Faculty Bibliography

OBJECTIVES: To evaluate functional swallowing outcomes in patients undergoing transoral robotic surgery vs primary chemoradiotherapy for the management of advanced-stage oropharynx and supraglottis cancers. DESIGN: Prospective nonrandomized clinical trial. SETTING: Academic research. PATIENTS: We studied 40 patients with stage III or stage IVA oropharynx and supraglottis squamous cell carcinoma. Group 1 comprised 20 patients who received transoral robotic surgery with adjuvant therapy, while group 2 comprised 20 patients whose disease was managed by primary chemoradiotherapy. MAIN OUTCOME MEASURES: Patients completed the M. D. Anderson Dysphagia Inventory (MDADI) before treatment and then at follow-up visits at 3, 6, and 12 months. The MDADI scores were analyzed and compared. RESULTS: The median follow-up period for both groups was 14 months (range, 12-16 months). When comparing the median MDADI scores between group 1 and group 2, we found no statistically significant differences before treatment or at the 3-month follow-up visit. However, this difference was significant at the posttreatment visits at 6 months (P = .004) and 12 months (P = .006), where group 1 had better swallowing MDADI scores. We also found significant differences in swallowing MDADI scores between the groups at the 6-month posttreatment visit for patients with T1, T2, and T3 disease and at the 12-month follow-up visit for patients with T2 and T3 disease, where group 1 had significantly better MDADI scores. Comparing tumor subsites, group 1 fared significantly better at the follow-up visits at 6 months (P = .02) and 12 months (P = .04) for patients with primary tumor at the tonsil. Compared with group 2, group 1 patients having base of tongue cancers exhibited significantly better swallowing MDADI scores at the 6-month follow-up visit (P = .02), and group 1 patients having lateral oropharynx disease had significantly better swallowing MDADI scores at the 12-month follow-up visit (P = .04). CONCLUSION: Advanced-stage oropharynx and supraglottis cancers managed by transoral robotic surgery with adjuvant therapy resulted in significantly better swallowing MDADI outcomes at the follow-up visits at 6 and 12 months compared with tumors treated by primary chemoradiotherapy.

OBJECTIVES: We performed a retrospective study of cases from 2005 to 2010 at an academic tertiary care center to analyze the factors that influence morbidity in surgical management of thyroid malignancy. METHODS: The rates of recurrent laryngeal nerve (RLN) injury and hypoparathyroidism (HPT) were analyzed in the entire cohort. The comparison groups were 1) primary surgery versus revision; 2) total thyroidectomy versus total thyroidectomy combined with neck node dissection; and 3) two groups defined by surgical technique according to the RLN approach: group 1, in which the RLN was identified inferiorly in the tracheoesophageal groove, and group 2, in which the RLN was identified near the cricothyroid joint point of entry. RESULTS: We reviewed 308 patients who underwent surgery for thyroid cancer. Thirty-six (11.7%) had temporary HPT, and 8 (2.6%) had permanent HPT. Of a total of 586 RLNs at risk, 16 (2.7%) had temporary damage and 2 (0.3%) had permanent damage. The incidences of temporary RLN injury significantly differed between the primary-surgery and revision-surgery groups (2.5% versus 15.6%; p = 0.001), and also between the groups with total thyroidectomy and thyroidectomy with neck dissection (1.2% versus 7.8%; p = 0.027). The incidences of temporary HPT were significantly different between the groups with primary surgery and revision surgery (6.6% versus 31.3%; p = 0.001), between the groups with total thyroidectomy and total thyroidectomy with neck dissection (4.7% versus 15.6%; p = 0.009), and between group 1 and group 2 (surgical technique in terms of RLN approach; 8.2% versus 17.9%; p = 0.011). Permanent HPT and permanent RLN injury both occurred rarely in this cohort, with no significant differences among comparison groups. CONCLUSIONS: Our study shows a higher incidence of temporary RLN injury and teniporary HPT in revision surgery cases and in total thyroidectomy with neck dissection. Temporary HPT was significantly more common when the RLN was identified near the cricothyroid joint.

The purpose of this study is to determine the accuracy with which a non-Gaussian measure of diffusion, mean kurtosis (MK), predicts the histologic grade of pediatric brain tumors. After institutional review board approval, 21 World Health Organization (WHO) grade I, 7 WHO grade II, and 7 WHO grade IV pathologically-proven intracranial pediatric malignancies were retrospectively reviewed for preoperative diffusional kurtosis imaging. Multiple diffusion metrics of the tumors including MK, mean diffusivity (MD) and fractional anisotropy (FA) were determined. Comparisons between groups were performed using the Mann-Whitney test (p < .05). Receiver operating characteristics analysis was done to assess accuracy of each metric in predicting histologic grade. MK was significantly higher for grade IV neoplasms (0.97, p < 0.0004) than grade I (0.62) or grade II (0.67) tumors. MD was significantly higher for grade I (1.43) compared with grade IV neoplasms (1.07, p < 0.018), however not for grade II (1.43) compared with grade IV (p < 0.08) tumors. FA did not differ significantly between grades. Area under the receiver operating characteristic curve was highest for MK (0.94) and lower for MD (0.89). FA performed only slightly better than chance (0.54). MK is an accurate diffusion metric for predicting histologic grade of pediatric brain tumors, consistent with conclusions from prior studies demonstrating similar results in adult populations

