The effects of nasal closure on quality of life in patients with hereditary hemorrhagic telangiectasia.

INTRODUCTION: Epistaxis is the most common symptom of hereditary hemorrhagic telangiectasia (HHT). Complete nasal closure is one of the treatment options for patients with severe, intractable epistaxis. In our experience, this surgery can be life changing in a positive sense; but many patients as well as their physicians understandably fear that such a procedure will diminish certain aspects of quality of life (QOL). METHODS: Case-control study of HHT patients treated at the University of Utah HHT Center of Excellence with and without nasal closure from January 2005 to January 2016. Patients were matched according to epistaxis severity. Each included patient was issued three surveys: Epistaxis Severity Score (ESS), the Pittsburg Sleep Quality Index (PSQI), and the Nasal Obstruction Symptom Evaluation (NOSE). RESULTS: After treatment, the mean PSQI and NOSE scores were not significantly different between the two groups. However, the mean ESS score in the nasal closure group was significantly lower at 1.10 compared to the severe epistaxis group with a mean score of 3.99 (P = .027). CONCLUSION: The results of this study demonstrate that nasal closure significantly improves epistaxis severity without having a significant effect on sleep or nasal obstruction as they relate to QOL. These findings suggest that nasal closure should be considered for HHT patients with chronic severe epistaxis. LEVEL OF EVIDENCE: 4.

Effect of 3 Commercially Available Botulinum Toxin Neuromodulators on Facial Synkinesis: A Randomized Clinical Trial.

IMPORTANCE: Botulinum toxin neuromodulators are an important treatment for facial synkinesis. Whether a difference in efficacy exists among the 3 different botulinum neuromodulators used in treating this condition remains unknown. OBJECTIVE: To evaluate the effectiveness of 3 commercially available botulinum toxin neuromodulators in the treatment of facial synkinesis. DESIGN, SETTING, AND PARTICIPANTS: In this single-blind, 3-arm comparison randomized clinical trial, 28 patients at the Facial Nerve Center, University of Utah, Salt Lake City, were randomized to onabotulinumtoxinA, abobotulinumtoxinA, or incobotulinumtoxinA treatment. Each patient was given the Synkinesis Assessment Questionnaire (SAQ) to assess severity of synkinesis before treatment and 1, 2, and 4 weeks after treatment, and improvements were compared among the groups. Data were collected from July 3, 2012, to March 31, 2015. INTERVENTIONS: Botulinum toxin type A neuromodulator (onabotulinumtoxinA, abobotulinumtoxinA, or incobotulinumtoxinA) injected into synkinetic areas of the face. MAIN OUTCOMES AND MEASURES: Synkinesis assessed using the SAQ (score range, 20-100; lower scores indicate less severe synkinesis) before treatment and 1, 2, and 4 weeks after treatment. RESULTS: A total of 28 patients (mean [SD] age, 49.1 [18.5] years; 8 [28.6%] male and 20 [71.4%] female), with 6 patients enrolled multiple times, received 38 treatments (15 onabotulinumtoxinA, 13 abobotulinumtoxinA, and 10 incobotulinumtoxinA). No significant difference existed in baseline pretreatment SAQ scores among the 3 groups. Mean (SD) SAQ score improvement at 4 weeks was 41% (31%) for the onabotulinumtoxinA, 42% (20%) for the abobotulinumtoxinA, and 17% (18%) for the incobotulinumtoxinA groups. No significant differences were noted in SAQ score improvements among the 3 groups at weeks 1 and 2 after treatment (week 1 mean improvements of 42% in the onabotulinumtoxinA, 45% in the abobotulinumtoxinA, and 26% in the incobotulinumtoxinA groups; P = .19; week 2 mean improvements of 43% in the onabotulinumtoxinA, 46% in the abobotulinumtoxinA, and 28% in the incobotulinumtoxinA groups; P = .20). The difference in mean SAQ score improvement for abobotulinumtoxinA vs incobotulinumtoxinA from pretreatment to 4 weeks after treatment was not significant (30 vs 12 points; P = .11) despite a significant difference in mean total SAQ score for abobotulinumtoxinA vs incobotulinumtoxinA (40.34 vs 58.00; P = .02). CONCLUSIONS AND RELEVANCE: AbobotulinumtoxinA had similar efficacy to onabotulinumtoxinA and incobotulinumtoxinA for the management of facial synkinesis up to 4 weeks after treatment. IncobotulinumtoxinA had significantly less effect on SAQ score improvement than onabotulinumtoxinA at 4 weeks, perhaps because of the shorter duration of action. Shorter intervals between treatments or larger doses may be required when using incobotulinumtoxinA treatment for facial synkinesis. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT03048383. LEVEL OF EVIDENCE: 1.

