The Doctor's Channel - Otolaryngology

Evaluating neoneates with micrognathia

2010-03-08T15:43:28+00:00

Reza Jarrahy MD, Assistant Professor, David Geffen School of Medicine at UCLA, Division of Plastic and Reconstructive Surgery, discusses how to evaluate neonates with micrognathia and avoid tracheostomy.

Reading:
Pradel W, Lauer G, Dinger J, Eckelt U. Mandibular traction--an alternative treatment in infants with Pierre Robin sequence. J Oral Maxillofac Surg. 2009 Oct;67(10):2232-7.
Horta R, Marques M, Gomes V, Rebelo M, Reis J, Amarante J. Mandibular distraction in a tracheostomized patient with Pierre-Robin sequence. Congenit Anom (Kyoto). 2009 Jun;49(2):89-92.
Morris LM, Lim FY, Elluru RG, Hopkin RJ, Jaekle RK, Polzin WJ, Crombleholme TM. Severe Micrognathia: Indications for EXIT-to-Airway. Fetal Diagn Ther. 2009 Sep 18.

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Micrognathia and neonatal mandibular distraction

2010-02-24T16:54:00+00:00

Reza Jarrahy MD, Assistant Professor, David Geffen School of Medicine at UCLA, Division of Plastic and Reconstructive Surgery, discusses micrognathia and the associated respiratory distress that occurs in neonates with Pierre Robin syndrome, which can be alleviated by mandibular distraction thereby avoiding the need for tracheostomy

Reading:
Hammoudeh JA, Kleiber GM, Nazarian-Mobin SS, Urata MM. Bilateral complex odontomas: a rare complication of external mandibular distraction in the neonate.
Kaufman Y, Cole PD, McKnight A, Hatef DA, Hollier LH. External distraction osteogenesis in the pediatric mandible. Plast Reconstr Surg. 2009 Jan;123(1):339-41. J Craniofac Surg. 2009 May;20(3):973-6.
Dauria D, Marsh JL. Mandibular distraction osteogenesis for Pierre Robin sequence: what percentage of neonates need it? J Craniofac Surg. 2008 Sep;19(5):1237-43.

Views: 425
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Cleft lip and palate

2010-02-01T15:31:11+00:00

Reza Jarrahy, MD, Assistant Professor, Division of Plastic and Reconstructive Surgery, UCLA, discusses cleft lip and palate, which has an incidence of around one in 600 births. Surgical interventions immediately after birth can significantly impact outcomes later on.

Reading:
Hodges AM. Combined early cleft lip and palate repair in children under 10 months - a series of 106 patients. J Plast Reconstr Aesthet Surg. 2009 Dec 24
Salyer KE, Xu H, Genecov ER. Unilateral cleft lip and nose repair; closed approach Dallas protocol completed patients. J Craniofac Surg. 2009 Sep;20 Suppl 2:1939-55.
Chong DK, Portnof JE, Xu H, Salyer KE. Reviewing the orthognathic surgical care of the patient with cleft lip and palate: the single surgeon experience. J Craniofac Surg. 2009 Sep;20 Suppl 2:1895-904.

Views: 888
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Novel feeding tube uses endoscope for placement

2010-01-27T23:12:00+00:00

NEW YORK (Reuters Health) – A new feeding tube that’s inserted while attached to an ultra-thin gastroscope will avoid the potentially disastrous consequences of blind tube placement, researchers report in a December 28th on-line publication in Chest.

"The inadvertent placement of feeding tubes into the lungs kills thousands of patients each year," Dr. Peter Belafsky told Reuters Health by email. This statistic, he said, amounts to "about 1 patient every 3 months in each major medical center in the US.”

He added, “These errors are underreported and nobody wants to acknowledge the mistakes."

Instead of accepting the risks, Dr. Belafsky of the University of California, Davis and his colleagues at the University of California, Davis Medical Center in Sacramento "devised a simple solution by pairing a feeding tube to an ultrathin endoscope."

