A. Simon Carney

Reflux and laryngitis: a systematic review.

OBJECTIVES: To investigate and compare the prevalence of pharyngeal reflux (PR) events in normal controls and patients with clinically diagnosed reflux laryngitis. METHOD: A systematic review of the literature was performed to identify all prospective studies on the results of 24-hour double-probe (pharyngeal and esophageal) pH monitoring in normal controls and in patients with symptoms and/or signs of reflux laryngitis. RESULTS: Eleven relevant studies on 192 normal controls and 13 studies on 512 patients with reflux laryngitis were identified. One or more PR events were detected in 51 normal controls (22.9%; 95% CI, 13.9% to 33.3%) and in 154 of 422 patients (38.3%; 95% CI, 25.4% to 52.1%). There is no significant difference in the prevalence of PR events between normal controls and patients with reflux laryngitis (P = 0.079). In addition, the prevalence of PR events in patients with reflux laryngitis is much lower than reported in previous reviews on this subject. CONCLUSION: This systematic review calculated that (1) only a minority of patients with clinically diagnosed reflux laryngitis will show PR events, and (2) there is no significant difference between the prevalence of PR events in patients with reflux laryngitis and healthy controls. At the moment, there is no reliable means to confirm reflux of gastric juice in patients with suspected reflux laryngitis. This diagnostic vacuum is fundamental and may pose important questions at the current concept of reflux of gastric juice as a common cause of laryngopharyngeal inflammation.

Postoperative pain following coblation tonsillectomy: randomized clinical trial.

Background:  Tonsillectomy is one of the commonest surgical procedures, with postoperative pain being an important source of morbidity. Coblation (cold ablation) is a new technique for tonsillectomy, promoted by claims of reduced postoperative pain levels. This study was designed to compare postoperative pain after tonsillectomy using coblation and tonsillectomy using the standard dissection techniques.

Upper airway reconstructive surgery long-term quality-of-life outcomes compared with CPAP for adult obstructive sleep apnea

OBJECTIVE: To measure long-term quality-of-life (QOL) improvement following contemporary multilevel upper airway reconstruction surgery, compared with continuous positive airway pressure (CPAP) therapy. Secondary aims were to investigate factors determining clinical effectiveness and QOL impact of reported side effects. DESIGN: Cohort study. SUBJECTS AND METHODS: Consecutive, simultaneously treated adult patients with moderate-severe obstructive sleep apnea (OSA) having upper airway surgery (N = 77) or CPAP (N = 89) therapy were studied by questionnaire. Glasgow Benefit Inventory (GBI), change in snoring status and Epworth Sleepiness Scale (ESS), subjective CPAP compliance, and side effects in both groups were measured at mean ± SEM 44.12 ± 5.78 months (3.68 ± 0.48 years) after commencement of therapy. RESULTS: No significant difference was seen between surgical outcomes for GBI, snoring, or ESS and CPAP controls. Multivariate analysis showed reduction in Respiratory Disturbance Index (RDI) predicted postoperative snoring and ESS, but not GBI outcomes. Snoring control and GBI were related to CPAP compliance (P < 0.001). CPAP side effects (reported in 26%) significantly reduced the QOL benefit of treatment, independent of compliance. Surgical complications (occurring in 44%) did not affect QOL treatment benefit. CONCLUSION: Patients with poor CPAP compliance and/or significant side effects of CPAP therapy (45% of cases in this series) should be evaluated for contemporary upper airway reconstructive surgery.

Surfactant Protein D Expression in Chronic Rhinosinusitis Patients and Immune Responses In Vitro to Aspergillus and Alternaria in a Nasal Explant Model

Objectives/Hypothesis: Common fungi have been implicated in the pathogenesis of chronic rhinosinusitis (CRS) with eosinophilic mucus (EMCRS). Surfactant protein (SP)‐D plays an important role in the immune response to Aspergillus fumigatus in the lungs. We sought to determine whether SP‐D is expressed in nasal mucosa and investigated the response of SP‐D in vitro to fungal allergens.

