Is a redefinition of the growth criteria of vestibular schwannomas needed?

Purpose

The natural history of vestibular schwannomas is poorly understood. Knowledge of growth rate and growth pattern is essential because the treatment strategy is based upon these. The purpose of this study was to determine the inter- and intraobserver variability in measuring VS size.

Materials and methods

Two consultant neuroradiologists independently made three linear measurements (d1, d2, d3) using digital MRI scans. MRI scans from 72 patients diagnosed between 2002 and 2010 with VS were obtained. These patients had a total of 223 MRI scans. d1 (medio-lateral diameter) was made perpendicular to d2. d2 was made parallel to the posterior border of the petrous ridge, and d3 was a measure of the cranio-caudal height of the tumor.

Results

Limits of Agreement ranges are larger for interobserver reliability compared to intraobserver reliability. Measurement error for all diameters (except d1, intraobserver) is greater than 2 mm. d1 measurements had the least variability and d3 measurements the highest variability, both for intra and interobserver measurements.

Conclusions

The optimal method of estimating VS size needs further investigation, and measurements need to be standardized and clearly defined. d3 seems to be the most difficult diameter to measure reliably. Interobserver measurement error for all diameters is greater than 2 mm. The current VS growth criterion of more than 1–2 mm, used to triage patients to surgery, lies within this error range, and thus is problematic as a guide for clinical practice. We therefore suggest that the growth criterion for VS be redefined.     

Is there a consensus in the division of the vocal folds in thirds?

INTRODUCTION: In clinical routine we have noticed a disagreement of ENT-specialists and phoniatricians in the division of the vocal folds in thirds. To show if there is consensus in this field by the german phoniatricians this study was done. MATERIAL AND METHODS: In two parts of a study, a pilot study and a follow up study, we sent twelve different images of the larynx to all german phoniatricians. In six of these images the physicians should set the marks of the ventral and dorsal limitation of the second third of the vocal folds. In six different images a mark should be related to the particular third of the vocal folds. The phoniatricians were asked to assess how certain they were in their valuation. They were asked either, how long they have been working as a physician and how long they have been specialized as a phoniatrician and as an ENT-surgeon. In the follow up study the phoniatricians were requested to first divide up the thirds in a way that the dorsal third corresponds to the cartilaginous part of the vocal folds (scheme 1) and second divide up the thirds in a way that all three thirds correspond to the ligamental part of the vocal folds. DISCUSSION AND FINDINGS: In the pilot study, when no instructions for the division of the thirds were given, the data differed much more than in the follow up study, when the physicians were told to use scheme 1 and scheme 2. That was because some phoniatricians divided up just the ligamental part and others the ligamental plus the cartilaginous part of the vocal folds in thirds. The more the physicians could overlook the membraneous part of the vocal folds the more certain they were in their assessment. CONCLUSION: The assessment of the division of the vocal folds in thirds is more homogeneous when the phoniatricians were requested to divide up the thirds in a way that the dorsal third corresponds to the cartilaginous part of the vocal folds (scheme 1). Therefore we suggest that this way of division should be used further on.     

Is corticosteroid a treatment choice for the management of peritonsillar abscess?

Objective

To investigate the effect of the single systemic use of corticosteroid following drainage procedure in patients with peritonsillar abscess (PTA).

Is microvascular compression of the vestibulocochlear nerve a cause of unilateral hearing loss?

OBJECTIVES: We sought to confirm earlier findings in the literature that microvascular compression of the vestibulocochlear nerve might cause unilateral sensorineural hearing loss. We measured the length and width of the internal auditory canal (IAC) to investigate a possible association between a narrow porus, the presence of an anterior inferior cerebellar artery (AICA) loop, and the development of a microvascular compression syndrome. METHODS: We performed a prospective blinded analysis of 167 magnetic resonance imaging scans of the cerebellopontine angle. The presence of an AICA loop was scored. We analyzed these 167 patients for unilateral sensorineural hearing loss, which was defined as an interaural difference of 20 dB at 1 frequency or 10 dB at 2 or more frequencies. Furthermore, the width and length of the IAC on magnetic resonance imaging were measured. RESULTS: An AICA loop was identified in 94% of the 167 patients. There were 196 type I loops, 106 type II loops, and 14 type III loops. Sixty-six patients had unexplained unilateral hearing loss. There was no association between type II and III vascular loops, the width of the IAC, and unilateral hearing loss (p > .05). CONCLUSIONS: In this study we found no association between the depth of extension of the AICA loop into the IAC and the presence of unilateral hearing loss.     