Treatment of severe refractory epistaxis in hereditary hemorrhagic telangiectasia using a two-flap nasal closure method.

BACKGROUND: Nasal closure has been shown to effectively manage severe epistaxis refractory to other treatments in patients with hereditary hemorrhagic telangiectasia (HHT). The nasal closure procedure may be underutilized because of its surgical complexity and flap breakdown. METHODS: This work is a retrospective review of 13 HHT patients treated for severe epistaxis with nasal closure between 2005 and 2013. Operating room (OR) time, need for revision surgery, preprocedure, and postprocedure epistaxis severity score (ESS), complete blood count values, and Glasgow Benefit Inventory (GBI) questionnaire results were collected for each patient. The technique is described. We characterize a typical nasal closure patient and compare outcomes based on our experience with the traditional 3-flap closure and a simplified 2-flap nasal closure procedure. RESULTS: The average candidate for nasal closure in this series had an ESS of 7.88, hemoglobin (Hgb) of 8.3 g/dL, and received multiple transfusions, iron therapy, and cautery/coagulation procedures. Average ESS subsequent to nasal closure using the 2-flap method is 0.92 and mean GBI score is 56.3. Comparison of 5 patients who underwent the traditional 3-flap nasal closure procedure and 8 patients receiving the 2-flap nasal closure showed no significant difference in postoperative ESS or GBI metrics. Mean operating room times of the traditional and simplified methods were 3.12 hours and 1.44 hours (p = 0.0001). Mean time to first revision for 8 nasal closure patients was 21.5 months. CONCLUSION: In short-term follow-up, the 2-flap procedure showed comparable effectiveness with significantly reduced complexity and operative time compared to the traditional nasal closure method.

An evaluation of the severity and progression of epistaxis in hereditary hemorrhagic telangiectasia 1 versus hereditary hemorrhagic telangiectasia 2.

OBJECTIVES/HYPOTHESIS: Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant vascular dysplasia whose hallmark symptom is spontaneous recurrent epistaxis. Two major genetic subtypes of this syndrome are HHT1 and HHT2. Severity of epistaxis ranges from occasional low-volume bleeding to frequent large-volume hemorrhage. This study evaluated the severity and progression of epistaxis in HHT1 versus HHT2. STUDY DESIGN: Retrospective cohort study. METHODS: A retrospective chart review was performed for 183 genotyped HHT patients seen at our center from 2010 to 2013. Data collected included epistaxis severity score (ESS), age of epistaxis onset, number and type of treatments, age at which treatments were sought, complete blood count values, ferritin, number of telangiectases, blood transfusions, iron therapy history, and patient demographics. RESULTS: 115 subjects with HHT2 were compared to 68 with HHT1. Subjects with HHT2 had a higher ESS compared to HHT1 (P = .043) and a later age of onset of epistaxis (P = .005). HHT2 subjects were more likely to use oral iron (P = .032) and were more likely to seek interventions to control their epistaxis (P = .029). CONCLUSIONS: HHT2 is associated with more severe epistaxis and a subsequent higher rate of interventions, requiring more aggressive therapy as compared to HHT1. LEVEL OF EVIDENCE: 4.

Clinical Consensus Statement: Septoplasty with or without Inferior Turbinate Reduction.

