Amit J. Sood

Endolymphatic sac surgery for Ménière's disease: a systematic review and meta-analysis.

Objective To analyze current endolymphatic surgery techniques and quantify their efficacy in controlling vertigo and maintaining hearing in the short and long term. Data Sources A comprehensive literature search using the PubMed-NCBI database from 1970 to 2013. Study Selection Articles on sac decompression and mastoid shunt (with and without silastic) were included. Included studies had to report data using the 1985 or 1995 American Academy of Otolaryngology–Head and Neck Foundation (AAO-HNS) guidelines, describe surgical technique in detail, include a minimum of 10 patients, and have minimum 12 months of follow-up. Data Extraction Endpoints were vertigo control and hearing preservation using AAO-HNS guidelines. Analysis included short-term (>12 mo) and long-term (>24 mo) follow-up. Data Synthesis Data analysis was performed using MedCalc 12.7.0. Each article was weighted according to the number of patients treated. Analysis of pooled proportion was performed, and Freeman–Tukey transformation was used to correct for probable variance. A t test (of proportions) was performed to compare differences between groups. Conclusion Endolymphatic sac surgery (sac decompression or mastoid shunt) is effective at controlling vertigo in the short term (>1 yr of follow-up) and long term (>24 mo) in at least 75% of patients with Ménière’s disease who have failed medical therapy. Sac decompression and mastoid shunting techniques provide similar vertigo control rates. Mastoid shunting, with and without silastic, also provides similar vertigo control rates. Non-use of silastic, however, seems to maintain stable or improved hearing in more patients compared to silastic sheet placement. The data suggest that, once the sac is opened, placing silastic does not add benefit and may be deleterious.

Facial Nerve Monitoring during Parotidectomy A Systematic Review and Meta-analysis

Objectives To determine the effectiveness of intraoperative facial nerve monitoring (FNM) in preventing immediate and permanent postoperative facial nerve weakness in patients undergoing primary parotidectomy. Data Sources PubMed-NCBI database from 1970 to 2014. Review Methods A systematic review and meta-analysis of the literature was conducted. Acceptable studies included controlled series that evaluated facial nerve function following primary parotidectomy with or without FNM (intraoperative nerve monitor vs control). Primary and secondary end points were defined as immediate postoperative and permanent facial nerve weakness (House-Brackmann score, ≥2), respectively. Results After a review of 1414 potential publications, 7 articles met inclusion criteria, with a total of 546 patients included in the final meta-analysis. The incidence of immediate postoperative weakness following parotidectomy was significantly lower in the FNM group compared to the unmonitored group (22.5% vs 34.9%; P = .001). The incidence of permanent weakness was not statistically different in the long term (3.9% vs 7.1%; P = .18). The number of monitored cases needed to prevent 1 incidence of immediate postoperative facial nerve weakness was 9, given an absolute risk reduction of 11.7% This corresponded to a 47% decrease in the incidence of immediate facial nerve dysfunction (odds ratio, 0.53; 95% CI, 0.35 to 0.79; P = .002). Conclusion In primary cases of parotidectomy, intraoperative FNM decreases the risk of immediate postoperative facial nerve weakness but does not appear to influence the final outcome of permanent facial nerve weakness.

Melanotic Neuroectodermal Tumor of Infancy: A Systematic Review.

Melanotic neuroectodermal tumor of infancy (MNTI) is a rare tumor, usually diagnosed within the first year of age, with a predilection for the maxilla. Although the tumor is usually benign, its rapidly growing nature and ability to cause major deformities in surrounding structures necessitate early diagnosis and intervention. It is important that medical and dental specialists are prepared to make the diagnosis and proceed with appropriate intervention. The authors performed a systematic review of the 472 reported cases from 1918 through 2013 and provided a comprehensive update on this rare entity that can have devastating effects on young patients. This investigation uncovered age at diagnosis as an important prognostic indicator, because younger age correlated with a higher recurrence rate. The authors also present a case report of a 5-month-old girl diagnosed with MNTI and review her clinical presentation and imaging and histopathologic findings.

Hyperbaric oxygen therapy for the treatment of radiation-induced xerostomia: a systematic review

OBJECTIVE Radiation-induced xerostomia is one of the most common morbidities of radiation therapy in patients with head and neck cancer. However, in spite of its high rate of occurrence, there are few effective therapies available for its management. The aim of this study was to assess the efficacy of hyperbaric oxygen on the treatment of radiation-induced xerostomia and xerostomia-related quality of life. STUDY DESIGN PubMed, Google Scholar, and the Cochrane Library were searched for retrospective or prospective trials assessing subjective xerostomia, objective xerostomia, or xerostomia-related quality of life. To be included, patients had to have received radiation therapy for head and neck cancer, but not hyperbaric oxygen therapy (HBOT). RESULTS The systematic review initially identified 293 potential articles. Seven studies, comprising 246 patients, qualified for inclusion. Of the included studies, 6 of 7 were prospective in nature, and 1 was a retrospective study; and 2 of the 7 were controlled studies. CONCLUSIONS HBOT may have utility for treating radiation-induced xerostomia refractory to other therapies. Additionally, HBOT may induce long-term improvement in subjective assessments of xerostomia, whereas other therapies currently available only provide short-term relief. The strength of these conclusions is limited by the lack of randomized controlled clinical trials.

