Head and neck surgery global outreach: Ethics, planning, and impact.

BACKGROUND: Head and neck surgical oncology and reconstruction are uniquely suited to address burdens of disease in underserved areas. Since these efforts are not well known in our specialty, we sought to understand global outreach throughout our society of surgeons. METHODS: Survey distributed to members of the American Head and Neck Surgery involved in international humanitarian head and neck surgical outreach trips. RESULTS: Thirty surgeons reported an average of seven trips to over 70 destinations. Identification of candidates, finances, on-site patient care, complications, long-term post-surgical care, ethics, and educational goals are reported. We report a success rate of 90% on 125 free flaps performed in these settings. CONCLUSIONS: The effort to answer the call for alleviating the global burden of surgical disease is strong within our specialty. There is a shared focus on humanitarian effort and teaching. Ethics of high resource surgeries such as free flap reconstruction remains controversial.

Community health worker-based hearing screening on a mobile platform: A scalable protocol piloted in Haiti.

OBJECTIVE: To establish the feasibility of a systematic, community health worker (CHW)-based hearing screening program that gathers Health Insurance Portability and Accountability Act-compliant electronic data (otoscopic images of tympanic membrane and audiometric evaluation) on a smartphone in an effort to streamline treatment options in resource-limited communities. METHODS: This is a cross-sectional study in which four schools were screened in Port-au-Prince, Haiti, during in April 2018. A total of 122 subjects (61% female) aged 5-17 years underwent an initial brief audiometric screen followed by a more comprehensive air conduction audiometric evaluation if they failed their initial screen. Participants with more than 35-dB loss in any frequency on their comprehensive audiometric evaluation received endoscopic otoscopy. RESULTS: Seventy-five percent of subjects (91/122) passed their initial screen. Of those who failed, 9% (4/44 ears) had a severe or profound hearing loss on comprehensive evaluation. Abnormal otoscopic findings (11/36 ears, 31%) included are cerumen impaction (n = 6), myringosclerosis (n = 3), tympanic membrane perforation (n = 1), and tympanic membrane retraction (n = 1). The average duration of the initial testing was 100 seconds (SD = 74 seconds), whereas the duration of comprehensive testing was 394 seconds (SD = 175 seconds). Extrapolating from these data, we estimate that a group of seven trained CHWs could gather formal audiologic and otologic data points for 100 children per hour using this protocol. CONCLUSIONS: A systematic approach that utilizes local resources (CHWs) and existing infrastructure (cell phones and the Internet) can significantly reduce the burden of hearing healthcare specialists while simultaneously facilitating early diagnosis and management of disabling hearing loss in low-resourced settings. LEVEL OF EVIDENCE: Level 4.

Expanding the Capacity of Otolaryngologists in Kenya through Mobile Technology.

OBJECTIVE: To determine if reliable, objective audiologic data can be obtained by nonotolaryngology and nonaudiology practitioners using novel mobile technology in an effort to expand the capacity for early identification and treatment of disabling hearing loss in the developing world. STUDY DESIGN: Cross-sectional, proof-of-concept pilot study. SETTING: Screenings took place during an annual 2-week otolaryngology surgical mission in October 2016 in semirural Malindi, Kenya. SUBJECT AND METHODS: Eighty-seven patients (174 total ears) were included from 2 deaf schools (n = 12 and 9), a nondeaf school (n = 9), a tuberculosis ward (n = 8), and a walk-in otology clinic at a local hospital (n = 49). An automated, tablet-based, language-independent, clinically validated, play audiometry system and wireless otoscopic endoscopy via an iPhone or laptop platform was administered by Kenyan community health workers (CHWs) and nursing staff. RESULTS: Various degrees of hearing loss and otologic pathology were identified, including 1 child presumed to be deaf who was found to have unilaterally normal hearing. Other pathology included 2 active perforations, 2 healed perforations, 2 middle ear effusions, and 1 cholesteatoma. CHWs and nursing staff demonstrated proficiency performing audiograms and endoscopy. Patients screened in a deaf school were more likely to complete an unreliable audiogram than patients screened in other settings (P < .01). CONCLUSION: This study demonstrates the feasibility of a non-otolaryngology-based hearing screening program. This may become an important tool in reducing the impact of hearing loss and otologic pathology in areas bereft of otolaryngologists and audiologists by allowing CHWs to gather important patient data prior to otolaryngologic evaluation.

Short and Long-Term Outcomes of Titanium Clip Ossiculoplasty.