OBJECTIVE: To develop a clinical consensus statement on septoplasty with or without inferior turbinate reduction. METHODS: An expert panel of otolaryngologists with no relevant conflicts of interest was assembled to represent general otolaryngology and relevant subspecialty societies. A working definition of septoplasty with or without inferior turbinate reduction and the scope of pertinent otolaryngologic practice were first established. Patients 18 years and older were defined as the targeted population of interest. A modified Delphi method was then used to distill expert opinion into clinical statements that met a standardized definition of consensus. RESULTS: The group defined nasal septoplasty as a surgical procedure designed to correct a deviated nasal septum for the purpose of improving nasal function, form, or both. After 2 iterative Delphi method surveys, 20 statements met the standardized definition of consensus, while 13 statements did not. The clinical statements were grouped into 8 categories for presentation and discussion: (1) definition and diagnosis, (2) imaging studies, (3) medical management prior to septoplasty, (4) perioperative management, (5) surgical considerations, (6) adjuvant procedures, (7) postoperative care, and (8) outcomes. CONCLUSION: This clinical consensus statement was developed by and for otolaryngologists and is intended to promote appropriate and, when possible, evidence-based care for patients undergoing septoplasty with or without inferior turbinate reduction. A complete definition of septoplasty with or without inferior turbinate reduction was first developed, and additional statements were subsequently produced and evaluated addressing diagnosis, medical management prior to septoplasty, and surgical considerations, as well as the appropriate role of perioperative, postoperative, and adjuvant procedures, in addition to outcomes. Additionally, a series of clinical statements were developed, such as "Computed tomography scan may not accurately demonstrate the degree of septal deviation," "Septoplasty can assist delivery of intranasal medications to the nasal cavity," "Endoscopy can be used to improve visualization of posterior-based septal deviation during septoplasty," and "Quilting sutures can obviate the need for nasal packing after septoplasty." It is anticipated that the application of these principles will result in decreased variations in the care of septoplasty patients and an increase in the quality of care.

Salivary gland disorders.

Salivary gland disorders include inflammatory, bacterial, viral, and neoplastic etiologies. The presentation can be acute, recurrent, or chronic. Acute suppurative sialadenitis presents as rapid-onset pain and swelling and is treated with antibiotics, salivary massage, hydration, and sialagogues such as lemon drops or vitamin C lozenges. Viral etiologies include mumps and human immunodeficiency virus, and treatment is directed at the underlying disease. Recurrent or chronic sialadenitis is more likely to be inflammatory than infectious; examples include recurrent parotitis of childhood and sialolithiasis. Inflammation is commonly caused by an obstruction such as a stone or duct stricture. Management is directed at relieving the obstruction. Benign and malignant tumors can occur in the salivary glands and usually present as a painless solitary neck mass. Diagnosis is made by imaging (e.g., ultrasonography, computed tomography, magnetic resonance imaging) and biopsy (initially with fine-needle aspiration). Overall, most salivary gland tumors are benign and can be treated with surgical excision.

Weekly chemotherapy with radiation versus high-dose cisplatin with radiation as organ preservation for patients with HPV-positive and HPV-negative locally advanced squamous cell carcinoma of the oropharynx.

BACKGROUND: Optimal treatment for locally advanced squamous cell carcinoma of the oropharynx (SCCOP) is not well defined. Here we retrospectively compare survival and toxicities from 2 different organ preservation protocols. METHODS: The matched dataset consisted of 35 patients from each trial matched for age, stage, smoking, and tumor human papillomavirus (HPV) status. Patients in the University of Michigan Cancer Center (UMCC) trial 9921 were treated with induction chemotherapy (IC) followed by high-dose cisplatin and radiation in responders or surgery in nonresponders. Patients in the UMCC trial 0221 were treated with weekly carboplatin and paclitaxel and radiation. RESULTS: Survival was comparable for both studies and did not differ significantly across each trial after stratifying by HPV status. Grade 3 and 4 toxicities were more frequent in UMCC 9921. At 6 months posttreatment, gastrostomy tube (G-tube) dependence was not statistically different. CONCLUSION: These data suggest that survival outcomes in patients with locally advanced SCCOP are not compromised with weekly chemotherapy and radiation therapy, and such treatment is generally more tolerable.

