad Dermatol 2016;75(5):889-96.

4. Saita B, Ishii Y, Ogata K, et al. Two sisters with guttate psoriasis responsive to tonsillectomy: Case reports with HLA studies. J Dermatol 1979;6(3):185-9.

5. Thorleifsdottir RH, Sigurdardottir SL, Sigurgeirsson B, et al.

Patient-reported outcomes and clinical response in patients with moderate-to-severe plaque psoriasis treated with tonsillectomy: A randomized controlled trial. Acta Derm Venereol 2017;97(3): 340-5.

6. Owen CM, Chalmers RJ, O’Sullivan T, Griffiths CE. Anti­strepto­ coccal interventions for guttate and chronic plaque psoriasis.

Cochrane Database Syst Rev 2000(2):CD001976.

7. Hone SW, Donnelly MJ, Powell F, Blayney AW. Clearance of recalcitrant psoriasis after tonsillectomy. Clin Otolaryngol Allied Sci 1996;21(6):546-7.

8. McMillin BD, Maddern BR, Graham WR. A role for tonsillectomy in the treatment of psoriasis? Ear Nose Throat J 1999;78(3):155-8.

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ORIGINAL ARTICLE

Post-turbinectomy nasal packing with Merocel versus glove finger Merocel: A prospective, randomized, controlled trial Rani Abu Eta, MD; Ephraim Eviatar, MD; Jacob Pitaro, MD; Haim Gavriel, MD Abstract

Nasal packs are widely used after septoplasty and turbinectomy. We conducted a prospective, randomized, controlled clinical trial including 100 patients who underwent septoplasty with/or without turbinectomy randomized into two groups. In the first group (the Merocel group), a standard tampon was inserted at the end of surgery. In the second group (the glove finger group), the tampon was first placed inside a glove finger. The main outcomes measured were pain and bleeding during the postoperative period and during tampon removal. Consumption of pain killers and tranexamic acid were also recorded. The mean visual analog scale score 12 hours after surgery and during tampon removal in the Merocel group were 6.78 and 8.92, respectively, compared to 4.06 and 5.27, respectively, in the glove finger group (p < 0.001). A statistically significant difference in the bleeding rate and tranexamic acid consumption during tampon removal in favor of the Merocel group was shown (p < 0.001). The use of Merocel in a glove finger is significantly less painful, although a higher chance of bleeding is reported. The influence of the surgeon’s experience in using this technique needs further investigation.

Introduction

Septoplasty and reduction of the inferior turbinates are the most commonly used surgical interventions to enhance nasal airways compromised secondary to nasal septal deviations and turbinate hypertrophy.

From the Department of Otolaryngology Head and Neck Surgery, Assaf Harofeh Medical Center, Zerifin, Israel, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel.

Corresponding author: Dr. Haim Gavriel, Department of Otolaryngology Head and Neck Surgery, Assaf Harofeh Medical Center, Zerifin 70300, Israel. Email: haim.ga@012.net.il 64 www.entjournal.com

Nasal packs are widely used after these operations to prevent nasal bleeding, to support the mucoperichondrial flaps, and to minimize the risk of forming septal hematomas and prevent adhesions.1 Since Hippocrates first defined nasal tampon packing in the fifth century BC, 2 various materials have been proposed for nasal packing, such as gauzes with or without medication (e.g., paraffin), Telfa cellulose and foam, Merocel (a polyvinyl acetate sponge; Medtronic Xomed; Jacksonville, Fla.), expanding sponges, ready-made or inflatable tampons, and Foley catheters. Ideally, nasal packs should be easy to insert and remove with minimal discomfort, and they should also effectively prevent postoperative bleeding. 3,4 The use of nasal packing may result in several side effects that include pain, dysphagia, eustachian tube blockage, sinusitis, synechia and toxic shock syndrome.5-7 Aspiration of nasal packing and airway obstruction have also been reported.8 However, the most frequent patient complaints appear to be pain and bleeding during removal of nasal tampons.

Merocel dressings are widely used after endonasal surgery.9,10 To reduce pain during their removal, several studies have proposed using Merocel within a glove finger after septoplasty and endoscopic sinus surgery.7,11 However, a higher risk of bleeding post-turbinectomy is expected and, to the best of our knowledge, no study on the use of Merocel in a glove finger has been reported in the English literature.

In this study, we prospectively compared the effects of two different types of nasal packs on pain and bleeding after turbinectomy with or without septoplasty: Merocel standard 8-cm nasal dressing and Merocel in a glove finger.

ENT-Ear, Nose & Throat Journal March 2018

Post-turbinectomy nasal packing with Merocel versus glove finger Merocel: A prospective, randomized, controlled trial

Patients and methods

A prospective, randomized, controlled clinical trial comparing Merocel nasal pack and Merocel within a glove finger regarding pain and bleeding before and during tampon removal was conducted. The study was approved by the Institute Ethical Committee.

The study group included 100 consecutive patients with an indication for septoplasty with turbinectomy or turbinectomy alone. Twelve operations were performed under general anesthesia and 88 under local anesthesia.

Local homeostasis was achieved with lidocaine HCl 1% and epinephrine 1:100,000.

Excluded were patients younger than 18 years, patients with a history of previous endoscopic sinus surgery (ESS) or underlying immunologic diseases, patients with Samter’s triad, those allergic to latex, and those who reported using anticoagulants or antiaggregants.

Surgical technique. Surgery was carried out under general or local anesthesia. After proper premedication, the nasal cavities were packed with 2% lidocaine with epinephrine (1: 100,000) and then removed after several minutes. Angled turbinate scissors were used for this procedure. One blade was inserted beneath the inferior turbinate and the other on top of it after the turbinate was fractured medially. Resection included the turbinate mucosa and, partially, the bone.

The extent of the resection depended on the degree of turbinate hypertrophy.

The patients were randomized into two groups according to the last digit of their identity number. Patients in the first group were packed at the end of surgery with a standard 8-cm Merocel tampon (Merocel group). Patients in the second group were packed with a Merocel tampon of the same size that was placed in a glove finger of a regular sterile glove (glove finger group).

All tampons in both groups were secured to the nose with tape and a 2-0 silk stich—through the anterior edge of the tampon in the Merocel group and through the anterior edge of the glove finger in the glove finger group. The same nasal packing materials were used for both sides of the nose for each patient. The nasal tampons were removed 48 hours postoperatively.

Surgical outcomes. The main outcomes measured were pain and bleeding during the postoperative period. Pain was evaluated by a nurse using a visual analog scale (VAS) numbered from 0 to 10 (0 representing the least pain and 10 the maximum pain) at two times: 12 hours after surgery and during the removal of the tampons. Patient painkiller intake was divided into three categories: category A, per os: dipyrone 1 g Volume 97, Number 3

(metamizole in the United States), acetaminophen 1 g, or oxycodone 5 mg and naloxone 2.5mg); category B, per os: oxycodone 5mg and acetaminophen 325 mg or tramadol 50 mg; and category C, intravenous: tramadol 100 mg.

Bleeding after the removal of the nasal tampon was evaluated according to the following scale created by the authors of this study: 0 = no bleeding; 1 = blood seeping from the nose; 2 = continuous bleeding from the nose; 3 = bleeding stopped in the operating room.

The need for intravenous tranexamic acid was recorded in both groups.

Statistical analyses. Categorical variables were reported as numbers (percentages), and continuous variables as means (standard deviations [SD]) or medians (interquartile ranges [IQR]). Continuous variables were tested for normal distribution using the Shapiro–Wilk test and quantile-quantile (q-q) plots. The chi-square test or Fisher exact test was used to compare categorical variables; continuous variables were compared by the independent-samples t test or the Mann-Whitney U test. A two-tailed p value of <0.05 was considered statistically significant. Analyses were performed with R (R Project for Statistical Computing) version 3.1.2.

Results

A total of 100 patients (87 men and 13 women; mean age: 22 years, range 18 to 69 years) were enrolled prospectively during the study period. The Merocel group consisted of 41 patients with a median age of 29 years, and the glove finger group consisted of 59 patients with a median age of 22 years (p = 0.012) (table 1).

Comorbidities were identified in 5 (5%) patients: 3 patients had hypertension, 1 patient had ischemic heart disease, and 1 patient had hypercholesterolemia.

The median VAS scores 12 hours after surgery and during tampon removal in the Merocel group were 7 and 9, respectively, compared to VAS scores of 4 and 5, respectively, in the glove finger group (p < 0.001) (table 1).

All patients in the Merocel group consumed an analgesic; 11 (18.6%) patients in the glove finger group did not (p = 0.002). Six (14.6%) patients in the Merocel group needed category A painkillers, 25 (61.0%) needed category B painkillers, and 10 (24.4%) needed category C painkillers. In the glove finger group, 11 (18.6%) patients needed no painkillers at all, 40 (67.8%) patients were treated with category A painkillers, and 8 (13.6%) with category B painkillers.

Thirty-five patients (85.4%) in the Merocel group showed no signs of bleeding during tampon removal www.entjournal.com 65

Abu Eta, Eviatar, Pitaro, Gavriel

Table 1. Differences in pain and pain control in the Merocel group vs. the glove finger group

Discussion

Septoplasty and reduction of the inferior turbinates are among the Merocel group Glove finger group most common surgical interven(n = 41) (n = 59) p Value tions in otorhinolaryngology. Since Sex, n (%) these operations may lead to signifMale 35 (85.4) 52 (88.1) 0.685 icant bleeding postoperatively, naFemale 6 (14.6) 7 (11.9) sal packing is widely used to reduce Median age, yr (IQR) 29 (21-41.5) 22 (20-25) 0.012 bleeding. The use of nasal packing may, by itself, lead to severe comSurgery, n (%) plications. One of the most signifSMR conchotomy 37 (90.2) 54 (91.5) >0.999 icant concerns of patients is pain Conchotomy 4 (9.8) 5 (8.5) during removal of the tampon while that of the surgeon is postopAnesthesia, n (%) 12 Local 33 (80.5) 55 (93.2) 0.066 erative bleeding.

Merocel packing is the most General 8 (19.5) 4 (6.8) commonly used material after nasal Analgesics, n (%) 41 (100) 48 (81.4) 0.002 surgery, with well-known advantages and reported complications Pain killers, n (%) and disadvantages such as pain and None 0 (0) 11 (18.6) <0.001 bleeding. Endeavors to alleviate the Category A 6 (14.6) 40 (67.8) disadvantages of Merocel tampons Category B 25 (61.0) 8 (13.6) by using glove fingers during ESS Category C 10 (24.4) 0 (0) and post-septoplasty have been previously reported.1,3-5 In these VAS during hospitalization, 7 (6-7) 4 (3-5) <0.001 median (IQR) studies, the major benefit of using a Merocel tampon in a glove finger VAS during removal, 9 (9-9.5) 5 (4-6) <0.001 was the reduced pain reported by the median (IQR) patients during tampon removal. No Key: IQR = interquartile range; SMR = submucous resection;VAS = visual analog scale. significant difference was observed in these studies regarding bleeding compared to only 2 (3.4%) patients in the glove finger after the removal of the tampons. However, none of group (p < 0.001). Mild bleeding was observed in these studies investigated the outcomes after inferior the other 6 (14.6%) patients in the Merocel group. turbinectomy.

Major bleeding during or after septoplasty is seldom However, in the glove finger group, mild bleeding was detected in 27 (45.8%) patients, continuous observed due to the good visualization of the surgical bleeding in another 27 (45.8%) patients, and in 3 field during the operation.7 In cases of significant (5.1%) patients the bleeding was stopped only in Table 2. Differences in bleeding between the Merocel and glove finger groups the operating room (p < 0.001) (table 2).

