Literature Review: A roundup of the important recent studies

From: ENT Today, July 2010

• Polydioxanone Foil Can Be Used to Support the Nasal Septum
• Intranasal Corticosteroid Not Recommended as Monotherapy for Acute Rhinosinusitis
• Thyroid Palpation Should Follow Serum Hormone Measurement
• Carbon Dioxide Laser-Assisted Cartilage Reshaping Otoplasty
• More Research Needed into Management of Facial Paralysis from Intratemporal Blunt Trauma
• Researchers Identify Patients at Risk for MRSA

 

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 to achieve a functional and aesthetically healthy nose. 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 non-perforated foil (NPF) and perforated foil (PF) groups were 51.5 and 20.5 months, respectively. Forty-three of 50 patients were completely satisfied and experienced no complications, whereas seven patients (7/26 NPF treated, 0/24 PF treated) required revision surgery. The results demonstrated increased negative outcomes with thicker NPF compared with thinner PF. Complications included minor tip and columella irregularity (2/7), septal granulation and swelling (1/7) and moderate dorsal saddling (4/7). All four patients experiencing saddling were treated with the thicker (0.25 mm thick) ZX5 NPF. Patients treated with the thinner (0.15 mm thick) ZX7 PF did well and experienced fewer complications. The patient who experienced the septal granuloma had been treated with the 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 is likely secondary to vascular compromise during prolonged isolation between the NPF, however. Therefore, conservative PF use is recommended for stabilizing the weakened septal L-strut when autogenous cartilage is unavailable. The thinner ZX7 PF 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

 

Intranasal Corticosteroid Not Recommended as Monotherapy for Acute Rhinosinusitis

CLINICAL QUESTION

Is an intranasal corticosteroid (INCS) effective monotherapy for treatment of acute rhinosinusitis?

Background: Acute rhinosinusitis is often treated with antibiotics as if it were a bacterial infection; however, estimates suggest that approximately 98 percent of cases may be of viral etiology. The natural history of acute sinusitis, even in cases of bacterial disease, is spontaneous resolution in the majority of cases. Given this fact, the routine use of antibiotics is sometimes questioned, and further questions have been raised regarding the potential role of interventions that might speed the rate of symptom resolution.

Study design: Case report and systematic review.

Setting: N/A

Synopsis: The authors discuss the results of their review within the framework of a clinical example describing a patient who has suffered fatigue, nasal discharge, obstruction, hyposmia and maxillary pain for a period of 10 days. Acknowledging overutilization of antibiotics for a disease that is largely self-limiting, while appreciating the significant impact that the disease has upon quality of life and function, the following question was posed as the basis of this systematic review: Does treatment with an INCS alone reduce the time to recovery in adults with acute, non-complicated rhinosinusitis?

Using a broad filter, search terms were chosen to select for patients with acute rhinosinusitis whose sole therapy had been INCS. This search yielded 811 articles that were further screened to four articles specifically addressing their focused clinical question. Full review of these four articles resulted in only two articles that satisfied the authors’ domain, determinant and outcomes.

The two studies were designed as randomized, prospective, double-blind, double-dummy placebo-controlled trials assessing the effectiveness of an INCS versus that of combinations of amoxicillin, combined therapy and placebo. Each of the studies differed with respect to specific INCS and methods of outcome assessment. Williamson and colleagues compared regular-strength budesonide to placebo, amoxicillin and combined therapy and showed neither difference in total symptom score nor proportion of cured patients attributable to the use of budesonide in any group at treatment day 10 (aRD: 0 percent [95 percent CI:-12.6 percent to 12.7 percent]). Meltzer and colleagues compared amoxicillin to once-daily (200mg) mometasone, twice-daily (400mg) mometasone and placebo and demonstrated a statistically significant dose-dependent improvement for those patients treated with single-dose (p<0.018) and double-dose (p<0.001) mometasone when compared to placebo. It may be of interest that, within the Meltzer study, double-dose mometasone also showed statistical superiority over amoxicillin (p=0.002).

The authors ultimately conclude that there are insufficient data to recommend the use of an INCS as monotherapy for the patient presented within their clinical example. Interestingly, the conclusion of the authors in this systematic review offers an example of the variability that can accompany individual authors’ interpretation as a component of systematic review of the literature. As an example of this variability, Cochrane recently conducted a similar systematic review of the literature involving the same two articles but arrived at the opposite conclusion.¹

Bottom line: Two well-performed outcomes studies addressing the effectiveness of INCS as monotherapy for the treatment of acute rhinosinusitis produced differing results.^2,3 The authors of this review felt that data remain insufficient to recommend the use of an INCS for this purpose. However, Cochrane evaluated the same data and concluded that current evidence supports the use of INCS as adjunctive or monotherapy for acute rhinosinusitis.¹

Reference: Venekamp RP, Sachs APE, Bonten MJ, et al. Intranasal corticosteroid monotherapy in acute rhinosinusitis: an evidence-based case report. Otolaryngol Head Neck Surg. 2010;142(6):783-788.

