Literature Review: A roundup of the most important recent studies

From: ENT Today, June 2010

• Presbyphonia Voice Therapy Effective in Older Patients
• Steroid-Impregnated Nasal Dressing Improves Post-ESS Healing
• The Faculty Mentor…from theResident’s Perspective
• Understanding Otosclerosis Etiology and Impacting Factors
• Irradiated Homologous Costal Cartilage Used Effectively in Rhinoplasty
• Polydioxanone Foil Can Be Used to Support the Nasal Septum

 

Presbyphonia Voice Therapy Effective in Older Patients

Clinical Question

Are factors such as age, gender, degree of vocal fold atrophy and the burden of medical problems associated with voice therapy outcomes for presbyphonia?

Background: Although voice therapy is generally considered the mainstay of rehabilitation for the aging voice, there is little data on its efficacy for this indication, especially with regard to the effects of age, degree of glottic closure, degree of vocal fold atrophy and the burden of medical problems. Previous studies of dysphonia in aged persons have shown physiologic aging to account for only a minority of voice problems, and therefore might lead to under-treatment of this group of patients.

Study Design: Retrospective review

Setting: Vanderbilt Voice Center, Vanderbilt University Medical Center, Nashville, Tenn.

Synopsis: Researchers screened the records of patients seen over a three-year period. For the study they chose 67 patients over age 55 with a primary complaint of hoarseness, presence of vocal fold atrophy on examination and absence of laryngeal or neurological pathology. They team assessed voice therapy outcomes with the American Speech-Language-Hearing Association National Outcomes Measurement System scale and performed statistical analysis. Of these patients, 85 percent demonstrated improvement with voice therapy, and the most common type of glottic closure was a slit gap. Gender or age had no effect on voice therapy outcomes. Larger glottic gaps on initial stroboscopy examination and more pronounced vocal fold atrophy were weakly correlated with less improvement and a weak correction was also found between the number of chronic medical conditions and poorer outcomes. The authors said the fact that many patients did not have large glottal gaps may be a source of bias in the overall favorable outcome from voice therapy.

Bottom Line: Advanced age does not portend poorer outcomes with voice therapy. Patients with larger glottal gaps and more severe atrophy may improve less with voice therapy than those with better glottic competence on initial examination. The degree of improvement may also be influenced by medical problems.

Reference: Mau T, Jacobson BH, Garrett CG. Factors associated with voice therapy outcomes in the treatment of presbyphonia. The Laryngoscope. 2010;120(6):1181-1187.

—Reviewed by Sue Pondrom

 

Steroid-Impregnated Nasal Dressing Improves Post-ESS Healing

Clinical Question

What is the impact of steroid-impregnated absorbable nasal dressing on wound healing and surgical outcomes after endoscopic sinus surgery (ESS)?

Background: Wound healing has been a significant determinant of successful outcomes in ESS, with factors leading to poor surgical outcomes including scarring/synechiae, ostial or middle meatal obstruction, infection and persistent inflammation in the opened sinus cavities. Intranasal triamcinolone acetonide has been evaluated in clinical trials and found to be beneficial in minimizing nasal secretory response and reducing inflammation, which has led to recommendations for intranasal steroids as a first-line therapy in allergic rhinosinusitis. The use of topical corticosteroid sprays post operatively, however, has met with mixed results. A short course of systemic steroids has been found to be helpful after ESS, but there remains a lack of consensus regarding optimal perioperative nasal dressing and packing as well as the optimal postoperative medical regimen.

Study Design: A prospective, randomized, double-blinded, placebo-controlled trial

Setting: Alberta Sinus Centre, University of Alberta, Edmonton, Alberta, Canada

Synopsis: Researchers recruited 19 chronic rhinosinusitis patients with polyposis who were to undergo bilateral ESS and randomized them to receive triamcinolone-impregnated bioresorbable dressing in one nasal cavity and saline-impregnated dressing contralaterally. Nasal packing remained in situ until about one week after surgery. Postoperative healing assessments of edema, crusting, secretions and scarring were done at postoperative days seven, 14, 28 and at three and six months using validated Lund-Kennedy and Perioperative Sinus Endoscopy (POSE) scores. There were no significant differences between the cavity scores preoperatively. A statistically significant difference, however, was seen at days seven and 14 and between the groups at the three- and six-months. The researchers said limitations to the study included the likely variable consistency and duration of delivery of the steroid. Additionally, ideal dosage needs further clarification.

Bottom Line: There is significant improvement in early postoperative healing in sinonasal cavities receiving triamcinolone-impregnated absorbable nasal packing following ESS and this is associated with significant improved healing up to six months postoperatively.

Reference: Côté DWJ, Wright ED. Triamcinolone-impregnated nasal dressing following endoscopic sinus surgery: a randomized, double-blind, placebo-controlled study. The Larynogoscope. 2010;120(6):1269-1273.

