George Mochloulis

Cochlear implantation under the first year of age—The outcomes. A critical systematic review and meta-analysis

OBJECTIVE To review the current knowledge on cochlear implantation in infancy, regarding auditory perception/speech production outcomes. STUDY-DESIGN Meta-analysis. EBM level: II. METHODS Literature-review from Medline and database sources. Related books were also included. RESULTS The number of cohort-studies comparing implanted infants with under 2-year-old children was five; three represented type-III and two type-II evidence. No study was supported by type I evidence. Overall, 125 implanted infants were identified. Precise follow-up period was reported in 82. Median follow-up duration ranged between 6 and 12 months; only 17 children had follow-up duration equal or longer than 2 years. Reliable outcome measures were reported for 42 infants; 15 had been assessed with open/closed-set testing, 14 with developmental rating scales, and 13 with prelexical speech discrimination tools. Ten implanted infants assessed with open/closed-set measures had been compared with under 2-year-old implanted children; 4 had shown better performance, despite the accelerated rate of improvement after the first postoperative year. CONCLUSION Neuroplasticity/neurolinguistic issues have led cochlear implant centers to implant deaf children in infancy; however, widespread policies regarding the aforementioned issue are still not justified. Evidence of these childrens outperformance regarding auditory perception/speech production outcomes is limited. Wide-range comparisons between infant implantees and under 2-year-old implanted children are lacking. Longer-term follow-up outcomes should be also made available. There is a need to develop and validate robust measures of monitoring implanted infants. Potential factors of suboptimal outcomes (e.g. misdiagnosis, additional disorders, device tuning, parental expectations) should also be weighted, when considering cochlear implantation in infancy.

Diagnostic challenges and safety considerations in cochlear implantation under the age of 12 months

AIM To review the current knowledge on cochlear implantation in infancy, regarding diagnostic, surgical and anesthetic challenges. STUDY-DESIGN Meta-analysis. EBM level: II. MATERIALS/METHODS Literature-review from Medline and database sources. Related books were also included. STUDY SELECTION Meta-analyses, prospective controlled studies, prospective/retrospective cohort studies, guidelines, review articles. DATA SYNTHESIS The diagnosis of profound hearing loss in infancy, although challenging, can be confirmed with acceptable certainty when objective measures (ABR, ASSR, OAEs) and behavioural assessments are combined in experienced centres. Reliable assessment of the prelexical domains of infant development is also important and feasible using appropriate evaluation techniques. Overall, 125 implanted infants were identified in the present meta-analysis; no major anesthetic complication was reported. The rate of surgical complications was found to be 8.8% (3.2% major complications) quite similar to the respective percentages in older implanted children (major complications ranging from 2.3% to 4.1%). CONCLUSION Assessment of hearing in infancy is feasible with adequate reliability. If parental expectations are realistic and hearing aid trial unsuccessful, cochlear implantation can be performed in otherwise healthy infants, provided that the attending pediatric anesthesiologist is considerably experienced and appropriate facilities of pediatric perioperative care are readily available. A number of concerns, with regard to anatomic constraints, existing co-morbidities or additional disorders, tuning difficulties, and special phases of the developing child should be also taken into account. The present meta-analysis did not find an increased rate of anesthetic or surgical complications in infant implantees, although long-term follow-up and large numbers are lacking.

Assessing day-case septorhinoplasty: prospective audit study using patient-based indices

The objective of this study was to evaluate the safety, efficacy and acceptability to patients of day-case septorhinoplasty. Twenty-nine patients undergoing elective septorhinoplasty in a dedicated teaching hospital day-case unit were asked to complete day surgery questionnaires (DSQ) at six weeks post-operatively. Details of surgery performed, demographic data, readmission rates and complications were collected prospectively. No major complications were recorded. One patient had to be admitted for overnight observation following post-operative bleeding. The DSQ showed that the great majority of patients were satisfied from the day-case setting (satisfaction score 81). This preliminary study showed that day surgery septorhinoplasty was acceptable to the patient and was associated with a very low re-admission rate. We believe that in carefully selected young healthy patients it is an acceptable alternative to an in-patient procedure.

Persistent otorrhoea with an abnormal tympanic membrane secondary to squamous cell carcinoma of the tympanic membrane.