OBJECTIVE: To report short (∼4 mo) and long-term (>12 mo) audiometric outcomes following ossiculoplasty using a titanium clip partial ossicular reconstruction prosthesis. METHODS: Case series at a single tertiary referral center reviewing 130 pediatric and adult patients with conductive hearing loss (CHL) secondary to chronic otitis media (n = 121, 93%) or traumatic ossicular disruption (n = 9, 7%) who underwent partial ossiculoplasty from January 2005 to December 2015 with the CliP prosthesis. RESULTS: At both short and long-term follow-up, postoperative air-bone gap (ABG) was significantly improved (18 dB HL, IQ range 13-26, p < 0.0001 and 18 dB HL, IQ range 13-29, p = 0.0002, respectively) when compared with preoperative values (29 dB HL, IQ range 19-37). No significant change in ABG was noted when comparing short and long-term intervals (18 versus 18 dB HL, p = 0.44). Fifty seven percent of cases (51/89) achieved a long-term ABG less than or equal to 20 dB at the time of their last follow-up. The extrusion and displacement rates were 1.5% (2/130), and 0.8% (1/130), respectively. There were no cases of iatrogenic sensorineural hearing loss. CONCLUSIONS: Partial ossiculoplasty with the titanium CliP produces good hearing outcomes with a favorable safety profile. At long-term follow-up (minimum of 12 mo), median ABG was 18 dB and remained stable when compared with short-term follow-up. The majority of patients had successful long-term results, with 57% of patients achieving an ABG is less than or equal to 20 dB. Low rates of extrusion (1.5%) and prosthesis displacement off the stapes (0.8%) support the long-term stability of the CliP prosthesis in the middle ear.

Expression of human papillomavirus oncoproteins E6 and E7 inhibits invadopodia activity but promotes cell migration in HPV-positive head and neck squamous cell carcinoma cells.

BACKGROUND: The rapid increase in the incidence of head and neck squamous cell carcinoma (HNSCC) is caused by high-risk human papillomavirus (HPV) infections. The HPV oncogenes E6 and E7 promote carcinogenesis by disrupting signaling pathways that control survival and proliferation. Although these cancers are often diagnosed with metastases, the mechanisms that regulate their dissemination are unknown. AIMS: The aim of this study was to determine whether the HPV-16 E6 and E7 oncogenes affected the invasive and migratory properties of HNSCC cells which promote their spread and metastasis. METHODS AND RESULTS: Invasiveness was determined using invadopodia assays which allow for quantitation of extracellular matrix (ECM) degradation by invadopodia which are proteolytic membrane protrusions that facilitate invasion. Using cell lines and genetic manipulations, we found that HPV inhibited invadopodia activity in aggressive cell lines which was mediated by the E6 and E7 oncogenes. Given these findings, we also tested whether HPV caused differences in the migratory ability of HNSCC cells using Transwell assays. In contrast to our invadopodia results, we found no correlation between HPV status and cell migration; however, blocking the expression of the E6 and E7 oncoproteins in a HPV-positive (HPV+) HNSCC cell line resulted in decreased migration. CONCLUSIONS: Our data suggest that the E6 and E7 oncoproteins are negative regulators of invadopodia activity but may promote migration in HPV+ HNSCC cells. Despite the need for ECM proteolysis to penetrate most tissues, the unique structure of the head and neck tissues in which these cancers arise may facilitate the spread of migratory cancer cells without significant proteolytic ability.

Fibrous dysplasia of the temporal bone: a review of 66 cases.

OBJECTIVES/HYPOTHESIS: Fibrous dysplasia is a condition of nonmalignant osseous change and may occur in a monostotic or polyostotic pattern, the latter potentially being associated with McCune-Albright syndrome. Symptoms are highly variable and dependent upon lesion location and size. STUDY DESIGN: Retrospective review. METHODS: Consecutive subjects with fibrous dysplasia of the temporal bone were evaluated between 2000 and 2013 at two tertiary academic referral centers. Main outcome measures included disease presentation, diagnostic evaluation, management strategy, and outcome. RESULTS: Sixty-six patients with fibrous dysplasia of the skull were found to have involvement of the temporal bone. The mean age at diagnosis was 25 years, 39 (59%) were female, and the mean duration of follow-up was 48 months. Six (11%) patients had monostotic disease, with the remaining 60 (89%) patients having the polyostotic form; 16 (24%) patients had McCune-Albright syndrome. The most common presenting complaint was headache (59%), followed by hearing loss (29%). The most common exam finding was cosmetic deformity (50%). Cholesteatoma (3%) and spontaneous cerebrospinal fluid fistula (1.5%) were found in a small percentage. No patients had evidence of motor cranial neuropathy by history or physical examination. CONCLUSIONS: The clinical presentation of fibrous dysplasia involving the temporal bone is variable. A growing number of patients are diagnosed incidentally through imaging, and since most patients experience a benign course, the majority can be followed clinically without need for intervention. LEVEL OF EVIDENCE: 4.

Vaccination recommendations and risk of meningitis following cochlear implantation.

PURPOSE OF REVIEW: The Centers for Disease Control and Prevention has established vaccination guidelines for cochlear implant recipients to address the concern for implant-associated bacterial meningitis. Since their inception in 2002, these guidelines have undergone several revisions. We review the rationale and development of the current vaccination schedule. RECENT FINDINGS: Bacterial meningitis is a rare yet potentially life-threatening complication of cochlear implantation. The recommendations for pneumococcal vaccination have evolved to a state in which nearly all cochlear implant patients receive a combination of both the PCV7 or PCV13 and PPSV23. SUMMARY: Streptococcus pneumoniae vaccinations have dramatically decreased the incidence of serotype-specific invasive pneumococcal disease across all age groups. However, the optimal timing of immunization remains unclear in cochlear implant candidates.