The association between T-stage and clinical nodal metastasis in HPV-positive oropharyngeal cancer

PURPOSE To evaluate the association between T-stage and primary tumor subsite with clinical nodal metastasis in HPV-positive oropharyngeal squamous cell carcinomas. STUDY DESIGN Retrospective medical record review. MATERIALS AND METHODS A retrospective analysis of all previously untreated patients with HPV-positive oropharyngeal squamous cell carcinoma evaluated by the senior author in a tertiary-care center over a 5-year period was performed. Medical records were evaluated for HPV status, clinical T-stage, clinical nodal stage, and anatomic location of primary oropharyngeal subsite. RESULTS 83% (59/71) of patients presented with clinical nodal disease. T-stage was not associated with the absence of regional disease (cN0) in tonsillar complex or base of tongue cancers. However, early T1/T2 tonsillar complex cancers were less likely to present with cN2c disease compared to T3/T4 lesions (0% vs. 18-33%, p=0.03). Further, base of tongue cancers were more likely to present with cN2c disease compared to tonsillar complex tumors (35% vs. 7%, p=0.01). CONCLUSION In HPV-positive tonsillar complex cancers, T-stage does not appear to predict the presence of clinical nodal metastasis (N0 vs. N1-N3), but may predict the extent of metastasis when present. This association does not appear to affect base of tongue cancers. Further, base of tongue cancers have a greater incidence of cN2c disease compared to tonsillar complex cancers.

Availability of patient-centered cancer support services: A statewide survey of cancer centers

The Institute of Medicine recommended in their landmark report “From Cancer Patient to Cancer Survivor: Lost in Transition” that services to meet the needs of cancer patients should extend beyond physical health issues to include functional and psychosocial consequences of cancer. However, no systems exist in the US to support state-level data collection on availability of support services for cancer patients. Developing a mechanism to systematically collect these data and document service availability is essential for guiding comprehensive cancer control planning efforts. This study was carried out to develop a protocol for implementing a statewide survey of all Commission on Cancer (CoC) accredited cancer centers in South Carolina and to implement the survey to examine availability of patient support services within the state. We conducted a cross-sectional survey of CoC-certified cancer centers in South Carolina. An administrator at each center completed a survey on availability of five services: 1) patient navigation; 2) distress screening; 3) genetic risk assessment and counseling, 4) survivorship care planning; and 5) palliative care. Completed surveys were received from 16 of 17 eligible centers (94%). Of the 16 centers, 44% reported providing patient navigation; 31% reported conducting distress screening; and 44% reported providing genetic risk assessment and counseling. Over 85% of centers reported having an active palliative care program, palliative care providers and a hospice program, but fewer had palliative outpatient services (27%), palliative inpatient beds (50%) or inpatient consultation teams (31%). This was a small, yet systematic survey in one state. This study demonstrated a practical method for successfully monitoring statewide availability of cancer patient support services, including identifying service gaps.

Calcium Hydroxylapatite Injection for Persistent Velopharyngeal Insufficiency after Sphincter Pharyngoplasty.

Background: The role of calcium hydroxylapatite injection pharyngoplasty after failed sphincter pharyngoplasty surgery has not previously been described. We report our technique of injecting calcium hydroxylapatite into the pharyngoplasty site to add bulk to specific areas of the velopharyngeal port. Methods: A retrospective review of children undergoing calcium hydroxylapatite injection pharyngoplasty for persistent velopharyngeal insufficiency after sphincter pharyngoplasty was performed. Our surgical technique is described. Outcome measures included postoperative perceptual assessment of resonance, improvement in phoneme-specific nasometry scores, and rate of revision surgery. Results: Fourteen patients were included in the study. Improvement in hypernasality on perceptual assessment was noted in the majority of children (85.7%). The rate of achievement of normal resonance on perceptual analysis was 35.7%. A significant decrease in nasometry scores was noted for the following phonemes: /pa/, /sa/, /sha/, and /pi/. There were no intraoperative complications or immediate postoperative complications associated with calcium hydroxylapatite injection. Conclusions: Our early experience suggests that calcium hydroxylapatite injection after failed sphincter pharyngoplasty is a safe, minimally invasive technique with favorable short-term results.