Is packing of the nose up-to-date ?

BACKGROUND: Generally accepted standards regarding the materials which should be used for packing, how long the packing should be left in place or the indications for nasal packing are lacking. Nasal packing is used primarily to control bleeding in endonasal surgery, to stabilize the cartilaginous and bony skeleton and to prevent synechiae or restenosis. For the latter some authors recommend to pack the nose for several days. We want to prove the acceptance according to time, particularly wether there is an increase in discomfort. PATIENTS: Prospective study in 60 patients who underwent septoplasty and submucosal resection of inferior turbinates (n = 30) or endonasal sinus surgery (n = 30, in 15 cases septoplasty was performed too). The nose was packed for 4 or 5 days. Using a visual analog scale (0 - 10) the patient's condition was examined regarding: stuffy nose, headache, sleeping disorders, overall judgement. RESULTS: In two patients the packing had to be removed early (once because of the development of swelling of the lower lid and cheek; once because of lacking acceptance). The average condition of the remaining 58 patients showed no worsening during time for all 4 features. Analyzing the individual, only two patients (3.5 %) showed continuous increasing of complaints. CONCLUSIONS: According to this investigation, nasal packing for 4 or 5 days is well accepted by most of the patients, if you be able to make clear its sense to the patient. Nevertheless, looking for alternative operative techniques or nasal packing materials is mandatory to improve the patient's comfort postoperatively.     

Is A Plexiform Neurofibroma Pathognomonic of Neurofibromatosis Type I?

Objectives/Hypothesis: Several prominent textbooks have claimed that a plexiform neurofibroma is pathognomonic for neurofibromatosis type I. This is not in agreement with the National Institutes of Health criteria, which require two signs to be present, one of which can be a plexiform neurofibroma. Is a plexiform neurofibroma pathognomonic for neurofibromatosis type I? Study Design: Retrospective chart review. Methods: Fifty‐one patients with surgically resected plexiform neurofibromas between the years 1991 and 2001 were identified, and their charts reviewed. The presence and absence of any manifestation of neurofibromatosis type I as detailed in the National Institutes of Health criteria were recorded. The pathology database at the Hospital for Sick Children (HSC) was searched retrospectively. Results: Five of the 51 patients had a single solitary plexiform neurofibroma. They were followed at the neurofibromatosis clinic at the HSC with regular detailed examinations and no other stigmata were found. Conclusion: Although plexiform neurofibromas are highly suggestive of neurofibromatosis type I, they are not pathognomonic as claimed.     

Is there a double innervation of the tensor tympani muscle in humans?

The middle ear muscles and their function have not yet been fully explored. The statement of Lawrence, for example, that the tensor tympani muscle of humans might have a dual innervation has never been proven or disproven. The question is of great interest; in our opinion, it represents one of the key questions in the putative afferent feedback loop of the middle ear muscles in humans. A light microscopic study was performed on 16 tensor tympani muscles taken from 11 cadavers. Six muscles were taken out in toto and stained according to the modified method of Sihler. The remaining 10 muscles were dehydrated and embedded in paraffin. In 5 of these muscles, complete transverse serial sections were made on a microtome at 7 microm and alternately stained by silver impregnation, S-100 protein immunohistochemistry, and ferric oxide. In the remaining 5 muscles, complete longitudinal serial sections were made at 10 microm. These sections were alternately stained by the methods of Cason and Maskar. Neither the surgical microscopic investigation nor the light microscopic investigation revealed any innervation to the human tensor tympani muscle other than the one arising from the mandibular branch of the trigeminal nerve. Our findings, apart from the fact that they clearly refute an unproven hypothesis, might represent another small step toward understanding the innervation of the tensor tympani muscle.     

