Peter L. Friedland

Impact of multidisciplinary team management in head and neck cancer patients

Background:We analysed the outcomes of 726 cases of primary head and neck cancer patients managed between 1996 and 2008, including those managed in the multidisciplinary clinic or team setting (MDT) and those managed outside of an MDT by individual disciplines (non-MDT) in the same institution.Methods:Data were collected from the Hospital Based Cancer Registry and a database within the Head and Neck Cancer Clinic. Univariable comparisons and multivariable analyses were performed using a logistic regression model. Survival by staging was analysed. Comparisons of management and outcomes were made between MDT and non-MDT patients.Results:395 patients (54%) had been managed in the MDT vs 331 patients (46%) non-MDT. MDT patients were more likely to have advanced disease (likelihood ratio χ2=44.7, P<0.001). Stage IV MDT patients had significantly improved 5-year survival compared with non-MDT patients (hazard ratio=0.69, 95% CI=0.51–0.88, P=0.004) and more synchronous chemotherapy and radiotherapy (P=0.004), and the non-MDT group had more radiotherapy as a single modality (P=0.002).Conclusions:The improved survival of MDT-managed stage IV patients probably represents both the selection of multimodality treatment and chemotherapeutic advances that these patients received in a multidisciplinary team setting by head and neck cancer specialists as opposed to cancer generalists in a non-MDT setting.

A review on the use of hyaluronic acid in tympanic membrane wound healing

Introduction: Tympanic membrane perforation represents a significant morbidity, especially if it occurs during a childs speech and language development. Recently, there has been an increased interest in hyaluronic-acid-related research and products as a potential therapeutic option for tympanic membrane perforation repair. Areas covered: This review describes the physical and chemical properties of hyaluronic acid and examines the role of hyaluronic acid in wound healing, in particular on the tympanic membrane. It also reviews the safety and efficacy of hyaluronic acid and its derivatives in animal studies as well as in clinical trials. Finally, it considers the potential future clinical applications in tympanic membrane perforation repair. Expert opinion: Hyaluronic acid has been found to accelerate tympanic membrane perforation closure, shorten the period of healing, produce a better quality neo-membrane and improve hearing. More importantly, hyaluronic acid is biodegradable, safe and biocompatible in the ear. Recently, there has been a trend towards the use of modified hyaluronic acid. However, there is a lack of higher-level evidence to support the use of hyaluronic acid in tympanic membrane perforations in the clinical setting. More large-scale randomised control trials are warranted before these bio-devices will be used routinely.

To Pack or Not to Pack? A Contemporary Review of Middle Ear Packing Agents

Middle ear packing agents are used in otologic surgery to provide support to the middle ear structures, maintain aeration of the middle ear, and promote hemostasis. However, there is currently a lack of standardization regarding the use of different types of packing agents. The choice of materials and how they are used remain controversial. In fact, some have recently advocated for no packing. In view of this, this review focuses on the types of materials available, a brief historical account of each material, characteristics of an ideal packing agent, and a discussion on the techniques of insertion to optimize surgical outcomes.

Animal models of chronic tympanic membrane perforation: A 'time-out' to review evidence and standardize design §

OBJECTIVE To review the literature on techniques for creation of chronic tympanic membrane perforations (TMP) in animal models. Establishing such models in a laboratory setting will have value if they replicate many of the properties of the human clinical condition and can thus be used for investigation of novel grafting materials or other interventions. METHODS A literature search of the PubMed database (1950-August 2014) was performed. The search included all English-language literature published attempts on chronic or delayed TMP in animal models. Studies of non English-language or acute TMP were excluded. RESULTS Thirty-seven studies were identified. Various methods to create TMP in animals have been used including infolding technique, thermal injury, re-myringotomy, and topical agents including chemicals and growth factor receptor inhibitors. The most common type of animal utilized was chinchilla, followed by rat and guinea pig. Twenty three of the 37 studies reported success in achieving chronic TMP animal model while 14 studies solely delayed the healing of TMP. Numerous experimental limitations were identified including TMP patency duration of <8 weeks, lack of documentation of total number of animals attempted and absence of proof for chronicity with otoscopic and histologic evidence. CONCLUSION The existing literature demonstrates the need for an ideal chronic TMP animal model to allow the development of new treatments and evaluate the risk of their clinical application. Various identified techniques seem promising, however, a need was identified for standardization of experimental design and evidence to address multiple limitations.