Merocel group Glove finger group (n = 41) (n = 59) p Value In the Merocel group, 2 2 (4.9) 19 (32.2) 0.001 (4.9%) patients needed in- Tranexamic acid, n (%) travenous administration of Bleeding, n (%) 6 (14.6) 57 (96.6) <0.001 tranexamic acid (1 g) after Bleeding grade, n (%) tampon removal due to conNo bleeding 35 (85.4) 2 (3.4) <0.001 tinuous bleeding compared Blood seeping from nose 6 (14.6) 27 (45.8) to 19 (32.2%) patients in Continuous bleeding from nose 0 (0) 27 (45.8) the glove finger group (p = Bleeding stopped in OR 0 (0) 3 (5.1) 0.001) (table 2).

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ENT-Ear, Nose & Throat Journal March 2018

Abu Eta, Eviatar, Pitaro, Gavriel

bleeding, cauterization is feasible and successful in most cases. ESS harbors great risk to major vessels with possible significant bleeding. However, the magnified surgical field and the ability of the surgeon to work with two hands enables better bleeding control.

ESS should be finalized with no significant bleeding and, therefore, the use of a tampon in a glove finger is mostly effective.

Inferior turbinectomy poses a unique challenge regarding nasal packing. In many cases, it will not be performed with endoscopic surgery, and the surgeon relies on his or her ability to view the turbinates throughout their entire length. Moreover, major bleeding from major branches of the sphenopalatine artery is usually encountered from the posterior half of the injured turbinate. Therefore, optimal packing should be used post-turbinectomy, especially when it is performed by a lesser-trained surgeon.

The results of the current study indicate that nasal packing with Merocel carries significantly higher pain scores when compared to the use of Merocel in a glove finger, either after septoplasty with inferior turbinectomy or turbinectomy alone. We attributed the lower degree of pain reported in patients in the glove finger group to less adherence of the Merocel glove finger to the structures inside the nose, thereby lowering the amount of superficial tissue injured by the exiting tampon and resulting in significantly less consumption of painkillers.13,14 Our study also demonstrates statistically significant greater postoperative bleeding when using a Merocel tampon in a glove finger, with a significantly greater need for intravenous tranexamic acid. Unfortunately, the advantage of less pain due to less adherence of the packing to the tissue and a smaller amount of tissue trauma during the pack removal brings with it the disadvantage of bleeding. As the amount of tissue in close contact with a Merocel tampon in a glove finger is reduced compared to Merocel, a higher chance of blood vessels not directly affected by the influence of the tampon is anticipated, leading to a higher chance of postoperative bleeding.

It is important to mention that all patients reported in this series were operated on by our skilled residents, experienced with these types of surgeries. However, we believe that an experienced consultant surgeon would have targeted the placement of the Merocel tampon in a glove finger to the higher bleeding risk areas of the nose, thereby possibly lowering the chances of postoperative bleeding.

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Conclusion

The use of Merocel in a glove finger is significantly less painful for the patient than Merocel directly inserted into the nostril, although a higher risk of bleeding is demonstrated. We are preparing for a comparative study to investigate the effect of the surgeon’s experience on the bleeding rate post-turbinectomy when using Merocel in a glove finger.

References 1. Acio lu E, Edizer DT, Yi it Ö, Alkan Z. Nasal septal packing: Which one? Eur Arch Otorhinolaryngol 2012;269(7):1777–81.

2. Singer AJ, Blanda M, Cronin K, et al. Comparison of nasal tampons for the treatment of epistaxis in the emergency depart­ ment: A randomized controlled trial. Ann Emerg Med 2005; 45(2):134–9.

3. Ozcan C, Vayisoglu Y, Kiliç S, Görür K. Comparison of rapid rhino and merocel nasal packs in endonasal septal surgery. J Otolaryngol Head Neck Surg 2008;37(6):826–31.

4. Bresnihan M, Mehigan B, Curran A. An evaluation of Merocel and Series 5000 nasal packs in patients following nasal surgery: A prospective randomised trial. Clin Otolaryngol 2007;32(5):352–5.

5. Ardehali MM, Bastaninejad S. Use of nasal packs and intranasal septal splints following septoplasty. Int J Oral Maxillofac Surg 2009;38(10):1022-4.

6. Taasan V, Wynne JW, Cassisi N, Block AJ. The effect of nasal packing on sleep-disordered breathing and nocturnal oxygen desaturation. Laryngoscope 1981;91(7):1163-72.

7. Celebi S, Caglar E, Develioglu ON, et al. The effect of the duration of merocel in a glove finger on postoperative morbidity.

J Craniofac Surg 2013;24(4):1232-4.

8. Koudounarakis E, Chatzakis N, Papadakis I, et al. Nasal packing aspiration in a patient with Alzheimer’s disease: A rare complication. Int J Gen Med 2012;5:643-5.

9. Badran K, Malik TH, Belloso A, Timms MS. Randomized controlled trial comparing Merocel and RapidRhino packing in the management of anterior epistaxis. Clin Otolaryngol 2005;30(4):333–7.

10. Corbridge RJ, Djazaeri B, Hellier WP, Hadley J. A prospective randomized controlled trial comparing the use of merocel nasal tampons and BIPP in the control of acute epistaxis. Clin Otolaryngol Allied Sci 1995;20(4):305–7.

11. Garth RJ, Brightwell AP. A comparison of packing materials used in nasal surgery. J Laryngol Otol 1994;108(7):564–6.

12. Eliashar R, Gross M, Wohlgelernter J, Sichel JY. Packing in endoscopic sinus surgery: Is it really required? Otolaryngol Head Neck Surg 2006;134(2):276-9.

13. Lemmens W, Lemkens P. Septal suturing following nasal septoplasty, a valid alternative for nasal packing? Acta Otorhino­ laryngol Belg 2001;55(3):215-21.

14. Weber R, Keerl R, Hochapfel F, et al. Packing in endonasal surgery. Am J Otolaryngol 2001;22(5):306–20.

ENT-Ear, Nose & Throat Journal March 2018

ORIGINAL ARTICLE

Comparison of anterior palatoplasty and uvulopalatal flap placement for treating mild and moderate obstructive sleep apnea Süheyl Haytoğlu, MD; Osman Kürşat Arikan, MD; Nuray Bayar Muluk, MD; Birgül Tuhanioğlu, MD; Mustafa Çörtük, MD

Abstract

We prospectively compared the efficacy of anterior palatoplasty and the uvulopalatal flap procedure for the treatment of patients with mild and moderate obstructive sleep apnea syndrome (OSAS). Our study group was made up of 45 patients who had been randomly assigned to undergo one of the two procedures. Palatoplasty was performed on 22 patients—12 men and 10 women, aged 28 to 49 years (mean: 39.2)—and the flap procedure was performed on 23 patients—14 men and 9 women, aged 28 to 56 years (mean: 41.3). Our primary outcomes measure was the difference in pre- and postoperative apnea-hypopnea index (AHI) as determined by polysomnography at 6 months after surgery. Surgical success was observed in 18 of the 22 palatoplasty patients (81.8%) and in 19 of the 23 flap patients (82.6%). Compared with the preoperative values, mean AHIs declined from 17.5 to 8.1 in the former group and from 18.5 to 8.6 in the latter; the improvement in both groups was statistically significant (p < 0.001). In addition, significant postoperative improvements in both groups were seen in mean visual analog scale (VAS) scores for snoring, in Pittsburgh Sleep Quality Index values, and in Epworth Sleepiness Scale scores (p < 0.001 for all). VAS scores for pain at rest were significantly lower in the palatoplasty group than in the flap group at 2, 4, and 8 hours postoperatively and on postoperative days 4 through 7 (p < From the ENT Clinic, Adana Numune Training and Research Hospital, Adana, Turkey (Dr. Haytoğlu, Prof. Arikan, and Dr. Tuhanioğlu); the ENT Department, Kırıkkale University Faculty of Medicine, Kırıkkale, Turkey (Prof. Muluk); and the Pulmonary Diseases Department, Karabük University Faculty of Medicine, Karabük, Turkey (Dr. Çörtük). The study described in this article was conducted at Adana Numune Training and Research Hospital.

Corresponding author: Prof. Nuray Bayar Muluk, ENT Department, Kırıkkale University Faculty of Medicine, Birlik Mahallesi, Zirvekent 2. Etap Sitesi, C-3 blok, No: 62/43 06610 Çankaya, Kırıkkale, Turkey. Email: nurayb@hotmail.com Volume 97, Number 3

0.002). Likewise, VAS scores for pain during swallowing were significantly lower in the palatoplasty group at 2, 4, 8, and 16 hours and on days 4 through 7 (p < 0.009).

We conclude that both anterior palatoplasty and uvulopalatal flap procedures are effective for the treatment of mild and moderate OSAS in patients with retropalatal obstruction. However, our comparison of postoperative pain scores revealed that anterior palatoplasty was associated with significantly less morbidity.

Introduction

Obstructive sleep apnea syndrome (OSAS) is characterized by episodes of partial or complete obstruction of the upper airway during sleep, which results in interruptions (apnea) or reductions (hypopnea) of the flow of air; the transient awakening that follows leads to the restoration of upper airway permeability.1 In the upper airway, the retropalatal area is the most common site of the obstructive process.2,3 Since Fujita et al first described uvulopalatopharyngoplasty (UPPP) in 1981,4 many studies have been published about its efficacy and complication rates. Studies have shown that while short-term success rates ranged from 76 to 95%, rates after 1 year fell to only 46 to 50%.5-9 Since UPPP has been associated with high recurrence and complication rates and patient discomfort, other procedures have been introduced to restore the space at the retropalatal area.9,10 One of them is the uvulopalatal flap procedure, which was first described by Powell et al in 1996.11 Studies showed that flap placement yielded success rates similar to those of UPPP but with less postoperative pain.11-13 Nevertheless, postoperative pain is still a common complication of the uvulopalatal flap procedure, as is temporary velopharyngeal insufficiency and a permanent foreign-body sensation in the pharynx.12,13 www.entjournal.com 69

HAYTO LU, ARIKAN, MULUK, TUHANIO LU, ÇÖRTÜK

A modified cautery-assisted palatal stiffening procedure was introduced by Pang and Terris in 2007 as an alternative to the flap procedure.14 They subsequently called this procedure anterior palatoplasty.15 In their first study, which looked at a small series of patients with mild OSAS, they observed surgical success in 6 of 8 patients (75.0%) as determined by polysomnography, as well as a reduction in daytime sleepiness scores in 11 of 13 patients (84.6%).14 In a subsequent study of 77 patients published in 2009, Pang et al found a success rate of 71.8% for anterior palatoplasty with or without tonsillectomy at a mean of 33.5 months of follow-up.15 With anterior palatoplasty, temporary velopharyngeal insufficiency and postoperative pain are also common, but a foreign-body sensation is not.

In a 2013 study by Marzetti et al, success rates for anterior palatoplasty and the uvulopalatal flap procedure were 86 and 84%, respectively.16 The authors reported lower pain scores in the palatoplasty group. In both groups, they performed a tonsillectomy first if the tonsil size was greater than grade 2. Previous studies of palatal surgeries in OSAS patients had not considered the possible effects of tonsillectomy on success rates and postoperative discomfort, especially pain.

In this article, we describe our comparison of the efficacy of anterior palatoplasty and the uvulopalatal flap procedure for the treatment of mild and moderate OSAS in patients with retropalatal obstruction who did not require a tonsillectomy.

Patients and methods

For this prospective study, we recruited 50 patients who had been diagnosed with mild or moderate OSAS in the ENT Clinic at Adana Numune Training and Research Hospital from June 2012 through January 2014.

