Literature Review: a roundup of the most important recent studies

From: ENT Today, February 2010

by Sue Pondrom, Nancy M. Baumann, MD

The Impact of Thyroidectomy on Vocal Quality Characteristics

CLINICAL QUESTION
With no laryngeal nerve injury, do vocal characteristics change after thyroidectomy?

Background: Vocal dysfunction is a feared complication of thyroidectomy. While operative injury to the recurrent laryngeal nerve is a primary cause of voice alterations, changes have also been noted in the absence of this injury.

Study Design: Prospective study of patients one week prior and one week, six weeks and three months after surgery

Setting: Subjective (auditory perceptual evaluation and videolaryngostroboscopy) and objective (aerodynamic, vocal range, acoustic and Dysphonia Severity Index (DSI)) assessments were utilized with 44 thyroidectomy patients in Belgium.

Synopsis: No significant differences were found in the Voice Handicap Index questionnaire between the preoperative and postoperative points. While complaints of roughness and vocal fatigue were reported one week after surgery, complaints decreased significantly by subsequent evaluations.

In the auditory perceptual evaluation, one week after surgery the overall grade of dysphonia and roughness were significantly higher than pre-surgery. However, the Wilcoxon test showed no significant differences between further evaluations and the pre-surgical assessment. The videostroboscopic evaluation showed no significant differences as to symmetry, regularity, glottic closure and mucosal wave.

The objective data indicated a significant decrease of the highest frequency, intensity, fundamental frequency and objective vocal quality by means of the DSI value at one week post-surgery. When repeated analysis of variance was later performed, no significant differences were noted.

Bottom Line: Although more vocal complaints occurred immediately after thyroidectomy, patients had a normal perceptual and objective vocal quality with no permanent change of vocal performance at six week and three month evaluations.

Reference: Lierde KV, D’haeseleer E, Wuyts FL, et al. Impact of thyroidectomy without laryngeal nerve injury on vocal quality characteristics: An objective multiparameter approach. The Laryngoscope. 2009;120(2):338-345.

—Reviewed by Sue Pondrom

 

Avastin Treatment for Hereditary Hemorrhagic Telangiectasia Epistaxis

CLINICAL QUESTION
Can the vascular endothelial growth factor (VEGF) inhibitor bevacizumab (Avastin) treat hereditary hemorrhagic telangiectasia (HHT) epistaxis?

Background: HHT is an autosomal dominant disorder involving abnormal blood vessel development. An estimated 90 percent of HHT patients have epistaxis which can lead to significant blood loss requiring IV iron, emergency room visits and blood transfusions. Surgical outcomes are generally poor. VEGF has recently been found to be elevated in HHT patients. Bevacizumab (Avastin) is a recombinant, humanized, monoclonal antibody that binds to and inhibits the activity of VEGF.

Study Design: Case report of a 45-year-old male with HHT and frequent epistaxis.

Setting: The patient’s epistaxis began prior to 10 years of age. With frequent nosebleeds, anemia and varying hemoglobin levels, he sought treatment at the University of California, San Diego nasal dysfunction clinic.

Synopsis: After local anesthesia, the patient was injected submucosally with 100 mg of bevacizumab into both anterior nasal cavities without injection into the cartilaginous septum. The patient had no difficulties and within a week all nasal bleeding stopped. At the end of four months, however, the bleeding resumed.

A total of 50 mg of bevacizumab was diluted in 5 mL of normal saline. For two consecutive weeks following nasal irrigation with hypertonic saline, 0.1 mL of the spray was delivered into each nostril twice a day. After four days, the epistaxis ceased. Following seven days, bleeding was reduced to less than once a week. Between three and four months, the epistaxis resumed.

The patient elected to pursue a second course of topical treatment. Bleeding once again ceased and has remained minimal for 2.5 months.

Bottom Line: If VEGF plays a role in the development of the telangiectasias that occur in HHT patients, bevacizumab may be useful in their treatment.

Reference: Davidson TM, Olitsky SE, Wei JL. Hereditary hemorrhagic telangiectasia/Avastin. The Laryngoscope. 2009;120(2):432-435.

—Reviewed by Sue Pondrom

 

Language Performance in Disabled Children with Cochlear Implants

CLINICAL QUESTION
What are the effects of cochlear implants (CIs) on language among children with disabilities?

Background: Early implantation of a CI in children with typical development is strongly associated with improved outcomes. There are few studies, however, showing the effects of CI among children with additional disabilities, making decision-making and standards of care difficult for families and providers.

Study Design: Small cohort study.

Setting: Twenty children with CIs and developmental disabilities were enrolled at Cincinnati Children’s Hospital.

Synopsis: The median age of CI was 24 months and median duration was 27.7 months. The range of nonverbal cognitive quotients (NVCQ) was 27 to 115, with 15 subjects having NVCQs less than 80. Seventy-five percent had cognitive deficits and 55 percent had motor delays.