Middle ear implants for rehabilitation of sensorineural hearing loss: a systematic review of FDA approved devices.

OBJECTIVE: To systematically review the safety and efficacy of the 3 Food and Drug Administration-approved middle ear implant (MEI) systems currently in use for the rehabilitation of sensorineural hearing loss. DATA SOURCES: MEDLINE and Cochrane Library databases were systematically searched by 2 independent reviewers. STUDY SELECTION: An initial search yielded 3,020 articles that were screened based on title and abstract. A full manuscript review of the remaining 80 articles was performed, of which 17 unique studies satisfied inclusion criteria and were evaluated. DATA EXTRACTION: Variables including functional gain, speech recognition score improvement, audiometric threshold shift following surgery, adverse events, and patient reported outcome measures were recorded. Study quality was appraised according to author conflict of interest, prospective or retrospective study design, inclusion criteria, number of patients, proper use of study controls, outcome measures reported, length of follow-up, and level of evidence. DATA SYNTHESIS: Heterogeneous outcome reporting precluded meta-analysis; instead a structured review was performed using best available data. CONCLUSION: The majority of studies evaluating the safety and efficacy of MEIs are retrospective in nature with limited follow-up. To date, no prospective randomized controlled trial exists comparing contemporary air conduction hearing aid performance and MEI outcomes. Based on available data for patients with sensorineural hearing loss, functional gain and word recognition improvement seems similar between conventional hearing aids and MEIs, whereas patient-perceived outcome measures suggest that MEIs provide enhanced sound quality and eliminate occlusion effect.

Cochlear implantation in Ménière's disease patients.

OBJECTIVE: A significant portion of the Ménière's disease (MD) population will ultimately have severe-to-profound hearing loss in their affected ear. When this occurs bilaterally or when a patient has poor hearing in the contralateral ear, these patients may meet criteria for cochlear implantation (CI). Here, we describe our institution's CI outcomes in MD patients. STUDY DESIGN: Retrospective chart and literature review. SETTING: Tertiary referral center. PATIENTS: Twenty-one patients with either bilateral MD or unilateral MD who underwent CI in their ear affected with MD. INTERVENTION(S): Cochlear implantation. MAIN OUTCOME MEASURE(S): Postoperative speech perception. RESULTS: Results for the MD patients were also compared with a standard sample of 178 adult recipients implanted with newest generation technology. Collapsing across status of MD activity, there was a significant difference between the MD CNC word recognition scores and that of the standard sample (43.2 versus 59.1%, p = 0.02). When separating the MD patients into groups according to the status of disease activity, those with active MD achieved scores that were not significantly different from the standard sample (55.7 versus 59.1%, p = 0.94), although those without active MD were significantly different from the standard group (38.2 versus, p = 0.002). Patients undergoing surgical or ablative procedures for their MD symptoms had statistically significant improvement in their CI hearing outcomes compared with those who did not (CNC words: p = 0.014; CNC phonemes: p = 0.035). Six patients had persistent vertiginous symptoms of MD before CI. After CI, 2 had complete resolution of vertigo, 3 had subjective improvement in their symptoms, and 1 noticed no change. CONCLUSION: Ménière's disease patients' hearing outcomes seem to be worse than the general CI population. However, those with active MD perform similarly to the general CI population.

Targeting autophagy augments the anticancer activity of the histone deacetylase inhibitor SAHA to overcome Bcr-Abl-mediated drug resistance.

Novel therapeutic strategies are needed to address the emerging problem of imatinib resistance. The histone deacetylase (HDAC) inhibitor suberoylanilide hydroxamic acid (SAHA) is being evaluated for imatinib-resistant chronic myelogenous leukemia (CML) and has multiple cellular effects, including the induction of autophagy and apoptosis. Considering that autophagy may promote cancer cell survival, we hypothesized that disrupting autophagy would augment the anticancer activity of SAHA. Here we report that drugs that disrupt the autophagy pathway dramatically augment the antineoplastic effects of SAHA in CML cell lines and primary CML cells expressing wild-type and imatinib-resistant mutant forms of Bcr-Abl, including T315I. This regimen has selectivity for malignant cells and its efficacy was not diminished by impairing p53 function, another contributing factor in imatinib resistance. Disrupting autophagy by chloroquine treatment enhances SAHA-induced superoxide generation, triggers relocalization and marked increases in the lysosomal protease cathepsin D, and reduces the expression of the cathepsin-D substrate thioredoxin. Finally, knockdown of cathepsin D diminishes the potency of this combination, demonstrating its role as a mediator of this therapeutic response. Our data suggest that, when combined with HDAC inhibitors, agents that disrupt autophagy are a promising new strategy to treat imatinib-refractory patients who fail conventional therapy.