Decision making in nasal reconstruction.

Nasal reconstruction is a challenging and rewarding discipline. The nasal subunit principle dramatically improved the surgeon's ability to reconstruct nasal defects by helping disguise incisions within subunit borders and by providing a tool to help in reconstructive decision making. Selection of the proper reconstruction must include the patient's medicosocial situation and the patient's cosmetic concerns. In addition, functional considerations, such as nasal obstruction, that may result from the chosen reconstruction must be carefully considered. For any defect, the most appropriate reconstructive technique is the simplest and most cost-effective method that meets each individual patient's medical, functional, social, and cosmetic goals.

Role of secondary intention healing.

Secondary intention wound healing is a simple, yet powerful tool in facial reconstruction. Considered as the most elementary form of wound reconstruction, it is often unused because of concern about the predictability of the result and the desire for immediate reconstruction. Secondary intention wound healing can successfully be used for reconstruction of defects for patients who may not be candidates for involved surgical procedures and should be considered an ideal form of reconstruction for certain defects. In general, superficial defects located in concave areas lead to the best results. Proper wound care, including keeping the wound clean and moist, is a simple, but important, aspect of result optimization. Avoiding the use of secondary intention healing on facial anatomic sites known to produce poor results minimizes complications. Complications encountered may include ectropion, nasal obstruction, alar retraction, alopecia, and poor cosmesis.

Assessment of otolaryngic knowledge in primary care residents.

OBJECTIVES: (1) Determine the amount of exposure to otolaryngology in medical training of non-otolaryngology residents. (2) Evaluate the general otolaryngic knowledge in these residents. STUDY DESIGN: Cross-sectional survey. SETTING: Academic medical center. SUBJECTS AND METHODS: A 10-question multiple-choice quiz was given to residents in family practice, pediatrics, emergency medicine, and internal medicine during scheduled educational conferences. Residents were also asked if they ever participated in an otolaryngology rotation during medical school or residency. Medical students and otolaryngology residents completed the quiz to act as controls. RESULTS: A total of 98 examinations were analyzed (49 non-otolaryngology residents, 10 otolaryngology residents, and 39 second-year medical students). Only 24% of the non- otolaryngology residents had an otolaryngology rotation during medical school. The same amount (24%) had a rotation during residency. The average percentage correct on the quiz was 48%, 56%, and 92% for medical students, non-otolaryngology, and otolaryngology residents, respectively (P < 0.05). Questions with surprising results included one with an endoscopic image of the middle turbinate and examinees asked to identify the structure (non-otolaryngology residents = 18% correct). A laryngectomy stoma was shown and participants asked what would happen if the stoma was occluded for 10 minutes (non-otolaryngology residents = 20% correct). CONCLUSION: In this sample of non-otolaryngology residents, a minority experienced a clinical rotation in otolaryngology during medical school or residency. This nonvalidated questionnaire also suggested significant deficiencies in basic otolaryngic knowledge in these residents. Identifying mechanisms to improve exposure to otolaryngology in the medical training curriculum is needed.

The Young's procedure for severe epistaxis from hereditary hemorrhagic telangiectasia.

BACKGROUND: Surgical treatment of epistaxis in hereditary hemorrhagic telangiectasia (HHT) has historically been managed with the laser procedure or the septodermoplasty procedure. For transfusion-dependent patients with severe epistaxis we have been performing the Young's procedure or surgical closure of the nostrils. The objective of this study was to report treatment of severe epistaxis related to HHT with the Young's procedure and assess patient outcome. METHODS: Patients with severe iron or blood transfusion-dependent epistaxis who underwent a Young's procedure in three otolaryngology HHT centers were reviewed. Patients were evaluated for postoperative epistaxis and subjective outcome. RESULTS: Forty-three patients underwent a Young's procedure for severe epistaxis and were observed for a mean of 34 months. The procedure was well tolerated by all patients and 30 of 36 patients (83%) experienced complete cessation of bleeding after the Young's procedure. Patients had a mean increase in hemoglobin of 4.68 g/dL after the procedure. The average Glasgow Benefit Inventory score after surgery was 43.56. No patients requested a reversal of the procedure. CONCLUSION: The Young's procedure is a safe and efficacious procedure with complete cessation of epistaxis in most patients with severe epistaxis and HHT.