Sinusitis is a common patient complaint that carries with it a large economic burden. It is one of the most common reasons patients visit their primary care physician. Acute bacterial rhinosinusitis (ABRS) can be distinguished from other forms of rhinosinusitis based on symptom duration of <4 weeks in a patient with purulent rhinorrhea associated with facial pain or pressure. Native upper aerodigestive tract bacteria are the most common etiologic agents. Treatment of ABRS is targeted primarily at symptom improvement. Amoxicillin can be used based on the clinical scenario and patient comorbidities. Computed tomographic scans are reserved for complicated presentations or when there is concern for intracranial extension or other complications. A systematic approach to ABRS will allow for improved patient quality of life and a decreased overall economic burden of this common entity.

PURPOSE OF REVIEW: To review current literature regarding the use and utility of nasal saline irrigation in nasal and sinus diseases. RECENT FINDINGS: Nasal irrigations, in various forms, are a widely used and accepted means of treatment of the symptoms of chronic rhinosinusitis and other sinonasal disease processes. Over the past two decades, significant research has been done to evaluate the role of nasal irrigations in the treatment of sinonasal disease. The use of a high-volume, low-pressure system like a squeeze bottle remains the optimal delivery device. Although additional research is required for many of the additives discussed, the use of xylitol in chronic rhinosinusitis and topical fluconazole in allergic fungal sinusitis appear promising. SUMMARY: Use of nasal saline irrigations can improve symptoms of sinonasal disease and may improve outcomes in certain settings. Ongoing research will continue to shape and optimize understanding of maximally effective nasal irrigations.

OBJECTIVES/HYPOTHESIS: To evaluate voice disorder differences between deployed and nondeployed US army soldiers. STUDY DESIGN: Cross-sectional study. METHODS: More than 1.3 million health records of active duty US army soldiers with no history of dysphonia were queried for voice disorder diagnoses over a 3.5-year period. A sample of 292 soldiers was further evaluated for known factors linked to dysphonia. RESULTS: US army soldiers were 1.13 times more likely to have a diagnosis of dysphonia if they were deployed. Risk factors and exposures common to patients with dysphonia were not statistically different between deployed and nondeployed soldiers. Additionally, the type of dysphonia diagnosis was not significantly different between deployed and nondeployed soldiers. CONCLUSIONS: US army soldiers deployed to war zones are more likely to be diagnosed with dysphonia. None of the reviewed parameters accounted for the difference in dysphonia rate between deployed and nondeployed soldiers, suggesting that occupational exposures of deployed soldiers account for the increase in the diagnoses of dysphonia.

Allergic fungal sinusitis (AFS), also referred to as allergic fungal rhinosinusitis (AFRS), is a noninvasive, eosinophilic form of recurrent chronic allergic hypertrophic rhinosinusitis. AFS has distinct clinical, histopathological, and prognostic findings that differentiate it from other forms of sinusitis. The core pathogenesis and optimum treatment strategies remain debated. Concerns surround the use of immunotherapy for AFS because allergen-specific immunoglobulin G (IgG) induced by immunotherapy could theoretically incite a Gell and Coombs type III (complex mediated) reaction. Type I hypersensitivity is established by high serum levels of allergen-specific IgE to various fungal antigens and positive Bipolaris skin test results. Type III hypersensitivity is established by an IgG-mediated process defined by the presence of allergen-specific IgG that forms complexes with fungal antigen inducing an immunologic inflammatory response. These reveal the multiple immunologic pathways through which AFS can impact host responses. Recent literature establishing benefits of fungal immunotherapy and no evidence of type III-mediated reactions, severe local reactions, or delayed reactions, indicate that application of AFS desensitization is a reasonable therapeutic strategy for this difficult to manage entity. Our review should encourage further clinical acceptance of AFS desensitization because the existing literature on this subject shows benefits of fungal immunotherapy and no evidence of type III-mediated reactions, severe local reactions, or delayed reactions.

Aging affects voice production and is associated with reduced communicative ability and quality of life. Voice therapy is a critical component of treatment, but its effects on neuromuscular mechanisms are unknown. The ultrasonic vocalizations (USVs) of rats can be used to test the effects of aging and voice use on the laryngeal neuromuscular system. This study tested the hypothesis that age-related changes in the USVs of rats and laryngeal neuromuscular junctions can be reversed through vocal exercise. Young and old rats were trained for 8 weeks to increase their USVs and were compared with a no intervention group pre- and post-treatment. USV acoustics and aspects of neuromuscular junction (NMJ) morphology were measured in the thyroarytenoid muscle. Vocal training reduced or eliminated some age differences found in both USVs and NMJs. We conclude that vocal exercise may assist in mitigating age-related changes in voice characteristics and underlying neuromuscular adaptations.