ENT Updates

·         Ketorolac is a recently released potent parenteral nonsteroidal analgesic without opioid-related side effects such as respiratory depression. The disadvantages of its use include a limited analgesic effect beyond the recommended doses and an impaired platelet function. Substantial gastrointestinal mucosal breakdown may occur with use over a period as short as 1 week.

·         The Combitube is one of the more recently developed airways that can be placed without laryngoscopy and in emergency situations. The airway contains two lumens: a distal lumen that sits in the esophagus and a proximal lumen for ventilation.

·         In 2002, Nathan found that the proto-oncogene eIF4E (4E) is elevated in 100% of head and neck squamous cell carcinoma tumors and is of prognostic value in predicting recurrence.

·         Recently, the Er:YAG laser was found safe in middle ear procedures given its high absorption rate by water, weak penetration through the otic bone, and weak transmission through the perilymph. Laser applications in middle ear surgery are not without complications. Facial nerve injury, severe vertigo, chorda tympani burn, and hearing loss can occur.

·         For cases with otosclerosis confined to the fissula ante fenestram only, a novel technique has been described, laser stapedotomy minus prosthesis (STAMP). The technique simply includes vaporization of anterior crus first and later anterior one third of the footplate with a hand-held probe of argon laser. Use of a prosthesis is not needed. If the otosclerosis is limited to the fissula ante fenestram only, this should free the remainder of the stapes. If so, the stapedotomy opening is sealed with adipose tissue. The technique may be converted to classic laser stapedotomy in appropriate cases. With this novel technique, it has been stated that high-frequency hearing (6–8 kHz) was better preserved compared with standard laser stapedotomy and also lasted as long as standard laser stapedotomy. Low incidence of refixation was also noteworthy.

·         Recent studies with topically applied liposomal T4 endonuclease-V indicate that it may show promise in reducing the number of new skin cancers in these children of XP.

·         Nonallergic rhinitis with eosinophilia (NARES) is a recently described syndrome in which patients present with nasal obstruction and congestion; these patients frequently experience more severe exacerbations, including the development of sinusitis and polyposis. These patients also display marked eosinophilia on nasal smears (> 25%) but are not allergic to any inhalant allergens by skin testing or in vitro testing. The cause of NARES remains unknown.

·         Recently, a temporal association between pharyngotonsillitis induced by group A beta-hemolytic Streptococcus and a new onset of obsessive compulsive disorders (OCDs) and other tics has been recognized in a subset of the pediatric population. The disease has been identified as PANDAS (pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections). The symptoms include obsessive thoughts and fears, ritualistic compulsions, tics, and anxiety disorders. The abrupt onset of the disease is clearly within a few weeks of the pharyngotonsillitis caused by group A beta-hemolytic Streptococcus, as opposed to Sydenham chorea, which is characterized by psychological disturbances and abnormal choreiform motor activity that develop many months later. The proposed cause is a cross-reactivity of antistreptococcal antibodies with basal ganglia neurons. The exacerbations of the disease can be monitored by measuring antistreptolysin-O titers. Treatment with either antibiotics or a tonsillectomy has been correlated with a decrease in OCD symptoms.

·         Electroglottography is another method of evaluating vocal cord vibration. This technology uses the principle of electrical impedance across tissue and open space. Electrodes are placed on the neck over the lamina of the thyroid cartilages; a weak current is passed between the electrodes, which generate an impedance curve that corresponds to the shape and nature of the vibratory cycle.

Other forms of glottographic technology include photoelectric and ultrasound glottography. A new technique of assessing vocal cord cycles based on the kymography principle has been recently introduced; however, its clinical value remains questionable at this time.

·         Recent additions to the electrophysiologic battery include ASSR (auditory steady-state response), which allows for a potentially more rapid means of establishing frequency-specific thresholds, stacked ABR (a more sensitive and specific method for the detection of small tumors), and CHAMP (cochlear hydrops analysis masking procedure) for detection of Meniere disease.

·         More recently, OAE, in conjunction with ABR, can be used in identifying individuals with auditory neuropathy, also termed auditory dyssynchrony.

·         Recent findings suggest an association between the measles virus and otosclerosis. Whether the measles virus is a factor that can initiate the otospongiotic process remains to be determined. However, current efforts to immunize against this virus would be expected to drastically reduce the incidence of otosclerosis.

