Limited literature exists on surgical outcomes after selective deep lobe parotidectomy (SDLP) with preservation of superficial lobe for patients with benign deep lobe tumors.
To compare the following ...factors for SDLP vs total parotidectomy for patients with benign tumors in the deep lobe: postoperative complications, including facial nerve paresis or paralysis, Frey syndrome, first bite syndrome, cosmetic defect, sialocele formation, and wound infection; and tumor control and recurrence.
This case series included 273 adults who underwent SDLP (n = 177) or total parotidectomy (n = 96) at a single tertiary care institution for benign parotid tumors located in the deep lobe or deep lobe and parapharynx from January 1, 2000, to December 31, 2020.
Selective deep lobe parotidectomy vs total parotidectomy.
Incidence of postoperative complications and tumor recurrence.
Among 273 patients (SDLP, 177 65%; 122 women 69%; median age at surgery, 58 years IQR, 46-67 years; total parotidectomy, 96 35%; 57 women 59%; median age at surgery, 59 years IQR, 40-68 years), the most common tumor was pleomorphic adenoma (SDLP, 128 of 177 72%; total parotidectomy, 62 of 96 65%). An abdominal dermal fat graft was less commonly performed for patients who underwent SDLP than those who underwent total parotidectomy (2 of 177 1% vs 20 of 96 21%; difference, -20% 95% CI, -28% to -11%). The rate of great auricular nerve preservation was higher in the SDLP group than in the total parotidectomy group (84 of 102 82% vs 20 of 34 59%; difference, 24% 95% CI, 5%-42%). No meaningful difference in length of hospital stay was found. The percentage of patients with House-Brackmann grade I immediately after surgery was 48% (85 of 177) in the SDLP group and 21% (20 of 96) in the total parotidectomy group (difference, 28% 95% CI, 16%-40%). There were no clinically meaningful differences in rates of hematoma, sialocele, seroma, ear numbness, wound infection, or unplanned return to emergency department or operating room. The SDLP group reported a lower rate of Frey syndrome than the total parotidectomy group (1 of 137 1% vs 12 of 78 15%; difference, -15% 95% CI, -23% to -7%), as well as a lower rate of facial contour defect (28 of 162 17% vs 25 of 84 30%; difference, -13% 95% CI, -24% to -1%) and a higher rate of first bite syndrome (34 of 148 23% vs 7 of 78 9%; difference, 14% 95% CI, 5%-23%). The percentage of patients with House-Brackmann grade I at their first follow-up visit was 67% (118 of 177) in the SDLP group compared with 49% (47 of 96) in the total parotidectomy group (difference, 17% 95% CI, 4%-30%). There was no clinically meaningful difference in House-Brackmann grade after 1 year.
Findings of this case series study suggest that SDLP can be considered an effective and even superior technique for management of benign tumors in the deep parotid lobe. Advantages associated with SDLP include reduction in need for reconstruction for facial contour defect and reduction in complications, such as immediate facial nerve weakness and Frey syndrome. The incidence of first bite syndrome was higher in the SDLP group. Tumor control was not compromised by SLDP.
To evaluate the impact of prolonged auditory deprivation on speech perception outcomes in adult acquired single-sided deafness (SSD) cochlear implant (CI) recipients.
Retrospective case series.
...Tertiary care academic center.
Acquired SSD in adults with and without prolonged duration of deafness (defined as >10 yr) who underwent CI between 2014 and 2019.
CI.
Consonant-nucleus-consonant (CNC) and AzBio in quiet scores within first year of follow-up.
A total of 35 adult patients with SSD were evaluated, with a median overall duration of deafness of 2.4 years (interquartile range IQR 1.2-6.0 yr): seven patients with prolonged auditory deprivation (median 18 yr, IQR 15-28) were compared with 28 SSD patients with duration of deafness less than 10 years (median 1.7 yr, IQR 1.1-3.2). At last follow-up, the median CNC scores were 39% (IQR 31-64) and 54% (IQR 46-64) for the prolonged and shorter duration of deafness cohorts, respectively (p = 0.3). The median AzBio scores were 66% (IQR 65-68) and 72% (IQR 60-82) for the prolonged and shorter duration of deafness cohorts, respectively (p = 0.6). In a separate analysis evaluating duration of deafness as a continuous variable across all 35 patients, Spearman correlation coefficients for associations of duration of deafness with most recent CNC and AzBio scores were -0.02 (p = 0.9) and 0.02 (p = 0.9), respectively.
Adult CI recipients with acquired SSD, with and without prolonged auditory deprivation, demonstrated comparable speech perception scores. Prolonged duration of deafness alone should not preclude a motivated SSD patient from undergoing cochlear implantation.
Objectives/Hypothesis
To review hearing preservation after microsurgical resection of sporadic vestibular schwannomas according to tumor size.
Study Design
Retrospective cohort.
Methods
Baseline, ...intraoperative, and postoperative patient and tumor characteristics were retrospectively collected for a cohort who underwent hearing preservation microsurgery. Serviceable hearing was defined by a pure tone average ≤50 dB and word recognition score ≥50%.
