Anthony Zeitouni

Systemic inflammatory markers as independent prognosticators of head and neck squamous cell carcinoma.

The purpose of this study was to investigate the prognostic value of the pretreatment inflammatory markers platelet‐to‐lymphocyte ratio (PLR) and the neutrophil‐to‐lymphocyte ratio (NLR) in patients with head and neck squamous cell carcinoma (HNSCC).

High prevalence of obstructive sleep apnea among patients with head and neck cancer.

OBJECTIVES To determine the prevalence of obstructive sleep apnea (OSA) in patients with cancer of the oral cavity and oropharynx scheduled for primary surgical resection. To correlate the presence of OSA and the occurrence of postoperative morbidities in this patient population. METHODS This was a prospective study involving 17 patients with malignancies of the oral cavity and oropharynx scheduled for primary surgical resection. Consecutive patients were approached to undergo overnight polysomnography to determine the apnea-hypopnea index (AHI). OSA was defined by an AHI value > or = 20 events per hour. Postoperative morbidities were evaluated in a blinded fashion for the patients completing surgery. RESULTS OSA was present in 13 of 17 patients, yielding a striking prevalence of 76% in this patient group. The mean AHI for patients with OSA was 44.7 +/- 3.5 (standard error) events per hour, with a mean nadir oxygen saturation of 88.2 +/- 1.8%, consistent with moderate to severe sleep-disordered breathing. The OSA and non-OSA patients were similar with respect to age and body mass index. The mean size of the primary tumour was 3.3 cm in patients with an AHI < 20 and 3.5 cm in those with an AHI > or = 20 (p = not significant). Overall, postoperative complications, defined as prolonged intensive care unit stay (> 24 hours), need for mechanical ventilation, and cardiopulmonary morbidities, were observed in 67% of OSA and 25% of non-OSA patients. CONCLUSIONS These findings point to a strong association between OSA and malignancies of the oral cavity and oropharynx. This relationship was independent of the size of the primary malignancy in this patient population with tumours ranging from 1 to 7 cm (p = not significant). When comparing the two groups (AHI < 20 and AHI > or = 20), there was a tendency for the group with OSA to have an increase in postoperative morbidities. Further research is warranted to further evaluate the postoperative morbidities and mortalities associated with OSA in this patient population and to determine the potential roles for preoperative treatment with continuous positive airway pressure and tracheotomy.

Laryngeal inflammation assessed using the reflux finding score in obstructive sleep apnea

OBJECTIVES: To evaluate the relationships between laryngeal inflammation assessed using the Reflux Finding Score (RFS), laryngeal sensory function, and apnea severity in patients with obstructive sleep apnea (OSA). METHODS: Endoscopic sensory testing (EST) was performed with subsequent blinded scoring from video of RFS. An RFS > 7 was indicative of increased inflammatory change. RESULTS: Of 34 patients evaluated, 29 had OSA (apneahypopnea index [AHI] ≥ 15 events/h) at polysomnography. Increased inflammation was present in 26/29 (90%), with changes suggestive of laryngopharyngeal reflux. There were significant correlations between: inflammation and OSA severity (eg, RFS vs AHI, r = 0.57, P < 0.001); inflammation and laryngeal sensory impairment (EST detection threshold and pressure required to elicit the laryngeal adductor reflex, LAR); and the degree of sensory impairment and OSA severity. CONCLUSIONS: Laryngeal inflammation is prevalent among OSA patients and correlates with laryngeal sensory dysfunction, attenuation of the LAR, and apnea severity. EBM rating: C-4

Autoimmune sensorineural hearing loss: the otology–rheumatology interface

Autoimmune sensorineural hearing loss (SNHL) is a rare clinical entity characterized by a progressive fluctuating bilateral asymmetric SNHL that develops over several weeks to months. Vestibular symptoms, tinnitus and aural fullness are present in up to 50% of patients. Due to the lack of specific diagnostic tests, both clinical suspicion and responsiveness to corticosteroids are the pillars for the diagnosis of autoimmune SNHL. The evaluation of patients in whom this condition is suspected should include a detailed history and physical examination, an audiogram, an MRI and a limited laboratory workup to exclude secondary causes of hearing loss. The low frequency of this condition, the heterogeneity in the designs of the available studies and the absence of randomized trials comparing treatment responses and assessing long-term outcomes are some of the factors accounting for the limited evidence to guide the clinician in the approach to the diagnosis and treatment of autoimmune SNHL.

