Chiang-Feng Lien

Otitis media with effusion in children with cleft lip and palate: A narrative review

OBJECTIVE Repair surgery of cleft lip and palate (CLP) can produce satisfactory cosmetic results but the problem of recurrent otitis media with effusion (OME) secondary to CLP may persist. This can cause long-term hearing loss and affect linguistic, academic, and personal development. The aim of this review is to provide the most recent information regarding OME in children with CLP. METHODS All papers referring to children with CLP and OME were identified from searches in Medline, PubMed, Cochrane Library, and Web of Science. Abstracts were read and relevant papers were obtained. Additional studies were obtained from the references of the selected articles. RESULTS Both current and previous research on OME in children with CLP focused on the controversy over treatment strategies. Evidence on the optimal treatment for OME in CLP children was lacking. Ventilation tube surgery using the same anesthetic as lip or palate procedures was not well-supported. After summarizing the literature review, a flowchart of management guidance for such patients is also recommended. Updated reviews such as this will provide clinicians and patients/parents with a valuable reference. CONCLUSIONS The lack of evidence on the optimal treatment for OME in children with CLP should prompt a relatively conservative approach. However, only a consensus between patients/parents and surgeons regarding the most suitable treatment strategy for OME can ensure the greatest benefit to individual patients.

Grommets for Otitis Media With Effusion in Children With Cleft Palate: A Systematic Review

BACKGROUND AND OBJECTIVE: No consensus has yet been reached with regard to the link between otitis media with effusion (OME), hearing loss, and language development in children with cleft palate. The objective of this study was to address the effectiveness of ventilation tube insertion (VTI) for OME in children with cleft palate. METHODS: A dual review process was used to assess eligible studies drawn from PubMed, Medline via Ovid, Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, and reference lists between 1948 and November 2013. Potentially relevant papers were selected according to the full text of the articles. Relevant data were extracted onto a data extraction sheet. RESULTS: Nine high- or moderate-quality cohort studies were included in this study. VTI was administered in 38% to 53% of the OME cases, and more severe cases appeared more likely to undergo VTI. Compared with conservative forms of management (eg, watchful waiting), VTI has been shown to be beneficial to the recovery of hearing in children with cleft palate and OME. A growing body of evidence demonstrates the benefits of VTI in the development of speech and language in children with cleft palate and OME. These children face a higher risk of complications than those undergoing conservative treatments, the most common of which are eardrum retraction and tympanosclerosis, with an incidence of ∼11% to 37%. CONCLUSIONS: This review provides evidence-based information related to the selection of treatment for OME in children with cleft palate. Additional randomized controlled trials are required to obtain bias-resistant evidence capable of reliably guiding treatment decisions. The conclusions in this review are based on underpowered cohort studies and very-low-strength evidence.

Updates and Knowledge Gaps in Cholesteatoma Research

The existence of acquired cholesteatoma has been recognized for more than three centuries; however, the nature of the disorder has yet to be determined. Without timely detection and intervention, cholesteatomas can become dangerously large and invade intratemporal structures, resulting in numerous intra- and extracranial complications. Due to its aggressive growth, invasive nature, and the potentially fatal consequences of intracranial complications, acquired cholesteatoma remains a cause of morbidity and death for those who lack access to advanced medical care. Currently, no viable nonsurgical therapies are available. Developing an effective management strategy for this disorder will require a comprehensive understanding of past progress and recent advances. This paper presents a brief review of background issues related to acquired middle ear cholesteatoma and deals with practical considerations regarding the history and etymology of the disorder. We also consider issues related to the classification, epidemiology, histopathology, clinical presentation, and complications of acquired cholesteatoma and examine current diagnosis and management strategies in detail.

How long is long enough to follow up children after cholesteatoma surgery? A 29-year study†

To identify an association between follow‐up period and cholesteatoma recidivism.

