Literature Review: A roundup of the most important recent studies

From: ENT Today, April 2010

• Fibula and Osteocutaneous Radial Forearm Free Flap Are Comparable
• PET-CT Adds to Management of Salivary Gland Malignancies
• Cidofovir Therapy Does Not Correlate with Worsening Dysplasia
• System Automatically Monitors Apnea-Hypopnea Index
• Prevalence of Dysplasia with Recurrent Respiratory Papillomatosis Is High
• Videolaryngostroboscopy Valuable in Pediatric Patients

 

Fibula and Osteocutaneous Radial Forearm Free Flap Are Comparable

Clinical Question

Does the osteocutaneous radial forearm free flap (OCRFFF) provide equivalent functional outcomes and improved morbidity compared to the fibular free flap (FFF) in mandibular reconstruction?

Background: Although widely used due to length and quality of bone, FFF routinely results in up to three months of antalgic gait and can cripple the elderly population. Recently there has been an increase in the use of OCRFFF.

Study Design: Retrospective review between January 2001 and December 2008 of 117 FFF patients and 51 OCRFFF patients

Setting: University of Alabama, Birmingham

Synopsis: Comparable functional outcomes were demonstrated after OCRFFF and FFF. An oral diet was tolerated in 72.6 percent of FFF and 79.1 percent of OCRFFF patients. An enterogastric feeding tube was retained in 27.4 percent of the FFF patients and 20.9 percent of the OCRFFF patients. There was no difference in length of hospital stay, and median survival rates were comparable. Early complications were seen in 17.9 percent of FFF and 25.5 percent of OCRFFF patients, with skin paddle necrosis requiring additional flap coverage the most common. Late complications were seen in 11.9 percent of FFF patients and 13.7 percent of OCRFFF patients, with malunion the most common, followed by infection. In general, older patients tended to receive OCRFFF due to concerns about prolonged difficulty with walking.

Bottom Line: Where appropriate for the defect, osteocutaneous radial forearm free flaps provide comparable functional outcomes to fibular free flap reconstruction.

Reference: Virgin FW, Iseli TA, Iseli CE, et al. Functional outcomes of fibula and osteocutaneous forearm free flap reconstruction for segmental mandibular defects. Laryngoscope. 2010;120(4):663-667.

—Reviewed by Sue Pondrom

 

PET-CT Adds to Management of Salivary Gland Malignancies

Clinical Question

What is the efficacy of combined positron emission tomography-computed tomography (PET-CT) in identifying salivary gland malignancies, and what is its role in the management of these patients?

Background: In early studies, PET information improved the sensitivity of CT in detecting primary salivary tumors, cervical metastases and distant metastases, but the small number of patients and the evolution to combined PET-CT scanning suggest a re-evaluation of the role of these scans.

Study Design: Chart review of 55 patients between January 2000 and October 2008

Setting: University of Pittsburgh

Synopsis: A total of 135 PET-CT scans (mean of 2.5 per patient) were reviewed and correlated with clinicopathological information. PET-CT was used primarily in the setting of surveillance for recurrent or distant disease but also for restaging patients with known recurrence and in initial staging and surgical planning. The sensitivity, specificity and positive and negative predictive values for PET-CT were analyzed. Overall, PET-CT demonstrated a sensitivity of 74.4 percent, specificity of 100 percent, positive predictive value of 100 percent and a negative predictive value of 61.5 percent. There was no significant difference in sensitivity between high-grade tumors and low-intermediate-grade tumors. PET-CT altered or confirmed management in 47.3 percent of the patients.

Bottom Line: PET-CT is effective in the evaluation of salivary cancers and is particularly useful in initial staging and for surgical and radiation therapy planning. There appears to be less benefit in long-term surveillance and detecting distant metastasis where CT with contrast alone is likely to be sufficient.

Reference: Razfar A, Heron DE, Branstetter BF IV, et al. Positron emission tomography-computed tomography adds to the management of salivary gland malignancies. Laryngoscope. 2010;120(4):734-738.

