Relationship between inflammation and the severity of Recurrent Respiratory Papillomatosis Publication date: Available online 18 November 2019 Source: American Journal of Otolaryngology Author(s): Vivian Narana Ribeiro El Achkar, Andressa Duarte, Román Carlos, Jorge Esquiche León, Alfredo Ribeiro-Silva, Shirley Shizue Nagata Pignatari, Estela Kaminagakura Abstract Objective To characterize inflammatory cells in Recurrent Respiratory Papillomatosis (RRP) and to correlate it with severity using the Derkay laryngoscopic scale. Materials and methods The data and biopsies from 36 patients with Juvenile (JRRP) and 56 patients with Adult (ARRP) were collected and analyzed under light microscopy. The patients were separated into groups according to the Derkay index: ≥20 for the most severe and < 20 for the less severe cases. Immunohistochemical analysis using CD3, CD4, CD8, CD15, CD20, CD68, FoxP3 and MUM-1 antibodies was performed, and the inflammatory cells were quantified. All the clinicopathological characteristics and the results of the immunohistochemical analysis were compared among the groups proposed using the Chi-Square test and correlated through the Spearman correlation test. Results The ARRP showed significantly higher quantities of CD3+, CD8+ and MUM1+ cells (p < .05) than the JRRP samples. The presence of CD15+ cells showed positive correlation with the Derkay index (p < .05), while the MUM-1+ cells showed an inverse correlation (p = .01). Conclusion There are differences between the inflammatory cells population in the juvenile and adult groups and it can be related to disease severity.

An association between marijuana use and tinnitus Publication date: Available online 13 November 2019 Source: American Journal of Otolaryngology Author(s): Z. Jason Qian, Jennifer C. Alyono Abstract Objective While some advocates have argued for marijuana as a treatment for tinnitus, the relationship between marijuana use and tinnitus is unknown. The objective of this study was to evaluate associations between marijuana use and the prevalence, severity, and rate of occurrence of tinnitus. Study design Cross-sectional analysis of nationally representative data. Setting National Health and Nutrition Examination Survey 2011–2012. Subjects and methods Statistical analysis was performed on data collected from 2705 non-institutionalized adults aged 20–69 who underwent audiometric testing and were administered questionnaires about hearing, drug use, current health status, and medical history. Results The use of marijuana at least once per month for the previous 12 months was significantly associated with experiencing tinnitus during that 12-month month (X2(1) = 19.41, p < 0.001). Subjects who used marijuana were more likely to experience tinnitus after accounting for covariables including age, gender, audiometric hearing loss, noise exposure history, depression, anxiety, smoking, salicylate use, cardiovascular disease, hypertension, and diabetes (OR = 1.75, 95% CI 1.02–3.01, p = 0.043). There were no associations between the severity or frequency of tinnitus occurrence and the quantity or frequency of marijuana use. Use of other substances such as alcohol, cocaine, methamphetamine, and heroin was not associated with tinnitus. Conclusion Regular marijuana use is associated with prevalent tinnitus. However, no dose response between marijuana use and tinnitus was observed. The relationship between marijuana use and tinnitus is complex and is likely modulated by psychosocial factors.

Investigation of vitamin D levels in patients with Sudden Sensory-Neural Hearing Loss and its effect on treatment Publication date: Available online 12 November 2019 Source: American Journal of Otolaryngology Author(s): Hossein Ghazavi, Amir-Abbas Kargoshai, Mohammad Jamshidi-koohsari Abstract Background Due to high prevalence of vitamin D deficiency and the possible association with Sudden Sensory-Neural Hearing Loss (SSNHL) finding the main causes and appropriate treatments are highly essential. This study aimed to investigate vitamin D levels in patients suffering SSNHL and its effect on response to treatment. Materials and methods This cross-sectional study was performed on two groups of case (34 SSNHL patients) and control (34 healthy subjects without risk of hearing loss). All patient information such as age, sex, audiogram illustration of hearing frequency and the level of vitamin D were recorded at baseline. Patients with SSNHL received routine treatments such as 10 days of 1 mg/kg/day steroid and the response or lack of complete response to treatment was recorded and analyzed according to the audiometry. Results Vitamin D level in SSNHL group with a mean of 19.28 ± 9.56 ng/ml was significantly less than the control group (25.71 ± 11.21 ng/ml; P value < 0.001). After treatment, 76.5% were completely recovered and 23.5% did not recover completely. Factors such as age, sex and level of initial hearing loss did not have a significant effect on the response to treatment, but the level of vitamin D in these patients had a significant relationship with the response to treatment (P value = 0.004); so that all patients with sufficient vitamin D level had completely recovered, versus 87.5% of patients with vitamin D deficiency and 12.5% of insufficient vitamin D had no response to treatment. Conclusion According to the results of the present study, the prevalence of vitamin D deficiency in patients with SSNHL was more than healthy people. SSNHL patients with deficient vitamin D had the highest percentage of no response to treatment.