Then, they tested their so-called Davis feeding tube in 50 patients who required transpyloric enteral feeding. Most (86%) of the tubes were placed transnasally. Sixty-six percent of patients also had endotracheal tubes or tracheotomies.

The feeding tube was secured to a 5.1mm-caliber transnasal gastroscope. Atomized lidocaine and phenylephrine was administered in each nasal cavity, and the device was lubricated with a 2% lidocaine gel and passed through a nostril or the mouth. A 1.8mm biopsy forceps was sometimes placed through the working channel of the scope to make it more rigid and facilitate passage into the small intestine.

Intravenous midazolam and fentanyl were given to the 72% of patients who requested sedation.

The tube was placed successfully in all patients. Post-pyloric success was achieved in all but 2 patients (96%), who had pyloric antrum placement because of pyloric stenosis.

Dr. Belafsky pointed out that although other endoscopic approaches to feeding tube placement have been studied, "We had a transpyloric success rate of 96% which is better than previously reported techniques."

"With this technology, confirmatory x-rays are no longer required, which will reduce unnecessary cost and patient radiation exposure," he said. The paper points out, however, that for purposes of the study, confirmatory x-rays were obtained for each patient.

Also, Dr. Belafsky said, "because the feeding tube can also be placed directly into the small bowel under direct vision, patient starvation times can be reduced as well as the risk of aspiration from regurgitated stomach contents and the associated risk of pneumonia."

Chest 2009.

Views: 1183
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Adverse events common with chemoradiation for head and neck cancer

2009-12-28T18:18:27+00:00

NEW YORK (Reuters Health) – Nearly all patients have complications from chemoradiation for head and neck cancer, a study in the Archives of Otolaryngology: Head and Neck Surgery for December suggests.

Typically, these events affect oropharyngeal and laryngeal function, senior author Dr. Gerry F. Funk, from University of Iowa Hospitals and Clinics, Iowa City, and colleagues report.

Intensity-modulated radiation therapy (IMRT), a system that reduces the radiation dose to critical nerve and salivary structures, can reduce the toxic effects, they add.

Their study involved 104 patients treated for head and neck cancer between February 1, 2000 and March 1, 2007. Roughly 88% of subjects had oropharyngeal or laryngeal tumors and 75% had advanced-stage disease.

Mucositis was by far the most common adverse event, seen in 92.3% of patients, although just 9.6% of patients had mucositis severe enough to warrant hospital admission.

Hematologic toxicity was the next most common complication, seen in 59.6% of patients, followed by toxicity-related treatment delay, identified in 46.2% of patients.

Other less common side effects included moist desquamation (28.8%), neurotoxicity and/or ototoxicity (26.9%), severe nausea or vomiting (26.9%), severe dehydration or malnutrition (26.0%), pneumonia (25.0%), mild or moderate fever (23.1%), elevated creatinine (19.2%), and severe fever (18.3%). Trismus, osteoradionecrosis, and treatment-related death were each seen in less than 10% of patients.

With IMRT, more toxicity-related treatment delays were noted, but fewer toxicities were seen and functional and quality of life outcomes were enhanced, the report indicates. For instance, the incidence of moist desquamation was 33% with lateral-opposing-fields radiation and 25.7% with the authors’ current IMRT protocol. The incidence of pneumonia fell from 33.3% with lateral-opposing-fields radiation to 20.0% with the current IMRT protocol.

“The results of the present study indicated that patients receiving chemoradiotherapy experience a substantial burden of treatment-related adverse events,” the authors conclude. “Continued efforts to reduce the incidence of these toxicities would not only lessen patients’ short-term pain and discomfort but would also potentially increase the duration of their long-term survival.”

Reference:
Arch Otolaryngol Head Neck Surg 2009;135:1209-1217.

Views: 3151
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Many endoscopy patients at high risk for obstructive sleep apnea

2009-12-21T15:22:02+00:00

NEW YORK (Reuters Health) – More than a third of patients undergoing routine outpatient endoscopic procedures are at high risk for obstructive sleep apnea (OSA), according to findings from a prospective study at a university hospital.

The good news is that high-risk patients are not more likely to experience transient hypoxia during sedation for endoscopic procedures.