Fungal allergens induce cathelicidin LL-37 expression in chronic rhinosinusitis patients in a nasal explant model

Background Fungus is thought to play an important role in some subgroups of chronic rhinosinusitis (CRS) patients with eosinophilic mucus (EMCRS). The cathelicidin LL-37 is an important innate defense peptide with antimicrobial activity but its responses in CRS and EMCRS patients have not been established. We investigated the innate immune responses of LL-37 in nasal tissue from CRS and EMCRS patients to fungal allergen challenge. Methods The levels of LL-37 produced by nasal tissue and secreted in response to fungal allergen challenge were determined by a nasal tissue explant in vitro model. LL-37 mRNA and protein levels were quantified by real-time reverse-transcriptase–polymerase chain reaction and immunoassay methods. Results LL-37 mRNA expression in CRS, but not EMCRS patients, is significantly upregulated by Aspergillus (mean fourfold increase) and Alternaria (mean sixfold increase) extracts in a dose-response manner (p < 0.001). LL-37 peptide levels in the nasal tissue from CRS patients are increased in response to Alternaria (p < 0.05). In contrast, with EMCRS patients, the expression of LL-37 peptide in nasal tissue is increased with Aspergillus (p < 0.001) but is reduced with Alternaria. We also observed a trend where levels of secreted LL-37 were decreased with higher doses of Alternaria and Aspergillus extracts. Conclusion LL-37 is significantly up-regulated at the mRNA and protein level in CRS patients in response to fungal allergens. However, EMCRS patients do not show increased LL-37 at either the mRNA or the protein level in response to Alternaria.

The coblation tonsillectomy learning curve

OBJECTIVE: To establish if there is a learning curve for coblation tonsillectomy. STUDY DESIGN: Regression analysis of data obtained from surgeons identified from the Australian Tonsillectomy Survey. SUBJECTS AND METHODS: Thirty otolaryngologists were invited to contribute audit data. Data were stratified into groups of 10 procedures and analysed with regression analysis. RESULTS: Nineteen (70%) surgeons responded. Complete data were obtained for 1700 cases and return to theatre data on 2062 cases. There was a significant learning curve with respect to both primary (P = 0.050) and secondary (P = 0.028) hemorrhage rates. Mean rates were 0.3% (95% CI 0.1% to 0.7%) and 2.1% (95% CI 1.5% to 2.9%) for primary and secondary bleeds, respectively, with return to theatre in 0.2% (95% CI 0.1% to 0.5%) and 1.3% (95% CI 0.9% to 1.9%), respectively. CONCLUSION: The introduction of coblation tonsillectomy into Australia was associated with a statistically significant learning curve with respect to both primary and secondary hemorrhage rates.

Radiofrequency coblation for the resection of head and neck malignancies

Objective To review the safety and efficacy of the use of radiofrequency coblation for endoscopic resection of upper aero-digestive tract malignancies and to compare length of procedures using coblation with CO2 laser surgery. Study Design and Setting A retrospective case-note review of 40 adult patients with endoscopically treated mucosal squamous cell carcinoma of the head and neck, 20 having undergone resection using radiofrequency coblation and being case-matched to 20 treated with CO2 laser. Results Coblation proved to be an effective method for resection of selected head and neck malignancies. It allows for much faster resection times than the CO2 laser (P = 0.017) especially in the oropharynx (P = 0.007), but the large probes currently available can cause problems in assessment of adequate resection margins. Conclusions Although current probe design limits the potential for resection of some tumors, radiofrequency coblation appears to be an attractive evolving technique for the endoscopic resection of selected upper aerodigestive tract malignancies.

