Piyush Jani

B-cell depletion with rituximab for refractory head and neck Wegener's granulomatosis: a cohort study.

Objectives:  This study aimed to evaluate the response of refractory Wegener’s granulomatosis affecting the ear, nose and throat and granulomatous eye disease to B‐cell depletion with rituximab.

A systematic review of 1143 parapharyngeal space tumors reported over 20 years

Parapharyngeal space tumours are rare and most clinicians will only see a small number during their career. We performed a systematic review of 1143 parapharyngeal space tumors published in the past 20 years to increase cumulative experience. A systematic literature review was performed and data on histological diagnosis, presentation, surgical approach and postoperative complications of cases published between 1989 and 2009 were compiled and reviewed. The systematic review identified a total of 1143 parapharyngeal space tumors presented in 17 studies. A majority (82%) were benign and 18% were malignant. The most common presentation was a cervical mass (50%) or an intraoral mass (47%). Approximately 70 different histologic subtypes of parapharyngeal space tumors were reported in the cumulative series. The most common primary lesion was a pleomorphic adenoma (34%). Ninety-five percent of patients underwent surgery. The most frequent approach and used to excise the lesions was the cervical approach (48%) and the commonest complication was the vagus nerve injury seen in 14% of the cases.

A prospective randomised controlled trial comparing Merocel and Rapid Rhino nasal tampons in the treatment of epistaxis

A prospective study was performed to compare the efficacy and patient tolerance of Merocel® and Rapid Rhino® nasal tampons in the treatment of epistaxis. A total of 42 patients were studied. There was no significant difference between the two types of pack in efficacy or patient discomfort with pack in situ. Rapid Rhino® produced significantly lower scores for subjective patient discomfort during insertion and removal of pack.

Radiologically Predicting When a Sternotomy May Be Required in the Management of Retrosternal Goiters

Objectives: Surgery remains the most effective treatment for retrosternal goiters. These commonly present as asymptomatic lesions in elderly patients, but may also cause airway and esophageal compression and, less commonly, may also be mali gnant. Although the majority of these goiters are amenable to transcervical thyroidectomy, in a minority of patients sternotomy is required. The ability to predict the need for sternotomy before operation would allow for safer surgery and operative counseling, as well as improved logistical efficiency if coordination with thoracic surgeons is required. In this report, we assess the radiologic factors that might be predictive of the need for sternotomy. Methods: We performed a retrospective review of 97 retrosternal goiters for which thyroidectomy was performed within the otolaryngology department at Addenbrookes Hospital, Cambridge, between 2001 and 2011. There were a total of 80 cervical excisions and 17 cases in which sternotomy was required. A detailed computed tomographic analysis of these 17 cases was undertaken to assess the predictive factors for the requirement of sternotomy. The factors assessed included posterior mediastinal extension, presence of an ectopic nodule, extension below the carina, extension below the aortic arch, a “conical shape” of the goiter, and tracheal compression. These were compared to the same factors in the control group of 80 patients, and Fishers exact test was used to determine statistical significance. Results: The significant predictive factors for sternotomy were posterior mediastinal extension, extension below the carina, and a “conical” goiter in which the thoracic inlet becomes a ring of constriction (all p < 0.05). Conclusions: Our results suggest that it is possible to predict on the basis of computed tomographic imaging the need for sternotomy in retrosternal goiters.

Management of tumors arising from the parapharyngeal space: A systematic review of 1,293 cases reported over 25 years

We present a systematic review of 1,252 lesions published in the past 25 years, the largest to date. We also include our own experience of 41 cases.Objectives We present a systematic review of 1,252 lesions published in the past 25 years, the largest to date. We also include our own experience of 41 cases. Data Sources Our data sources were MEDLINE and Embase databases. Review Methods A systematic review of the literature (1988–2014) was performed and data on histological diagnosis, presentation, surgical approach, and postoperative complications were reviewed. Results In total, 22 studies (including our own institution) revealed 82% of lesions were benign. The most common presentation was an intraoral mass (52%) followed by a cervical mass (48%), and the most common primary lesion was a pleomorphic adenoma (29%). Ninety-six percent of patients underwent surgery. The cervical approach was most frequently used (46%), and the most common complication was vagus nerve injury (13%). Within our institution, 5-year progression-free survival for benign and malignant disease was 93% and 61%, respectively (P = .196). Conclusions A parapharyngeal space mass is an uncommon tumor and requires careful preoperative assessment. Definitive treatment is usually surgery, and these patients should be counseled appropriately about the potential for permanent cranial nerve deficits. Level of Evidence NA Laryngoscope, 125:1372–1381, 2015

Langerhans cell sarcoma: A systematic review

Langerhans cell sarcoma (LCS) is a rare malignant tumour of Langerhans cells with a poor outcome. Given its rarity, there is a lack of evidence regarding the most appropriate treatment for this condition. Therefore the aim of this work was to review, compile, analyse and present clinical details and to determine the optimal treatment regimen. A search of PubMed, CINAHL, EMBASE, Cochrane, CENTRAL, clinicaltrials.gov and Google Scholar was supplemented by hand searching. Data extracted included demographics, treatment, type of LCS and clinical outcome. Of 510 citations identified by a systematic literature search, 46 case series including 66 subjects with LCS met criteria for analysis. The most common treatment modality was chemotherapy, used alone or in combination in 47 cases (71%) followed by surgery in 31 cases (47%). Overall mean (S.E.) disease specific survival and disease free survival were 27.2 (3.9) and 18.3 (3.8) months respectively. There was a significant difference in both disease specific and disease free survival between the local, loco-regional and disseminated disease cohorts (DSS p=0.014; DFS p<0.001). More localised disease confers a survival advantage. Multi-modality therapy appears to be most effective, with the addition of radiotherapy to chemotherapy appearing beneficial. Complete surgical excision with clear margins being most effective for local disease control. Any adjuvant therapy should not be delayed. Bone marrow transplant appears to be the most reliable treatment in terms of outcome especially in disseminated disease however has well known patient selection and toxicity/tolerance issues. The role of cell surface markers for prognostication remains unclear.

