Greg A. Krempl

Radiofrequency Treatment of Turbinate Hypertrophy: A Randomized, Blinded, Placebo-Controlled Clinical Trial

OBJECTIVES: We sought to evaluate the short-term efficacy of radiofrequency volumetric tissue reduction (RFVTR) in treating nasal obstruction in subjects with inferior turbinate hypertrophy. STUDY DESIGN AND SETTING: We conducted a prospective, randomized, single-blinded, placebo-controlled trial with crossover option, involving 32 patients and performed in a clinical office setting at the University of Oklahoma Medical Center. RESULTS: The outcomes were measured using 10-cm visual analog scales (VASs) before treatment and at 8 weeks and 6 months posttreatment. Improvement was shown in frequency of obstruction, severity of obstruction, and overall ability to breathe for both the placebo and RFVTR treatment arms at 8 weeks (P < 0.05). The amount of improvement, however, was significantly better in the treatment arm compared with placebo for the severity of obstruction and overall ability-to-breathe categories. At 6 months, the mean improvement scores were significantly better than the pretreatment scores for all 3 categories. CONCLUSIONS: RFVTR is an effective alternative for the treatment of patients with nasal obstruction due to inferior turbinate hypertrophy. SIGNIFICANCE: This is the first randomized trial that demonstrates that RFVTR is significantly better than placebo in treating nasal obstruction due to inferior turbinate hypertrophy. (Otolaryngol Head Neck Surg 2004;130:291–9.)

Hyaluronic Acid Hydrogel Sustains the Delivery of Dexamethasone across the Round Window Membrane

Background: The use of intratympanic (IT) steroids for the treatment of inner ear disorders is promising, but the clinical challenges of prolonged middle ear drug application have proven burdensome, and a sustainable delivery system is yet to be developed. Method: In this study, a guinea pig model was used to determine if dexamethasone in combination with a hyaluronic-acid (HA)-based hydrogel is an efficient, stable and sustainable dexamethasone delivery system to the inner ear. For each animal, right and left middle ear bullae were randomly selected to be filled with dexamethasone alone or dexamethasone-HA (Dex-HA) gel. Perilymph samples were collected at different time points and dexamethasone levels were determined using an ELISA. Results: Dexamethasone was measurable in the perilymph samples up to 72 h after treatment. At 24 h after treatment, the perilymph dexamethasone concentrations were significantly higher (p = 0.01) in the ears treated with Dex-HA gel than in those treated with dexamethasone alone. While the perilymph dexamethasone concentration had decreased at 48 h after treatment with Dex-HA gel, the levels were still higher than those observed at 24 h in ears treated with dexamethasone alone. A high variability in dexamethasone concentration was observed between the samples, and the variability between matched ears receiving different treatments was remarkably lower than the variability within each treatment group, suggesting that individual parameters might play a major role in perilymph dexamethasone concentration. There was no statistically significant correlation between dexamethasone concentration and sex, weight or laterality. Conclusions: Our results show that the Dex-HA gel used in this study provides an effective and sustained dexamethasone release mechanism that might be utilized to treat conditions such as sudden sensorineural hearing loss. This could potentially reduce the morbidity and costs associated with IT treatment.

Carotid Blowout in Patients with Head and Neck Cancer

Objectives The objective was to review the clinicopathologic features of carotid blowout syndrome (CBS) in patients with head and neck cancer (HNC) and present a management algorithm. Methods We reviewed all HNC patients with a diagnosis of CBS seen at our tertiary cancer hospital from 1994 to 2009 and performed a retrospective review of all English-language studies documenting CBS cases within the past 15 years. Results Eight patients with HNC developed CBS at our institution, and another 132 HNC patients were presented in 21 studies. Patients with CBS typically have a history of radiotherapy (89%), nodal metastasis (69%), and neck dissection (63%). This disease usually occurs proximal to the carotid bifurcation and is commonly associated with soft tissue necrosis in the neck (55%) and mucocutaneous fistulas (40%). Half of CBS patients present with sentinel bleeding, but 60% of patients will develop a life-threatening hemorrhage requiring emergent intervention. Over 90% of patients with CBS were treated with endovascular therapy, and surgical ligation was rarely indicated. The morbidity and mortality rates of patients with CBS are significant; only 23% have survived without evidence of disease. Conclusions Carotid blowout syndrome is uncommon and can be rapidly fatal without prompt diagnosis and intervention. Although endovascular treatment within the carotid system can have a significant risk of mortality and neurologic morbidity, it has become the treatment of choice for CBS.

Long-term results of inferior turbinate hypertrophy with radiofrequency treatment: a new standard of care?

Objective: The objective of this study was to report the long‐term efficacy of radiofrequency volumetric tissue reduction (RFVTR) and to compare this with other accepted surgical treatments of inferior turbinate hypertrophy.

Treatment of giant cell granuloma of the maxilla with intralesional injection of steroids.

