Randall P. Morton

Transcervico-mandibulo-palatal approach for surgical salvage of recurrent nasopharyngeal cancer

Local relapse of nasopharyngeal carcinoma is a difficult problem of management that is usually treated by re‐irradiation. Surgical salvage is rarely offered, judging by the paucity of reports in the literature.

Late ear sequelae in cleft palate patients.

This retrospective study looks at the incidence and nature of ear disease in 50 adolescent patients who had cleft palates repaired in infancy. Half of these patients had a history of grommet insertion. We found that most patients had normal hearing (81%) and middle-ear pressures (86%), although about half had tympanic membrane abnormalities. Grommet insertion did not result in better long-term hearing in this study but was strongly associated with tympanosclerosis. Cleft type did not influence the degree of ear disease although more patients with complete clefts had a history of repeated grommet insertion. Otitis media with effusion is almost universal in cleft palate infants and may influence later language, speech and educational development. At the time of palatal repair grommets should be inserted to improve hearing in these infants.

Quality of life and functional outcomes in the management of early glottic carcinoma: a systematic review of studies comparing radiotherapy and transoral laser microsurgery

Clin. Otolaryngol. 2010, 35, 373–382

Etiology and management of recurrent parotid pleomorphic adenoma

The objective of this review study was to encompass the relevant literature and current best practice options for this challenging, sometimes incurable problem. The source of the data was Ovid MEDLINE from 1946 to 2014. Review methods consisted of articles with clinical correlates. The most important cause of recurrence is enucleation with rupture and incomplete tumor excision at operation. Incomplete pseudocapsule, extracapsular extension, pseudopods of pleomorphic adenoma tissue, and satellite pleomorphic beyond the pseudocapsule are also likely linked to recurrent pleomorphic adenoma. Most recurrent pleomorphic adenoma are multinodular. Magnetic resonance imaging is the imaging study of choice for recurrent pleomorphic adenoma. Nerve integrity monitoring may reduce morbidity for recurrent pleomorphic adenoma. Treatment of recurrent pleomorphic adenoma must be individualized. Total parotidectomy, given the multicentricity of recurrent pleomorphic adenoma, is appropriate in many patients, but may be inadequate to control recurrent pleomorphic. There is accumulating evidence from retrospective series that postoperative radiation therapy results in significantly better local control. Laryngoscope, 125:888–893, 2015

Systematic review on treatment of Zenker’s diverticulum

This study was designed to compare rates of failure, revision and morbidity from endoscopic and open approaches as treatment for pharyngeal pouch. Systematic review was conducted using MEDLINE and PubMed databases. Search terms treatment, Zenker’s, hypopharyngeal, pharyngeal, diverticulum, and pouch. There were no randomised clinical trials. Therefore, cohort and comparative studies with at least 10 patients in each arm, a follow-up of a least 12xa0months and reporting on all patients were included. Seventy-one studies met inclusion criteria. Diverticulectomy with or without cricopharyngeal myotomy comprised 33 studies (1,990 patients), and endoscopic stapler diverticulotomy was in 22 studies (1,089 patients). Failure of open and endoscopic approaches was 4.2 and 18.4xa0%, respectively, and corresponding complication rates were 11 and 7xa0%. Within endoscopic techniques, failure rates were 18.9xa0% for stapler diverticulotomy and 21.7xa0% for laser diverticulotomy. Corresponding complication rates were 4.3 and 7.9xa0%. Flexible endoscopy techniques have a higher failure (29xa0%) and overall complication rate (14.3xa0%). Most reported complications for transcervical techniques relate to the recurrent nerve (3.4xa0%) and salivary fistula (3.7xa0%) and for endoscopic group emphysema (3.0xa0%) and mediastinitis (1.2xa0%). Operation-related deaths were infrequent in both groups, but more frequent with open approach (0.9 vs. 0.4xa0%). Open approaches have more success but more complications than endoscopic techniques. Taking in account overall complications and failure rates, open approaches and stapler diverticulotomy yield different patterns, but are arguably comparable. In younger patients open approach is preferred, as well in patients with unfavourable anatomic conditions for endoscopic exposure. Flexible endoscopic techniques provide a suitable option for patients who do not tolerate general anaesthesia.

Therapeutic ultrasound as treatment for chronic rhinosinusitis: preliminary observations.

BACKGROUNDnBacterial biofilms have been implicated in the pathogenesis of chronic rhinosinusitis. In the laboratory setting, ultrasound is effective in disrupting such biofilms; however, few clinical studies have evaluated the role of therapeutic ultrasound in chronic rhinosinusitis.nnnOBJECTIVEnThis study was performed to investigate the short-term effectiveness of therapeutic ultrasound as a treatment modality for chronic rhinosinusitis.nnnMETHODSnTwenty-two patients with a positive history of chronic rhinosinusitis, according to the criteria set out by the Rhinosinusitis Task Force, together with a previous computed tomography scan compatible with a diagnosis of chronic rhinosinusitis, and who had failed previous, aggressive medical management, were treated with therapeutic pulsed ultrasound at 1 MHz two to three days per week for six sessions. Patients completed an assessment of individual sinus symptom severity and the 20-Item Sino-Nasal Outcome Test questionnaire before treatment, prior to session four and after completion of session six.nnnRESULTSnTwo patients were unable to complete the study protocol. After completion of session six, 18 patients had experienced improvement in symptoms, while two patients noted a worsening of symptoms. Median percentage improvement of the total overall symptom score was 16.7 per cent (Wilcoxon signed rank, p < 0.001). The 20-Item Sino-Nasal Outcome Test score improved by 34.1 per cent (Wilcoxon signed rank, p < 0.0001).nnnCONCLUSIONnThis study demonstrated a significant improvement in chronic rhinosinusitis symptoms after a six-session course of pulsed ultrasound therapy. Treatment with ultrasound alone or combined with antibiotics may provide a strategy to target biofilms on the sinus mucosa. Therapeutic ultrasound warrants further investigation as a potential treatment modality for chronic rhinosinusitis.