All diagnoses had been based on the results of polysomnography. All patients had undergone a complete head and neck examination, including flexible fiberoptic nasopharyngoscopy to evaluate the posterior airway space. All were found to have retropalatal collapse, based on the Müller maneuver.

Our inclusion criteria were an apnea-hypopnea index (AHI) of greater than 5 and less than 30, a body mass index (BMI) of less than 30 kg/m2, a tonsillar hypertrophy grade of 0 or 1,17 and the presence of retropalatal obstruction. Exclusion criteria included previous palatal surgery, the presence of a retrolingual obstruction, and the presence of a chronic disease that prevented surgery.

Of the 50 patients, 25 were randomly assigned to undergo anterior palatoplasty and 25 were randomized to uvulopalatal flap surgery. Tonsillectomy was not performed in either group. During surgery, sutures became unraveled in 3 palatoplasty patients and 2 flap 70 www.entjournal.com

patients, and thus these cases were not included in our final analysis. As a result, our final study population was made up of 45 patients. The palatoplasty group included 22 patients—12 men and 10 women, aged 28 to 49 years (mean: 39.2)—and the flap group included 23 patients—14 men and 9 women, aged 28 to 56 years (mean: 41.3).

Surgical procedures. Anterior palatoplasty. All palatoplasties were performed with general anesthesia.

First, the mucosa and submucosal tissue (including fat) were removed as a horizontal rectangular strip (70 to 100 mm long and 40 to 50 mm wide) from the lingual surface of the soft palate down to the muscle layer. Bipolar cautery was used for hemostasis. The remaining tissue was sutured with 4-0 Vicryl and a round-body curved needle.

Uvulopalatal flap procedure. All flap procedures were likewise performed with general anesthesia. After insertion of a Dingman mouth gag, the projection formed by folding the uvula toward the soft palate was determined and the mucosa, submucosa with glands, and the fat on the lingual surface of the uvula and soft palate according to the determined area were removed with a scalpel. Then the uvular tip was amputated. Once bleeding was controlled, horizontal incisions were made to the upper part of the posterior plicas of the tonsils.

The uvula was folded into its new position and was fixed with 3-0 Vicryl sutures.

During the postoperative period, patients were administered analgesia in the form of acetaminophen at 250 mg/5 ml in doses of 10 to 15 mg/kg per dose 4 times a day.18 Patients were permitted to take additional acetaminophen as long as the total daily dose did not exceed 4 g. All acetaminophen intake was recorded.

Data collection. In addition to demographic information, we compiled pre- and postoperative data on patients’ AHI, snoring, sleep quality, daytime sleepiness, and postoperative pain. We also recorded the duration of surgery and the amount of intraoperative blood loss.

AHI. The primary outcomes measure was the difference between pre- and postoperative AHI at 6 months after surgery as determined by polysomnography. The other findings were secondary outcomes.

Snoring. Snoring was assessed by bed partners preoperatively and 6 months postoperatively with the use of a visual analog scale (VAS) of 0 (none) to 10 (extremely loud).

Quality of sleep. We assessed the quality of sleep with the Pittsburgh Sleep Quality Index (PSQI), which is one of the most commonly used scales in sleep research.19 It was originally designed for use in clinical populations as a simple and valid assessment of both sleep quality and sleep disturbance that might affect sleep quality.

ENT-Ear, Nose & Throat Journal March 2018

COMPARISON OF ANTERIOR PALATOPLASTY AND UVULOPALATAL FLAP PLACEMENT FOR TREATING MILD AND MODERATE OBSTRUCTIVE SLEEP APNEA

The advantages of the PSQI include its ability to (1) discern patterns of sleep dysfunction over a stipulated period of 1 month by assessing qualitative as well as quantitative data and (2) allow for the calculation of a simple global score that can convey both the number and severity of sleep problems for use in both clinical practice and research.

The PSQI consists of 19 individual items that produce seven component scores and a global sleep quality score.

The seven components include sleep quality, sleep latency, sleep duration, sleep efficiency, sleep disturbance, use of sleeping medications, and daytime dysfunction.

These components were chosen on the basis of the standard areas that are assessed by clinicians during routine examinations of sleep problems. The PSQI is based on variable response categories pertaining to a patient’s usual bedtime, usual wake time, the number of hours actually slept, and the number of minutes that passed before falling asleep, as well as forced-choice Likert-type responses.

The total PSQI score can range from 0 to 21. A score of more of than 5 indicates poor sleep quality.

Daytime sleepiness. The Epworth Sleepiness Scale (ESS) is an 8-item questionnaire designed to capture an individual’s propensity to fall asleep during commonly encountered situations.13 Each item score ranges from 0 to 3, and the total score can range from 0 to 24. In adults, an ESS score of 10 or more is taken to indicate increased daytime sleepiness.20 Pain. Patients’ postoperative pain was evaluated at 2, 4, 8, 16, and 24 hours and once each on days 2, 3, 4, 5, 6, and 7. We assessed pain at rest and pain during swallowing on a VAS of 0 (none) to 10 (worst pain imaginable).

Statistical analysis. Statistical analysis was performed with the Statistical Package for the Social Sciences software (v. 16.0). Analyses were performed with the chi-square test, Mann-Whitney U test, and Wilcoxon

signed rank test. A p value <0.05 was considered statistically significant.

Ethical considerations. This study was conducted in accordance with the principles of the Declaration of Helsinki.21 Approval of the study protocol was granted by the Ethics Committee at Adana Numune Training and Research Hospital. All patients provided written informed consent.

Results

Sex and age. There were no statistically significant differences between the two study groups in terms of sex (p = 0.668) or age (p = 0.290).

BMI, duration of surgery, and blood loss. There were no statistically significant differences in BMI between the two groups and no significant differences within groups pre- and postoperatively. The mean duration of surgery was 29.1 minutes in the palatoplasty group and 32.9 minutes in the flap group (p = 0.057). The mean amount of intraoperative blood loss in the two groups was 6.8 and 7.4 ml, respectively (p = 0.991) (table 1).

AHI. The mean AHI in the palatoplasty group improved significantly from 17.5 before surgery to 8.1 at 6 months postoperatively (p < 0.001). In the flap group, the AHI fell from 18.5 to 8.6 (p < 0.001). There were no significant differences between the two groups either pre- or postoperatively (table 2).

Based on the AHI, we determined that the surgical success rates were 81.8% in the palatoplasty group (18 of 22 patients) and 82.6% in the flap group (19 of 23 patients). We defined success as described by Sher et al 22 as a postoperative reduction of at least 50% in the AHI combined with a postoperative AHI of less than 10.

Snoring. The VAS score for snoring was 8.1 preoperatively and 3.0 postoperatively (p < 0.001) in the palatoplasty group and 8.6 and 2.8, respectively, in the

Table 1. Comparison of BMI values, duration of surgery, and amount of intraoperative blood loss between the two groups Palatoplasty group

Flap group

Mean ± SD

Range

Mean ± SD

Range

Statistical difference*

Preoperative

28.0 ± 1.6

24.8 to 29.9

27.3 ± 1.8

23.4 to 29.9

p = 0.266

Postoperative

27.9 ± 1.4

25.1 to 29.7

27.3 ± 1.7

23.0 to 29.6

p = 0.195

Variable BMI

Statistical difference†

p = 0.797, z = –0.257

p = 0.722, z = –0.356

Duration of surgery, min

29.1 ± 6.4

20.0 to 40.0

32.9 ± 5.9

23.0 to 42.0

p = 0.057

Blood loss, ml

6.8 ± 2.9

5.0 to 15.0

7.4 ± 4.2

5.0 to 20.0

p = 0.991

* Indicates p value according to the Mann-Whitney U test, reflecting differences between the two groups. † Indicates p value according to the Wilcoxon signed rank test, reflecting differences between pre- and postoperative values.

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Table 2. Comparison of AHI, snoring, sleep quality, and daytime sleepiness values between the two groups pre- and postoperatively Palatoplasty group

Flap group

Mean ± SD

Range

Mean ± SD

Range

Statistical difference*

Preoperative

17.5 ± 8.2

5.8 to 29.9

18.5 ± 7.9

6.1 to 29.7

p = 0.555

Postoperative

8.1 ± 7.3

1.4 to 32.5

8.6 ± 6.9

2.1 to 32.1

p = 0.593

Variable AHI

Statistical difference†

p < 0.001, z = –4.043

p < 0.001, z = –4.000

Snoring (VAS score) Preoperative Postoperative Statistical difference

†

8.1 ± 1.7

5 to 10

8.6 ± 1.4

5 to 10

p = 0.376

3.0 ± 2.7

0 to 10

2.8 ± 2.9

0 to 10

p = 0.736

p < 0.001, z = –3.835

p < 0.001, z = –3.911

Sleep quality (total PSQI) Preoperative

5.9 ± 1.9

4 to 9

6.7 ± 1.5

4 to 10

p = 0.090

Postoperative

4.3 ± 1.2

3 to 8

4.7 ± 1.2

3 to 9

p = 0.142

Statistical difference†

p < 0.001, z = –3.588

p < 0.001, z = –3.498

Daytime sleepiness (total ESS) Preoperative Postoperative Statistical difference

†

13.6 ± 3.3

9 to 20

10.8 ± 3.3

6 to 18

p = 0.010

6.4 ± 3.3

3 to 18

5.4 ± 4.8

1 to 20

p = 0.010

p < 0.001, z = –4.023

p < 0.001, z = –3.599

Key: VAS = visual analog score (0 to 10); PSQI = Pittsburgh Sleep Quality Index (0 to 21); ESS = Epworth Sleepiness Scale (0 to 24). * Indicates p value according to the Mann-Whitney U test, reflecting differences between the two groups. † Indicates p value according to the Wilcoxon signed rank test, reflecting differences between pre- and postoperative values.

flap group (p < 0.001). Again, the differences between groups were not significant (table 2).

Sleep quality. The PSQI score in the palatoplasty group was 5.9 preoperatively and 4.3 postoperatively (p < 0.001); in the flap group, the corresponding scores were 6.7 and 4.7 (p < 0.001). The differences between the two groups at both assessments were not significant (table 2).

Daytime sleepiness. ESS values in the palatoplasty group improved from 13.6 to 6.4 (p < 0.001), and in the flap group they improved from 10.8 to 5.4 (p < 0.001).

The differences between the two groups were not significant (table 2).

Postoperative pain. VAS scores for postoperative pain at rest were significantly lower in the palatoplasty group than in the flap group at postoperative hours 2, 4, and 8 and on days 4 through 7 (p < 0.002). Scores in the palatoplasty group peaked throughout the first 24 hours after surgery. In the flap group, scores were likewise highest on the day of surgery, and they generally declined afterward (figure 1).

Likewise, scores for pain during swallowing were significantly lower in the palatoplasty group at 2, 4, 8, and 16th hours and on days 4 through 7 (p < 0.009). Scores in both groups generally declined after day 1 (figure 2).

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Other complications. No primary or secondary hemorrhage or velopharyngeal insufficiency was observed in any patient. In the flap group, 8 patients reported a continuing foreign-body sensation in the pharynx at 6 months postoperatively; only 1 patient in the palatoplasty group reported the same.

Discussion

The goal of surgery in OSAS patients is to create greater airway dimensions while causing minimal postoperative complications after the operation.23 One of the complications that surgeons wish to avoid is postoperative discomfort.

In our study, we found that anterior palatoplasty and the uvulopalatal flap procedure were equally efficacious in treating OSAS. There were no significant differences in outcomes between the two groups in terms of the duration of surgery, intraoperative blood loss, and postoperative AHI, snoring, sleep quality, and daytime sleepiness. Moreover, in both groups, the AHI, snoring, PSQI, and ESS values were all significantly lower at 6 months postoperatively than they were preoperatively.

