Sherif Khalil

Endoscopic Airway Management of Laryngeal Sarcoidosis

OBJECTIVE To report the results of treating laryngeal sarcoidosis with intralesional steroids and minimally invasive laser surgery. Sarcoidosis is a rare multisystem inflammatory disorder of unknown cause. Laryngeal involvement is extremely rare, and its optimal management remains controversial. DESIGN Retrospective medical chart review. Settings Tertiary care center/national referral airway reconstruction center. PATIENTS Ten consecutive patients treated for laryngeal sarcoidosis between 2004 and 2008. MAIN OUTCOME MEASURES Demographic and clinical information including extralaryngeal manifestations obtained from patient records, laryngeal anatomic subsite manifestation of disease, intraoperative findings, and scores from the Medical Research Council (MRC) dyspnea outcome assessment instrument (which was administered preoperatively, at the first postoperative outpatient visit 4-6 weeks later, and at last follow-up). RESULTS The patients included 9 women and 1 man, a total of 2.8% of the units adult surgical airway case mix (10 of 353). Mean (SD) age at presentation was 37 (17) years. All patients presented with dyspnea and dysphonia; 2 required emergency tracheostomy prior to treatment. Six patients presented with isolated laryngeal sarcoid. Supraglottis and arytenoids were affected in all patients. The median number of endoscopic treatments was 2 (range, 1-4). Significant improvement in MRC dyspnea grading was found postoperatively (P < .05), and patients with tracheostomy were successfully decannulated. The mean (SD) follow-up time was 24 (18) months. There were no adverse effects of surgery. Nine patients had a substantial dose reduction or discontinuation of their systemic corticosteroid therapy following endoscopic treatment. CONCLUSIONS Minimally invasive endoscopic surgery with intralesional corticosteroid injection and laser reduction is an effective method of controlling laryngeal sarcoid. It improves symptoms immediately with minimal morbidity and, most importantly, reduces the need for systemic steroid administration in most patients. This study supports early recognition and endoscopic intervention in the management of laryngeal sarcoidosis.

Ectopic sequestered thyroid tissue: an unusual cause of a mediastinal mass.

An 80-year-old female presented with an incidental finding of a retrosternal mass on magnetic resonance imaging. Ultrasound demonstrated a mediastinal lesion adjacent to but separate from the inferior pole of the right thyroid lobe. Fine needle aspiration cytology demonstrated colloid and follicular cells. At surgery, the right thyroid lobe was found to be normal. A discrete 5 cm nodule was found in the anterior mediastinum separate from the thyroid and just anterior and to the right of the trachea and thymus. The nodule had a vascular pedicle arising from the mediastinum. The differential diagnosis included metastatic thyroid carcinoma. Histology was consistent with a benign ectopic sequestered thyroid nodule. Extensive investigations demonstrated no sign of a thyroid malignancy.

Balloon Sinuplasty™: balloon-catheter dilation of paranasal sinus ostia for chronic rhinosinusitis

More than 100 million patients worldwide suffer from chronic rhinosinusitis, and a considerable amount of money has been spent on research and treatments by healthcare providers. In the northern hemisphere, damp, temperate climates, along with higher concentrations of pollen, are associated with a higher prevalence of chronic rhinosinusitis. Owing to its persistent nature, the disease can become a significant cause of morbidity. If untreated, it can reduce quality of life and productivity. When medical treatment is not effective, surgery may offer an excellent outcome. Although functional endoscopic surgery has proven to be effective, many cases could be managed medically. Recent research has suggested that optimal medical treatment is as effective as surgery in patients with chronic rhinosinusitis at the end of 1 year. Balloon Sinuplasty™ (Acclarent, Inc., CA, USA) is a new technique in the management of sinusitis and is a hotly debated topic. It is a delicate, minimally invasive tool, and early research demonstrates promising outcomes in terms of safety and effectiveness. This novel technique has been approved by the US FDA. Recently, NICE raised no concerns regarding its safety and efficacy but will continue to review this procedure.