Vitamin D and tonsil disease – Preliminary observations

OBJECTIVEnTo estimate the prevalence of 25(OH) vitamin D deficiency in children undergoing (adeno)tonsillectomy.nnnMETHODSnFrom 1st November 2008 to 20th December 2008, 33 children aged from 4 to 16 and resident in Auckland, New Zealand (latitude 36° 52 S) undergoing (adeno)tonsillectomy for difficulty breathing/sleep apnoea and/or recurrent tonsillitis had 25(OH) vitamin D, iron and zinc levels measured.nnnRESULTSnOf the 32 patients who had 25(OH) vitamin D levels measured, 15.6% were vitamin D deficient (25(OH) vitamin D<50nmol/L), and 78% had levels, <75nmol/L. 25(OH) vitamin D level was inversely correlated with Fitzpatrick skin type (Spearmans rho=-0.713, p<0.01), body mass index (BMI) (Spearmans rho=-0.434, p=0.013) and tonsil size (Spearmans rho=-0.417, p=0.017). However regression modeling demonstrated that only Fitzpatrick skin type (β=-0.687, p=0.001) and BMI (β=-0.256, p=0.044) were significant predictors of vitamin D levels (R(2)=0.572).nnnCONCLUSIONSnSeventy-eight percent of Auckland children undergoing (adeno)tonsillectomy had a 25(OH) vitamin D level<75nmol/L, a level which is associated with an increased incidence of upper respiratory tract infection. Low 25(OH) vitamin D levels were related to a darker skin, increased BMI and larger assessed tonsil size. The association of larger tonsil size with lower 25(OH) vitamin D status needs further evaluation but offers a potential explanation why black and Hispanic children are more likely than white children to have (adeno)tonsillectomy for snoring or obstructive sleep apnoea.

Microstructure of the vocal fold in elderly humans

Significant changes in the voice occur after the age of 50 years. Changes in the structure of the vocal fold (VF) can interfere with the voice. The aim of this study is to investigate the structure of the VF of elderly people that may contribute to the tendency of the human voice to deteriorate. Larynges were obtained from eight embalmed cadavers aged 72–98 years. The middle portion of each vocal fold was removed and placed in 4% buffered formalin. Tissue blocks were then processed and embedded in wax. Four to six micron coronal sections were cut and stained with Haematoxylin and Eosin (H&E), Massons Trichrome (MTS), Elastin van Gieson (EVG), Herovici (HERO), picrosirius and CD31 immunohistochemical marker in order to study the collagen fibers, elastic fibers and microvasculature of the VF. The maturity of collagen fibers within the VF were noted to increase from the superficial to the deep layer of the lamina propria (LP). Contrary to current literature, the amount of elastic fibers was sparse in the superficial layer of the LP in the vocal tissue of elderly cadavers. Numerous cross‐sectioned blood vessels were seen in the lamina propria near the free edge, and near the superior and inferior surfaces of the VF. The presence of lymphatic vessels was confirmed in the VF of elderly subjects. This study revealed that the collagenous component of the deep layer of the VF LP was made up of mature fibers whilst immature collagen fibers made up the superficial layer of the LP. There was a notable scarcity of elastic fibers in the superficial layer of the LP. Lymphatics were seen and were orientated differently in the geriatric vocal folds. Clin. Anat. 24:544–551, 2011.

The accuracy of otomicroscopy for the diagnosis of paediatric middle ear effusions

OBJECTIVEnTo determine the diagnostic accuracy of otomicroscopy performed by otolaryngology specialists for the diagnosis of paediatric middle ear effusions.nnnMETHODSnProspective study of consecutive children receiving tympanostomy tubes between December 2004 and February 2005 within the Department of Otolaryngology-Head & Neck Surgery, Manukau Surgery Centre, Middlemore Hospital, New Zealand. Eighty-six children were included in the study. Intraoperative otomicroscopic examination of the ears was performed under general anaesthesia by two otolaryngology specialists. The presence or absence of middle ear effusion was predicted prior to myringotomy. Intraoperative myringotomy findings were used as the diagnostic reference standard.nnnRESULTSnThe prevalence of middle ear effusions was 52.6% (71/135 ears). Otomicroscopy had a sensitivity 94.4% (95% CI: 85.5-98.2), and specificity 93.8% (95% CI: 84.0-98.0). The positive predictive and negative predictive values of otomicroscopy for the identification of middle ear effusions were 94.4% (95% CI: 85.5-98.2), and 93.8% (95% CI: 84.0-98.0) respectively. The overall accuracy of otomicroscopy was 94.1%. There was an excellent level of agreement between otomicroscopy and myringotomy findings (kappa=0.88, 95% CI: 0.80-0.96).nnnCONCLUSIONSnOtomicroscopy performed by the specialist otolaryngologist is an accurate tool for the diagnosis of middle ear effusions. Otomicroscopy performed on the anaesthetised child achieves greater diagnostic accuracy than tympanometry and pneumatic otoscopy.

Postoperative Systolic Blood Pressure as a risk factor for haematoma following thyroid surgery.

To examine potential factors that may predict development of postoperative haematoma following thyroid surgery, with particular attention to postoperative systolic blood pressure.