·         Nonsyndromic hereditary hearing impairment is classified by the mode of inheritance. Autosomal recessive transmission (designated by prefix DFNB) is implicated in approximately 80% of cases, autosomal dominant transmission (DFNA) is present in approximately 20% of cases, and X-linked (DFN) and mitochondrial transmission are responsible for < 2% of cases (see Figure 54–1). One single gene, GJB2 (Gap-Junction Beta 2 or connexin 26), has emerged to be the most common cause of recessive deafness, and up to 40% of the onset of sporadic prelingual hearing impairment can be attributed to defects in this gene both in Europe and the United States. The prevalence is higher in southern Europe than in northern Europe, probably owing to one single gene mutation, 35delG. In a stretch of six guanines extending from position 30 to 35, one base pair is deleted. The high incidence of this mutation seems to be due to a common ancestor. Other common mutations include 167delT in Ashkenazi Jews and 235delC in the Japanese population. Recently, a common digenic pattern of inheritance involving GJB2 and GJB6 has been detected. Patients with a monoallelic mutation in GJB2 harbor in addition a deletion of GJB6.

·         Various mutation detection methods exist and are in use. The methods are based on either conformation-based techniques such as single-stranded conformational polymorphism (SSCP) or on base-mismatch recognition such as denaturing gradient gel electrophoresis (DGGE). The former is more common. Both methods—SSCP, because of its simplicity, and DGGE, because of its high sensitivity—are the favored techniques. Recently, a relatively new technology for rapid automated mutation screening, denaturing high-performance liquid chromatography (DHPLC), has been assessed and found to be highly sensitive and specific for detecting GJB2 mutations. However, each of these methods for detecting mutations has significant shortcomings, including expense, time, and limited sensitivity. Direct sequencing of the gene is the only method available to identify any number and type of mutation. Although its use is becoming increasingly automatic, the screening of a large population is expensive.

·         Recent studies have shown a decrease in Type II vestibular hair cells in cases of Meniere disease. The role and significance of the decrease of these Type II hair cells are currently not known. The endolymphatic sac has been shown to be important in inner ear metabolic homeostasis. The endolymphatic sac secretes glycoprotein conjugates in response to osmotic challenges, and preliminary studies have shown an alteration in glycoprotein metabolism in Meniere disease. There has been no conclusive proof of an infectious agent related to this disease.

·         Recent studies have improved our molecular understanding of VS. VS occurs as a result of mutations in a tumor suppressor protein, merlin, located on chromosome 22q12. Merlin is a cytoskeletal protein and may control cell proliferation by regulating the abundance, localization, and turnover of cell-surface receptors. The formation of VS requires mutations of both copies of the merlin gene. One functioning merlin gene prevents the formation of VS. Somatic mutations in both copies of the merlin gene result in sporadic VS. The probabilities of two spontaneous, independent mutations at one locus predict a unilateral VS presenting in the fourth to sixth decades of life.

·         Traditionally, many surgeons rerouted the facial nerve anterior to obtain unobstructed access to the jugular foramen. However, this frequently leads to transient palsy, which does not always recover to normal. More recently, a fallopian bridge technique has gained popularity. In this procedure, the facial nerve remains in situ, and microdissection is carried out around it. Some surgeons use facial nerve rerouting selectively when encasement of the carotid artery necessitates obtaining augmented anterior exposure.

·         Facial contouring is a recent trend in facial aesthetic surgery. Facial implants serve to add volume, providing a more appealing shape to a person's face. Facial injectables have reached tremendous popularity due to their safety, "no-down-time" appeal, and economics.

·         Poly-L-lactic acid (Sculptra) is a volumetric filler currently FDA approved for treatment of lipoatrophy in HIV patients. Lipoatrophy in HIV is due to a number of factors including reverse transcriptase inhibitors and the disease process itself. Recently, poly-L-lactic acid has been used in an off-label capacity as a non-HIV facial filler. The main complication is nodule formation. This can be avoided by injecting deep to subcutaneous tissues and not in areas of significant muscle motion such as the lips. The duration of augmentation with poly-L-lactic acid is up to 3 years.