Five‐year hearing results with the shape memory nitinol stapes prosthesis

To evaluate the long‐term (5‐year) results of the shape‐memory nitinol stapes piston in the surgical treatment of otosclerosis.Objectives/Hypothesis To evaluate the long-term (5-year) results of the shape-memory nitinol stapes piston in the surgical treatment of otosclerosis. Study Design Retrospective case review in a tertiary referral center. Methods The patients were adults with clinically proven otosclerosis undergoing stapedotomy. Stapedotomy and ossicular chain reconstruction using a shape-memory nitinol stapes piston were performed. The main outcome measure was masked air and bone conduction audiometry. Results Forty-eight out of a potential 58 ears had complete audiometric data. The mean preoperative air-bone gap was 29.2 dB (standard deviation [SD] 9.4). The postoperative gap at 1 year was 4.6 dB (SD 3.1), and P at 5 years was 7.0 dB (SD 6.2). Conclusions These data suggest that the Smart piston provides a stable long-term hearing result in the surgical treatment of otosclerosis. Level of Evidence 4. Laryngoscope, 124:2591–2593, 2014

Comparison of Audiometric and Functional Outcomes Between the Standard and Modified 360 Nitinol Shape Memory Stapes Prostheses.

Objective To compare audiometric and functional outcomes between two designs of heat-activated self-crimping stapes prostheses—a modified shape memory circumferential nitinol-Teflon piston versus its predecessor—in patients with otosclerosis. Study Design A retrospective analysis of preoperative and postoperative hearing thresholds. Setting Tertiary referral center and teaching hospital. Patients One hundred sixty-three consecutive procedures of primary stapes surgery for clinically proven otosclerosis in 108 women and 55 men with an average age of 46 years. Intervention Stapedotomy and insertion of either a standard or a circumferential stapes prosthesis. Main Outcome Measures Four-frequency pure-tone average preoperative and postoperative air-bone thresholds were recorded. A secondary outcome measure was stability of the implant, as measured by failure rates. Results Success of closure of the air-bone gap to within 10 dB was achieved in 97% and comparable in both groups (original prosthesis, 23.6; standard deviation, 7.3, with the average reduction seen in the circumferential prosthesis group being 22.6, standard deviation, 5.6). All the differences were not statistically significant using two-way analysis of variance. Failure rate for the original piston was 6%, with no failures seen with the circumferential piston. Conclusion Both prostheses showed comparable postoperative hearing outcomes, with the circumferential prosthesis being found to be more stable.

Evaluating inter-aural hearing preservation in bilateral paediatric cochlear implantation

Objective: To examine inter-aural hearing preservation results in children undergoing simultaneous bilateral cochlear implantation (CI). Methods: Retrospective case review in tertiary referral centre. All children undergoing simultaneous bilateral CI between January 2013 and June 2014 (18 months). Patients eligible for inclusion in the study had pre-operative hearing thresholds of <90 dB at 250 Hz and ≥100 dB at 500 Hz. Patients with anatomical cochlear anomalies or missing data were excluded. Seven patients were included, 1 male, 6 female, mean age of 12 years 11 months at the time of surgery. All patients had simultaneous bilateral cochlear implant surgery, using the same implant and technique. All patients had pre- and post-operative unaided pure tone audiometry. Inter-aural hearing preservation results were compared in each patient. Results: The achieved hearing preservation for 14 ears was complete in 5, partial in 7, and minimal in 2. Measurable hearing preservation was achieved in 86% overall. Inter-aural analysis revealed that only 2 (subjects 1 and 4) of the 7 patients had preservation results within the same preservation group (complete/partial/minimal). The mean inter-aural preservation difference was 30.7% with a range from 12.4% to 65.2%. Conclusions: Several factors and techniques have already been identified in the wider literature to explain differences in hearing preservation results in CI. However, despite controlling for known factors, we demonstrate variable inter-aural results. This suggests that there may be more factors beyond the surgeon’s control influencing our ability to provide consistent results.