Ultrasound Localization during Parotid Sialolithotomy

Objective: 1) To describe a novel operative technique that has been demonstrated to be successful in stone localization and subsequent retrieval in patients with parotid sialolithiasis. 2) To demonstrate feasibility of the technique and discuss its indications. Method: From August 2009 to January 2012, patients with symptomatic parotid sialolithiasis underwent ultrasound needle localization and open sialolithotomy in a tertiary-level hospital setting. Outcomes included success of delivery, presence of infection, ductal stenosis, loss of glandular function, or facial nerve paralysis. Independent variables included size of and location of sialoliths. Results: Five patients were treated using transcutaneous ultrasound-guided needle placement and injection of methylene blue prior to external sialolithotomy in the operating room. Patients were chosen if they had failed prior sialendoscopic extraction. Postoperative outcomes and long-term follow-up results were obtained. Follow-up ranged from 6 to 12 months. Mean operative time from skin incision to closure was 52 minutes (range, 43-85 minutes). Five of 5 (100%) cases were successful for stone retrieval. Stents were placed in 4 of 5 cases. The average stone size was 5.3 mm. There were no complications of infection, ductal stenosis, loss of glandular function, or permanent buccal facial nerve paralysis. No patients had salvage parotidectomy. Conclusion: After failing a purely endoscopic approach, sialoliths of the parotid gland pose a problem for precise localization and treatment. Ultrasound has been demonstrated to be reliable for identifying sialoliths. We propose a novel technique and assert that ultrasound-guided needle localization is a reliable aid to effective external parotid sialolithotomy.

Ultrasound Localization during Submandibular Sialolithotomy

Objective: 1) To describe a novel office-based operative technique that has been demonstrated to be successful in stone localization and retrieval of proximally located submandibular sialoliths. 2) To demonstrate the feasibility of the technique and discuss its indications. Method: From August 2009 to January 2012, patients with symptomatic submandibular sialolithiasis underwent ultrasound needle localization and open sialolithotomy in a tertiary-level clinic setting. Outcomes included success of delivery, presence of infection, ductal stenosis, loss of glandular function, or lingual nerve paralysis. Independent variables included size and location of sialoliths. Results: Sixteen in-office cases of ultrasound-guided needle localization and open sialolithotomy were performed for patients who had failed sialendoscopy and stone extraction. Follow-up ranged from 6 months to 1 year. Sixteen of 16 (100%) were successful. The average size of sialoliths was 6.7 mm (range, 5-11 mm). Mean procedure time was 24 minutes (range, 18-42 minutes) from needle localization. There were no complications of infection, ductal stenosis, loss of glandular function, presence of additional sialoliths, or permanent lingual nerve paralysis. No patients had salvage submandibular sialadenectomy. Conclusion: After failing a purely endoscopic approach, proximally located sialoliths of the submandibular gland pose a problem for precise localization and treatment. Ultrasound has been demonstrated to be reliable for identifying sialoliths. We propose a novel technique and assert that ultrasound-guided needle localization is a reliable aid to effective transoral sialolithotomy.

Ultrasound Findings after Submandibular Sialolithotomy

Objective: 1) To demonstrate the utility of ultrasound in the assessment of the submandibular gland after endoscopic-assisted or purely open sialolithotomy. 2) To discuss limitations of using ultrasound for assessment after submandibular sialolithotomy. Method: From August 2009 to January 2012, 22 adult patients with symptomatic submandibular sialolithiasis underwent endoscopic-assisted or purely open sialolithotomy in a tertiary-level clinic setting. Pre- and immediate postprocedure ultrasound was performed. Examinations were analyzed for evidence of persistent obstruction. Results: Twenty patients with symptomatic submandibular sialolithiasis underwent either endoscopic-assisted sialolithotomy or pure open sialolithotomy for proximally located stones. Three of 22 (13%) demonstrated residual stones on ultrasound characterized by acoustic shadowing immediately after sialolithotomy and were retreated in the same setting with success. Fifteen of 22 (68%) demonstrated proximal ductal dilatation after stone removal. Eighteen of 22 (81%) demonstrated trace hyperechogenic foci without shadowing indicating air bubbles or blood. At 2 weeks, all findings had resolved. There were no instances of infection, ductal stenosis, loss of glandular function, or permanent lingual nerve paralysis with follow-up ranging from 6 months to 1 year. Conclusion: Ultrasound can be used to assess for residual obstruction immediately after submandibular sialolithotomy. Only the presence of posterior shadowing reliably predicted pathology. The presence of proximal ductal dilatation and hyperechogenic foci without shadowing take longer to resolve after sialolithotomy, and should not be used to influence treatment decisions during procedures.