Results
A total of 243 patients had serviceable hearing preoperatively. Fifty (21%) tumors were confined to the internal auditory canal, and the median tumor size was 16.2 mm (interquartile range IQR 11.3–23.2) for tumors with cerebellopontine angle extension. Serviceable hearing was maintained in 64% of patients with tumors confined to the internal auditory canal, 28% with cerebellopontine angle extension <15 mm, and 9% with cerebellopontine angle extension ≥15 mm. On multivariable analysis, the odds ratios of acquiring nonserviceable hearing postoperatively for tumors extending <15 mm and ≥15 mm into the cerebellopontine angle were 5.75 (95% confidence interval CI 2.13–15.53; P < .001) and 22.11 (95% CI 7.04–69.42; P < .001), respectively, compared with intracanalicular tumors.
Conclusions
The strongest predictor of hearing preservation with microsurgery after multivariable adjustment is tumor size. Approximately 10% of patients with tumors ≥15 mm of cerebellopontine angle extension will retain serviceable hearing after microsurgery. Furthermore, hearing preservation techniques offer cochlear nerve preservation and cochlear patency allowing for possible future cochlear implantation. An attempt at hearing preservation, including avoiding surgical approaches that necessarily sacrifice hearing, is worthwhile even in larger tumors if serviceable hearing is present preoperatively.
Level of Evidence
4 Laryngoscope, 132:1657–1664, 2022
Interpretation of laryngoscopy is an important diagnostic skill in otolaryngology. There is, however, limited understanding of the specific visual strategies used while assessing flexible ...laryngoscopy video. Eye-tracking technology allows for objective study of eye movements during dynamic tasks. The purpose of the present study was to explore visual gaze strategies during laryngoscopy interpretation of unilateral vocal fold paralysis (UVFP) across clinician experience from novice to expert.
Thirty individuals were shown five flexible laryngoscopy videos, each 10 seconds long. After viewing each video, participants reported their impressions of “left vocal fold paralysis,” “right vocal fold paralysis,” or “no vocal fold paralysis.” Eye tracking data were collected and analyzed for duration of fixation and number of fixations on select areas of interest (AOI). Diagnostic accuracy and visual gaze patterns were compared between novice, experienced, and expert groups.
Diagnostic accuracy among learners in the novice group was significantly lower than those in the more experienced groups (P = 0.04). All groups demonstrated similar visual gaze patterns when viewing the video with normal bilateral vocal fold mobility, spending the greatest percentage of time viewing the trachea. There were differences among groups when viewing the videos of left or right VFP, but the trachea was always in the top three structures for greatest fixation duration and highest number of fixations.
Eye-tracking is a novel tool in the setting of laryngoscopy interpretation. With further study it has the potential to be useful for the training of otolaryngology learners to improve diagnostic skills.
Compare speech perception performance growth and benchmark score achievement among adult cochlear implant (CI) recipients with single-sided deafness (SSD) versus bilateral moderate to profound ...hearing loss.
Retrospective matched cohort analysis.
Tertiary referral center.
Adults with SSD or bilateral moderate to profound hearing sensorineural hearing loss who underwent cochlear implantation from 2014 to 2019.
Cochlear implantation.
Time-to-benchmark speech perception score (CNC, AzBio in quiet) and speech performance within first postoperative year.
Thirty-three SSD patients were matched to 66 bilateral hearing loss patients (referent cohort) for duration of deafness and preoperative ipsilateral CNC scores. Although SSD patients were more likely to achieve benchmark CNC scores more quickly compared with matched referents, this difference did not reach statistical significance (HR 1.72; 95% CI 0.78-3.82; p = 0.18). AzBio scores showed similar trends (HR 1.40; 95% CI 0.66-2.98; p = 0.38). At last follow-up, the SSD cohort had lower CNC (median 54% vs. 62%; p = 0.019) and AzBio scores (median 72% vs. 84%; p = 0.029) compared to the referent cohort.
No significant difference in speech perception performance growth (i.e., time-to-benchmark speech perception score) was identified between SSD and bilateral hearing loss CI recipients, although patients with bilateral hearing loss achieved higher scores in the implanted ear within the first year of follow-up.
The objective of this study is to assess the influence of age on facial nerve recovery after microsurgical resection of sporadic vestibular schwannoma.
A historical cohort study was performed.
The ...study was performed at a tertiary referral center.
The studied cohort included patients with a House-Brackmann (HB) Grade III or worse in the immediate postoperative period.
The studied intervention was microsurgical resection.
The main outcome measure was complete recovery of facial nerve function to HB Grade I at least 12 months postoperatively.