The objectives of the study were to evaluate language development post-CI and to determine the role that cognition plays in predicting language outcomes among children with developmental disabilities. The team used a combination of retrospective and prospective designs for evaluations.

Although children had significant increases in language age pre- to post-CI, median language quotients did not significantly change after implantation. NVCQ, age at hearing loss diagnosis, implant duration and number of different therapies attended were significant, with NVCQ contributing the most unique variance. Pre-CI language performance did not predict post-CI performance.

Bottom Line: Early measures of nonverbal cognition were the strongest predictor of language, although cognition is not always sufficient for good language development. Earlier ages at hearing loss diagnosis also contributed to higher language skills, although post-CI language skills were not a predictor of post-CI language outcomes. Information gained from this study sets the foundation of understanding appropriate expectations regarding language gains post-implant.

Reference: Meinzen-Derr J, Wiley S, Grether S, et al. Language performance in children with cochlear implants and additional disabilities. The Laryngoscope. 2009;120(2):405-413.

—Reviewed by Sue Pondrom

 

Propranolol Effective, Well-Tolerated for Symptomatic IH

CLINICAL QUESTION
Will propranolol become the mainstay of treatment for symptomatic infantile hemangiomas (IH)?

Background: IH are the most common tumor of infancy, affecting four to 10 percent of infants. Spontaneous involution is the expected outcome, but nearly 10 percent cause symptoms warranting early therapy. Propranolol was serendipitously found to hasten IH involution, with fewer side effects than traditional corticosteroid therapy, in an index case and 10 additional cases reported in the New England Journal of Medicine (2008;358:2649-2651).

Study Design: Observational case series of 32 patients, including previously reported 11.

Setting: Children’s Hospital, Pellegrin Hospital and Saint Andre Hospital, Bordeaux, France; Purpan Hospital, Toulouse, France; Strasbourg Hospital, Strasbourg, France; Fort de France Hospital, Fort de France, France.

Synopsis: Propranolol (2 mg/kg/day) was given during the proliferative phase (n=27, mean 4.2 m) or plateau phase (n=5, mean 31 m) for a mean of six months. Softening and lightening of the hemangioma was immediately noted in all patients. Dyspnea, ocular opening and hemodynamics were the most common indications for starting therapy and improved within the first week. Ulcerations healed within two months. Ultrasound showed 40 percent regression in maximal thickness (n=11, 60 days). Corticosteroids were first used in 13 patients with minimal response and all were stopped within the first month of starting propranolol.

Adverse effects were rare. It is unclear whether vital signs were monitored for the first six or 24 hours; however, transient hypotension was only reported in one patient. Propranolol was stopped after three months in another patient due to wheezing. Therapy was concluded in 16 patients at the time of the report and had to be resumed in two patients with symptomatic regrowth.

Bottom Line: Propranolol appears to be an effective and well-tolerated as a first-line treatment for symptomatic IH. Prospective studies comparing efficacy and side effects with corticosteroids are needed.

Reference: Sans V, Dumas de la Roque E, Berge J, et al. Propranolol for severe infantile hemangiomas: Follow-up report. Pediatrics. 2009;124:e423-31.

—Reviewed by Nancy M. Baumann, MD

 

Submandibular Gland Excision Successful for Surgical Management of Sialorrhea

CLINICAL QUESTION
What is the best procedure for surgical management of drooling?

Background: Surgical treatment for sialorrhea is considered when conservative measures fail. Options include sublingual gland excision, submandibular gland (SMG) duct ligation or rerouting, submandibular gland excision, parotid duct ligation or rerouting and combinations of these procedures. The authors reviewed the literature to compare efficacy, recognizing the limitation that surgical success is typically based on subjective caretaker reports.

Study Design: Meta analysis.

Setting: Department of Otolaryngology, Walter Reed Army Medical Center, Washington, D.C.

Synopsis: Data was extracted from 59 study subsets reported in 50 manuscripts, nearly all of which were case series (CEBM 4). The median study sample size was 18 (range, 8-181), and median minimum follow-up was eight months (2 m-43m). The overall caretaker-reported success rate was high at 82 percent.

The most common procedure performed was bilateral SMG rerouting (36 percent). The success rate was highest with bilateral SMG excision with bilateral parotid duct rerouting (Wilke procedure, 87.8 percent) and lowest with four duct ligation (64.1 percent, p=0.001). Recognizing limitations of such a review, the authors found that more invasive procedures targeting four major salivary glands were more effective than less invasive procedures.

Bottom Line: Overall, SMG excision combined with parotid duct rerouting or ligation has highest caretaker-reported success for surgical management of sialorrhea.

Reference: Reed J, Mans CK, Brietzke SE . Surgical management of drooling, a meta-analysis. Arch Otolaryngol. 2009;135:24-31.

—Reviewed by Nancy M. Baumann, MD

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