Non-steroid, non-antibiotic anti-biofilm therapy for the treatment of chronic rhinosinusitis: a systematic review.

OBJECTIVE: Chronic rhinosinusitis patients with biofilms cultured from their sinonasal cavity have greater symptom burden and risk of recalcitrant disease. A number of non-antibiotic, 'anti-biofilm' treatments exist which show anti-biofilm properties in preclinical studies. There is little evidence evaluating their impact on clinical symptom scores in chronic rhinosinusitis. METHOD: A systematic review was performed to assess the literature regarding the efficacy of non-steroid, non-antibiotic, anti-biofilm specific topical therapies in the treatment of chronic rhinosinusitis. The primary outcome assessed was change in validated patient reported outcome measures before and after anti-biofilm treatment. RESULTS: Thirteen studies assessing the effect of anti-biofilm therapies in chronic rhinosinusitis through validated patient-reported outcome measures were included. Seven different anti-biofilm specific therapies for chronic rhinosinusitis were identified. None of the seven anti-biofilm therapies was identified as being confidently efficacious beyond placebo. Only one therapy (intranasal xylitol) showed a statistically significant reduction in symptom scores compared with placebo in more than one trial. CONCLUSION: Robust evidence supporting the use of various anti-biofilm therapies in chronic rhinosinusitis is lacking. Further high quality, human, in vivo trials studying the effect of anti-biofilm therapies in chronic rhinosinusitis are needed to address the deficiencies of the current evidence base.

Piezoelectric technology in otolaryngology, and head and neck surgery: a review.

BACKGROUND: Piezoelectric technology has existed for many years as a surgical tool for precise removal of soft tissue and bone. The existing literature regarding its use specifically for otolaryngology, and head and neck surgery was reviewed. METHODS: The databases Medline, the Cochrane Central Register of Controlled Trials, PubMed, Embase and Cambridge Scientific Abstracts were searched. Studies were selected and reviewed based on relevance. RESULTS: Sixty studies were identified and examined for evidence of benefits and disadvantages of piezoelectric surgery and its application in otolaryngology. The technique was compared with traditional surgical methods, in terms of intra-operative bleeding, histology, learning curve, operative time and post-operative pain. CONCLUSION: Piezoelectric technology has been successfully employed, particularly in otology and skull base surgery, where its specific advantages versus traditional drills include a lack of 'blunting' and tissue selectivity. Technical advantages include ease of use, a short learning curve and improved visibility. Its higher cost warrants consideration given that clinically significant improvements in operative time and morbidity have not yet been proven. Further studies may define the evolving role of piezoelectric surgery in otolaryngology, and head and neck surgery.

Free fat grafting in superficial parotid surgery to prevent Frey's syndrome and improve aesthetic outcome.

BACKGROUND: Frey's syndrome and cosmesis are important considerations in parotid surgery. Placement of an interpositional barrier can prevent these complications; however, surgical technique and efficacy remain controversial. METHODS: A prospective case series was collected comprising all patients undergoing primary superficial parotidectomy for benign pathology with abdominal free fat grafting between June 2007 and December 2010, performed by a single surgeon. A survey was also distributed to otorhinolaryngology consultants across Australia to assess current practice. RESULTS: Twenty-eight patients were included. No patient had clinical symptoms of Frey's syndrome. Seventy-five per cent of patients were completely satisfied with their aesthetic outcome, 18 per cent scored 4/5 and the remaining 7 per cent (2 patients) scored 3/5. The survey revealed that 79 per cent of respondents did not use interpositional grafts. CONCLUSION: Abdominal free fat is ideal for grafting as it is an effective, safe, simple, accessible, fast and inexpensive method of providing an interpositional graft.

Comparison of functional endonasal sinus surgery with and without partial middle turbinate resection.

The aim of endonasal sinus surgery is to ameliorate sinonasal symptoms and to achieve a functional nose. Although the importance of opening the ostiomeatal complex is accepted, the role of middle turbinate surgery remains controversial. Although some surgeons emphasize the importance of maintaining the middle turbinate as a physiological humidifier and anatomic landmark, others resect it without adverse sequelae. To date, there have only been limited reviews published to support either approach. This paper examines 1,106 matched patients who underwent similar functional endonasal sinus surgery with (509 patients) or without (597 patients) middle turbinate surgery. We demonstrate a paucity of complications and the potential outcome benefits of judicious partial middle turbinate resection in some patients with more severe rhinosinusitis.

A management strategy for vocal process granulomas.