There were six patients with intracanalicular tumors and 100 with cerebellopontine angle (CPA) tumors eligible for study. Given the few patients with intracanalicular tumors, no further analysis was pursued in this subset. For patients with CPA tumors, a multivariable analysis of several patient and tumor characteristics demonstrated age at surgery (odds ratio for 10-year increase of 0.68; 95% confidence interval CI, 0.47-0.98; p = 0.04) and immediate postoperative HB grade (odds ratio for one-grade increase of 0.27; 95% CI, 0.15-0.50; p < 0.001) to be jointly significantly associated with complete recovery to HB Grade I, indicating that the likelihood of complete facial nerve recovery was higher for younger patients and for those with better immediate postoperative HB grades. For example, the predicted probability of complete facial nerve recovery for a 30-year-old with immediate postoperative HB Grade III was 0.76 (or 76% when expressed as a percentage), whereas the predicted probability for a 50-year-old with immediate postoperative HB Grade V was only 0.10.
After considering immediate postoperative HB grade, younger age at surgery was independently significantly associated with complete facial nerve recovery, which can assist in intraoperative decision-making regarding extent of resection and postoperative counseling.
Objectives:
The purpose of this study was to evaluate visual gaze patterns and the ability to correctly identify cancer among participants of different experience levels when viewing benign and ...malignant vocal cord lesions.
Methods:
Thirty-one participants were divided into groups based on level of experience. These included novice (medical students, PGY1-2 otolaryngology residents), intermediate (PGY3-5 otolaryngology residents, gastroenterology fellow), advanced practice providers (physician assistants, nurse practitioners, and speech language pathologists), and experts (board-certified otolaryngologists). Each participant was shown 7 images of vocal cord pathology including glottic cancer, infectious laryngitis, and granuloma and asked to determine the likelihood of cancer on a scale of certain, probable, possible, and unlikely. Eye tracking data were collected and used to identify the area of interest (AOI) that each participant fixated on first, fixated on the longest, and had the greatest number of fixations.
Results:
No significant differences were seen among groups when comparing AOI with first fixation, AOI with longest fixation, or AOI with most fixations. Novices were significantly more likely to rate a low likelihood of cancer when viewing infectious laryngitis compared to more experienced groups (P < .001). There was no difference in likelihood of cancer rating among groups for the remaining images.
Conclusions:
There was no significant difference in gaze targets among participants of different experience levels evaluating vocal cord pathology. Symmetric appearance of vocal cord lesions may explain differences seen in likelihood of cancer rating among groups. Future studies with larger sample sizes will better elucidate gaze targets that lead to accurate diagnosis of vocal cord pathology.
To compare clinical outcomes in patients with and without history of tobacco use who underwent Zenker's diverticulotomy (ZD).
Single institution retrospective review.
Tertiary care academic hospital.
...A retrospective review of patients who underwent ZD via an open stapler, rigid endoscopic CO2 laser, stapler or harmonic scalpel, and flexible endoscopic technique from January 2006 to December 2020 was performed. Data were abstracted for patient demographics, diverticular features, and rates of adverse events and symptomatic recurrence.
Out of 424 patients, 146 (34.4 %) had a history of tobacco use: 126 (29.7 %) were former smokers, and 20 (4.7 %) were active smokers. In univariable cross-sectional analyses, the likelihood of postoperative bleeding, perforation, emergency department visits, unplanned readmission, or recurrence did not demonstrate an association with tobacco use history even after adjustment for age, sex, and surgical approach. Similarly, in Cox Proportional Hazards regression, tobacco use was not associated with an increased risk of recurrence, even after correcting for age, sex, and type of surgery. The median time to recurrence observed in our cohort was 11.5 years amongst non-smokers, 8.7 years amongst former smokers, and 1.2 years amongst active smokers (p = 0.94).
There were no significant differences in post-operative adverse events or frequency of recurrence of ZD between active, former, and non-smokers. Although underpowered and not statistically significant, median time to recurrence appears to be shorter in smokers when compared with former and non-smokers following surgery.
Parotidectomies have historically been performed on an inpatient basis despite being well-tolerated surgeries with minimal postoperative wound care and low rates of complications at high-volume ...institutions. Past studies have supported the safety of outpatient surgery for parotidectomy but have been limited to superficial parotidectomy and have not addressed the patient experience surrounding the surgical intervention such as pre-operative and post-operative care and communication.
This study assesses the impact of outpatient superficial, deep, and partial parotid surgery on various parameters including surgical safety, distance traveled for care, utilization of telehealth, and patient-initiated communication.
Retrospective study from January 2020 to October 2021. Patients undergoing superficial lobe, deep lobe, and partial parotidectomies for benign and malignant pathologies were divided into inpatient and outpatient cohorts. A multivariable model examined the relationship between admission status and surgical complications, adjusted for age, sex, and tumor size.
159 patients total, 94 outpatient and 65 inpatients. No statistical difference in rates of surgical complications with the exception of salivary leak. There was an increased rate of salivary leak reported in the inpatient group (OR 5.4, 95 % CI 1.6 to 18.0, p = 0.01). Mean patient travel distance of 354 miles one-way. Post-operatively, 76 % were evaluated via video visit. Following discharge, >55 % of patients initiated communication with the surgical team, which was not statistically different between the groups.
Outpatient parotidectomy is safe and can be more convenient, but telehealth communication must be balanced with rigorous attention to patient education.