Other References:

1. Zalmanovici A, Yaphe J. Intranasal steroids for acute sinusitis. Cochrane Database Syst Rev. 2009;(4):CD005149.
2. Williamson IG, Rumsby K, Benge S, et al. Antibiotics and topical nasal steroid for treatment of acute maxillary sinusitis: a randomized controlled trial. JAMA. 2007;298(21):2487-2496.
3. Meltzer EO, Bachert C, Staudinger H. Treating acute rhinosinusitis: comparing efficacy and safety of mometasone furoate nasal spray, amoxicillin, and placebo. J Allergy Clin Immunol. 2005;116(6):1289-1295.

—Reviewed by Bradley F. Marple, MD

 

Thyroid Palpation Should Follow Serum Hormone Measurement

CLINICAL QUESTION

What are the effects of routine thyroid gland palpation on serum thyroid hormone levels?

Background: The assessment of serum thyroid hormone levels in association with thyroid palpation is widely used for the diagnosis of thyroid gland pathologies, often with blood sampling for thyroid function taking place after physical examination. While previous studies have shown that external trauma might cause variations in serum thyroid hormone levels, the effect of thyroid palpation is unknown.

Study design: Prospective study.

Setting: Haydarpa Numune Research and Education Hospital, Istanbul, Turkey.

Synopsis: Twenty adults with a diagnosis of nodular thyroid disease and 30 healthy subjects had their thyroid glands palpated by the same physician. Blood samples were obtained both before and two hours after thyroid gland palpation. The researchers found that routine palpation in both the patients with nodular thyroid disease and healthy individuals caused a significant increase in serum levels after palpation. Differences in TSH and TT4 levels were not significant in either group. The authors said their results indicate that palpation might cause a transient increase in thyroid hormone levels with high levels due only to the effects of palpation. Therefore, misleading reports of hormone levels might lead to misdiagnosis and mismanagement of patients. Additionally, the authors said that in patients with previously unknown raised levels of thyroid hormones, palpation might aggravate the disease process. In their discussion, the researchers noted previous studies involving increased serum levels. One study they mentioned, by Lever and colleagues, found that external manual palpation did not influence serum TG levels, but surgical palpation and FNAB resulted in elevations of serum TG.

Bottom line: The data suggest an effect of routine thyroid gland palpitation on serum thyroid hormone levels and suggest that serum thyroid hormone measurements should be performed before any manipulation of the gland, including palpation, to avoid misdiagnosis.

Reference: Toros SZ, Ozel L, Yekrek MM, et al. Does thyroid gland examination by palpation alter serum hormone levels? Laryngoscope. 2010;120(7):1322-1325.

—Reviewed by Sue Pondrom

 

Carbon Dioxide Laser-Assisted Cartilage Reshaping Otoplasty

CLINICAL QUESTION

How does the new technique of carbon dioxide laser-assisted cartilage reshaping (CO₂ LACR) otoplasty work and what are the outcomes?

Background: With more than 200 different otoplasty techniques, no single technique is considered the standard of care. Otoplasty techniques are cartilage sculpting (cutting), cartilage sparing (suturing) or a composite of the two. Problems associated with these techniques include suture extrusion, loss of correction over time, difficulty reshaping thick cartilage and permanent distortion of the ear.

Study design: Prospective case study.

Setting: Department of Otorhinolaryngology, Menoufyia University Hospital, Shibin Elkom, Menoufyia, Egypt.

Synopsis: Sixteen patients ages four to seven with bilateral prominent ears with unfurled antihelixes and without other associated ear deformities underwent early and final outcome assessments after carbon dioxide LACR otoplasty operations. Assessments included McDowell’s basic goals of otoplasty, patient/parent satisfaction, doctors’ satisfaction and measurements of early and late postoperative degree and change of protrusion. The same doctor performed each procedure, which is described in the article. The average follow-up time was 2.4 years, with no cases requiring revision surgery. In late assessment, 14 patients were pleased and two were “satisfied.” The author said the outcome of laser beams on cartilage depends on the laser wavelength, pulse duration, irradiance and tissue optical and thermal possessions. This retroauricular open approach allocated precise laser application, maintained control of the auricular reshaping process and passed up skin laser interactions. The author commented that there can be multiple negative results with LACR, noting a study by Leclère and colleagues in which LACR was performed without otoplasty surgery, and its drawbacks included prolonged mold use and development of contact dermatitis in six patients.