Self-reported hearing loss in baby boomers from the Busselton Healthy Ageing Study: audiometric correspondence and predictive value.

BACKGROUND The baby boomer population will become high users of the health-care system in coming years. Self-report of hearing loss at a primary health-care visit may offer timely referrals to audiological services, but there has been no population-based study of self-reported hearing loss in the baby boomer generation. PURPOSE To determine the clinical value and audiometric correspondence of self-reported hearing loss as a screening tool for the baby boomer population. RESEARCH DESIGN A population-based study, Busselton Healthy Ageing Study (BHAS), surveying baby boomers born between 1946 and 1964 from the shire of Busselton, Western Australia. STUDY SAMPLE A randomized sample of noninstitutionalized baby-boomers listed on the electoral roll (n = 6690) and resident in the shire are eligible to participate. This study reports on data from the first 1004 attendees (53.5% female) with a mean age of 56.23 (SD = 5.43). DATA COLLECTION AND ANALYSIS Data from a self-report question on hearing loss and diagnostic pure tone audiometry was utilized for this study. Analysis included screening performance measures of self-report compared to audiometric cut-offs, receiver operator curve (ROC) to determine optimal level, analysis of variance to compare hearing status to self-report, and binary logistic regression to determine best audiometric predictors. RESULTS Of the sample, 16% self-reported hearing loss (72.1% males). Logistic regression indicated 4000 Hz as the most important individual frequency related to self-report while the four-frequency average (500, 1000, 2000, and 4000 Hz) >25 dB in the worse ear was the most significant averaged cutoff with 68% sensitivity and 87% specificity. Of those who self-reported a hearing loss, 80% had either a four-frequency average hearing loss >25 dB in the worse ear or a high-frequency average (4000 and 8000 Hz) hearing loss greater than 35 dB in the worse ear. CONCLUSIONS Baby boomer adults who self-report hearing impairment on direct inquiry are most likely to have a hearing loss. A simple question at a primary health care visit may facilitate a timely referral for audiological services in a baby boomer adult, who may be more amenable to rehabilitation.

Otitic meningitis, superior semicircular canal dehiscence, and encephalocele: a case series.

Background Otitic meningitis in the postantibiotic era is still a serious condition, requiring intensive treatment and prolonged rehabilitation. In view of the significant morbidity and mortality rate, conditions that may increase the likelihood of otitic meningitis developing should be treated promptly. The incidence of meningitis after asymptomatic encephaloceles of the middle cranial fossa varies greatly, and the management differs between elective surgical repair and expectant careful observation. Superior semicircular canal dehiscences (SSCDs) are postulated to have a congenital origin and are associated with a thin or dehiscent tegmen. Several cases of simultaneous SCCD and tegmen defects have been reported, but the findings of otitic meningitis, SCCD, and encephaloceles has, to the best of our knowledge, not been previously explored in the literature. Methods We reviewed a series of 4 patients who all presented with a combination of otitic meningitis, encephaloceles, and SSCD. Results All the 4 patients we reviewed had meningitis secondary to otitis media with computed tomographic scans confirming the presence of SCCD with ipsilateral tegmen tympani defects and associated cephaloceles. All patients were treated with intravenous antibiotics and underwent surgery that ranged from myringotomy and ventilation tube insertions, mastoidectomy, and burr hole drainage for temporal lobe abscess. They were all associated with intensive care unit admission, significant morbidity, and prolonged hospital stays. There were no mortalities. Conclusion We propose that in all SSCD patients, a careful computed tomographic examination of the cranial base should be undertaken to exclude other associated tegmen tympani defects. In cases of SSCD requiring surgery, we support the view that elective surgical repair be recommended where asymptomatic ipsilateral encephaloceles are found, to reduce the risk of otitic meningitis.

Human papillomavirus and gene mutations in head and neck squamous carcinomas

Background:  Human papillomavirus (HPV) infection is implicated as an aetiological factor in head and neck squamous carcinomas (HNSCC), especially in the tonsils of the oropharyngeal region. This study investigates the frequency of HPV infection, p16 and p53 tumour profile and mutations in epidermal growth factor receptor (EGFR), Kirsten RNA Associated Rat Sarcoma 2 Virus (KRAS) and B‐Raf proto‐oncogene serine/threonine protein kinase (BRAF) genes in tonsillar and non‐tonsillar HNSCCs and correlates with clinical outcome and histopathological parameters in previously unstudied cohort of patients.