Giant cell granuloma is rare in the head and neck region and most commonly affects the maxilla and mandible. Although it is a benign disease process, it may be locally destructive. Surgery is the treatment currently recommended. Because of the location of the disease, surgery may be disfiguring. Because it is a benign process, less radical nonsurgical treatment alternatives are desirable.

Prophylactic PEG placement in head and neck cancer: how many feeding tubes are unused (and unnecessary)?

AIM To determine the rate of use and non-use of prophylactic percutaneous endoscopic gastrostomy (PEG) tubes among patients with head and neck cancer (HNC) patients. METHODS All patients with HNC undergoing PEG between January 1, 2004 and June 30, 2006 were identified. Patients (or their next-of-kin) were surveyed by phone and all available medical records and cancer registry data were reviewed. Prophylactic PEG was defined as placement in the absence of dysphagia and prior to radiation or chemoradiation. Each patient with a prophylactic PEG was assessed for cancer diagnosis, type of therapy, PEG use, and complications related to PEG. RESULTS One hundred and three patients had PEG tubes placed for HNC. Thirty four patients (33%) could not be contacted for follow-up. Of the 23 (22.3%) patients with prophylactic PEG tubes, 11/23 (47.8%) either never used the PEG or used it for less than 2 wk. No association with PEG use vs non-use was observed for cancer diagnosis, stage, or specific cancer treatment. Non-use or limited use was observed in 3/6 (50%) treated with radiation alone vs 8/17 (47.1%) treated with chemoradiation (P = 1.0), and 3 of 10 (30%) treated with surgery vs 8 of 13 (62%) not treated with surgery (P = 0.21). Minor complications were reported in 5/23 (21.7%). One (4.3%) major complication was reported. CONCLUSION There is a high rate of unnecessary PEG placement when done prophylactically in patients with head and neck cancer.

Effect of concurrent medications on cisplatin-induced nephrotoxicity in patients with head and neck cancer.

The goal of this study was to identify clinical characteristics and concurrent medications associated with an increased or decreased incidence of cisplatin-induced nephrotoxicity. The medical records for 62 subjects with head and neck cancer who received cisplatin 100 mg/m2 (day 1) plus fluorouracil 1000 mg/m2 (days 1–5) with or without radiation therapy were reviewed from three medical centers. The demographics, concurrent medication therapy, co-existing illnesses and clinical laboratory values were extracted from the medical records. Nephrotoxicity was defined as a minimum rise in serum creatinine of 0.5 mg/dl or above. The concurrent use of hydrochlorothiazide or multivitamins was associated with a higher incidence of nephrotoxicity after cycle 1. Use of albuterol, atenolol or hydrochlorothiazide was also associated with a higher incidence of nephrotoxicity after cycle 1 or 2. In contrast, subjects prescribed dexamethasone or ondansetron were less likely to experience nephrotoxicity. None of these medications affected treatment response. Race/ethnicity was independently correlated with the incidence of nephrotoxicity; African-American subjects were more likely to develop nephrotoxicity independent of the influence of these concurrent medications. Medications may modulate cisplatin-induced nephrotoxicity by altering the metabolic activation of cisplatin to a nephrotoxin. Genetic differences in the drug-metabolizing enzymes may contribute to the correlation with race. The results from this retrospective study provide data to support a larger prospective study to further investigate the associations between these concurrent medications and cisplatin-induced nephrotoxicity.

Use of oxymetazoline in the management of epistaxis

The purpose of this study was to determine if use of an intranasal vasoconstrictor (oxymetazoline) could be used to effectively treat epistaxis, avoiding nasal packing. The charts of 60 patients who presented to the emergency room with the diagnosis of epistaxis and who required medical management were reviewed. Sixty-five percent of these patients were successfully managed with oxymetazoline as their sole therapy. An additional 18% were managed successfully with silver nitrate cautery in combination with oxymetazoline. In only 17% of patients was it necessary to use nasal packing as treatment for epistaxis after an initial attempt with oxymetazoline alone or in combination with silver nitrate failed. These data suggest that pharmacologic management may be adequate in the majority of patients with epistaxis, thus avoiding the need for nasal packing with its associated complications.

Early oral feeding after salvage laryngectomy.

Our aim was to determine the feasibility and safety of initiating early oral feeding in patients who underwent salvage laryngectomy on postoperative day 5 and to review the rate of pharyngocutaneous fistula formation.

Fistula rates after salvage laryngectomy: Comparing pectoralis myofascial and myocutaneous flaps

Salvage laryngectomy after failed organ preservation often has a high complication rate, pharyngocutaneous fistulas being the most common. These fistulas increase morbidity, prolong hospitalization, and potentially delay adjuvant treatment. Fistula rates in the literature range from 3% to 65%. Use of the pectoralis flap to prevent fistula formation has been adopted as a common practice at our institution. A review of our experience using the overlay myofascial showed a higher than desired complication rate. The aim of this study is to assess whether the use of integrated myocutaneous flap results in a lower fistula rate.