—Reviewed by Sue Pondrom

 

Cidofovir Therapy Does Not Correlate with Worsening Dysplasia

Clinical Question

What is the association between an increasing degree of papilloma dysplasia and the use of cidofovir in the context of the natural progression of dysplasia in recurrent respiratory papillomatosis (RRP)?

Background: RRP is a benign disease characterized by recurrent lesions in the airway. The prevalence and degree of dysplasia present in the natural course of RRP is not well established. While adjuvant therapies such as cidofovir have been used to decrease the interval between repeat surgeries, there has been concern regarding carcinogenic transformation following the use of cidofovir.

Study Design: Retrospective chart review of 13 patients with RRP

Setting: University of Iowa Hospitals

Synopsis: The 13 cases studied were patients with RRP who had histopathologic biopsies done before and after exposure to cidofovir. Pathologic data was collected over 10 years and the highest degree of dysplasia noted. Because many records did not comment on the presence or absence of dysplasia in the squamous papilloma, all of the surgical slides were reviewed by a single senior pathologist who was blinded to the previous interpretation and to patients’ data. The highest dysplasia scores for each patient’s multiple surgeries were plotted across time to determine whether obvious patterns existed. The longitudinal results indicated that the grade of dysplasia got worse for two patients after cidofovir injection, improved in four patients, and remained relatively equivalent for the remaining patients. Of the 176 specimens collected, 5.7 percent had no dysplasia, 57.4 percent had mild dysplasia (grade 1), 28.4 percent had moderate dysplasia (grade 2) and 8.5 percent had severe dysplasia (grade 3). There was no clear-cut pattern between the use of cidofovir and the degree of dysplasia over time. Study limitations were lack of standardization of cidofovir dosage, administration with alternate treatments such as other antivirals, and lack of scheduled follow-up protocol.

Bottom Line: Although this study showed a high rate of dysplasia among RRP patients, it suggested that cidofovir is not clearly associated with progression of dysplasia.

Reference: Gupta HT, Robinson RA, Murray RC, et al. Degrees of dysplasia and the use of cidofovir in patients with recurrent respiratory papillomatosis. Laryngoscope. 2010;120(4):698-702.

—Reviewed by Sue Pondrom

 

System Automatically Monitors Apnea-Hypopnea Index

Clinical Question

Does a new, full-night automatic system for the detection of snoring provide information on the acoustic characteristics of snores that differ in relation to the apnea-hypopnea index (AHI)?

Background: The probability of obstructive sleep apnea syndrome (OSAS) is 3.2 times higher in snorers than in non-snorers. Although several studies have shown differences in acoustic snoring characteristics between patients with OSAS and simple snorers, usually only a few manually isolated snores have been analyzed, with an emphasis on postapneic snores in OSAS patients.

Although automatic snore detection systems may offer more objective measurement over a longer period of sleep, they have not been applied to full-night analysis, mainly because of problems of recording noise from ambient sounds.

Study Design: Thirty-seven nonsmoking snorers were monitored for six hours.

Setting: Sleep Disorders Laboratory, University Hospital Germans Trias i Pujol, Badalona, Spain

Synopsis: Full-night polysomnography was performed in patients classified as either simple snorers, snorers with an AHI <5, snorers with an AHI ≥5 and <15 and snorers with an AHI ≥15. Snoring sounds were recorded for six hours using a unidirectional electric condenser microphone coupled to the skin through a conic air cavity. The microphone was placed over the trachea at the level of the cricoid cartilage using an elastic band.

The snoring episodes were identified by an automatic detector and analyzer developed by the Spanish research group. Snore number, average intensity and power spectral density parameters were computed for each subject and compared among AHI groups. The system was able to identify and isolate snores from other noises, relate each snore to body position and provide statistical results for the entire night of study.

Bottom Line: The automatic analyzer, which takes into consideration all snoring episodes detected throughout the night, showed that snoring intensity and the snore frequency spectrum seem to be significantly different in snorers with different AHIs. This could be a tool for automatic screening for OSAS, but further validation is needed.

Reference: Fiz JA, Jané R, Solà-Soler J, et al. Continuous analysis and monitoring of snores and their relationship to the apnea-hypopnea index. Laryngoscope. 2010;120(4):853-861.