Long-term Outcome of Airway Stenosis in Granulomatosis With Polyangiitis (Wegener Granulomatosis): An Observational Study

IMPORTANCE Airway stenosis occurs in patients with granulomatosis with polyangiitis (GPA or Wegener granulomatosis). It produces significant morbidity and contributes to mortality. OBJECTIVE To investigate the frequency and distribution of airway stenoses in GPA and evaluate the efficacy of local interventions in maintaining airway patency. DESIGN, SETTING, AND PARTICIPANTS A retrospective single-center study of 44 patients with GPA and airway stenosis assessed and treated as needed by a multidisciplinary team at a university medical center between 1997 and 2012. The median duration of observation for each patient from the time of diagnosis was 146 months. INTERVENTIONS Patients who had critical stenoses underwent either dilatation or laser radial cuts to the lesion. In some cases, intralesional administration of steroids or topical mitomycin C was used. MAIN OUTCOMES AND MEASURES The main outcome measure was airway patency for at least 12 months and the number of interventions required to achieve this end point. Details of patients and interventions were recorded at baseline and at each treatment. RESULTS The median age at diagnosis was 37.6 years; 73% of patients were women (n = 34). The median follow-up after the initial intervention was 62.5 months. Subglottic stenosis was found in 36 patients, lower airway stenosis in 30. There were 213 interventions in 39 patients, including balloon and bougie dilatation and laser treatment. Adjuvant local treatment was used in 71 interventions. A 12-month period of airway stability was achieved in 34 of 36 cases (97%) (5 had no procedures and 3 had follow-up shorter than 12 months). The median interval between procedures was 4.9 months, and after the last intervention recorded, patients had at least 27 months of airway stability. Fourteen adverse events were recorded (6.6%). CONCLUSIONS AND RELEVANCE The frequency and distribution of airway stenoses in 44 patients with GPA has been described. In the 39 patients who required intervention, multiple procedures were required, but 97% then achieved a prolonged period of airway patency. The procedures and adjuvant treatments were found to be safe. Our experience with a variety of techniques in this rare presentation has permitted design of a structured approach and an algorithm to manage and evaluate airway stenosis in GPA.

Haemostasis in head and neck surgical procedures: Valsalva manoeuvre versus Trendelenburg tilt

INTRODUCTION The aim of the study was to identify whether Trendelenburg position helps detect any further bleeding points following Valsalva manoeuvre in order to achieve adequate haemostasis in head and neck surgery. PATIENTS AND METHODS Fifty consecutive patients undergoing major head and neck surgical procedures were included. The protocol consisted in performing Valsalva manoeuvre to check haemostasis and treated any bleeding points identified. The operating table was tilted 30 degrees and haemostasis was checked again and treated accordingly. The number of vessels identified and the treatment was recorded. RESULTS Twelve male and 38 female patients were included. The median age was 53 years and 74% had an ASA of 1. Twelve patients had complicating features such as retrosternal extensions or raised T4 levels pre-operatively. Thyroid resections were the most common operations performed. The total number of bleeding vessels identified in Trendelenburg tilt was significantly greater than when using Valsalva manoeuvre (P < 0.0001). All bleeding points found on Valsalva manoeuvre were minor (< 2 mm) and dealt with using diathermy. In Trendelenburg position, 11% of bleeding vessels required ties or stitching. The time taken during Valsalva manoeuvre was 60 s on average and 360 s in Trendelenburg position. CONCLUSIONS The results show that the Trendelenburg position is vastly superior to the Valsalva manoeuvre in identifying bleeding vessels at haemostasis. It has become our practice to put patients in Trendelenburg tilt routinely (we have discontinued the Valsalva manoeuvre), to check its adequacy before closing the wound. We have not noticed any intracranial complications using a tilt angle of 30 degrees .

Multi‐institutional validation of a novel textural analysis tool for preoperative stratification of suspected thyroid tumors on diffusion‐weighted MRI

Ultrasound‐guided fine needle aspirate cytology fails to diagnose many malignant thyroid nodules; consequently, patients may undergo diagnostic lobectomy. This study assessed whether textural analysis (TA) could noninvasively stratify thyroid nodules accurately using diffusion‐weighted MRI (DW‐MRI).

A disease activity score for ENT involvement in granulomatosis with polyangiitis (Wegener's)

Accurate assessment of disease activity in patients with otorhinolaryngological manifestations of granulomatosis with polyangiitis (Wegeners) (ENT/GPA) is necessary for treatment decisions and clinical trials. We have designed a disease activity score (ENT/GPA DAS) for this purpose.