OSA is under-recognized, and it is unclear how many endoscopy patients may have undiagnosed OSA. OSA patients are known to be at higher risk for anesthesia-related cardiopulmonary complications during deep sedation. Their risk of complications during conscious sedation is not known, however.

To address this question, Dr. Vijay S. Khiani, from Yale University, New Haven, Connecticut, and associates administered the validated Berlin OSA questionnaire to 233 patients before routine esophagogastroduodenoscopy or colonoscopy. Based on their responses, patients categorized either as low or high risk for OSA.

During endoscopy, the subjects were assessed for transient hypoxia, defined as a pulse oximetric reading below 92% that required an increase in supplemental oxygen.

Overall, 90 patients (39%) were at high risk for OSA. The rate of transient hypoxia in this group, 10%, was not significantly different from the 7% rate in the low risk group.

The results suggest that “the majority of patients at risk of OSA can safely undergo conscious sedation for routine endoscopic procedures by using standard sedation and monitoring practices,” the authors conclude.

Reference:
Gastrointest Endosc 2009;70:1116-1120.

Views: 3043
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Dexamethasone, glycerol fail to prevent hearing loss in kids with meningitis

2009-12-15T11:48:44+00:00

NEW YORK (Reuters Health) – In children with bacterial meningitis, age and presenting neurologic status are the most important predictors of hearing loss, and neither dexamethasone nor glycerol help alleviate the risk, a new study shows.

The randomized multicenter trial, reported in a December 14 online publication in Pediatrics, was headed by Dr. Heikki Peltola, from Helsinki University Central Hospital, Finland. He and his co-authors note that hearing loss accompanies up to 50% of cases of pediatric bacterial meningitis and that dexamethasone and glycerol have reputations for protecting children’s hearing.

“The basic problem is that not a single study has shown the clinical benefits of dexamethasone in pediatric meningitis, not even in cases caused by Haemophilus influenzae type b (Hib),” Dr. Peltola told Reuters Health. “With biochemical parameters, the advantages are demonstrated, but this does not necessarily translate into improvement in the prognosis.”

He continued: “All meta-analyses to date, which ‘demonstrate’ the benefits of dexamethasone, combine very dissimilar patient series, lump together retrospective and prospective studies, various ages, etc. And they completely neglect the two most important predictors of outcomes: the child's presenting condition (which can be measured with Glasgow Coma Scale), and the age.”

Their study, which they describe as “the largest in pediatrics,” included 383 children, ages 2 months to 16 years, with bacterial meningitis. All were treated with IV ceftriaxone for 7 to 10 days, and in addition, they were randomly assigned to one of four groups:
-- IV dexamethasone 0.15 mg/kg every 6 hours for 48 hours, started 15 minutes before ceftriaxone if possible, plus oral placebo (n = 101);
-- oral glycerol 1.5 g/kg every 6 hours for 48 hours, maximum 25 mL, plus IV placebo (n = 92);
-- both active agents (n = 95); or
-- only placebos (n = 95).

Impairment was classified on the basis of hearing threshold in the patient’s better ear: mild impairment, from 40 to 59 dB; moderate hearing loss, 60 to 79 dB; and severe impairment, >/= 80 dB.

Audiology testing showed mild impairment in 44 patients (11%), at least moderate impairment in 46 (12%), and severe impairment in 27 (7%). Fifteen patients (4%) became totally deaf.

“Regardless of the threshold level, no treatment differed from each other or placebo,” Dr. Peltola’s group reports. Outcomes were similar regardless of etiology.

On multivariate analysis, only the child’s initial Glasgow Coma Scale score and age were independent predictors of audiological outcome. Specifically, starting from the maximum Glasgow score, each lower point increased the risk of hearing impairment by 15% to 21%. Each increasing month of age decreased the risk by 2% to 6%.

“Although glycerol -- but not dexamethasone -- statistically significantly prevented severe neurological sequelae (and almost significantly prevented death), neither glycerol nor dexamethasone, or their combination, was effective against hearing impairment caused by bacterial meningitis,” Dr. Peltola said.