OBJECTIVES/HYPOTHESIS: Review the roles of aggressive gastroesophageal reflux management and speech therapy in the treatment of patients with vocal process granulomas. Describe and assess our investigation and management protocol. STUDY DESIGN: Retrospective review of 55 patients with 61 vocal granulomas treated according to a standard protocol at the Sydney Voice Clinic. Comparison with previous published series and review of the relevant literature pertaining to granulomas and to reflux. Description of laryngopharyngeal reflux grading, investigative modalities, and treatment regimen. METHODS: Case notes were reviewed and tabulated for age, sex, diagnosis, predisposing factors for granuloma formation, grade of laryngopharyngeal reflux, investigations, treatment, resolution, and recurrence. All patients were followed up for at least 12 months after resolution. RESULTS: Fourteen of the 61 granulomas occurred after intubation. Ten patients were professional voice users. Our assessment of the 55 granuloma patients revealed an incidence of 76% of gastroesophageal reflux disease in patients with and without known vocal fold trauma. There was a 50% recurrence rate following surgical excision. However, aggressive antireflux therapy, lifestyle modifications, and adjuvant speech therapy were successful in achieving resolution of most of the granulomas and preventing recurrence. In four patients, antireflux surgery was required and total resolution of the granulomas followed. CONCLUSIONS: Vocal process granulomas have perplexed laryngologists with their indeterminate pathogenesis and tendency to recur. Multiple surgical excisions and a variety of combined medical regimens have been used to treat granulomas with variable success. Recurrence after excision commonly occurs as the underlying causative factors have not been appropriately managed and may re-establish the chronic inflammatory process. We found acid reflux to be a common factor in the majority of our patients with granulomas. Therefore treatment should focus on managing both reflux and any functional voice disease or disorder. The only indications for laryngeal surgery are to resolve diagnostic doubt or to treat acute airway compromise. Based on results, we suggest an algorithm for the investigation and management of vocal process granulomas founded on appropriate antireflux and speech therapy.

Multicentric chemodectoma in the head and neck.

A case of a multicentric chemodectoma, with the unusual combination of glomus vagale and glomus tympanicum, is presented. The patient, though asymptomatic, showed elevated levels of urinary catecholamines, suggesting some biochemical activity of the tumour. Multicentricity was unsuspected prior to selective carotid arteriography. Intra-operative haemostasis was assisted by the utilization of pre-operative selective embolization of the tumour mass. Subsequently, the injected Ivalon was confirmed histologically in the specimen. The asymptomatic small glomus tympanicum tumour was treated using embolization alone but only time will determine the effectiveness of this method of management. The vagus nerve was anatomically spared, but complete function had not returned after 2 years of follow-up.

Prevalence of incidental abnormalities on computed tomographic scans of the paranasal sinuses.

A prospective analysis of 666 patients was performed to examine the prevalence of radiologic abnormalities of the paranasal sinuses in asymptomatic adults. The initial sample group included 1000 patients who were referred for cranial computed tomographic scans for conditions such as head injuries and seizures. Patients in whom there was clinical suspicion of sinus disease were excluded from the study. A questionnaire was completed by each patient and cranial computed tomography, including magnetic resonance imaging of the paranasal sinuses, was performed. Abnormality of one or more of the paranasal sinuses was reported in 42.5% of scans. Mucosal thickening in the ethmoid sinus was the abnormality most often identified. The high frequency of reported radiologic abnormalities in asymptomatic patients highlights the importance of correlation with the clinical presentation when interpreting computed tomographic scans of the paranasal sinuses.

The incidence and management of chylous fistulae.

Two hundred neck dissections performed at Toronto General Hospital over a 3 year period are reviewed. There were six intra-operative lymph leaks and five postoperative chylous fistulae. The postoperative chylous fistulae are analysed in detail and the approach to conservative management of lymph leaks is discussed. Two cases required re-exploration of the neck; difficulty in identifying the site of leakage and of sealing lymph channels is discussed. Also reported is the successful use of topical tetracycline powder in two cases and a review of the various treatment modalities advocated in the literature.

Alterations in nasal physiology after laryngectomy: the nasal cycle.

Several changes in nasal physiology have been reported following laryngectomy. This paper reviews these changes and investigates the cycle of alternating distribution of nasal airflow in 20 adults. Information about the cyclic activity was obtained from the areas of condensation formed by nasal expiration on the surface of a Gertner-Podoshin plate. Consecutive measurements of these areas were made at 15-minute intervals during a 6-8 hour period. Five control subjects demonstrated a nasal cyclic activity which was absent in five patients 1-3 years post-laryngectomy. Two patients with preoperative cycles showed none three weeks after laryngectomy. Three patients with a temporary surgical diversion of supraglottic airflow showed cessation of the cycle, which resumed after restoration of the natural airway; one of these patients had undergone hemilaryngectomy with section of both superior laryngeal nerves. Five patients showed no alteration after operation involving no diversion of supraglottic airflow (tonsillectomy). These results demonstrate cessation of the cycle following chronic absence of supraglottic airflow, temporary, cessation during acute absence, and independence of the cycle from superior laryngeal innervation.