Osteoradionecrosis of the mandible: Why not to be more aggressive in earlier stage? Publication date: Available online 12 November 2019 Source: American Journal of Otolaryngology Author(s): Nidal F. AL Deek

Impact of perforation size and predictive factors for successful pediatric gelfoam myringoplasty Publication date: Available online 12 November 2019 Source: American Journal of Otolaryngology Author(s): Elizabeth O. Shay, Janki Shah, Blake Smith, Samantha Anne Abstract Objectives Rates of success with pediatric myringoplasty range from 35 to 95%. The objective of this study is to evaluate the impact of perforation size on successful closure of the tympanic membrane (TM) after gelfoam myringoplasty. We also aim to identify variables that affect perforation closure rates and define predictive factors for successful TM closure. Methods A retrospective chart review of all patients that underwent gelfoam myringoplasty by a single surgeon from August 2008 through January 2015 was performed. Results One hundred fifty-nine patients met inclusion criteria and underwent a total of 219 procedures. Overall, gelfoam myringoplasty had an 83.1% rate of successful closure. Average perforation size was 15.31%. Classification tree analysis separated our cohort into three groups based on perforation size: Group 1 (<16.25%) had a 91% closure rate, group 2 (16.25% to <31.25%) had a 66.0% closure rate and group 3 (≥31.25%) had a 30.0% closure rate. Smaller perforations (P ≤0.001) were associated with increased success rates. Other factors associated with successful closure of the TM included younger age at the time of myringoplasty (P ≤0.001), fewer number of prior tympanostomy tubes (P = 0.016), and lesser duration of tube retention (P = 0.003). Conclusion Gelfoam myringoplasty provides good overall TM closure rates and may be considered as a potential first-line option for repair of perforations, including those involving up to 40% of the TM. Younger patients with smaller perforations, fewer sets of tubes, shorter length of tube retention are more likely to have successful closure of the tympanic membrane.

Surgical management of Eagle syndrome: A 17-year experience with open and ransoral robotic styloidectomy Publication date: Available online 12 November 2019 Source: American Journal of Otolaryngology Author(s): Thomas H. Fitzpatrick, Benjamin D. Lovin, Marcus J. Magister, Joshua D. Waltonen, James D. Browne, Christopher A. Sullivan Abstract Eagle Syndrome (ES) is a rare disorder that can present with symptoms ranging from globus sensation to otalgia that is attributed to an elongated styloid process and/or calcified stylohyoid ligament. No standardized treatment algorithm exists, and although various surgical approaches have been described, data on the use of transoral robotic surgery (TORS) in this population is limited. To investigate the utility of TORS in the treatment of ES, a retrospective review in 19 ES patients was carried out at a single academic, tertiary medical center between 2000 and 2017. Nineteen patients underwent twenty-one styloid resections: 6 performed via TORS and 15 via transcervical approach. Across all patients, 90% reported some degree of lasting improvement in symptoms while 55% reported significant improvement. When TORS was compared to transcervical resection, there was no difference in the subjective rate of “meaningful” (83 vs. 57%) versus rate of “non-meaningful” symptom improvement (17 vs. 43%) (p = .35). There was a trend towards less estimated blood loss (EBL), operative time, and post-operative length of stay (LOS) with TORS versus transcervical cases (9.2 mL vs. 30.0 mL, 98 vs. 156 min, and 0.7 vs. 1.2 days); however, these did not reach statistical significance (p = .11, 0.13, and 0.42, respectively). Three patients (14% of total) experienced complications associated with an open approach, as compared to none with TORS. In select patients, TORS styloidectomy is a reasonable surgical alternative to traditional transoral and transcervical techniques as it provides similar symptom improvement, and reduced length of stay, blood loss, and operative time.