Experience-Dependent Modulation of Feedback Integration during Singing: Role of the Right Anterior Insula

Somatosensation plays an important role in the motor control of vocal functions, yet its neural correlate and relation to vocal learning is not well understood. We used fMRI in 17 trained singers and 12 nonsingers to study the effects of vocal-fold anesthesia on the vocal-motor singing network as a function of singing expertise. Tasks required participants to sing musical target intervals under normal conditions and after anesthesia. At the behavioral level, anesthesia altered pitch accuracy in both groups, but singers were less affected than nonsingers, indicating an experience-dependent effect of the intervention. At the neural level, this difference was accompanied by distinct patterns of decreased activation in singers (cortical and subcortical sensory and motor areas) and nonsingers (subcortical motor areas only) respectively, suggesting that anesthesia affected the higher-level voluntary (explicit) motor and sensorimotor integration network more in experienced singers, and the lower-level (implicit) subcortical motor loops in nonsingers. The right anterior insular cortex (AIC) was identified as the principal area dissociating the effect of expertise as a function of anesthesia by three separate sources of evidence. First, it responded differently to anesthesia in singers (decreased activation) and nonsingers (increased activation). Second, functional connectivity between AIC and bilateral A1, M1, and S1 was reduced in singers but augmented in nonsingers. Third, increased BOLD activity in right AIC in singers was correlated with larger pitch deviation under anesthesia. We conclude that the right AIC and sensory-motor areas play a role in experience-dependent modulation of feedback integration for vocal motor control during singing.

The McGill simulator for endoscopic sinus surgery (MSESS): a validation study

BackgroundEndoscopic sinus surgery (ESS) is a technically challenging procedure, associated with a significant risk of complications. Virtual reality simulation has demonstrated benefit in many disciplines as an important educational tool for surgical training. Within the field of rhinology, there is a lack of ESS simulators with appropriate validity evidence supporting their integration into residency education. The objectives of this study are to evaluate the acceptability, perceived realism and benefit of the McGill Simulator for Endoscopic Sinus Surgery (MSESS) among medical students, otolaryngology residents and faculty, and to present evidence supporting its ability to differentiate users based on their level of training through the performance metrics.Methods10 medical students, 10 junior residents, 10 senior residents and 3 expert sinus surgeons performed anterior ethmoidectomies, posterior ethmoidectomies and wide sphenoidotomies on the MSESS. Performance metrics related to quality (e.g. percentage of tissue removed), efficiency (e.g. time, path length, bimanual dexterity, etc.) and safety (e.g. contact with no-go zones, maximum applied force, etc.) were calculated. All users completed a post-simulation questionnaire related to realism, usefulness and perceived benefits of training on the MSESS.ResultsThe MSESS was found to be realistic and useful for training surgical skills with scores of 7.97 ± 0.29 and 8.57 ± 0.69, respectively on a 10-point rating scale. Most students and residents (29/30) believed that it should be incorporated into their curriculum. There were significant differences between novice surgeons (10 medical students and 10 junior residents) and senior surgeons (10 senior residents and 3 sinus surgeons) in performance metrics related to quality (p < 0.05), efficiency (p < 0.01) and safety (p < 0.05).ConclusionThe MSESS demonstrated initial evidence supporting its use for residency education. This simulator may be a potential resource to help fill the void in endoscopic sinus surgery training.

Head and neck cancer patients want us to support them psychologically in the posttreatment period: Survey results.