Tonsillectomy in Australia: An audit of surgical technique and postoperative care

Objective To assess current tonsillectomy practice among Australian otolaryngologists. Study Design An audit based on an anonymous 19-item postal questionnaire on tonsillectomy technique and perioperative management sent to all Australian otolaryngology specialists. Subjects and Methods Two hundred eighty-four otolaryngologists registered with the Australian Society of Otolaryngology-Head and Neck Surgery database were sent the questionnaire. Results A 72.5 percent response rate was obtained. Monopolar diathermy was the most common technique for dissection (45%) and hemostasis (54%). Bipolar diathermy was used for hemostasis in 20 percent. Cold-steel dissection was routinely used by 36 percent, ties were used for hemostasis only by 11 percent of surgeons. The use of local anesthetic, dexamethasone, and postoperative antibiotics was 45 percent, 40 percent, and 20 percent, respectively. Seventy-six percent of surgeons always observed tonsil patients overnight. Conclusion Australian surgeons still use monopolar diathermy as their preferred technique for tonsillectomy. Local anesthetic, dexamethasone, and postoperative antibiotics are used infrequently, and fewer than 1:4 surgeons perform day-case tonsillectomy.

The microbiome of otitis media with effusion in Indigenous Australian children

INTRODUCTION Indigenous Australian children have a high prevalence of otitis media with effusion (OME) and associated conductive hearing loss. Only three microbiological studies of middle ear fluid (MEF) from Indigenous Australian children with OME have been reported. All of these were reliant on culture or species-specific PCR assays. The aim of this study was to characterise the middle ear fluid (MEF), adenoid and nasopharyngeal (NP) microbiomes of Indigenous Australian children, using culture-independent 16S rRNA gene sequencing. METHODS MEF, NP swabs and adenoid specimens were collected from 11 children in the Alice Springs region of Central Australia. Bacterial communities in these specimens were characterised using 16S rRNA gene sequencing. RESULTS The microbiota in MEF samples were dominated (>50% relative abundance) by operational taxonomic units (OTUs) consistent with Alloiococcus otitidis (6/11), Haemophilus influenzae (3/11) or Streptococcus sp. (specifically, Mitis group streptococci which includes Streptococcus pneumoniae) (1/11). Anatomical site selectivity was indicated by the presence of a single conserved Haemophilus OTU in 7/11 MEF samples. In comparison, there were ten distinct Haemophilus OTUs observed across the NP and adenoid samples. Despite significant differences between the MEF and NP/adenoid microbiomes, Streptococcus sp., H. influenzae and Moraxella catarrhalis OTUs were common to all sample types. Co-occurrence of classical otopathogens in paired MEF and NP/Adenoid samples is consistent with earlier culture-based studies. CONCLUSION These data highlight the need to further assess H. influenzae traits important in otitis media and to understand the role of canal flora, especially A. otitidis, in populations with a high prevalence of tympanic membrane perforation.

Submucosal lingualplasty for adult obstructive sleep apnea

Objective To measure quality-of-life outcomes, polysomnographic outcomes, and adverse effects for a new technique of tongue reduction in obstructive sleep apnea. Study Design Case series. Setting Tertiary hospital. Subjects and Methods Consecutively treated adult patients (N = 27) with obstructive sleep apnea having submucosal lingualplasty in 2007 were studied. All had concurrent or previous uvulopalatoplasty ± palatal advancement. Full polysomnography preoperatively and 3.7 ± 0.4 months postoperatively, scored using the American Academy of Sleep Medicine 2007 criteria, was recorded. Snoring severity score, Epworth Sleepiness Scale, and complication data were collected at a 2.61 ± 0.08-year follow-up via questionnaire. Results Mean snoring severity score fell from 7.1 ± 0.4 to 2.3 ± 0.6 (P < .05). Epworth Sleepiness Scale score fell from 8.3 ± 1.1 to 5.8 ± 1.0 (P < .05). The apnea-hypopnea index (AHI) fell from 44.0 ± 4.3 to 12.5 ± 2.3 (P < .05). Success, defined as achieving an AHI <15 postoperatively, was observed in 74% (20/27), with each of these patients achieving a reduction in AHI >50%. Lowest oxygen saturation improved from 84 ± 1 to 88 ± 1 (P < .05). Pain was mild to moderate. Short-term postoperative complications included bleeding (3.7%) and infection (14.8%). Some minor long-term (6 months) alteration in tongue function was reported with regard to speech (47%), swallow (33%), and taste (33%). Conclusion Submucosal lingualplasty with concurrent palatal surgery is a promising treatment option in adult patients with obstructive sleep apnea with macroglossia.