—Reviewed by Sue Pondrom

 

The Faculty Mentor…from the Resident’s Perspective

Clinical Question

What is the experience of residents regarding mentorship during their otolaryngology residency?

Background: Integral to the educational experience is the relationship between faculty and residents, which is based upon multiple types of encounters, including formal teaching sessions, clinical care of patients, surgical training and research activities. The embodiment of this relationship is the faculty mentor whose potential role includes guidance with clinical and educational aspects, fellowship and career planning, research and personal well being. Despite the importance of mentorship, an understanding of its availability and effectiveness in otolaryngology is limited.

Study Design: Internet-based anonymous survey of chief residents in otolaryngology residency

Setting: New York researchers conducted the survey via the Accreditation Council for Graduate Medical Education website and surveymonkey.com.

Synopsis: Forty-seven respondents completed the survey. Eighteen (38 percent) were assigned an official faculty mentor and 23 (49 percent) were assigned a research mentor during their residency. Thirty-nine (83 percent) reported receiving meaningful mentorship from faculty who were not officially assigned mentors. Overall, 18 respondents (38 percent) were neutral or not satisfied with the experience. Statistically significant higher scores were noted for mentorship in career preparation versus mentorship in research and resident quality of life. Lower scores were noted for availability of mentorship in preparation for a career in private practice versus academic medicine. Residents officially assigned mentors reported statistically significant higher scores with regard to satisfaction with the overall mentorship experience. A limitation of the study was the low response rate and associated potential failure of the sample to accurately represent the entire population. Sub-categorical analysis (e.g., gender, race, future fellowship plans) was generally not possible due to the low response rate and inherent limitations of survey-based research.

Bottom Line: Variability in the mentorship experience was noted indicating that deficiencies may exist, including absence of formal mentorship in some residency programs, and the need for increased attention to mentorship.

Reference: Hsu AK, Tabaee A, Persky MS. Mentorship in otolaryngology residency: the resident perspective. The Laryngoscope. 2010;120(6):1263-1268.

—Reviewed by Sue Pondrom

 

Understanding Otosclerosis Etiology and Impacting Factors

Clinical Question

What is the current understanding of the etiology of otosclerosis and what are the genetic and environmental factors that have been implicated in the disease?

Background: A common disease characterized by a disordered bone remodeling in the otic capsule, otosclerosis has a prevalence of about 0.3 percent to 0.4 percent in the Caucasian population. In 10 percent of cases, a sensorineural hearing loss is present in addition to the conductive hearing loss. Although many environmental and genetic factors have been suggested for the development of otosclerosis, a great part of the etiology remains a mystery.

Study Design: A contemporary review

Setting: Department of Medical Genetics, University of Antwerp, Antwerp, Belgium

Synopsis: The data suggest that measles virus infection is probably a susceptibility factor involved in otosclerosis but not the single cause or necessary for the disease to manifest. Endocrine factors could be involved because of the large difference in prevalence between males and females (1:2). In addition, epidemiological studies show otosclerosis associated with low fluoride content in the drinking water. Evidence for genetic variants in otosclerosis has been discovered in different parts of the spectrum, but the extent to which these contribute to the disease is unclear since only a limited number of genetic studies have been done. Most cases of otosclerosis, however, do not have a clear familial background. The success in identifying loci in large otosclerosis families by linkage analysis has been hampered by the presence of reduced penetrance and phenocopies. The authors noted that recently they have been able to provide strong evidence for T cell receptor beta as the responsible gene at the OTSC2 region. The authors also discussed association studies for otosclerosis, including genes in the immune system, in bone remodeling and in hormonal and other pathways. Regarding otosclerosis as an autoimmune disease, the authors said the precise underlying mechanism might vary among otosclerosis patients as several factors can influence and contribute to a similar disease outcome and it is unclear whether an autoimmune pathology underlies disease development.

Bottom Line: Overall, studies suggest a heterogeneous etiology for otosclerosis with the extent of involvement of environmental versus genetic factors unclear.

Reference: Schrauwen I, Van Camp, G. The etiology of otosclerosis: a combination of genes and environment. Laryngoscope. 2010; 120(6):1195-1202.

—Reviewed by Sue Pondrom

 

Irradiated Homologous Costal Cartilage Used Effectively in Rhinoplasty

Clinical Question

Can irradiated homologous costal cartilage be safely and reliably utilized as a grafting material for primary and secondary rhinoplasty?

Background: Early reports on irradiated homologous costal cartilage (IHCC) used in nasal grafting were confounded by many factors, making its long-term survivability difficult to assess. Preliminary results from the first large-scale study limiting grafts to nasal reconstruction were encouraging. However, long-term follow-up was necessary to draw further conclusions.