Diagnostic modalities for distant metastasis in head and neck squamous cell carcinoma: are we changing life expectancy?

OBJECTIVES/HYPOTHESIS: To determine if the various imaging modalities for distant metastasis (DM) diagnosis alters life expectancy in head and neck squamous cell carcinoma (HNSCC). STUDY DESIGN: Retrospective. METHODS: One hundred seventy patients (mean age, 59.1 years; male:female, 135:35) with HNSCC who developed DM were reviewed. The main outcome measures were the method of DM diagnosis and time from DM diagnosis to death while controlling for clinical parameters (age, gender, tobacco status, primary tumor site, initial TNM classification, number and site of DM, administration of palliative chemotherapy). RESULTS: Tumor subsites were: 40 oral cavity, 75 oropharynx, 36 larynx, 10 hypopharynx, one nasopharynx, and eight unknown primary. Of the patients, 16.5% (28/170) had distant metastasis at presentation; the remaining 142 patients were diagnosed with DM at a median of 324 days from diagnosis. Although patients diagnosed with DM by positron-emission tomography (PET) scan were more likely to have multiple DM sites (P = .0001), there were no differences in life expectancy in patients who were diagnosed with or without PET scan (median, 185 vs. 165 days, P = .833). There were no differences in life expectancy based on age, gender, site of primary tumor, or number/site of DM. The use of palliative chemotherapy resulted in a significantly longer life expectancy (median, 285 vs. 70 days; P = .001). CONCLUSIONS: Although a PET scan is more likely to diagnose multiple DM sites, there was no difference in life expectancy based on imaging modality. Patients who are symptomatic from their distant metastasis have a worse life expectancy, and palliative chemotherapy was able to increase life expectancy, even in patients who were symptomatic from the distant metastasis.

Orbitocranial approach for treatment of adenoid cystic carcinoma of the lacrimal gland.

OBJECTIVES: Multiple treatment options exist for management of adenoid cystic carcinoma of the lacrimal gland. Our objective was to perform an analysis of outcomes in a cohort of patients with adenoid cystic carcinoma of the lacrimal gland treated identically with an orbitocranial approach. METHODS: We performed a retrospective review of 7 consecutive patients who presented to a tertiary care academic medical center between 1995 and 2009 with adenoid cystic carcinoma of the lacrimal gland. RESULTS: All patients were treated with an orbitocranial approach to tumor resection followed by postoperative radiotherapy. The mean and median follow-up times were 39 and 19 months, respectively (range, 7 to 138 months). Six patients had orbital reconstruction using free tissue transfer, and 1 patient had a split-thickness skin graft to line the orbital cavity. Two patients developed distant metastases 18 months and 29 months after surgery and ultimately died with disease. Five patients are alive without disease. CONCLUSIONS: The orbitocranial approach followed by postoperative irradiation achieves excellent local and regional control rates for adenoid cystic carcinoma of the lacrimal gland, although patients remain at risk long-term for distant metastases. Orbital bone removal to obtain adequate margins should be a routine part of tumor resection for these malignancies.

Reconstructive perspectives of cutaneous defects involving the nasal tip: a retrospective review.