The only significant difference we observed between the two groups was that the degree of postoperative ENT-Ear, Nose & Throat Journal March 2018

HAYTO LU, ARIKAN, MULUK, TUHANIO LU, ÇÖRTÜK

and daytime sleepiness before and 24 months after surgery, along with postoperative pain. They found that mean snoring VAS scores and ESS scores were significantly lower after surgery in both groups (p < 0.025 for both). Pain scores were significantly lower in the palatoplasty group (p < 0.001). Patient satisfaction Figure 1. Graph shows the VAS scores for postoperative pain at rest in the two groups. Scores were significantly lower in the palatoplasty group at postoperative hours 2, 4, and 8 and on days 4 through scores were 85% in the palatoplasty group and 7 (p < 0.002).

70% in the mUPPP group. pain at rest and during swallowing was less in the Cekin et al compared UPPP and uvulopalatal flap palatoplasty group. placement in OSAS patients and found that snoring The success rates in our study—81.8% in the palato- was relieved in 85% of the UPPP patients and 83.3% plasty group and 82.6% in the flap group—were similar of the flap patients 90 days after surgery.13 The degree to those observed in previous studies.14-16 As mentioned, of postoperative pain was greater in the UPPP group, Pang and Terris reported a success rates of 75.0%,14 and and the mean duration of pain was significantly lonPang et al reported a success rate of 71.8%15 in their ger. The authors concluded that the uvulopalatal flap studies of anterior palatoplasty. procedure was preferable to UPPP. In the previously mentioned comparison of anterior Akcam et al compared the severity of pain occurpalatoplasty and uvulopalatal flap placement by Mar- ring after different surgical procedures and sought to zetti et al, the success rates with both procedures—86 determine appropriate analgesic requirements for the and 84%, respectively—were very similar to ours.16 In first 24 hours postoperatively.25 In their study, patients that study, mean ESS values fell from 8.5 ± 3.7 preop- underwent either anterior palatoplasty, lateral pharyneratively to 4.9 ± 3.2 postoperatively (p < 0.001) after goplasty, or tongue base suspension suturing. Tramadol anterior palatoplasty and from 8.1 ± 3.5 to 5.2 ± 3.2 after delivered by a patient-controlled analgesia device and, the flap procedure (p < 0.001). A satisfactory reduction when necessary, rescue pethidine (meperidine in the in the volume of snoring on polysomnography data United States) were used for pain relief. was achieved in both groups. In addition, responses Postoperative pain scores in the tongue base susto the Müller maneuver improved from 2.7 ± 1.0 to 1.1 pension group of the Akcam study were higher than ± 0.9 (p < 0.001) after anterior palatoplasty and, to a those in the palatoplasty group at all time points except lesser extent, from 2.8 ± 1.1 to 1.8 ± 1.1; p < 0.05) after at hour 12, and they were higher than those in the the flap procedure. The mean duration of pain was 7.1 lateral pharyngoplasty group except at hour 10; pain and 10.8 days, respectively; mean pain scores during scores were significantly higher in the lateral pharynthe first 3 days were 5.1 and 6.8. The authors suggested that anterior palatoplasty was more practical and resulted in less discomfort than the flap procedure.

In a study published in 2013, Ugur et al compared the long-term efficacy of anterior palatoplasty and modified uvulopalatopharyngoplasty (mUPPP) Figure 2. Graph shows the VAS scores for postoperative pain during swallowing in the two groups. in 50 patients.24 The au- Scores were significantly lower in the palatoplasty group at 2, 4, 8, and 16 hours and on days 4 through thors evaluated snoring 7 (p < 0.009).

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HAYTO LU, ARIKAN, MULUK, TUHANIO LU, ÇÖRTÜK

goplasty group than in the palatoplasty group at hour 1.25 Mean total tramadol consumption was highest in the tongue base suspension group and lowest in the palatoplasty group.

Akcam et al concluded that patient-controlled analgesia with tramadol effectively treated the pain caused by anterior palatoplasty and lateral pharyngoplasty, but alleviation of the pain caused by tongue base suspension suturing usually required a rescue opioid analgesic. In our study, pain scores were lower in the palatoplasty group than in the flap group, which might reflect the fact that anterior palatoplasty is a less invasive procedure.

In our study, the degree of postoperative pain at rest was significantly less in the palatoplasty group than in the flap group at 2, 4, and 8 hours and on days 4 through 7. Pain scores in the palatoplasty group peaked at 24 hours. In the flap group, pain at rest values peaked between 8 and 16 hours.

Postoperative pain scores during swallowing were significantly lower in the palatoplasty group than in the flap group at 2, 4, 8, and 16 hours and on days 4 through 7. Scores peaked at 24 hours in the palatoplasty group and at 16 hours in the flap group.

In conclusion, our study found that anterior palatoplasty and uvulopalatal flap placement were equally effective in the treatment of patients with mild and moderate OSAS secondary to retropalatal obstruction.

However, we recommend anterior palatoplasty because it is associated with less postoperative pain.

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15. Pang KP, Tan R, Puraviappan P, Terris DJ. Anterior palatoplasty for the treatment of OSA: Three-year results. Otolaryngol Head Neck Surg 2009;141(2):253-6.

16. Marzetti A, Tedaldi M, Passali FM. Preliminary findings from our experience in anterior palatoplasty for the treatment of obstructive sleep apnea. Clin Exp Otorhinolaryngol 2013;6(1):18-22.

17. Brodsky L. Modern assessment of tonsils and adenoids. Pediatr Clin North Am 1989;36(6):1551-69.

18. Goldman RD, Scolnik D. Underdosing of acetaminophen by parents and emergency department utilization. Pediatr Emerg Care 2004;20(2):89-93.

19. Buysse DJ, Reynolds CF III, Monk TH, et al. The Pittsburgh Sleep Quality Index: A new instrument for psychiatric practice and research. Psychiatry Res 1989;28(2):193-213.

20. Johns MW. A new method for measuring daytime sleepiness: The Epworth sleepiness scale. Sleep 1991;14(6):540-5.

21. No authors listed. World Medical Association Declaration of Helsinki: Ethical principles for medical research involving human subjects. JAMA 2000;284(23):3043-5.

22. Sher AE, Schechtman KB, Piccirillo JF. The efficacy of surgical modifications of the upper airway in adults with obstructive sleep apnea syndrome. Sleep 1996;19(2):156-77.

23. Lye KW, Waite PD, Meara D, Wang D. Quality of life evaluation of maxillomandibular advancement surgery for treatment of obstructive sleep apnea. J Oral Maxillofac Surg 2008;66(5):968-72.

24. Ugur KS, Kurtaran H, Ark N, et al. Comparing anterior palato­ plasty and modified uvulopalatopharyngoplasty for primary snoring patients: Preliminary results. B-ENT 2013;9(4):285-91.

25. Akcam T, Arslan HH, Deniz S, et al. Comparison of early postoperative pain among surgical techniques for obstructive sleep apnea. Eur Arch Otorhinolaryngol 2012;269(11):2433-40.

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ORIGINAL ARTICLE

Psoriasis, chronic tonsillitis, and biofilms: Tonsillar pathologic findings supporting a microbial hypothesis Herbert B. Allen, MD; Saagar Jadeja, BS; Rina M. Allawh, MD; Kavita Goyal, MD

Abstract

Group A Streptococcus has been identified as a possible etiologic agent in psoriasis in epidemiologic, immunologic, immunopathologic, medical, and surgical studies.

Tonsillectomy has been shown to provide considerable relief to 75% of patients with plaque psoriasis. Even with the substantial evidence supporting group A Streptococcus as a causative pathogen in psoriasis, it is an elusive pathogen because it is not culturable, nor does it exhibit any positive serologic evidence of its presence.

One possible reason for the negative cultures and negative serology findings with group A Streptococcus is the development of biofilms. We conducted a pathologic study to determine whether biofilms were present in the tonsillar tissues of 10 patients with psoriasis—6 men and 4 women, aged 25 to 64 years (mean: 48)—and in 10 age- and sex-matched controls with chronic tonsillitis who did not have psoriasis. We found that biofilms were present in every tonsillectomy specimen we examined, including those of the controls. Whereas psoriasis has been considered a “double hit” phenomenon, we believe that the development of skin lesions is likely attributable to the presence of the gene PSORS together with the biofilm in psoriasis patients rather than to the biofilm itself. Biofilms have been identified in both extra- and intracellular locations. We believe our findings add further evidence supporting a microbial pathogenesis of this disease.

Introduction

Psoriasis is a chronic immunomediated inflammatory disease that affects 2 to 3% of adults.1 Patients with psoriasis develop erythematous, scaly plaques on their skin along with disfiguring nail and joint involvement.

Affected patients are more likely to experience major From the Department of Dermatology, Drexel University College of Medicine, Philadelphia.

Corresponding author: Herbert B. Allen, MD, Department of Dermatology, Drexel University College of Medicine, 219 N. Broad St., 4th Floor, Philadelphia, PA 19107. Email: hba25@drexel.edu Volume 97, Number 3

depression and have a higher risk of developing certain cardiovascular comorbidities, further contributing to the debilitating nature of the disease.1,2 The pathogenesis of psoriasis is multifactorial. It involves an intricate interplay between the immune system, individual genetics, and the environment.

One environmental factor of particular interest is the connection between tonsillar infection with group A Streptococcus and the development and maintenance of the psoriatic phenotype. It has been well reported that group A streptococcal pharyngitis often precedes the development of guttate psoriasis.3 Epidemiologic studies have shown that the prevalence of environmental group A Streptococcus correlates with the incidence of psoriasis.4 Moreover, psoriasis patients who have been treated with long-term penicillin injections have reported a very significant improvement in their Psoriasis Area and Severity Index (PASI) score.5 This connection notwithstanding, there is insufficient evidence demonstrating that persistent group A streptococcal infection is present in plaque psoriasis because (1) the group A pathogen Streptococcus pyogenes is not easily cultured and (2) elevated antistreptolysin titers are not present in all affected individuals.6 One possible explanation for the lack of culturability and the lack of serum markers is evasion of the host’s immune response via the formation of intricate biofilms within the tonsils. Evasion of the immune system promotes bacterial growth and survival despite the use of antistreptococcal agents, which are unable to penetrate the biofilms.

Biofilms are clusters of microorganisms that adhere to biologic or nonbiologic surfaces. They exist in a matrix of extracellular polysaccharides, amyloid, adhesive fibers, and DNA. The term extracellular polysaccharides refers to the biomass outside the bacteria, which makes up the bulk of the biofilm; the term intracellular biofilms refers to the biofilms within the host cells. The bacteria manufacture both the extracellular polysaccharides and the amyloid, which form the infrastructure of the biofilm. www.entjournal.com 79

Allen, Jadeja, Allawh, Goyal

In a meta-analysis of studies of tonsillectomy and psoriasis, Thorleifsdottir et al concluded that tonsillectomy was a worthwhile treatment in 70% of psoriasis patients.7 In a recent surgical study, Rachakonda et al found that tonsillectomy reversed the development of plaque psoriasis in 13 of 15 patients.8 In this article, we describe our investigation aimed at evaluating the presence of biofilms in tonsillectomy specimens obtained from patients with psoriasis.

Materials and methods

We performed a histopathologic analysis of tonsillectomy specimens obtained from 10 patients—6 men and 4 women, aged 25 to 64 years (mean: 48)—who had been given a clinical diagnosis of plaque psoriasis. We compared the findings in these specimens with those of an age- and sex-matched control group of patients with chronic tonsillitis who did not have psoriasis. All tonsillar specimens were stained with routine hematoxylin and eosin, periodic acid–Schiff (PAS), and Congo red. Routine light microscopy was employed for evaluation.