Study Design: Retrospective medical record review

Setting: Single facial plastic surgeon private practice in Houston, Texas

Synopsis: Three hundred fifty-seven patients undergoing primary or revision rhinoplasty utilizing 1,025 IHCC grafts were evaluated for complications during follow-up from four days to 24 years (mean 13.45 years). A 3.25 percent total complication rate resulted from warping in 10 of 941 IHCC grafts (1.06 percent), infection in nine of 1,025 IHCC grafts (0.87 percent), infective resorption in five of 1,025 IHCC grafts (0.48 percent), non-infective resorption in five of 943 (0.53 percent), and graft mobility in three of 941 (0.31 percent). Overall resorption and septal perforation repair associated graft complications were higher with autogenous cartilage (AC) than IHCC grafts with 1.37 percent vs. 1.01 percent and 8 percent vs. 2.46 percent complications, respectively.

Despite the long-term follow-up in a number of patients, only 8 percent were evaluated at >10 years. This limits the ability to refute previous concerns of long term IHCC resorption. IHCC warping is also likely underestimated, with smaller grafts in the nasal tip and other locations more difficult to palpate than non-dorsal onlay grafts. Cartilage grafts such as spreader grafts are placed deep between the upper lateral cartilages and dorsal septum, and any warping would be difficult to assess. This study, however, does demonstrate safety and reliability with IHCC grafts. The authors obtained the IHCC from one of two locations: the University of Texas Health Sciences Center in Dallas, Texas and Northern California Tissue Bank in San Francisco, Calif. The IHCC can be difficult to obtain due to shortages of cadaver donor materials.

Bottom Line: IHCC is a useful grafting material that is safe and can be used effectively when autogenous cartilage is unavailable for primary and secondary rhinoplasty. There is still some question as to the long-term survivability of IHCC.

Reference: Kridel RW, Ashoori F, Lui ES, et. al. Long-term use and follow-up of irradiated homologous costal cartilage grafts in the nose. Arch Facial Plast Surg. 2009;11(6): 378-394.

—Reviewed by Bo Brobst, MD, and Dean M. Toriumi, MD

 

Polydioxanone Foil Can Be Used to Support the Nasal Septum

Clinical Question

Is polydioxanone foil an effective material for stabilizing septal segments in nasal septal reconstruction?

Background: Post surgical nasal septal integrity must be restored if a functionally and aesthetically healthy nose is desired. When autogenous cartilage for reconstruction is unavailable or procurement is excessively morbid, allografts are often considered. Resorbable polydioxanone foil may be useful in nasal septal reconstruction for stabilizing septal segments.

Study Design: Retrospective medical record review.

Setting: Single facial plastic surgeon practice in the department of otolaryngology and facial plastic surgery, Royal Surrey County Hospital in Guildford, England

Synopsis: Fifty patients were treated between April 2004 and February 2008 using polydioxanone foil. These cases involved septal reconstruction with or without rhinoplasty performed via endonasal or external rhinoplasty approaches. Median follow-up for the NPF and PF groups were 51.5 and 20.5 months, respectively. Forty-three of 50 patients were completely satisfied and without complications, whereas seven patients (7/26 NPF treated, 0/24 PF treated) required revision surgery. The results demonstrated increased negative outcomes with thicker, non-perforated foil (NPF) compared with thinner, perforated foil (PF). Complications included minor tip and collumella irregularity (2/7), septal granulation and swelling (1/7), and moderate dorsal saddling (4/7). All four patients experiencing saddling were treated with the unperforated thicker (0.25 mm thick) ZX5 foil. Patients treated with the thinner perforated (0.15 mm thick) perforated ZX7 foil did well with fewer complications. The patient who experienced the septal granuloma also was treated with the thicker unperforated ZX5 foil.

Although complications only occurred in those patients treated with NPF, the increased experience level and shorter follow-up in the PF group may limit what can be extrapolated from these results. The loss of septal cartilage support, however, is likely secondary to vascular compromise during prolonged isolation between the NPF. Therefore, conservative PF use is recommended for stabilizing the weakened septal L- strut when autogenous cartilage is unavailable. The thinner perforated ZX7 foil will allow vascular ingrowth and support of the cartilage.

Bottom Line: Perforated thinner ZX7 polydioxanone foil is an effective reconstructive material for providing temporary septal support when autogenous cartilage is unavailable. The resorbable foil can be used to splint cartilage segments until scarring can set the segments into position.

Reference: Tweedie DJ, Lo S, Rowe-Jones JM. Reconstruction of the nasal septum using perforated and unperforated polydioxanone foil. Arch Facial Plast Surg. 2010;12(2):106-113.

—Reviewed by Bo Brobst, MD, and Dean M. Toriumi, MD

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