Estimated versus actual; The accuracy of accounting for blood loss during endoscopic sinus surgery Publication date: Available online 11 November 2019 Source: American Journal of Otolaryngology Author(s): Michael J. Eliason Abstract Purpose Endoscopic sinus surgery (ESS) is the mainstay for chronic inflammatory and neoplastic sinonasal process and as a result many modalities have been studied to minimize blood loss and patient morbidity and to maximize intraoperative visualization. However, often conclusions of actual blood loss are based on surgeons' estimations without ever actually assessing the accuracy of these estimations. The objective of this study was to determine the accuracy of intraoperative blood loss estimates by attending otolaryngology surgeons among patients undergoing ESS. Materials and methods After obtaining institutional review board approval, data were collected on six surgeons performing ESS at a military academic medical center for 21 surgical cases. Specifically, both hourly and end-of-case total “estimated” (EBL) and “calculated actual” (ABL) blood loss values were recorded and compared statistically. Surgeons were blinded to the results until after all data were collected. Results The difference between mean EBL and ABL was 62.5 ml and was statistically significant (p = .007, Power 86.2%). EBL lagged ABL for both hourly intervals during a surgical case and the total end-of-surgery values. Conclusion The surgeons studied had EBL that were statistically significantly less than ABL both at hourly intervals during the surgery and at the conclusion of the case. As a result there exists potential for adverse consequences in clinical care and in efforts in medical research/advancement.

The role of molecular testing in the diagnosis of medullary thyroid cancer: A case report of oncocytic medullary thyroid carcinoma and review of the literature Publication date: Available online 11 November 2019 Source: American Journal of Otolaryngology Author(s): Sarah L. Spaulding, Rebecca Ho, Sedef Everest, Raymond L. Chai Abstract Background Medullary thyroid carcinoma (MTC) is a somewhat rare, particularly aggressive form of thyroid cancer. The authors present what we believe to be the first case of MTC diagnosed solely on the basis of molecular testing, as well as a review of the literature concerning this topic and oncocytic variants of MTC. Case description A 30-year-old female patient with a 1.1 cm thyroid nodule underwent a fine-needle aspiration biopsy showing a Bethesda IV Hurthle cell neoplasm. Molecular testing of the specimen identified a RET M918 T mutation. The patient underwent a total thyroidectomy and bilateral central neck dissection. Initial pathologic analysis yielded a diagnosis of Hurthle cell adenoma. Based on the patient's known RET mutation, immunohistochemistry for calcitonin was performed and yielded a positive result. The final diagnosis was amended to an oncocytic variant of medullary thyroid carcinoma. Discussion Had this patient undergone fine-needle aspiration (FNA) biopsy without molecular testing or serum calcitonin measurement, the patient's disease would have been diagnosed as a Hurthle cell adenoma. Despite the lack of characteristic features of malignancy and the rarity of oncocytic MTC, the diagnostic pitfall in this oncocytic lesion was avoided due to molecular testing at the time of FNA biopsy. Conclusion This case draws attention to the unique clinical value of molecular testing in the diagnosis of MTC. The authors believe this case supports the consideration for molecular testing to prevent missed diagnoses in cases of rare benign-appearing disease.

Cerumen impaction was composed of abnormal exfoliation of keratinocytes that was correlated with infection Publication date: Available online 7 November 2019 Source: American Journal of Otolaryngology Author(s): Shoude Zhang, Mao Jin, Guojin Zhou, Yuejiao Zhang Abstract Objective This study investigated the exact composition and tried to be helpful in explaining the etiologic mechanism of cerumen impaction in the external auditory canal (EAC). Methods A hundred impacted cerumen samples and 15 normal cerumen samples were collected by manual removal and divided into 2 groups. All samples were examined via microbial culture, hematoxylin–eosin staining, periodic acid–Schiff staining, and fungal fluorescent staining. Results Eighty-eight patients in group 1 were in the habit of using cotton buds. Forty-seven impacted cerumen samples tested positive for microbes, while only 1 sample of normal cerumen tested positive for microbes (p < .05). The most commonly isolated bacterium and fungus was Staphylococcus aureus and Aspergillus terreus respectively. All cerumen samples were composed of exfoliated keratinocytes and microorganisms assessed via pathologic examination. However, unlike normal cerumen, impacted cerumen contained nucleated keratinocytes and infiltrated neutrophils. Recurrent impaction was found only among patients who tested mold culture-positive. Conclusion Impacted cerumen is composed of abnormal exfoliated keratinocytes that was correlated with microbial-induced neutrophil-mediated inflammation. Mold infection is highly correlated with recurrent cerumen impaction. Microbial culture of removed impacted cerumen is strongly recommended. Ear cleaning with cotton buds, particularly when the EAC is wet might be one of the important causes of cerumen impaction which is need further studied. Level of evidence 2b.