All protocols were approved by the Drexel University College of Medicine Institutional Review Board.

Results

On gross examination, we found no appreciable differences in the tonsillectomy specimens between the psoriasis patients and the controls. On histopathologic evaluation, all tonsillectomy specimens from the psoriasis patients demonstrated positive extra- and intracellular staining with both PAS and Congo red. The positive PAS staining indicated the presence of polysaccharides (figure 1, A), while the positive Congo red staining indicated the presence of amyloid (figure 1, B). The tonsillectomy specimens from the controls exhibited similar features.

Uninvolved crypts that A showed no PAS or Congo red staining were present in both cohorts (figure 2). Using these crypts as internal controls could possibly make for a better evaluation.

PAS and Congo red staining within the tonsillar epithelial cells, our results showed that group A streptococcal organisms persist within intracellular biofilms in psoriasis patients. Extracellular biofilms are evident, as well. These findings raise important considerations regarding the role of group A streptococcal infection in the pathogenesis of psoriasis.

One of these considerations is that the psoriatic phenotype may be propagated by chronic group A streptococcal tonsillitis. This is supported by the work of El-Rachkidy et al, who found that a significantly greater number of patients with chronic plaque psoriasis had elevated titers of IgG-reactive proteins to S pyogenes compared with healthy age- and sex-matched controls.9 Support for this consideration was reported by Zhang et al, who found Toll-like receptor 2 in the upper dermal capillaries in psoriatic plaques.10 It appears that both the innate and adaptive immune systems may be involved.

The concept of group A Streptococcus as a pathogen in psoriasis was further corroborated in a study by Saxena and Dogra, who found that patients exhibited a significant improvement in PASI scores after receiving long-term penicillin or azithromycin therapy for chronic plaque psoriasis.11 However, they noted that 20% of their patients had developed a recurrence of their symptoms at 1 year of follow-up.5,11 We hypothesize that these recurrences were attributable to the antibiotics addressing the transient bacteremia that occurs in chronic group A streptococcal tonsillitis because antibiotics would kill any cells released (exported) from the biofilm and not allow those microbes to generate an immune response.

The organisms still exist latently within both extra- and intracellular biofilms and thus they are protected from the effects of the antibiotics.

A word about the controls in our study: We believe psoriasis is a “double hit” phenomenon in which the

B

Discussion

To the best of our knowledge, this is the first study to look for the presence of tonsillar extra- and intracellular biofilms in patients with psoriasis. As evidenced by the positive 80 www.entjournal.com

Figure 1. Images show stains of tonsillar specimens obtained from a patient with psoriasis. A: PAS staining shows an extracellular biomass (red arrow) that consists mostly of polysaccharides. An intracellular biofilm with retained nuclei (black arrows) is also seen (original magnification ×40).

B: Congo red staining is positive for amyloid in the cell’s cytoplasm, which forms the infrastructure of biofilms (black arrows). The nuclei of these cells are clearly present. Large areas of staining (without nuclei) represent extracellular biofilms (white arrows) (original magnification ×40).

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gating the relationship between chronic group A streptococcal tonsillitis and the psoriatic phenotype, as well as the utility of antistreptococcal and biofilm-dispersing agents in the management of psoriasis, should be encouraged.

References

1. Kurd SK, Troxel AB, Crits-Christoph P, Gelfand JM. The risk of depression, anxiety, and suicidality in patients with psoriasis: A population-based cohort study. Arch Dermatol 2010;146(8):891-5.

Figure 2. Tonsillar crypt in a patient with psoriasis shows no staining with Congo red. 2. Gelfand JM, Neimann AL, Shin DB, et al. Risk of myocardial infarction in patients with psoriasis.

Tonsillar epithelial cells line the crypt (original magnification ×10).

JAMA 2006;296(14):1735-41.

3. Telfer NR, Chalmers RJ, Whale K, Colman G. The role of environmental component is group A Streptococcus streptococcal infection in the initiation of guttate psoriasis. Arch and the genetic component is one of the PSORS genes or Dermatol 1992;128(1):39-42.

12 another gene. Thus, in patients with chronic tonsillitis, 4. McFadden JP, Baker BS, Powles AV, Fry L. Psoriasis and streptococci: The natural selection of psoriasis revisited. Br J psoriasis would become evident only in those who have Dermatol 2009;160(5):929-37. a gene for the disease. Therefore, the tonsillar microbio5. Saxena VN, Dogra J. Long-term use of penicillin for the treatment logic/pathologic findings would be the same in chronic of chronic plaque psoriasis. Eur J Dermatol 2005;15(5):359-62. tonsillitis in patients with and without psoriasis. The high 6. Kim SK, Kang HY, Kim YC, Lee ES. Clinical comparison of levels of Streptococcus-specific IgG in some controls, as psoriasis in Korean adults and children: Correlation with serum anti-streptolysin O titers. Arch Dermatol Res 2010;302(4):295-9. noted by El-Rachkidy et al,9 help support this hypothesis.

7. Thorleifsdottir RH, Sigurdardottir SL, Sigurgeirsson B, et al.

We, among others, have previously described the Improvement of psoriasis after tonsillectomy is associated with presence of biofilms and their role in the pathogenesis a decrease in the frequency of circulating T cells that recognize of a variety of skin diseases, including atopic dermatitis, streptococcal determinants and homologous skin determinants.

13,14 Lyme disease, and tinea versicolor. In these disease J Immunol 2012;188(10):5160-5.

8. Rachakonda TD, Dhillon JS, Florek AG, Armstrong AW. Effect processes, the biofilms were extracellular rather than of tonsillectomy on psoriasis: A systematic review. J Am Acad intracellular. More recently, we reported that intracelDermatol 2015;72(2):261-75. lular biofilms were found in hippocampal specimens 9. El-Rachkidy RG, Hales JM, Freestone PP, et al. Increased blood 15 in patients with Alzheimer disease. levels of IgG reactive with secreted Streptococcus pyogenes The distinction between extra- and intracellular proteins in chronic plaque psoriasis. J Invest Dermatol 2007; 127(6):1337-42. biofilms is particularly important because intracellular 10. Zhang J, Shaver C, Neidig L, et al. Toll-like receptor 2 and its biofilms provide another level of protection against both relationship with Streptococcus in psoriasis. Skinmed 2017; the immune system and antibiotics, and thus they are 15(1):27-30.

16 increasingly difficult to eradicate. In the context of 11. Saxena VN, Dogra J. Long-term oral azithromycin in chronic psoriasis, tonsillar intracellular biofilms may serve as a plaque psoriasis: A controlled trial. Eur J Dermatol 2010;20(3): 329-33. nidus of infection and can provide antigens that stimu12. Chang YT, Chou CT, Shiao YM, et al. Psoriasis vulgaris in late skin-homing T cells through molecular mimicry.17 Chinese individuals is associated with PSORS1C3 and CDSN This chronic state may help explain the relapsing and genes. Br J Dermatol 2006;155(4):663-9. remitting nature of the psoriatic phenotype.

13. Gantz M, Allen HB. Psoriasis, atopic dermatitis, Lyme disease The current treatment paradigm for psoriasis is and tinea versicolor: All caused by microbes but none a classic infection. J Clin Exp Dermatol Res 2016;4:362. based on using topical and systemic agents to modify 14. Allen HB, Vaze ND, Choi C, et al. The presence and impact of the immune pathways that contribute to keratinocyte biofilm-producing staphylococci in atopic dermatitis. JAMA proliferation and the development of psoriatic lesions.

Dermatol 2014;150(3):260-5.

Despite the availability of multiple treatment modalities, 15. Allen HB, Allawh R, Touati A, et al. Alzheimer’s [sic] disease: including newer systemic immunomodulatory agents, The novel finding of intracellular biofilms. J Neuroinfect Dis 2017;8(2):247. patients often require life-long treatment and are subject 16. Scott VC, Haake DA, Churchill BM, et al. Intracellular bacterial to a host of side effects. Given our findings, it may be communities: A potential etiology for chronic lower urinary tract that immunomodulatory therapies work too far downsymptoms. Urology 2015;86(3):425-31. stream and do not directly address the causative entity.

17. Valdimarsson H, Thorleifsdottir RH, Sigurdardottir SL, et al.

Additional weight should likely be given to tonsillecPsoriasis—as an autoimmune disease caused by molecular mimicry. Trends Immunol 2009;30(10):494-501. tomy in psoriasis because it has the capability of being

curative with a single procedure. Also, studies investi-

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ORIGINAL ARTICLE

Quality of life in patients with larynx cancer in Latin America: Comparison between laryngectomy and organ preservation protocols Alvaro Sanabria, MD, PhD, FACS; Daniel Sánchez, MD; Andrés Chala, MD; Andres Alvarez, MD

Abstract

The effect on quality of life (QOL) of laryngectomy and organ preservation protocols is important in decision making. The aim of this cross-sectional study was to evaluate QOL outcomes of patients with advanced laryngeal tumors who were treated with laryngectomy or organ preservation protocols in Latin America. A total of 35 patients from three oncology units were enrolled. Patients with stage III/IV laryngeal cancer who were treated using organ preservation protocols or laryngectomy were assessed with the University of Washington QOL Questionnaire. The most important domains that affected QOL for both groups were speech and activity. In the laryngectomy group, the next most important domains were appearance, taste, pain, and recreation, whereas in the organ preservation group, they were saliva, recreation, mood, and swallowing. There were no statistically or clinically significant differences in the global score or the 7 days of QOL assessments before patients were interviewed. Global QOL assessments were similar when comparing laryngectomy and organ preservation protocols.

Introduction

Laryngeal cancer is one of the most common tumors of the respiratory tract. Chemoradiotherapy and surgery are believed to offer similar final outcomes; however, laryngectomy impairs quality of life (QOL) as a result of definitive tracheostomy and the loss of vocal speech.1 From the Department of Surgery, Universidad de Antioquia, Medellin, Colombia (Dr. Sanabria and Dr. Sánchez); Fundación Colombiana de Cancerología–Clínica Vida, Medellin, Colombia (Dr. Sanabria); the Department of Surgery, Universidad de Caldas, Manizales, Colombia (Dr. Chala); and the Department of Surgery, Universidad del Rosario, Bogota, Colombia (Dr. Alvarez).

Corresponding author: Alvaro Sanabria, MD, PhD, FACS, Department of Surgery, Universidad de Antioquia, Calle 67 No. 53 - 108, Medellin, Colombia. Email: alvarosanabria@gmail.com Volume 97, Number 3

Organ preservation protocols focusing on larynx preservation are widely offered to patients with T3 tumors without massive invasion of cartilage.2 For patients with more advanced tumors, the effectiveness of chemoradiotherapy compared with total laryngectomy is controversial, with an increasing acceptance of laryngectomy as a more effective strategy.3 In arriving at a therapeutic modality, most physicians and patients consider QOL concerns to be as important as long-term survival.4 One factor favoring organ preservation treatments is the possibility of breathing and talking with natural organs but with a higher rate of adverse effects related to the long-term sequelae of chemotherapy or radiotherapy, such as xerostomia and swallowing disorders. Laryngectomy, therefore, is not usually considered to be the first alternative due to attitudes related to poorer QOL. Many studies have evaluated QOL outcomes in cohorts of patients who underwent organ preservation or laryngectomy; few randomized controlled trials, however, have compared the results between both strategies. The few randomized comparisons that have been conducted show similar or better results in organ preservation treatments.5,6 Most of this information comes from QOL assessments in English literature and primarily in patients from developed countries with specific social and economic characteristics.

Data from patients in developing countries and in different cultural settings are lacking. Despite QOL findings coming from Brazilian investigators,7,8 data are scarce for Spanish-speaking countries.9,10 Because QOL assessments change according to socioeconomic factors, results are difficult to extrapolate to different populations.