—Reviewed by Sue Pondrom

 

Prevalence of Dysplasia with Recurrent Respiratory Papillomatosis Is High

Clinical Question

What is the prevalence of dysplasia in recurrent respiratory papillomatosis?

Background: Recurrent respiratory papillomatosis (RRP) is a debilitating disease caused by the human papilloma virus (HPV). Between two percent and four percent of cases are reported to undergo malignant degeneration. Epithelial dysplasia is implicated in the progression towards malignancy.

Study design: Retrospective case series review

Setting: Two academic health centers

Synopsis: The authors reviewed 170 pathological specimens taken from 73 patients during a six-year period. They identified a degree of dysplasia in 13 percent (22 of 170) of the specimens. In addition, they found that 21.9 percent of patients had dysplasia during the period of review. One patient progressed from dysplasia to carcinoma in situ. No patients progressed to invasive squamous cell carcinoma. Although patients with dysplasia were older on average than patients without dysplasia (56.3 vs. 48.3 years old), this difference trended toward, but did not reach, statistical significance. Neither gender, tobacco use, operative frequency, nor cidofovir use were associated with increased rates of dysplasia. Findings between the two institutions, located in different geographic areas of the U.S., were nearly identical. The strengths of the paper are the large number of patients and pathological samples that were studied and the concordance of findings between the two institutions. The authors noted several shortcomings of the study. One weakness, aside from the retrospective design, is a relatively short study period. It is plausible that progression from dysplasia to malignancy may require a longer time period. Furthermore, HPV subtyping was not routinely performed and may have implications in RRP progression toward malignancy.

Bottom Line: The prevalence of dysplasia in patients with RRP is high (22 percent). There is no clear correlation with age, gender, tobacco use or surgical frequency.

Reference: Blumin JH, Handler EB, Simpson CB, et al. Dysplasia in adults with recurrent respiratory papillomatosis: incidence and risk factors. Ann Otol Rhinol Laryngol. 2009;118(7):481-485.

—Reviewed by Michael M. Johns, MD

 

Videolaryngostroboscopy Valuable in Pediatric Patients

Clinical Question

What is the diagnostic value of laryngeal videostroboscopy in pediatric patients with dysphonia?

Background: Laryngeal videostroboscopy has been proven to be a valuable tool in the evaluation of adult voice disorders. It allows for detailed assessment of glottal closure, mucosal pliability and subtle vocal fold lesions. Pediatric dysphonia is found in six percent to nine percent of children. Stroboscopy is presently used infrequently to evaluate pediatric dysphonia.

Study Design: Retrospective case series review

Setting: A single academic health center

Synopsis: Patients with prolonged dysphonia between the ages of three and 17 were included in the study. All patients were referred following failed speech therapy, with diagnoses of vocal nodules or unresolved dysphonia. Clinicians performed rigid transoral or flexible transnasal stroboscopy in all patients. In general, older children tolerated rigid stroboscopy better than younger children, but children as young as eight tolerated rigid exams. Researchers identified benign mucosal disease of the vocal fold in 89 percent of patients. Only 51 percent of patients had vocal nodules, however. Polyps were found in 19 percent, and cysts were found in 10 percent. Sulcus vocalis was found in five percent. Coexistent inflammatory disease was diagnosed in 51 percent and was attributed to reflux laryngitis, non-specific laryngitis and rhinosinusitis. Voice therapy was the most common intervention, but endoscopic laryngeal microsurgery was performed in 20 percent of patients. This study demonstrates that laryngeal videostroboscopy can be routinely performed in children. The use of stroboscopy in this study changed the diagnosis in a substantial number of children with dysphonia. Despite being referred with a diagnosis of nodules, researchers identified other vocal fold lesions in almost 35 percent of patients.

Bottom Line: Laryngeal videostroboscopy provides important diagnostic information in pediatric patients with dysphonia, differentiating nodules from polyps, cysts and other pathology.

Reference: Mortensen M, Schaberg M, Woo P. Diagnostic contributions of videolaryngostroboscopy in the pediatric population. Arch Otolaryngol Head Neck Surg. 2010;136(1):75-79.

—Reviewed by Michael M. Johns, MD

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