Healthy‐side dominance of middle‐ and long‐latency neuromagnetic fields in idiopathic sudden sensorineural hearing loss

Any lesion along the neural axis may induce a subsequent functional reorganization at the level above. The present study used magnetoencephalography to investigate auditory‐evoked magnetic fields [a component of the middle‐latency auditory evoked fields peaking at ~50 ms (P50m) and a component of the long‐latency auditory evoked fields peaking at ~100 ms (N100m)] on stimulation of both healthy and affected ears in patients with acute unilateral idiopathic sudden sensorineural hearing loss (ISSNHL) of moderate degree in order to elucidate the functional plasticity of the auditory system. Sixteen right‐handed, previously untreated adult patients with acute unilateral left (n = 8) or right (n = 8) ISSNHL of moderate degree were studied. Sixteen right‐handed healthy volunteers with normal hearing served as control. Auditory neuromagnetic responses, measured by a whole‐head 306‐channel neuromagnetometer, were detected by monaural tone stimulation applied to affected and healthy ears, respectively, in different sessions. Intragroup and intergroup interhemispheric differences of peak dipole strengths and latencies of P50m and N100m, respectively, to monaural tones were evaluated. Healthy‐side amplitude dominance of both P50m and N100m was found in ISSNHL, i.e. contralateral dominance was preserved on affected‐ear stimulation but ipsilateral dominance was seen on healthy‐ear stimulation. The phenomena could be attributed to the combined contralateral attenuation and ipsilateral enhancement of P50m and N100m activity in response to healthy‐ear stimulation. Our findings confirmed that functional modulation can occur within the first few tens of milliseconds of evoked response at the auditory cortex in ISSNHL. The mechanisms of healthy‐side dominance might be ascribed to a functional retune of auditory pathways, i.e. conjoined contralateral inhibition and ipsilateral excitation of the auditory pathway in response to healthy‐ear stimulation. The effect could be registered in cortical responses.

Healthy-side dominance of cortical neuromagnetic responses in sudden hearing loss.

Previous brain imaging and mapping studies have reported findings indicating functional reorganization in the central auditory pathways of patients with profound unilateral hearing loss. This study reports for the first time to our knowledge, using a whole‐head neuromagnetometer with monaural stimulation of both intact and affected ears, a pattern of healthy‐side dominance for cortical neuromagnetic responses in adult patients in the early stage of idiopathic sudden sensorineural hearing loss, and a pattern of contralateral dominance is verified in controls. Ann Neurol 2003;53:810–815

Mastoid Obliteration for Pediatric Suppurative Cholesteatoma: Long-Term Safety and Sustained Effectiveness after 30 Years' Experience with Cartilage Obliteration

Objective: To analyze the long-term safety of mastoid obliteration with cartilage in children with suppurative cholesteatomatous ears. Methods: The medical records of children (≤18 years) with cholesteatomas after primary tympanomastoidectomies were performed with cartilage obliteration over a 30-year period (1982-2012) were analyzed. The recidivism rate was calculated using the Kaplan-Meier survival analysis. Potentially confounding factors of recidivism were entered into a Cox regression model as covariates for multivariate analysis. Results: Of the 150 cholesteatomatous ears in 146 children, there were 95 discharging ears (63%) in 94 children. Among the 95 discharging ears, tympanomastoidectomy was performed with cartilage obliteration (CO group) in 77 ears (81%) and without cartilage obliteration (WO group) in 18 ears (19%). The mean follow-up period was 12 years. Recidivism was observed in 16 ears in the CO group and 4 ears in the WO group. The 10-year cumulative recidivism rates were comparable between the CO and WO groups (19 vs. 25%, p = 0.762). Multivariate analysis confirmed that mastoid obliteration was not a negative predictor of recidivism (p = 0.760). Recidivism of cholesteatoma was detected within 6.5 years after surgery in the WO group and was found as late as 16.1 years after surgery in the CO group. Cartilage could be maintained in the cavity with limited resorption, preventing reretraction pockets and subsequent recidivism. Conclusion: This study provides evidence supporting the long-term safety, feasibility and effectiveness of mastoid cartilage obliteration for children with suppurative cholesteatomatous ears. Despite comparable recidivism rates between the groups, the potential for the delayed detection of recidivism with cavity obliteration may warrant long-term follow-up, with careful attention paid to the potential for recidivism during postoperative care in children. i 2014 S. Karger AG, Basel

Can long-term hearing preservation be expected in children following cholesteatoma surgery? Results from a 14-year-long study of atticotomy-limited mastoidectomy with cartilage reconstruction.