The aim of this study was to evaluate the QOL outcomes of patients with advanced laryngeal tumors who were treated with laryngectomy or organ preservation protocols in Latin America. www.entjournal.com 83

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Patients and methods

Results This study was approved by the Ethics in Research We included 35 patients, 14 of whom were treated with Committee of the Hospital Pablo Tobón Uribe, and an organ preservation protocol; 21 patients underwent informed consent was obtained for inclusion. Patients laryngectomy. The demographic data and clinical and with laryngeal cancer classified as stage III or IV who treatment characteristics are shown in table 1. The were treated under organ preservation protocols (in- mean age was 61.4 ± 9.5 years (median: 62; range: 41 cluding chemoradiotherapy or exclusive radiotherapy) to 87). A total of 94.3% of the 35 patients were men. or laryngectomy were included. The choice of treat- Patients were interviewed for symptoms 17.7 ± 21.4 ment was at the discretion of the treating physicians, months after diagnosis (median: 10.9). who were following the guideline established by the Ten patients (71.4%) who were treated with an organ National Comprehensive Cancer Network.11 preservation protocol needed definitive tracheostomy, All patients must have completed their definitive and half of the patients in each group had a gastrostomy treatment and were being followed at the Head and tube. A total of 22.9% had recurrence at the time of the Neck Section of the Hospital Pablo Tobón Uribe Oncol- interview. The only baseline difference between the two ogy Unit, Medellin; Hospital Universitario de Caldas, groups was that the group that underwent laryngectomy Manizales; and the Hospital Mederi, Bogotá, Colombia. had a lower proportion of adjuvant chemoradiotherapy.

Patients with physical impairments that prevented The burden of symptoms on the UW-QOL instrument reading, hearing, or understanding the QOL scale, is shown in table 2. The most important factors on QOL those for whom the last treatment date was more than 5 for both groups were speech and activity, respectively. years ago, and those who did not consent to participate In the laryngectomy group, the next most important were excluded. factors were appearance, taste, pain, and recreation; for Patient data were collected prospectively during rou- the organ preservation group, the next most important tine clinical visits from February 2013 to January 2015. factors were saliva, recreation, mood, and swallowing.

To evaluate QOL outcomes, we used the Spanish val- The descriptive distribution of domains of the UW-QOL idated version of the University of Washington Quality is shown in table 3. of Life (UW-QOL) questionnaire for patients with head Statistically significant differences were found in and neck cancer, assisting those patients who could not activity and speech, with worse scores for the larynread the instrument to obtain the relevant information. gectomy group. Although not statistically significant, This instrument has been evaluated in many clinical more than a 10-point decrement (clinically relevant) settings and has been translated to and validated in was found in the shoulder, anxiety, swallowing, taste, many languages.12-17 and appearance domains among the patients who The UW-QOL has three domains (symptom, priority of underwent laryngectomy, and in the saliva domain symptoms, and global health-related QOL) with separate among the patients who received an organ preservation items (pain, ap­pearance, activity level, recreation, swallow- protocol. Both social and physical subscales had a difing, chewing, speech, shoulder function, taste, and saliva production) scored on a scale from 0 to 100. Table 1. Clinical characteristics in patients with advanced The burden of symptoms was defined fol- laryngeal cancer treated with or without laryngectomy lowing the coding instruction of the UW-QOL Without instrument, according to the rank that patients laryngectomy Laryngectomy gave to each symptom. We also obtained patient (n = 14) (n, %) (n = 21) (n, %) p Value demographics and information on stage and Eu12 (85.7) 21 (100) 0.07 ropean Cooperative Oncology Group functional Sex (male) Age (years)* 60.5 ± 10.2 (61) 62.0 ± 9.2 (62) 0.67 status from the clinical charts.

The categorical variables are presented as per- T3/4 11 (78.6) 21 (100) 0.16 centages and ranges, and the continuous variables N2-3 5 (35.7) 11 (52.4) 0.68 are shown as the means and standard deviation.

Radiotherapy 14 (100) 15 (71.4) 0.02 For the analysis, some continuous variables were Chemotherapy 12 (85.7) 5 (23.8) <0.01 categorized. The significance level was set at p < 7 (50) 11 (52.4) 0.89 0.05. Between-group differences were assessed Gastrostomy with the nonparametric Mann-Whitney and Recurrent disease 5 (35.7) 3 (14.3) 0.14 Kruskal-Wallis tests due to the non-normal ECOG 2-3 3 (21.4) 5 (23.8) 0.46 distribution of variables and the small sample size. We used the Stata statistical software v9.1 *Kruskal-Wallis test Key: ECOG = Eastern Cooperative Oncology Group.

(StataCorp; College Station, Texas).

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QUALITY OF LIFE IN PATIENTS WITH LARYNX CANCER IN LATIN AMERICA: COMPARISON BETWEEN LARYNGECTOMY AND ORGAN PRESERVATION PROTOCOLS

trials and meta-analyses.19,20 The introduction of these proWithout laryngectomy (n = 14) Laryngectomy (n = 21) tocols relegated laryngectomy to a secondary method in the Problem domain n % Problem domain n % Speech 6 42.9 Speech 16 76.2 treatment of advanced tumors due to the negative impact of a Activity 6 42.9 Activity 15 71.4 definitive tracheostomy with Saliva 6 42.9 Appearance 10 47.6 the loss of vocal ability and the Recreation 5 35.7 Taste 9 42.9 related consequences of this 21 Mood 4 28.6 Pain 9 42.9 procedure on appearance.

Swallowing 4 28.6 Recreation 9 42.9 However, for transglottic tumors with massive cartilage Pain 3 21.4 Mood 8 38.1 invasion, laryngectomy has Appearance 3 21.4 Anxiety 7 33.3 recently been demonstrated Anxiety 3 21.4 Swallowing 7 33.3 to offer advantages in terms Chewing 3 21.4 Shoulder 5 23.8 of disease-free and overall surTaste 3 21.4 Chewing 5 23.8 vival compared with chemoradiotherapy, producing a Shoulder 1 7.1 Saliva 3 14.3 renaissance of indications for and the use of total laryngecference of >10 points between groups, with lower scores tomy.22 Nonetheless, patients and physicians are aware observed for the laryngectomy group. No statistically of the negative effects of total laryngectomy on QOL, or clinically significant differences in the global score which impedes its wide use. or QOL assessments were observed during the 7 days QOL assessments have been made in patients who before the interview. underwent laryngectomy or organ preservation protocols and have shown similar or better results with organ Discussion preservation in the most recent studies.5,6 However, the QOL assessment has become important in decision perception of laryngectomy as a disastrous event has not making for patients with head and neck cancer. The been proven by data. List et al23 and Eadie and Bowker24 impact of a disease and its treatment is correlated with suggested that the ability to cope with impairments survival, ability to return to work, and social function- produced by laryngectomy shortens early differences ing.18 Many instruments with a general or specific fo- compared with organ preservation in QOL scores. cus have been designed to evaluate QOL in patients In periodic assessments, Deleyiannis et al25 found that with head and neck cancer. Although generic QOL in- QOL scores return to values similar to the presurgical struments can be used in a wide range of patients with stage after 2 years postlaryngectomy, whereas Hamdifferent types of tumors, they lack responsiveness for merlid et al26 found that a 1-year period is sufficient to specific ailments of each disease. The UW-QOL for compensate for the acute effects of treatment on QOL head and neck cancer is a widely used instrument with score. Therefore, although functional limitations persist high reliability that has been validated in the Spanish over time, the overall QOL scores reach those that are language, which enables its use in populations of de- similar to those of other diseases with an intact larynx.27 In our study, we found that the UW-QOL instrument veloping countries in Latin America.16 Due to its location in the body and its close relation- could define the specific ailments that decrease QOL in ship with feeding, communication, and interpersonal patients with head and neck cancer who had undergone (or relationships, head and neck cancer imposes an import- had not undergone) laryngectomy. For patients who have ant burden on QOL. Moreover, its related treatments undergone laryngectomy, the importance of appearance (chemotherapy, radiotherapy, and surgery) adversely due to the scar, neck deformity produced by the surgery, affect functions such as swallowing, speech, breathing, and the presence of a definitive tracheostomy in the neck and mastication, which can lead to even poorer QOL. were ranked as important domains that affect QOL. Since the 1990s, organ preservation protocols for The taste factor also ranked high due to the loss of smell patients with advanced tumors have been considered and the difficulty in rehabilitating this sense after surgery. to offer outcomes similar to those of laryngectomy In contrast, patients in the organ preservation group refollowed by radiotherapy, with the enormous advan- vealed that saliva and swallowing were important factors tage of larynx preservation and the consequent gain in QOL. The recreation factor ranked high in both groups in QOL, as demonstrated in randomized, controlled and represents a new finding. No data exist that shed Table 2. Significant problems in patients treated with or without laryngectomy

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light on the meaning of Table 3. Comparison of UW-QOL scale between patients treated with or without this finding for patients laryngectomy with head and neck canWithout laryngectomy (n = 14) Laryngectomy (n = 21) p Value* cer, although it may be a mean ± SD (median) mean ± SD (median) proxy for depression or Global 69.8 ± 18.7 (74.7) 61.4 ± 18.4 (66.3) 0.13 life enjoyment.

71.4 ± 32.3 (75) 66.3 ± 37.4 (75) 0.71 The most important Previous QOL finding of this study was QOL last 7 days 60.0 ± 27.2 (50) 67.4 ± 26.8 (60) 0.35 that QOL global scores Social subscale 75.1 ± 21.1 (74.6) 65.9 ± 18.9 (70) 0.27 were similar in both 65.6 ± 21.1 (65.4) 57.0 ± 20.1 (62.5) 0.29 groups, even though in- Physical subscale 57.1 ± 31.9 (70) 26.8 ± 28.1 (30) <0.01 dividual domains such Speech 73.2 ± 26.8 (75) 52.4 ± 26.1(50) 0.03 as activity and speech Activity ranked lower in the lar- Appearance 78.6 ± 19.2 (75) 65.5 ± 23.0 (75) 0.09 yngectomy group. These Saliva 59.3 ± 38.3 (70) 80.5 ± 25.6 (100) 0.10 results are similar to 70.0 ± 35.9 (70) 52.9 ± 38.2 (70) 0.17 those reported in other Taste 88.6 ± 27.7 (100) 73.3 ± 37.7 (100) 0.18 studies. In 42 patients, Shoulder 76.4 ± 33.7 (100) 65.2 ± 31.9 (70) 0.23 Hanna et al could not Anxiety find global differences in Swallowing 62.3 ± 24.9 (70) 51.5 ± 31.2 (70) 0.36 QOL between patients Chewing 61.5 ± 41.6 (50) 66.6 ± 42.8 (100) 0.66 who underwent laryn67.8 ± 28.5 (75) 65.5 ± 24.3 (75) 0.71 gectomy or organ pres- Recreation 67.8 ± 31.7 (75) 64.3 ± 33.1 (75) 0.76 ervation protocols, as Mood 76.8 ± 22.9 (75) 75 ± 28.5 (100) 0.98 measured with the Eu- Pain ropean Organization for *Kruskal-Wallis test Research and Treatment Key: UW-QOL = University of Washington quality of Life questionnaire, SD = standard deviation, of Cancer Quality of Life QOL = quality of life.