Clinical validation of automated audiometry with continuous noise-monitoring in a clinically heterogeneous population outside a sound-treated environment

Abstract Objective: Examine the accuracy of automated audiometry in a clinically heterogeneous population of adults using the KUDUwave automated audiometer. Design: Prospective accuracy study. Manual audiometry was performed in a sound-treated room and automated audiometry was not conducted in a sound-treated environment. Study sample: 42 consecutively recruited participants from a tertiary otolaryngology department in Western Australia. Results: Absolute mean differences ranged between 5.12–9.68 dB (air-conduction) and 8.26–15 dB (bone-conduction). A total of 86.5% of manual and automated 4FAs were within 10 dB (i.e. ±5 dB); 94.8% were within 15 dB. However, there were significant (p < 0.05) differences between automated and manual audiometry at 250, 500, 1000, and 2000 Hz (air-conduction) and 500 and 1000 Hz (bone-conduction). The effect of age (≥55 years) on accuracy (p = 0.014) was not significant on linear regression (p > 0.05; R2 =  0.11). The presence of a hearing loss (better ear ≥26 dB) did not significantly affect accuracy (p = 0.604; air-conduction), (p = 0.218; bone-conduction). Conclusions: This study provides clinical validation of automated audiometry using the KUDUwave in a clinically heterogeneous population, without the use of a sound-treated environment. Whilst threshold variations were statistically significant, future research is needed to ascertain the clinical significance of such variation.

Malleostapedotomy prosthesis size and shape: key measurements from a temporal bone study

Hypothesis By determining the dimensions of middle ear anatomic relationships pertinent to malleostapedotomy (MS), a simplified, yet optimized scheme for sizing, shaping, and placing a prosthesis can be generated. Methods Surgical dissection of 20 fresh (nonpreserved) cadaveric temporal bones was undertaken. Needlepoint calipers were used to manually measure pertinent distances between the ossicles. These measurements were then used to calculate the dimensions of anatomic triangles within the middle ear that were applied to the process of MS prosthesis sizing, shaping, and placement. Results Mean distances were 6.3 mm (range, 5.75–7.0 mm) between the usual MS crimp site and stapedotomy site, 3.6 mm (range, 3.00–4.25 mm) between the crimp site and the lateral edge of the distal incus long process, 4.9 mm (range, 4.50–5.00) between the lateral edge of the distal incus long process and the stapedotomy site, 3.7 mm (range, 3.25–4.00) between the crimp site and the umbo, and 3.3 mm (range, 2.75–3.75) between the umbo and lateral edge of the distal incus long process. Conclusion A total crimped prosthesis length of at least 7.75 mm is required to accommodate the range of interossicular measurements, yet production of longer prostheses is wise owing to the limited number of temporal bones studied. Furthermore, the use of a single-length prosthesis for all MS cases will not suffice except when cutting a sufficiently long prosthesis to its desired length. Understanding of the ossicular anatomy can be used to bend the MS piston to favorably affect the orientation of the prosthesis barrel into the vestibule.

Incus Replacement Malleostapedotomy in Quiescent Chronic Otitis Media With a Mobile Stapes Footplate: An Alternative to TORP in Select Cases

Objective: To review the results of malleostapedotomy for incus replacement in the setting of quiescent chronic otitis media and a mobile stapes footplate and to discuss the potential application for this technique in select cases. Patients: Seven individuals having undergone malleostapedotomy in the setting of quiescent chronic otitis media and a mobile stapes footplate between 2004 and 2009. Intervention: Review of surgical results and hearing outcomes as measured by preoperative and postoperative pure-tone audiometry. Main Outcome Measures: Closure of preoperative air-bone gap and change in preoperative versus postoperative pure-tone bone conduction thresholds. Results: Improvement in air-bone gap was noted in 6 of 7 subjects with an average closure of 17 dB. In 5 of 7 subjects, the air-bone gap was closed to 20 dB or less, and in 3 of 7 subjects, the air-bone gap was closed to 10 dB or less. No significant changes in postoperative bone conduction pure-tone average thresholds were noted. No immediate or delayed complications were encountered over an average follow-up time of 23.6 months (range, 5-42 mo). Conclusion: Although the data are limited by the small sample size, malleostapedotomy seems to be a potentially safe and effective alternative to placement of a total ossicular replacement prosthesis in properly selected specialized instances of quiescent chronic otitis media. Further study is recommended to more definitively establish the safety and efficacy of this technique.