Bottom line: CO₂ LACR otoplasty results in endurance of auricular appearance and symmetry, with good to satisfactory outcomes, but further follow-up is still needed.

Reference: Ragab A. Carbon dioxide laser-assisted cartilage reshaping otoplasty: a new technique for prominent ears. Laryngoscope. 2010;120(7):1312-1382.

—Reviewed by Sue Pondrom

 

More Research Needed into Management of Facial Paralysis from Intratemporal Blunt Trauma

CLINICAL QUESTION

What is the management and outcome of facial paralysis from intratemporal blunt trauma?

Background: Many temporal bone fractures, most commonly from motor vehicle accidents, are complicated by facial nerve dysfunction. Frequently, the initial diagnosis of facial nerve injury is delayed due to the altered mental status of the patient and the attention diverted to life-threatening injuries. Multiple factors, such as the onset of nerve dysfunction and test results, can determine management.

Study design: Literature review.

Setting: Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin and Affiliated Hospitals, Milwaukee, Wisconsin.

Synopsis: A systematic literature review identified 35 relevant articles in PubMed, with the majority of articles reporting paresis secondary to a temporal bone fracture. All studies were classified as level four evidence as defined by the Oxford Centre for Evidence-Based Medicine. Marked variation in the quality of the studies, with inconsistent outcome measures, diagnostic testing and follow-up, ruled out a formal meta-analysis. The authors said their review highlights the numerous inconsistencies in reporting and the subsequent difficulty in interpreting data. They said correlations between outcomes and radiographic findings, surgical approach, topognostic testing or electrodiagnostic testing could not be made. A total of 612 cases of facial weakness in 606 patients were available for analysis, with outcome variables including severity of paralysis, time of onset of paralysis, surgical or nonsurgical management, steroid use and final facial nerve function. The patients were grouped into categories of those followed observationally (used as the standard to compare other treatment outcomes), those treated with steroids and those who received surgery. Overall, the authors said the papers were so varied in outcome measures and depth of reporting that the data set was too heterogeneous and incomplete to warrant meaningful analysis. However, the team did assign a grade of C (on a scale of A to D) for the overall strength of evidence regarding surgical facial nerve decompression in the setting of intratemporal blunt trauma. The role of steroids was called “unclear,” with the possibility that some patients were administered corticosteroids that were not reported.

Bottom line: The role of surgical versus nonsurgical intervention, as well as the prognostic capability of electrodiagnostic testing and radiographic studies, remain inconclusive. Further investigations with standardized reporting and comparison cohorts are needed.

Reference: Nash JJ, Friedland DR, Boorsma KJ, et al. Management and outcomes of facial paralysis from intratemporal blunt trauma: a systematic review. Laryngoscope. 2010;120(7):1397-1404.

—Reviewed by Sue Pondrom

 

Researchers Identify Patients at Risk for MRSA

CLINICAL QUESTION

What patients are at risk for methicillin-resistant Staphylococcus aureus (MRSA) infection following septorhinoplasty and the need for antibiotic prophylaxis?

Background: Local infection is a rare complication following septorhinoplasty, but it has been suggested that at least half of the patients who undergo septorhinoplasty or rhinoplasty will be colonized with Staphylococcus aureus (S. aureus), and a percentage of those patients will be colonized with MRSA.

Study design: Literature review.

Setting: Department of Otolaryngology/Head and Neck Surgery, Oregon Health and Science University, Portland, Oregon.

Synopsis: The authors reviewed and summarized several studies and reviews covering MRSA nasal carriage, MRSA in septorhinoplasty, prevention of MRSA infections following surgery and the role of antibiotics in septorhinoplasty. They said previous studies have shown that patients considered at increased risk of MRSA colonization include elderly patients over 60 years, particularly those in residential homes or rehabilitation units, those with previous hospital admissions or antibiotic use and patients who work in the health care setting (along with their household members). Regarding the role of antibiotics, the authors referred to two previous studies. The first study failed to demonstrate a difference between patients who received antibiotic prophylaxis during nasal surgery and those who did not. The second was a double-blinded randomized study of 100 patients in which the authors concluded that it is advisable to give prophylactic antibiotics in complicated revision rhinoplasty.

Bottom line: MRSA infections following rhinoplasty are exceedingly rare according to the literature. Those at risk include elderly patients over 60 years, particularly those in residential homes or rehabilitation units, those with previous hospital admissions or antibiotic use and patients who work in the health care setting (along with their household members). However, there remain no clear guidelines for prophylaxis for MRSA infection following rhinoplasty.

Reference: Angelos PC, Wang TD. Methicillin-resistant Staphylococcus aureus infection in septorhinoplasty. Laryngoscope. 2010;120(7):1309-1311.

—Reviewed by Sue Pondrom

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