The use of topical tetracycline in the management of persistent chylous fistulae.

The management of chylous fistulae remains controversial. A detailed conservative protocol and guidelines regarding surgical intervention are lacking in the literature. This paper presents our experience in the management of two cases of persistent chylous fistulae by successfully employing topical tetracycline. Our regimen of management is discussed and illustrated with the above two cases. An updated review of the pertinent anatomy, physiology, and literature is presented.

The nasal cycle after laryngectomy.

The cycle of alternating distribution of nasal airflow was investigated in 15 adults. Information about cyclic activity was obtained from the areas of condensation formed by nasal expiration on the surface of a Gertner-Podoshin plate. Consecutive measurements of these areas were made at 15 minute intervals during a 6-8 h period. Five control subjects demonstrated a nasal cyclic activity which was absent in 5 patients 1-3 years post laryngectomy. Two patients with preoperative cycles showed none 3 weeks after laryngectomy. Three patients with temporary surgical diversion of supraglottic airflow showed cessation of the cycle, which resumed after restoration of the natural airway; one of these patients had undergone hemilaryngectomy with section of both superior laryngeal nerves. These results demonstrate cessation of the cycle following chronic absence of supraglottic airflow, temporary cessation during acute absence, and independence of the cycle from superior laryngeal innervation.

Adult epiglottitis.

Epiglottitis (supraglottitis) in the adult, once thought a rare entity, has been reported in the literature with increasing frequency since the late 1960s. Five cases occurring in our hospital over a 12-week period prompted this report. Historical and literature reviews followed by five case reports and discussion, illustrate the important diagnostic and therapeutic features of this disease.

The effects of combined H1 and H2 histamine antagonists on alterations in nasal airflow resistance induced by topical histamine provocation.

A clinical trial was undertaken to assess the effects of oral H1 (diphenhydramine hydrochloride) and H2 (cimetidine) histamine blockade on nasal resistance induced by topical histamine. Ten adult volunteers were tested on two separate occasions. Their noses were pretreated by oral administration of either combined H1 and H2 histamine antagonists or H1 antagonist and placebo. The nasal airflow resistive response to topical histamine was then determined. Combined histamine antagonism was significantly more effective in reducing the nasal resistive response to topical histamine than H1 antagonist alone (p less than 0.0001). Furthermore, ingestion of the oral H1 histamine antagonist, diphenhydramine hydrochloride, alone led to an increase in resistance of the unprovoked nose, whereas combined H1 and H2 antagonism did not lead to a significant change.

Resistance to respiratory airflow of the nasal passages: comparisons between different common methods of calculation.

Computer assisted active posterior rhinomanometric determinations of resistance were made with four adult subjects. A face mask and pneumotach were used to measure respiratory airflow. The magnitude and variation of six different instantaneous and time averaged methods of calculation of resistance resulting from simultaneous measurements were compared. Over a resistance range of 1-6 cm H2O/l/sec (0.1-0.6 Pa/cm3/sec) time averaged results approximated those computed at 75 Pa and were 20-25% less than those at 150 Pa. Over the same range of nasal patencies, the coefficients of variation averaged 6-8% in 144 series of 10 measurements which were obtained from six modes of resistance computation in four subjects (total 1440). Time averaged results showed the least variation. A frequency range of 10-26 breaths/min increased the coefficient of variation only to 9% and a ventilation range of 7-24 l/min increased it to 11%, quantitative relationships between resistances and pattern of breathing were not evident. Mask positioning was critical, small maladjustments resulted in large resistive changes.

Mandibular reconstruction with metal plate and myocutaneous flap.

The combination of a myocutaneous flap with a three dimensional, bendable reconstruction plate has provided very satisfactory results in restoration of mandibular defects following surgical resections in irradiated patients. Twenty-four cases have been treated and evaluated prospectively using this technique. Patients requiring postoperative irradiation were excluded from this study. Two groups were identified. Group A (n = 20) required a myocutaneous flap to resurface the soft tissue defect and Group B (n = 4) were treated by primary closure. No failures were encountered in the group handled primarily with a myocutaneous flap combined with an AO plate. One failure occurred in the group closed primarily. Nine (38%) of the patients have maintained their plate for over 1 year. Twelve (55%) have functioned for more than 9 months. Of the remaining three (7%), one failed and the other two have been in place for more than 5 months. The results of this study demonstrate that a well-vascularized soft tissue bed in combination with stainless steel plate provides a very satisfactory, functional, esthetic and reliable method in rehabilitation of mandibular defects primarily in irradiated patients.