Objective: Following cholesteatoma surgery, effective long-term hearing preservation in children is difficult and is not typically expected. Hence, long-term data on hearing outcomes are lacking. The aim of this study was to analyze long-term hearing outcomes in children following cholesteatoma surgery. Methods: For this study, 49 ears in 47 children (≤16 years) with acquired cholesteatomas following atticotomy-limited mastoidectomy with cartilage reconstruction (inside-out approach) during 1986–2010 were included. Pre- and post-operative recidivism-free audiometric results were compared. Hearing success was defined as a post-operative air conduction (AC) threshold of ≤30 dB (serviceable hearing). Logistic regression analyses were used to evaluate potential prognostic factors that independently contributed to the prediction of hearing success. These factors included stapes condition, pre-operative AC threshold, ossicular chain integrity, disease severity, age, and gender. Results: The mean duration of follow-up was 14.2 years. The post-operative AC (33.55 ± 15.42 dB) and air-bone gap (17.88 ± 12.94 dB) were significantly improved compared with the pre-operative AC (42.90 ± 16.47 dB, p < 0.001) and air-bone gap (30.23 ± 13.68 dB, p < 0.001). The probability of hearing success following surgery (40.8%) was significantly higher than prior to surgery (24.5%, p = 0.008). Multivariate logistic regression analyses revealed a statistically significant correlation between hearing success and stapes integrity only (p = 0.005). Conclusions: This study provides important information on effective long-term hearing preservation over a mean follow-up of 14 years. In addition, stapes destruction is an independent negative prognostic determinant of achieving hearing success. The prediction model in this study provides otologists with useful pre-operative information to inform patients and parents on expected hearing outcomes and may be useful for post-operative observations.

Acid reflux and head and neck cancer risk: A nationwide registry over 13 years

OBJECTIVE Gastro-esophageal reflux disease (GERD) is a highly prevalent disorder; however, important questions remain regarding the link between GERD and extra-esophageal cancers. This nationwide cohort study investigated the risk of developing head and neck cancers (HNCs) among patients with GERD. METHODS Newly diagnosed GERD patients aged ≥20 years without antecedent cancer were included. Case data were obtained from the National Health Insurance Research Database covering period from 1998 to 2010. We compared the standardized incidence ratios (SIRs) of cancer among GERD patients with those of the general population. RESULTS A total of 98 cancers were identified among the 39,845 GERD patients in the study, representing 128,361 person-years. The SIR for all cases of cancer was 1.59 (95% CI 1.29-1.93). GERD patients exhibited significantly higher SIRs for oropharyngeal (SIR 3.58, 95% CI 1.85-6.25) and hypopharyngeal (SIR 3.96, 95% CI 2.35-6.26) cancers. Male patients had a significantly higher risk of HNCs (SIR 1.70, 95% CI 1.36-2.10), particularly oropharyngeal (SIR 4.01, 95% CI 2.00-7.17) and hypopharyngeal (SIR 3.91, 95% CI 2.28-6.26) cancers. Following adjustment for age and co-morbidities, the hazard ratio was 9.06 (95% CI 4.70-17.44) for males compared to females. CONCLUSION There may be a potential association between GERD and risk of HNCs, which however merits further studies to confirm the causal relationship. Our observations indicate a need for careful extra-esophageal examination of patients with acid reflux. Our findings also underline the importance of raising awareness among clinicians regarding the possibility of concurrent HNCs in GERD patients with refractory laryngo-pharyngeal symptoms.

An Audiometer to Monitor Progressive Hearing Change in School-aged Children:

Objective The purpose of this study was to develop a cost-effective and easy to use audiometer to monitor progressive hearing change in school-aged children. Design The hardware of the audiometer developed included a computer, an external sound blaster and a headphone The hearing screening software was developed to control the pure tone sound level with modulability in the range of 0-45 dB HL at 1, 2, 4 and 0.5 kHz frequencies. Thirty sixth-grade children, aged 12-13 years old, were randomly divided into two groups for a hearing test in a conference room. Testing for one group was performed by a person with experience and the other group was examined by a graduate student who was not familiar with the device. After the hearing test, all children were immediately screened using a clinical diagnostic audiometer in a soundproof room by an audiologist. Results Most of the threshold dB values obtained by the audiometer in a conference room (55 ears, 93.2%) were significantly greater than those obtained by the clinical audiometer in a soundproof room. Most of the differences between these two measurements were within 5 dB (94.9%). Only 5.1% had a discrepancy within the maximum range of 10 dB. The correlation and intraclass correlation coefficients between the two measurements were 0.861 and 0.929, respectively. The results also indicated that the experience level of the screening personnel did not affect the testing. Conclusion The newly developed audiometer is quite cost-effective and can be easily operated. The threshold dB values obtained by the audiometer developed in a conference room were comparable with the results of a clinical audiometer in a soundproof room. The audiometer developed could measure the hearing threshold values and, therefore, be useful in monitoring progressive hearing change in school-aged children.