OBJECTIVE The authors present an extremely rare case of carcinoma of the tympanic membrane. METHOD A case report and review of the literature concerning carcinoma of the tympanic membrane and temporal bone are presented and discussed. RESULTS The authors present a patient with recurrent otorrhoea and an abnormal tympanic membrane. Biopsy was inconclusive, but resection demonstrated squamous cell carcinoma of the tympanic membrane. We also discuss the investigation, diagnosis, natural history and management of this rare condition, as well as the staging and management of tumours of the temporal bone and the differences between these closely related but prognostically different entities. CONCLUSION This rare entity can be managed by primary surgical resection if there is no evidence of metastasis.

Plasmacytoma of the atlas presenting as hoarseness: a rare cause of unilateral vocal fold palsy

INTRODUCTION Solitary bone plasmacytoma is a rare haematological malignancy that can present in a variety of ways. This study aimed to present a case of plasmacytoma of the atlas, as a rare cause of unilateral vocal fold palsy. METHOD Case report. RESULTS Following diagnosis via imaging and direct biopsy through the posterior pharyngeal wall, the patient was referred to the haematologists for further treatment of his plasmacytoma. CONCLUSION Solitary bony plasmacytoma of the cervical spine is a rare haematological malignancy. Its presentation with a unilateral vocal fold palsy has not been previously described.

Vagal versus recurrent laryngeal nerve monitoring in thyroid surgery

Recurrent laryngeal nerve (RLN) palsy is considered a serious complication of thyroid surgery. Permanent lesions are still occurring in about 1% of patients, despite the standardized surgical approach to the nerve, and the availability of RLN monitoring [1]. Intraoperative RLN monitoring is based on the visual or acoustic registration of evoked electromyography of the laryngeal muscles. Primarily, it proves conductivity of the stimulated nerve segment towards the muscle. However, a recent meta-analysis did not demonstrate a statistically signiWcant diVerence in the rate of transient or persistent vocal cord palsy after using intraoperative neuromonitoring versus RLN identiWcation alone during thyroidectomy [2], conWrming the anecdotal views of many experienced thyroid surgeons on this issue. In addition, following an iatrogenic lesion of the RLN in a porcine model, the distal nerve segment showed unchanged amplitude of the electrophysiological response for an observational period of more than 1 h [1], thus revealing a potential pitfall for the neuromuscular monitoring of the RLN in the human surgical setting; the false assumption of an anatomically intact nerve even after transection. Newly developed vagal stimulation probes permit continuous intraoperative neuromonitoring of the RLN during thyroid surgery. We had recently performed a hemithyroidectomy for a pedunculated right thyroid lobe lesion, which was preoperatively classiWed as THY 2 with groups of follicular thyrocytes on U/S-guided FNA. During the operation a monitoring probe was attached onto the right vagal nerve (Fig. 1). In detail, after identiWcation of the right carotid sheath medial to the right sternomastoid muscle, the omohyoid was divided, and the vagus nerve accessed, behind and lateral to the internal jugular vein. The monitoring system was the NIM-Response 3.0 (Medtronic Inc.), which uses the automatic periodic stimulation (APSTM) electrode. The obtained waveform amplitude (the amount of current going through the nerve) was 111 V, and was above the standard amplitude setting of 103 V, according to the manufacturer’s instructions. The system is designed in such a manner that a decrease of 50% in nerve conduction, which is shown as an amplitude drop below the level of 50 V, sets oV an alarm (Fig. 2). In the presented case, the alarm was indeed set oV intraoperatively before the visual identiWcation of the right RLN (Fig. 2), indicating related strain, however, the standard RLN probing (also incorporated to the system) after the

Facelift approach to upper cervical surgery.

Interest among surgeons in cosmetic approaches to nonaesthetic head and neck surgery has developed as a result of the often visible scarring following procedures in this region. This is especially true for incisions made above the collar line and in non–hair-bearing skin, as well as in patients with a tendency for hypertrophic/keloid scarring. There is also evidence that patients are increasingly aesthetically aware, as indicated by the increased rates of cosmetic surgery reported in recent years, further driving this interest into routine practice. The best described use of a cosmetic approach to nonaesthetic head and neck surgery is the facelift approach for parotid surgery. This has been demonstrated to provide as good access to all areas of the gland as the traditional Blair incision. Cosmetic and minimally invasive approaches have also been described for the surgical management of other head and neck conditions, with similar or often improved complication rates and patient satisfaction scores when compared to conventional techniques. Intraoral, endoscopic, and retroauricular (sub-superficial musculoaponeurotic system [SMAS]/platysma) approach have been described for submandibular gland surgery. Application of sub-SMAS/ platysma facelift approach has also been described in fixation of posterior mandibular fractures and melanoma sentinel node biopsy. We describe our preliminary experience of a novel application of the original/subcutaneous (above-SMAS/platysma) facelift approach to the excision of upper cervical masses.