“It has become very clear that hearing impairment develops via other mechanisms than those leading to the neurological sequelae and/or death,” the researcher added. “Therefore, these outcomes should not be lumped together but examined separately.”

“The best solution would be to implement large-scale Haemophilus influenzae type B and Streptococcus pneumoniae vaccinations,” the authors write, “but globally, few children are privileged to those.”

They conclude: “To save a child from hearing loss in meningitis, better agents than dexamethasone or glycerol should be sought.”

Until such agents are found and proven, Dr. Peltola advises clinicians, “Do not give dexamethasone, because no data show its benefits and animal studies suggest that it may be harmful. Instead, give oral glycerol, because it is the first agent since effective antibiotics were developed that has demonstrated efficacy in preventing severe neurological sequelae in children; dexamethasone has never done this.”

Reference:
Pediatrics 2009.

Views: 2813
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Hip hearing aids

2009-12-07T17:26:55+00:00

Alison M. Grimes, Head, Audiology Clinic, Assistant Clinical Professor, Head and Neck Surgery, University of California, Los Angeles, discusses new hearing aids, which use digital signaling to differentiate speech from background noise and also look more attractive.

Reading:
Summers V, Grant KW, Walden BE, Cord MT, Surr RK, Elhilali M. Evaluation of a "direct-comparison" approach to automatic switching in omnidirectional/directional hearing aids. J Am Acad Audiol. 2008 Oct;19(9):708-20.
Bentler R, Wu YH, Kettel J, Hurtig R. Digital noise reduction: outcomes from laboratory and field studies. Int J Audiol. 2008 Aug;47(8):447-60.
Stone MA, Moore BC, Meisenbacher K, Derleth RP. Tolerable hearing aid delays. V. Estimation of limits for open canal fittings. Ear Hear. 2008 Aug;29(4):601-17.

Views: 1177
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Hearing aids

2009-11-17T10:32:16+00:00

Alison M. Grimes, Head, Audiology Clinic, Assistant Clinical Professor, Head and Neck Surgery, University of California, Los Angeles, discusses hearing aids, which are amplifiers, rather than a cure for hearing loss, and often avoided by patients because of stigma and cost. They can however be the key to maintaining a social life and properly- fitted hearing aids do work.

Hearing aids are amplifiers, they do not restore hearing or provide perfect hearing, and patients avoid them because of stigma and cost, but their advantage is they allow social interaction.

Reference:
Hogan A, O'Loughlin K, Miller P, Kendig H. The Health Impact of a Hearing Disability on Older People in Australia. J Aging Health. 2009 Dec;21(8):1098-1111.

Frachet B, Poncet-Wallet C, Ernst I, Quéruel F, Eshraghi A. [Management of hearing impairment in adults] Rev Prat. 2009 Oct 20;59(8):1097-101. French.

Palmer CV. A contemporary review of hearing AIDS. Laryngoscope. 2009 Nov;119(11):2195-204.

Views: 1599
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Noise-Induced Hearing Loss

2009-11-17T10:18:52+00:00

Alison M. Grimes, Head, Audiology Clinic, Assistant Clinical Professor, Head and Neck Surgery, University of California, Los Angeles, discusses loud noise and preventable hearing loss.

Loud noise is the most common preventable cause of hearing loss. It damages the cochlear outer hair cells and repeated episodes of temporary threshold shift lead to permanent threshold shift or hearing loss.

Reading:
Kujawa SG, Liberman MC. Adding insult to injury: cochlear nerve degeneration after "temporary" noise-induced hearing loss. J Neurosci. 2009 Nov 11;29(45):14077-85.

Perbellini L, Veronese N, Raineri E, Rava M, Riolfi A. [Noise-induced hearing loss: are health service surveillance programs always effective?] Med Lav. 2009;100 Suppl 1:20-3. Italian.

El Dib RP, Mathew JL. Interventions to promote the wearing of hearing protection. Cochrane Database Syst Rev. 2009 Oct 7;(4):CD005234.

Views: 1279
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