Is the information about a test important? Applying the methods of evidence-based medicine to the clinical examination of swallowing

A hotly debated topic in oropharyngeal dysphagia is the Clinical Swallowing Examination's (CSE) importance in clinical practice. That debate can profit from the application of evidence-based medicine's (EBM) principles and procedures. These can guide both appropriate data collection and interpretation as will be demonstrated in the present report. The study's purpose from which data for this report are drawn was to determine the relationship among signs elicited by a CSE and aspiration on a subsequent videofluoroscopic swallowing examination (VFSE). Sensitivity, specificity; positive and negative predictive values (NPV); likelihood ratios; and post-test probabilities for a variety of signs in isolation and in combinations are reported. These data, if judiciously selected and interpreted contribute to the clinician's knowledge about whether to follow a CSE with a VFSE and about what to expect if the VFSE is completed. LEARNING OUTCOMES: (1) Clinicians will learn how to use EBM principles in conjunction with clinical assessments of swallowing to enhance patient care. (2) Clinicians will learn how to identify combinations of patient signs during he CSE to predict VFSE performance.     

Is Ki67 a marker for the transformation of laryngeal dysplasia to carcinoma?

CONCLUSION: Ki67 is not a reliable marker of malignant transformation in laryngeal dysplasia. OBJECTIVES: No reliable means of predicting which cases of laryngeal dysplasia will undergo malignant transformation currently exists. Our aim was to evaluate Ki67, a marker of cell proliferation, as a potential marker for the transformation of laryngeal dysplasia to squamous cell carcinoma. PATIENTS AND METHODS: Eighty consecutive cases of previously untreated patients with a histological diagnosis of laryngeal dysplasia from 1987 to 1993 were identified from the pathological archives. Standard immunohistochemical techniques were used to identify Ki67-positive cells and activity was scored on a scale of 0-4 using defined criteria. RESULTS: Of the 80 cases there were 24 females and 56 males with a mean age of 56 years (range 29-80 years). Twenty cases subsequently transformed to a squamous cell carcinoma. For each Ki67 score (0-4), the rate of malignant transformation was: 0, 1 of 6 patients (17%); 1, 7 of 33 patients (21%); 2, 5 of 22 patients (23%); 3, 4 of 13 patients (31%); and 4, 3 of 6 patients (50%). A higher Ki67 score seemed to correlate with a higher likelihood of malignant transformation but this did not reach statistical significance (p=0.17, Pearson chi(2) test). Considering a score of 3 or 4 as positive for predicting malignant transformation produced a test of relatively high specificity (80%) but poor sensitivity (35%).     

Is OperaVOX a clinically useful tool for the assessment of voice in a general ENT clinic?

Background

Objective acoustic analysis is a key component of multidimensional voice assessment. OperaVOX is an iOS app which has been shown to be comparable to Multi Dimensional Voice Program for most principal measures of vocal function. As a relatively cheap, portable and easily accessible form of acoustic analysis, OperaVOX may be more clinically useful than laboratory-based software in many situations. This study aims to determine whether correlation exists between acoustic measurements obtained using OperaVOX, and perceptual evaluation of voice.

Methods

Forty-four voices from the multidisciplinary voice clinic were examined. Each voice was assessed blindly by a single experienced voice therapist using the GRBAS scale, and analysed using OperaVOX. The Spearman rank correlation co-efficient was calculated between each element of the GRBAS scale and acoustic measurements obtained by OperaVOX.

Results

Significant correlations were identified between GRBAS scores and OperaVOX parameters. Grade correlated significantly with jitter (ρ?=?0.495, p?<?0.05), shimmer (ρ?=?0.385, p?<?0.05), noise-to-harmonic ratio (NHR; ρ?=?0.526, p?<?0.05) and maximum phonation time (MPT; ρ?= ?0.415, p?<?0.05). Roughness did not correlate with any of the measured variables. Breathiness correlated significantly with jitter (ρ?=?0.342, p?<?0.05), NHR (ρ?=?0.344, p?<?0.05) and MPT (ρ?= ?0.336, p?<?0.05). Aesthenia correlated with NHR (ρ?=?0.413, p?<?0.05) and MPT (ρ?= ?0.399, p?<?0.05). Strain correlated with Jitter (ρ?=?0.560, p?<?0.05), NHR (ρ?=?0.600, p?<?0.05) and MPT (ρ?= ?0.356, p?<?0.05).