Is the Extent of the Preoperative Air-Bone Gap an Indicator of Potential Success in Stapedectomy?

Objectives: Could preoperative air-bone gap magnitude act as a predictor of postoperative outcome in patients undergoing stapedectomy for otosclerosis? If this were to occur, is it frequency specific? Methods: Retrospective case series from January 2010 to December 2012 in a tertiary London teaching hospital. Patients: Evaluation of 302 stapedectomy procedures under the care of a single consultant. Intervention: Laser stapedectomy using Smart Nitinol stapes prosthesis. Retrospective analysis comparing preoperative and postoperative air-bone gap (ABG) in patients undergoing stapedectomy. Patients were stratified into subgroups according to their preoperative air-bone gap and this was compared with their postoperative result of air-bone closure. In addition, for each commonly tested frequency (0.5, 1, 2, 3, 4 kHz) the preoperative and postoperative air-bone gap were analyzed in order to ascertain whether the preoperative ABG could act as a predictor. Having not passed normality testing, Wilcoxon matched paired signed rank test and Spearman’s rank coefficient were used for analysis. Results: Throughout the statistical analysis, preoperative ABG correlated most strongly with net difference in postoperative ABG (P < .0001). For each commonly tested frequency assessed this demonstrated a “very strong” positive correlation. As such, the greater the preoperative ABG, the greater the closure obtained through stapedectomy in this series. Conclusions: In performing stapedectomy for otosclerosis, our series suggested the preoperative ABG may have a role in preoperative patient counseling and consent, but is unable to predict success in stapedectomy surgery.

Laser Stapedotomy Using SMART Piston: 5-Year Results

Objective: The SMART piston is composed of a nitinol-based hook and a Teflon-based piston. Nitinol is a metal alloy of nickel and titanium that allows self-crimping by heat activation. The aim of this study is to evaluate the long-term (5 years) auditory results after the use of the SMART piston in primary laser stapedotomy. Method: This is a retrospective review of prospectively collected data. The 5-year postoperative follow-up data for 32 patients is presented. Preoperative pure tone audiograms recording air and bone conduction thresholds at 0.5, 1, 2, 3, and 4 kHz were recorded. Postoperative pure tone audiograms at the same frequencies were recorded after 6 weeks, 6 months, 1, 2, 3, 4, and 5 years. Air-bone gaps and pure tone averages at 0.5, 1, 2, and 3 kHz were calculated. Results: The 4-frequency pure tone average of 0.5, 1, 2, and 3 kHz had a mean preoperative value of 58.4dB (SD ± 14.3dB) in air-conduction thresholds. This has shown a drop in mean thresholds to 28.7 dB (SD ± 11.0 dB) in the 5-year follow-up. The air-bone gap also decreased from 30.1 dB (SD ± 9.6 dB) to 1.5 dB (SD ± 3.8 dB), which was statistically significant (P = .001). There was no significant change in the pure tone average bone conduction threshold when comparing the preoperative thresholds (28.3 dB, SD ± 12.5dB) and postoperative thresholds (23.9dB, SD ± 11.1 dB; P = .551). Conclusion: Results demonstrate that the SMART piston provides excellent long-term auditory outcome. The ease of the self-crimping and the tightness of the crimp provide the advantage of long-term results.

Is the UK Contribution to Published Clinical Otolaryngology Research Changing

The UK led other European countries in the number of otolaryngology publications between 1995 and 2000 and accounted for 19.6% of all papers in ten leading otolaryngology journals over the period of 1985 to 1994. Sandhu and Wright reviewed the trends in eight journals, between January 1997 and December 1999, and found no major change in the output when compared with an earlier study by Hussain and Nunez between January 1984 and December 1989.