Questionnaire, Head and Neck Module.28 Most of our scores were comparatively lower than The same results were obtained by other authors.25,29-31 The consistency of these findings confirms that after an those reported elsewhere, which indicates that the initial period of adaptation (as long as 2 years), patients relative importance of domains is different in our who undergo laryngectomy reach QOL scores that are population and that these differences should be similar to those of patients treated with chemoradio- considered when treatments are offered. In the Scottherapy and weakens the notion that laryngectomy is a land Laryngectomy Audit, Robertson et al found a disastrous event in a patient’s life. This lack of difference global score of 72.9 with high importance for speech, also may be explained by the high frequency of definitive swallowing, activity, mood, and appearance. 27 In our tracheostomy in the organ preservation group, which study, taste, pain, and recreation were important reduces the potential advantages offered by organ pres- domains. They are not currently reported in other ervation treatments in the voice and breath domains. studies and could represent a different weight for In other studies, the rate of tracheostomy was approx- items in the QOL questionnaire as rated by Latin imately 30%, whereas in our study, nearly three-fourths American patients.

Some weaknesses of this study should be noted. of patients had a tracheostomy. It is impossible to discard any of these hypotheses due to the design of this study. The first is related to the small sample size, which can Most studies on QOL in laryngectomy or organ explain clinically meaningful but not statistically sigpreservation protocols were performed in developed nificant differences in some domain scores. The second countries with specific socioeconomic and cultural limitation is related to the design of this study. It was characteristics. Until now, little information was avail- not a randomized trial, and treatment decisions were able on outcomes in patients in developing countries. A made by surgeons; thus, comparisons can introduce study by Vilaseca et al in 49 laryngectomized patients bias. Third, although a clear treatment protocol has found mean scores on the UW-QOL that ranged from been established, not all patients received the same 72 for taste to 89 for chewing.32 In our study patients, treatments, doses, and procedures. All of these factors domain scores varied from 26 for speech to 80 for saliva. can affect the measurement of QOL. 88 www.entjournal.com

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Sanabria, Sánchez, Chala, Alvarez

In conclusion, in a cohort of Latin American patients with laryngeal cancer, global QOL assessments were similar when comparing laryngectomy with organ preservation protocols. Important differences in specific domains should be identified to better explain the consequences of treatment. The relevance of domains and the scores of the UW-QOL instrument differ from those reported in developed countries; thus, local evaluations of QOL should be integrated in decision making.

References

1. Department of Veterans Affairs Laryngeal Cancer Study Group, Wolf GT, Fisher SG, et al. Induction chemotherapy plus radiation compared with surgery plus radiation in patients with advanced laryngeal cancer. N Engl J Med 1991;324(24):1685-90.

2. Forastiere AA, Weber RS, Trotti A. Organ preservation for advanced larynx cancer: Issues and outcomes. J Clin Oncol 2015; 33(29):3262-8.

3. Hoffman HT, Porter K, Karnell LH, et al. Laryngeal cancer in the United States: Changes in demographics, patterns of care, and survival. Laryngoscope 2006;116(9 Pt 2 Suppl 111):1-13.

4. McNeil BJ, Weichselbaum R, Pauker SG. Speech and survival: Tradeoffs between quality and quantity of life in laryngeal cancer.

N Engl J Med 1981;305(17):982-7.

5. Hillman RE, Walsh MJ, Wolf GT, et al. Functional outcomes following treatment for advanced laryngeal cancer. Part I—Voice preservation in advanced laryngeal cancer. Part II—Laryngectomy rehabilitation: The state of the art in the VA System. Research Speech-Language Pathologists. Department of Veterans Affairs Laryngeal Cancer Study Group. Ann Otol Rhinol Laryngol Suppl 1998;172:1-27.

6. Terrell JE, Fisher SG, Wolf GT. Long-term quality of life after treatment of laryngeal cancer. The Veterans Affairs Laryngeal Cancer Study Group. Arch Otolaryngol Head Neck Surg 1998; 124(9):964-71.

7. Vartanian JG, Carvalho AL, Yueh B, et al. Long-term qualityof-life evaluation after head and neck cancer treatment in a developing country. Arch Otolaryngol Head Neck Surg 2004; 130(10):1209-13.

8. Vartanian JG, Kowalski LP. Acceptance of major surgical procedures and quality of life among long-term survivors of advanced head and neck cancer. Arch Otolaryngol Head Neck Surg 2009;135(4):376-9.

9. Alvarez-Buylla Blanco M, Herranz González-Botas J. Evolución de la calidad de vida en pacientes intervenidos de carcinomas de orofaringe, laringe o hipofaringe [in Spanish]. Acta Otorrinolaringol Esp 2011;62(2):103-12.

10. Nazar GP, Gonzalez I, Messina A. Evaluación de la calidad de vida en pacientes tratados por cáncer de laringe [in Spanish]. Rev Otorrinolaringol Cir Cabeza Cuello 2004;64:9.

11. National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology (NCCN guidelines). Head and neck cancers. Version 2.2017. https://www.nccn.org/professionals/ physician_gls/pdf/head-and-neck.pdf. Accessed January 12, 2018.

12. Rogers SN, Lowe D, Brown JS, Vaughan ED. A comparison between the University of Washington Head and Neck DiseaseSpecific measure and the Medical Short Form 36, EORTC QOQ-C33 and EORTC Head and Neck 35. Oral Oncol 1998; 34(5):361-72.

13. Omoro SA, Fann JR, Weymuller EA, et al. Swahili translation and validation of the Patient Health Questionnaire-9 depression scale in the Kenyan head and neck cancer patient population. Int J Psychiatry Med 2006;36(3):367-81.

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14. Vartanian JG, Carvalho AL, Yueh B, et al. Brazilian-Portuguese validation of the University of Washington Quality of Life Questionnaire for patients with head and neck cancer. Head Neck 2006;28(12):1115-21.

15. D’cruz AK, Yueh B, Das AK, et al. Validation of the University of Washington quality of life questionnaires for head and neck cancer patients in India. Indian J Cancer 2007;44(4):147-54.

16. Nazar G, Garmendia ML, Royer M, et al. Spanish validation of the University of Washington Quality of Life questionnaire for head and neck cancer patients. Otolaryngol Head Neck Surg 2010;143(6):801-7.

17. Chang MY, Rogers SN, Lowe D, et al. The Korean version of the University of Washington Quality of Life Questionnaire for Patients with head and neck cancer, and its use in an initial validation study of 56 patients. Int J Oral Maxillofac Surg 2012;41(10):1201-5.

18. Østhus AA, Aarstad AK, Olofsson J, Aarstad HJ. Prediction of survival by pretreatment health-related quality-of-life scores in a prospective cohort of patients with head and neck squamous cell carcinoma. JAMA Otolaryngol Head Neck Surg 2013;139(1):14-20.

19. Blanchard P, Baujat B, Holostenco V, et al. Meta-analysis of chemotherapy in head and neck cancer (MACH-NC): A comprehensive analysis by tumour site. Radiother Oncol 2011; 100(1):33-40.

20. Pignon JP, le Maître A, Bourhis J, MACH-NC Collaborative Group. Meta-analyses of chemotherapy in head and neck cancer (MACH-NC): An update. Int J Radiat Oncol Biol Phys 2007;69(2 Suppl):S112-4.

21. Harwood AR, Rawlinson E. The quality of life of patients following treatment for laryngeal cancer. Int J Radiat Oncol Biol Phys 1983;9(3):335-8.

22. Megwalu UC, Sikora AG. Survival outcomes in advanced laryngeal cancer. JAMA Otolaryngol Head Neck Surg 2014; 140(9):855-60.

23. List MA, Ritter-Sterr CA, Baker TM, et al. Longitudinal assess­ ment of quality of life in laryngeal cancer patients. Head Neck 1996;18(1):1-10.

24. Eadie TL, Bowker BC. Coping and quality of life after total laryngectomy. Otolaryngol Head Neck Surg 2012;146(6):959-65.

25. Deleyiannis FW, Weymuller EA Jr, Coltrera MD, Futran N. Quality of life after laryngectomy: Are functional disabilities important? Head Neck 1999;21(4):319-24.

26. Hammerlid E, Silander E, Hörnestam L, Sullivan M. Healthrelated quality of life three years after diagnosis of head and neck cancer—a longitudinal study. Head Neck 2001;23(2):113-25.

27. Robertson SM, Yeo JC, Dunnet C, et al. Voice, swallowing, and quality of life after total laryngectomy: Results of the west of Scotland laryngectomy audit. Head Neck 2012;34(1):59-65.

28. Hanna E, Sherman A, Cash D, et al. Quality of life for patients following total laryngectomy vs chemoradiation for laryngeal preservation. Arch Otolaryngol Head Neck Surg 2004;130(7):875-9.

29. Williamson JS, Ingrams D, Jones H. Quality of life after treatment of laryngeal carcinoma: A single centre cross-sectional study.

Ann R Coll Surg Engl 2011;93(8):591-5.

30. Finizia C, Hammerlid E, Westin T, Lindström J. Quality of life and voice in patients with laryngeal carcinoma: A posttreatment comparison of laryngectomy (salvage surgery) versus radio­ therapy. Laryngoscope 1998;108(10):1566-73.

31. LoTempio MM, Wang KH, Sadeghi A, et al. Comparison of quality of life outcomes in laryngeal cancer patients following chemoradiation vs. total laryngectomy. Otolaryngol Head Neck Surg 2005;132(6):948-53.

32. Vilaseca I, Chen AY, Backscheider AG. Long-term quality of life after total laryngectomy. Head Neck 2006;28(4):313-20.

ENT-Ear, Nose & Throat Journal March 2018

ORIGINAL ARTICLE

“Split to save”: Accessing mandibular lesions using sagittal split osteotomy with virtual surgical planning Stanley Yung-Chuan Liu, MD, DDS; Douglas Sidell, MD; Leh-Kiong Huon, MD; Carlos Torre, MD

Abstract

Large, benign intramandibular lesions are frequently removed by resection followed by extensive free tissue transfer or delayed bone grafting. We outline a protocol to remove benign mandibular lesions using sagittal split osteotomy (SSO) with virtual surgical planning (VSP) to mitigate risks involved with this effective, tissue-saving approach. Patients with benign mandibular lesions accessed by SSO with VSP during 2014 were included in this study. Computed tomographic data were imported into VSP software. Using VSP, the exact locations of mandibular lesions and the inferior alveolar nerve canal were delineated. SSO was designed virtually and provided surgeons exact measurements to gain access to lesions and to avoid vital structures intraoperatively. SSO with VSP preserved the cortical mandibular bone and the inferior alveolar neurovascular bundle in 3 patients with benign mandibular lesions. Twelve months after surgery, no patient had pathologic fracture, prolonged paresthesia (except for the patient who required inferior alveolar nerve resection), or malocclusion. No patient required bone grafting. There were no functional or aesthetic jaw deficits.

SSO is an effective approach to access intramandibular lesions. The technique does not result in loss of mandibular bone, and patients return to full masticatory function compared with those who require resection From the Department of Otolaryngology–Head and Neck Surgery, Stanford University School of Medicine, Stanford, Calif. (Dr. Liu); the Division of Pediatric Otolaryngology, Department of Otolaryngology–Head and Neck Surgery, Stanford University Medical Center, Stanford, Calif. (Dr. Sidell); the Department of Otolaryngology–Head and Neck Surgery, Cathay General Hospital, Taipei, Taiwan (Dr. Huon); and the Department of Otolaryngology– Head and Neck Surgery, University of Miami, Miller School of Medicine, Miami, Fla. (Dr. Torre).

Corresponding author: Stanley Yung-Chuan Liu, MD, DDS, Department of Otolaryngology, Stanford University, 801 Welch Rd., Stanford, CA 94304. Email: ycliu@stanford.edu Volume 97, Number 3

and reconstruction. VSP may mitigate technical challenges associated with SSO. Introduction

Sagittal split osteotomy (SSO) was conceived more than 60 years ago to correct maxillofacial deformities.