Conclusions

OperaVOX provides objective acoustic analysis which has shown statistically significant correlation to perceptual evaluation using the GRBAS scale. The accessibility of the software package makes it possible for a wide range of health practitioners, e.g. general ENT surgeons, vascular surgeons, thyroid surgeons and cardiothoracic surgeons to objectively monitor outcomes and complications of surgical procedures that may affect vocal function. Given the increasing requirement for surgeons to monitor their outcomes as part of the move towards ‘surgeon reported outcomes’ this may become an invaluable tool towards that goal.

     

Is electronystagmography of diagnostic value in the elderly?

Is electronystagmography of diagnostic value in the elderly? We aimed to determine the diagnostic value of electronystagmography (ENG) in a community‐based sample of dizzy subjects over 65 years old. A total of 96 asymptomatic controls and 149 dizzy subjects underwent ENG. Clinical diagnoses were made on standardized criteria. ENG results were classed as normal or abnormal, according to reference ranges derived from the controls. Rates of ENG abnormality in different diagnostic categories, sensitivities, specificities and predictive values were calculated. Central vascular disease was common (105 out of 149 subjects); peripheral vestibular disease was not (14). Spontaneous nystagmus had a positive predictive value of 95% for central vascular disease, but was only 18%‐sensitive, and was usually detectable clinically. ENG had no other significant diagnostic value. ENG failed to discriminate dizzy subjects from controls and failed to differentiate various dizziness syndromes. ENG was of no practical value in this community‐derived sample of dizzy elderly subjects.     

Is hearing loss a feature of Joubert syndrome, a ciliopathy?

Objective

To assess if hearing loss is a feature of Joubert syndrome (JBS), one of the ciliopathies and therefore possibly associated with hearing loss.

Design

Retrospective case series.

Setting

University Children's Hospital.

Patients

Dutch patients with JBS.

Main outcome measures

Audiological data.

Results

Data from 22 Dutch Joubert syndrome (JBS) cases (17 males, 5 females) aged 3-40 years were available. Audiological tests were successfully performed in 14 cases. Three cases (aged 17-26 years) showed very mild sensorineural hearing loss (SNHL) at different frequencies. Conductive hearing loss due to middle ear infections occurred frequently in young JBS children (6 out of 22 cases). In three cases (aged 3-13 years) the parents reported the child was hypersensitive to sound.

Conclusion

We found no evidence for significant hearing loss in Joubert syndrome patients. However, given the compromised speech development in JBS, conductive hearing loss due to middle ear infections should be treated vigorously. SNHL at a later age cannot be excluded on the basis of our data, given the sample size. Three of the older cases showed discretely increased hearing thresholds. Analogous to the ciliopathy Bardet-Biedl syndrome, where hearing thresholds were reported to be subclinically increased in a group of adolescents patients, we recommend follow-up of JBS patients in view of the possibility of progressive, late-onset SNHL.     

Is glutathione-S-transferase-pi expression a reliable predictor of chemoradiation response in cancer of the head and neck?

PURPOSE: Concurrent radiation and chemotherapy is being evaluated as an alternative treatment to surgery for patients with advanced squamous cell carcinoma of the head and neck, because organ preservation maybe possible without compromising survival. However, the response to concurrent chemoradiation treatment varies from patient to patient, and there is currently no available molecular predictor of response for this particular treatment modality. There is some evidence to indicate that glutathione S-transferase-pi (GST-pi), which is one of the drug detoxifying enzymes, may decrease the effectiveness of platinum-based chemotherapy in the treatment of a variety of tumor types. This study was performed to investigate whether GST-pi expression was correlated with response to concurrent chemotherapy and radiotherapy in patients with advanced squamous cell carcinoma of the head and neck. MATERIALS AND METHODS: Diagnostic biopsy specimens of 36 patients who underwent concurrent chemoradiotherapy for the treatment of advanced squamous cell carcinoma of the head and neck were examined for GST-pi expression by using immunohistochemistry with polyclonal antihuman GST-pi antibodies. GST-pi expression scores were compared among responders and nonresponders. RESULTS: Although the staining rate with antiGST-pi was slightly lower in the responder group in comparison with the nonresponders (82% vs 100%), the difference was not statistically significant. CONCLUSION: GST-pi expression is unlikely to be a valuable predictor of response to concurrent chemotherapy and radiation treatment in patients with advanced squamous cell carcinoma of the head and neck.