Role of transnasal oesophagoscopy in diagnosis of early malignancy in the area of the oesophagus and hypopharynx. A review of the literature.

Globus is a common condition and a significant amount of patients with this problem present every day in ENT departments. The concern is that a small number of patients with mainly oesophageal and to a lesser extent hypopharyngeal malignancies will present to the ENT surgeon with vague globus type symptoms. It is well known that the incident of oesophageal adenocarcinoma is on the increase and any delay in the diagnosis can have grave impact in the prognostic outlook of the patient. In the year 2000, the United Kingdom (UK) had the highest reported incidence worldwide for reasons yet unknown. The pool of globus patients is a heterogeneous one. In the UK, there is no consensus for investigation protocols. Gold standard is endoscopy. Until now, the oesophagus could represent a ‘‘grey’’ area between ENT and Gastroenterology. End result may have been only a part of this group of patients receiving a complete examination of the oesophagus. Recent technological advancement is the transnasal oesophagoscopy (TNO). It comes with several benefits, and evidence to support the increasing use and related cost [1, 2]. So how reliable is it in detecting cancer particularly in the ‘‘difficult’’ areas of hypopharynx and upper oesophagus? Monnier et al. [3] in a series of endoscopy in 100 patients demonstrated that early oesophageal malignancies are barely or not visible. Price et al. [1] describing 116 procedures over a period of 1 year mentioned the diagnosis of 18 neoplasias in the upper aerodigestive tract (level of larynx and above). It was further used in 16 patients as part of H&N cancer surveillance and 2 further radio-recurrent tumours were recorded without a clear anatomical identification being reported. Postma et al.[2] in a series of over 700 endoscopies report using the TNO in 50 cases for screening examination in H&N cancer patients, with ‘‘carcinoma’’ findings in 27 of them, without giving any further anatomical clarifications. Other studies comparing TNO with standard panendoscopy and standard flexible oesophagoscopy describe 100 % accuracy. Su et al. [4] in a series of 398 endoscopies in 293 H&N cancer patients discovered a metachronous oesophageal SCC in 15. The prevalence was higher in patients with hypopharyngeal cancer (15.9 %). Finally, Wang et al. [5] in a series of 33 endoscopies in cancer patients with post treatment dysphagia discovered neoplasia in 13. The incidence of oesophageal carcinoma is low in Europe and therefore there is no need for systematic screening or good evidence to support it. It may be the case that the new TNO technology will change this view and the evidence. This does not apply for head and neck cancer patients for whom endoscopy remains the best (if not only) way to diagnose an early oesophageal carcinoma. Is there a better alternative for accurate diagnosis? Monierre et al. [3] describes a series of a 100 early stage oesophageal cancer. He suggests that a routine ‘‘heavy’’ bronchoesophagoscopy in high risk patients combined with endoscopic ultrasonography provides the best chance for an early diagnosis which can have an impact in the outcome. A. Tsikoudas (&) G. Mochloulis Department of ORL, Lister Hospital, Corey’s Mill Lane, Stevenage, Hertfordshire, UK e-mail: atsikoudas@nhs.net

How we do it: the intra-operative identification of a pharyngocele

A pharyngocele is an uncommon condition, where pharyngeal mucosa herniates through the thyrohyoid membrane. It can be difficult to locate when the patient is at rest. To locate the pharyngocele intra-operatively, a bag valve mask was used to inflate the herniated mucosa. We describe a cost-effective and simple way to locate the pharyngocele intra-operatively.

Manipulation of fractured nose using mallet and champagne cork

We describe an alternative method of manipulating fractured nasal bones using a surgical mallet and a champagne cork. This method enables accurate fracture reduction with minimal skin trauma, by affording the surgeon a high level of control. This method may be applied successfully to late-presenting fractures.