OBJECTIVES: To create an algorithm that derives our preferred reconstruction technique for cutaneous defects involving the nasal tip and to review the management and outcomes of patients with nasal tip cutaneous defects after their initial reconstruction. METHODS: A retrospective review of patients undergoing repair of cutaneous defects involving the nasal tip between January 2006 and January 2009. After data compilation, a defect-based algorithm deriving our repair technique was created. RESULTS: Seventy-two patients were identified: 57% underwent full-thickness skin graft repair (n = 41), 19% underwent forehead flap repair (n = 14), and 17% underwent bilobe flap repair (n = 12). The remaining 7% underwent repair using nasal cutaneous flaps harvested adjacent to the defect (n = 5). Nasal tip defect involvement of an adjacent nasal aesthetic unit was the most critical factor in selecting a reconstruction technique. Further categorization by the presence of nasal ala involvement, cartilage exposure, and defect surface area allowed reliable prediction of our reconstruction technique. Dermabrasion was routinely performed early in the postoperative course (25% [18 of 72 patients]). Corticosteroid injection was commonly used for those undergoing forehead flap (71% [10 of 14 patients]) and bilobe flap (50% [6 of 12 patients]) repair. Aesthetic revision surgery was infrequently required (15% [11 of 72 patients]). All aesthetic outcomes were good or satisfactory. CONCLUSION: The included algorithm offers a systematic approach for managing cutaneous defects involving the nasal tip and derives our preferred technique with high reliability.

Perioperative outcomes in patients undergoing the transglabellar/subcranial approach to the anterior skull base.

We analyzed the effect of predefined patient demographic, disease, and perioperative variables on the rate of complications in the perioperative period following subcranial surgery for anterior skull base lesion. A secondary goal of this study was to provide a benchmark rate of perioperative mortality and morbidity through comprehensive analysis of complications. Retrospective review of a consecutive series of patients (n = 164) who underwent the transglabellar/subcranial approach to lesions of the anterior skull base between December 1995 and November 2009 in a tertiary referral center. Main outcome measures were perioperative morbidity and mortality. No perioperative mortalities were observed over the period of consecutive review. The overall complication rate was 28.7%, with 30 (18%) patients experiencing major complication. Multivariate analysis revealed that the following variables were independent predictors of perioperative complication of any type: positive margins on final pathology, perioperative lumbar drain placement, and dural invasion. The subcranial approach provides excellent access to the anterior skull base with zero mortality and acceptable morbidity in comparison with other contemporary open surgical approaches. It should be considered a procedure with distinct advantages in terms of perioperative morbidity and mortality when selecting a therapeutic approach for patients with anterior skull base lesions.

Esthesioneuroblastoma: Results and Outcomes of a Single Institution's Experience.

OBJECTIVES: Analysis of outcomes of a cohort of patients with esthesioneuroblastoma. DESIGN: Retrospective cohort analysis. SETTING: PATIENTS presenting with esthesioneuroblastoma from 1994 to 2006 in a tertiary care academic medical center. PATIENTS: Fifteen consecutive patients diagnosed as having esthesioneuroblastoma were treated during this time period using a subcranial resection. The mean follow-up is 75 months (range, 2 to 240 mos). RESULTS: The overall survival was 100% and the overall disease-free survival was 49% and 24% at 5 and 15 years, respectively. PATIENTS treated with radiation therapy following surgical resection had a 5- and 15-year disease-free survival of 83.3% compared with a 5- and 15-year disease-free survival of 26.7% and 0%, respectively, for patients whose initial treatment was surgery alone. The mean time to recurrence was 82.1 months. None of the patients had a decrease in Karnofsky Performance Score following subcranial resection. CONCLUSIONS: PATIENTS with esthesioneuroblastoma whose initial treatment consists of surgical resection followed by radiation therapy have a longer disease-free survival than patients treated with surgery alone. However, initial treatment modality did not have an effect on survival. Long-term, close follow-up is necessary to identify recurrences, which can be treated with a high degree of success.

Long-term results of carbon dioxide laser resurfacing of the face.

OBJECTIVE: To evaluate the long-term effectiveness of, and the complications associated with, carbon dioxide laser treatment of rhytidosis and solar aging. METHODS: This retrospective report describes our experience with 47 patients who underwent entire facial carbon dioxide laser resurfacing. RESULTS: The mean improvement in facial rhytid score at long-term follow-up was 45%. This improvement was consistent in all facial subsites. With the exception of 1 case of hyperpigmentation, which resolved within 2 years of treatment, hypopigmentation was the only long-term adverse effect. This complication was present in 6 patients (13%). The patients who developed hypopigmentation were more likely to have a greater response to treatment. CONCLUSION: Our findings show that carbon dioxide laser resurfacing is a safe and effective treatment for facial rhytids.