It involves sagittal osteotomies of the mandible that allow repositioning of the dentate segment to address congenital or acquired dentofacial deformity.1 SSO has occasionally been used as an alternative to expose and remove benign intramandibular lesions.2-5 Advantages include avoidance of large mandibular resections for benign but extensive lesions, preservation of cortical bone and associated dentition (particularly important for growing individuals), rapid return to premorbid jaw function, and avoidance of secondary bone grafting or free tissue transfer.

Despite these advantages, SSO is underused for access to mandibular lesions because of the potential for complications, such as unintended fractures or injury to the inferior alveolar nerve (IAN). Recent advances in virtual surgical planning (VSP) may greatly reduce these risks.3,6 We describe how VSP can be used to plan SSO that removes mandibular lesions while preserving the entirety of mandibular cortical bone and minimizing the risk of injury to adjacent vital structures.

Patients and methods

Patients with biopsy-proven benign intramandibular lesions accessed by SSO with VSP during 2014 were included. All patients were managed by the Stanford University otolaryngology service.

Preoperative planning. Preoperative computed tomography (CT) scans in DICOM (Digital Imaging and Communications in Medicine) format are imported www.entjournal.com 91

Liu, Sidell, Huon, Torre

into VSP software (Materialise N.V.; Leuven, Belgium).

Planning includes (1) localizing and demarcating the lesion of interest, (2) outlining ideal positions of osteotomies, and (3) delineating the intrabony course of the IAN to avoid severing or tearing the IAN during sagittal split.

The facial-lingual position of the IAN in the mandibular body is best seen in the coronal view, and the nerve can be traced through its entire length (figure 1). Two planned osteotomies are a ramus osteotomy extending just past the lingula and an anterior mandibular vertical osteotomy. The position of the anterior osteotomy is often dictated by the location of the lesion.

Optimal methods of fixation also can be planned before the operation with the customary combination of bicortical positional screws at the ramus and fracture plates using nonlocking screws across the vertical osteotomy at the body.

Intraoperative considerations. SSO begins with a subperiosteal exposure of the lateral mandibular body and anterior ramus including the lingula, behind which the IAN inserts and begins its intramandibular course.

The ideal incision is a linear one starting about 1 cm inferior to the mucogingival junction of the second molar. This incision is carried down to bone with a blade; this region is almost always avascular with no muscle attachments. A periosteal elevator can then be inserted through this pocket, and the lateral masseter muscle can be lifted subperiosteally with ease.

Electrocautery divides the mucosal junction between the lateral and medial pterygoid muscles along the anterior ramus. The medial pterygoid muscle is reflected to allow identification of the lingula, which is identified preoperatively using VSP. Its precise distance from the anterior border of the ramus is known, and a nerve hook can be used with a marker at the predetermined length.

A mark can be made on the saw blade so that the medial ramus osteotomy does not extend past the lingula (resulting in full-length ramus fractures) or underextend (incarcerating the IAN after the mandible is split).

With SSO, only three osteotomies are made with the saw (medial ramus osteotomy, anterior vertical mandibular body osteotomy, and an osteotomy connecting the two). The osteotomies are followed by a controlled fracture with osteotomes (figure 2, A and B). An ideal SSO allows the mandible to open like a book (figure 2, C).

With VSP, the position of the IAN is known, providing two advantages. First, the depth of the anterior osteot92 www.entjournal.com

omy can be planned. During the split, the osteotomes can also be guided appropriately prior to visualizing the IAN (figure 1).

After the removal of the lesion, fixation of the split mandibular cortices involves positional bicortical screws at the ramus and a fracture plate across the anterior vertical mandibular osteotomy (figure 2, D).

Before fixation, maintaining occlusion with intermaxillary fixation (IMF) is important. The condyle is seated by pushing the lateral cortex of the SSO (the condylar segment) posteriorly. Jaw movement is assessed after fixation by releasing the patient from IMF. Occlusion should be as it was before surgery.

Results

Three patients treated with this approach are presented in detail. All underwent successful SSO exposure and complete removal of mandibular lesions. They achieved full recovery of mandibular function including institution of a regular diet within 6 weeks of surgery. Patient 2 required IAN resection, but the other 2 patients had full return of IAN sensation postoperatively.

Clinical scenario 1: Extensive cyst in the mandibular body and ramus. A 55-year-old man presented with

Figure 1. Using virtual surgical planning, the inferior alveolar nerve (IAN) can be traced through its entire intramandibular course. Illustrations courtesy of Dr. Huon.

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intermittent left lower facial swelling.

Magnetic resonance imaging of the head and neck showed infiltration of an intraosseous lesion in the left mandibular body with erosion near the mental foramen, suspicious for a peripheral nerve sheath tumor.

SSO using VSP was performed. The IAN was exposed and traced along its C D entire length from the ramus to the mental foramen (figure 4) after sagittal split and separation of the facial and lingual cortices of the mandible. The IAN was excised in its entirety within this region. Despite erosion of the medullary bone, bicortical positional screws at the ramus and an anterior Figure 2. Illustrations depict the process of a sagittal split osteotomy. A: Sagittal split osteotomies are initiated with a reciprocating saw. Three osteotomies are made fracture plate with nonlocking screws (medial/posterior horizontal, anterior vertical, and superior connecting). B: The were adequate to maintain jaw stability. inferior osteotomy requires a controlled fracture using osteotomes. With virtual No masticatory or aesthetic deficits surgical planning, the position of the inferior alveolar nerve (IAN) is known. This guides the depth of the anterior osteotomy and the directionality of osteotomes. C: This were apparent at the 1-year follow-up. is the point in the procedure when the ideal sagittal split osteotomy opens like a book. The patient’s facial growth had not been After splitting the distal, or dentate, segment and condylar segment of the mandibular ramus, the lesion and inferior alveolar nerve are clearly identified, and the lesion is impeded by the operation. removed without unnecessary bone loss. D: Bone cortices are reset after positioning Clinical scenario 3: Multiple cysts the condylar segment upward and backward to the articular fossa. Rigid fixation is in the mandibular body and ramus. done using two bicortical screws at the ramus and a rigid plate across the anterior lower border. (In panels B to D, A = dentate segment; B = condylor segment.)

A 19-year-old man presented with numerous asymptomatic intramandibular slowly enlarging right lower facial swelling. The CT scan radiolucencies in the ramus and body of the mandible showed a 6 × 3 × 3-cm radiolucent lesion associated with found during routine panoramic radiography. Incisional a third molar dislocated to the posterior ramus (figure biopsy had been performed previously in the anterior 3). The lesion had eroded through the buccal cortex mandibular body, with removal of overlying cortical near the mental nerve, where an incisional biopsy had bone. Pathologic diagnosis was inconclusive. To obtain been performed, and a diagnosis of dentigerous cyst more tissue, biopsy of the lesions in the posterior ramus was confirmed (figure 3). was necessary.

SSO using VSP was performed. After the mandibSSO using VSP was performed, and the exposure ular split, the cystic lining along the inner buccal and allowed for extensive visualization between the split lingual cortices was removed easily in one piece along with the third molar.

Bony cortices were reapproximated and fixated. The patient’s jaw was banded closed for 1 week, and the patient was gradually released to full diet in 6 weeks. There were no limitations to jaw function at the 1-year follow-up. Lower facial and mandibular bony contours were preserved.

Clinical scenario 2: Inferior alveolar nerve sheath tumor. A 15-year-old boy Figure 3. In this illustration and radiograph, a 6 × 3 × 3-cm cystic lesion is seen the mandibular body and ramus with a cortical defect noted near the mental presented with acute onset of left men- within foramen. The lesion is associated with a third molar that is displaced toward the tal nerve paresthesia associated with posterior ramus.

A

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B

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The SSO approach has been reported in the literature only sporadically. Complications related to SSO include injury to the IAN, postoperative malocclusion, and unanticipated fractures and unfavorable splits.7,8 Although reports demonstrate the efficacy of SSO with VSP, discussion about ways to make the SSO more predictable and reproducible for all surgeons has been inadequate. VSP helps surgeons appreciate the location of the lesion relative to other structures of interest, to design optimal osteotomies to ensure good mandibular splits, and to avoid injury to the IAN. It is also cost-effective when one considers the alternative approach, which requires resection and reconstruction. We hope that VSP encourages surgeons to consider “split to save.”

Figure 4. Illustration and photograph show the sagittal split osteotomy of the left mandible and the preoperative virtual surgical plan model in this inferior alveolar nerve sheath tumor (A = dentate segment; B = conydlar segment; IAN = inferior alveolar nerve).

ramus and body cortices. Multiple bony cavities with scant cystic lining were found in the ramus. With the exposure obtained, lesions within the posterior ramus were removed with endoscopic assistance. Preservation of the IAN in the ramus was also confirmed with endoscopic visualization. Biopsy was consistent with a history of giant cell granulomas that had regressed.

The patient returned to a regular diet in 2 weeks.

He had no functional or aesthetic deficits at the 1-year follow-up.

Discussion

We describe three clinical scenarios in which SSO allowed optimal access to the lesion of interest in the mandible while preserving bony integrity. Classic segmental resection followed by secondary bone grafting or primary free tissue transfer are more usual approaches in these scenarios. SSO was effective in saving healthy bony tissue, preserving bony integrity, allowing patients an immediate return to premorbid occlusion and mastication, and obviating the need for reconstructive surgery. In these circumstances, VSP provided surgeons with important landmarks and measurements that assisted in carrying out SSO safely.

We propose the use of SSO with VSP for the management of (1) benign and extensive intramandibular lesions that otherwise would have required mandibular resection, (2) IAN lesions, and (3) multiple lesions within the mandibular ramus and body. This approach is particularly ideal for growing individuals because jaw development is not disrupted, in contrast with resection.

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Conclusion

For access to extensive or multiple benign intramandibular lesions, SSO prevents the need for extensive resection and reconstruction, avoids injury to the IAN, and allows rapid return to full jaw function. These benefits are particularly pertinent for growing individuals and medically compromised patients who are not ideal candidates for resection and reconstruction. VSP mitigates risks involved with SSO. References 1. Trauner R, Obwegeser H. The surgical correction of mandibular prognathism and retrognathia with consideration of genioplasty.

II. Operating methods for microgenia and distoclusion. Oral Surg Oral Med Oral Pathol 1957;10(9):899-909.

2. Lee HG, Rhee SH, Noh CA, Shin SH. Enucleation of large kerato­ cystic odontogenic tumor at mandible via unilateral sagittal split osteotomy: A report of three cases. J Korean Assoc Oral Maxillofac Surg 2015;41(4):208-12.

3. Casap N, Zeltser R, Abu-Tair J, Shteyer A. Removal of a large odontoma by sagittal split osteotomy. J Oral Maxillofac Surg 2006; 64(12):1833-6.

4. Mahmood L, Demian N, Weinstock YE, Weissferdt A. Mandi­ bular nerve schwannoma resection using sagittal split ramus osteotomy. J Oral Maxillofac Surg 2013;71(11):1861-72.

5. Wong GB. Surgical management of a large, complex mandibular odontoma by unilateral sagittal split osteotomy. J Oral Maxillofac Surg 1989;47(2):179-84.

6. Rittersma J, van Gool AV. Surgical access to multicystic lesions, by sagittal splitting of the lower jaw. J Maxillofac Surg 1979; 7(3):246-50.

7. Shawky M, Mosleh M, Jan AM, Jadu FM. Meta-analysis of the incidence of lingual nerve deficits after mandibular bilateral sagittal split osteotomy. J Craniofac Surg 2016;27(3):561-4.

8. Steenen SA, van Wijk AJ, Becking AG. Bad splits in bilateral sagittal split osteotomy: Systematic review of fracture patterns.

Int J Oral Maxillofac Surg 2016;45(8):971-9.

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