OBJECTIVES No study systematically has investigated the supportive care needs of general head and neck cancer patients using validated measures. These needs include physical and daily living needs, health system and information needs, patient care and support needs, psychological needs, and sexuality needs. Identifying the unmet needs of head and neck cancer patients is a necessary first step to improving the care we provide to patients seen in our head and neck oncology clinics. It is recommended as the first step in intervention development in the Pan-Canadian Clinical Practice Guideline of the Canadian Partnership Against Cancer (see Howell, 2009). This study aimed to identify: (1) met and unmet supportive care needs of head and neck cancer patients, and (2) variability in needs according to demographics, disease variables, level of distress, and quality-of-life domains. METHODS Participants were recruited from the otolaryngology-head and neck surgery clinics of two university teaching hospitals. Self-administered questionnaires included sociodemographic and medical questions, as well as validated measures such as the Supportive Care Needs Survey-Short Form (SCNS-SF34), the Hospital Anxiety and Depression Scale (HADS), and the Functional Assessment of Cancer Therapy-General (FACT-G) and Head and Neck Module (FACT-H&N) (quality of life measures). RESULTS One hundred and twenty-seven patients participated in the survey. 68% of them experienced unmet needs, and 25% revealed a clinically significant distress level on the HADS. The highest unmet needs were psychological (7 of top 10 needs). A multiple linear regression indicated a higher level of overall unmet needs when patients were divorced, had a high level of anxiety (HADS subscale), were in poor physical condition, or had a diminished emotional quality of life (FACT-G subscales). SIGNIFICANCE OF RESULTS The results of this study highlight the overwhelming presence of unmet psychological needs in head and neck cancer patients and underline the importance of implementing interventions to address these areas perceived by patients as important. In line with hospital resource allocation and cost-effectiveness, one may also contemplate screening patients for high levels of anxiety, as well as target patients who are divorced and present low levels of physical well-being, as these patients may have more overall needs to be met.

An investigation of the effect of tailored information on symptoms of anxiety and depression in Head and Neck cancer patients

OBJECTIVE To investigate if tailored information provision decreases symptoms of anxiety and depression in late stage Head and Neck (H&N) cancer patients. METHODS This non-randomized, controlled trial was conducted with stage III or IV H&N cancer patients. Subjects were recruited at two academic health centers in Montreal. At the test center, subjects received the Multimode Comprehensive Tailored Information Package (MCTIP), while at the control center, they received normal information provision. Participants were evaluated using the Hospital Anxiety and Depression Scale (HADS) at baseline and 3 and 6 month later. Data were analyzed using descriptive statistics then T tests and chi square tests to compare group differences and finally mixed model analysis to test differences in outcome variables. RESULTS A total of 103 subjects were recruited and of them 96 (47 tests and 49 controls) participants completed baseline, 3 and 6 month evaluations. The test group experienced lower levels of anxiety (p = 0.001) and depression (p = 0.089) than the control group. CONCLUSION The subjects receiving tailored information had lower levels of anxiety than their counterparts. In addition, depression showed a reduction in the expected direction in the test group. PRACTICE IMPLICATIONS Our results need to be further confirmed using a randomized approach in different samples but they suggest benefits for stage III and IV H&N cancer patients receiving tailored, multi-modal information concerning their cancer.

Volumetric Measurement of Vestibular Schwannoma Tumour Growth Following Partial Resection: Predictors for Recurrence

Vestibular schwannomas (VS) have a higher risk of recurrence following subtotal resection than following near-total resection. We measured tumor remnant growth volumetrically in an attempt to determine potential predictors for postoperative recurrence following subtotal resection. We reviewed the charts of patients who had undergone VS surgery between 1998 and 2007. Thirty patients had an incomplete resection. The principal outcome measure was change in tumor volume (TV) on serial imaging. At a median follow-up of 6.8 years, volumetric measurements showed that 12 patients (40%) developed further tumor growth, while 18 patients remained with stable residual disease. The median rate of growth was 0.53 cm(3)/year. Two-dimensional measurements confirmed growth in only eight of these patients. The postoperative residual TV correlated significantly with subsequent tumor growth (p = 0.038). All patients with residual volumes in excess of 2.5 cm(3) exhibited recurrence. On univariate analysis, only postoperative TV was significantly associated with growth. Median time to failure was 21.5 months. This is the first report of volumetric measurements of VS tumor growth postoperatively. Volumetric measurements appear to be superior to two-dimensional measurements in documenting VS growth and patients with residual tumors >2.5 cm(3) have a significantly higher rate of recurrence.

Intraparotid facial nerve solitary plexiform neurofibroma: a first paediatric case report.

Solitary plexiform neurofibromas of the intraparotid facial nerve are extremely rare tumours that can present a diagnostic challenge. Knowledge of their existence is key to its proper management. Only two cases have been reported in the English literature. We describe the first paediatric case of an intraparotid facial nerve solitary plexiform neurofibroma.