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Journal: Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery


Objective This update of the 2008 American Academy of Otolaryngology-Head and Neck Surgery Foundation cerumen impaction clinical practice guideline provides evidence-based recommendations on managing cerumen impaction. Cerumen impaction is defined as an accumulation of cerumen that causes symptoms, prevents assessment of the ear, or both. Changes from the prior guideline include a consumer added to the development group; new evidence (3 guidelines, 5 systematic reviews, and 6 randomized controlled trials); enhanced information on patient education and counseling; a new algorithm to clarify action statement relationships; expanded action statement profiles to explicitly state quality improvement opportunities, confidence in the evidence, intentional vagueness, and differences of opinion; an enhanced external review process to include public comment and journal peer review; and 3 new key action statements on managing cerumen impaction that focus on primary prevention, contraindicated intervention, and referral and coordination of care. Purpose The primary purpose of this guideline is to help clinicians identify patients with cerumen impaction who may benefit from intervention and to promote evidence-based management. Another purpose of the guideline is to highlight needs and management options in special populations or in patients who have modifying factors. The guideline is intended for all clinicians who are likely to diagnose and manage patients with cerumen impaction, and it applies to any setting in which cerumen impaction would be identified, monitored, or managed. The guideline does not apply to patients with cerumen impaction associated with the following conditions: dermatologic diseases of the ear canal; recurrent otitis externa; keratosis obturans; prior radiation therapy affecting the ear; previous tympanoplasty/myringoplasty, canal wall down mastoidectomy, or other surgery affecting the ear canal. Key Action Statements The panel made a strong recommendation that clinicians should treat, or refer to a clinician who can treat, cerumen impaction, defined as an accumulation of cerumen that is associated with symptoms, prevents needed assessment of the ear, or both. The panel made the following recommendations: (1) Clinicians should explain proper ear hygiene to prevent cerumen impaction when patients have an accumulation of cerumen. (2) Clinicians should diagnose cerumen impaction when an accumulation of cerumen, as seen on otoscopy, is associated with symptoms, prevents needed assessment of the ear, or both. (3) Clinicians should assess the patient with cerumen impaction by history and/or physical examination for factors that modify management, such as ≥1 of the following: anticoagulant therapy, immunocompromised state, diabetes mellitus, prior radiation therapy to the head and neck, ear canal stenosis, exostoses, and nonintact tympanic membrane. (4) Clinicians should not routinely treat cerumen in patients who are asymptomatic and whose ears can be adequately examined. (5) Clinicians should identify patients with obstructing cerumen in the ear canal who may not be able to express symptoms (young children and cognitively impaired children and adults), and they should promptly evaluate the need for intervention. (6) Clinicians should perform otoscopy to detect the presence of cerumen in patients with hearing aids during a health care encounter. (7) Clinicians should treat, or refer to a clinician who can treat, the patient with cerumen impaction with an appropriate intervention, which may include ≥1 of the following: cerumenolytic agents, irrigation, or manual removal requiring instrumentation. (8) Clinicians should recommend against ear candling for treating or preventing cerumen impaction. (9) Clinicians should assess patients at the conclusion of in-office treatment of cerumen impaction and document the resolution of impaction. If the impaction is not resolved, the clinician should use additional treatment. If full or partial symptoms persist despite resolution of impaction, the clinician should evaluate the patient for alternative diagnoses. (10) Finally, if initial management is unsuccessful, clinicians should refer patients with persistent cerumen impaction to clinicians who have specialized equipment and training to clean and evaluate ear canals and tympanic membranes. The panel offered the following as options: (1) Clinicians may use cerumenolytic agents (including water or saline solution) in the management of cerumen impaction. (2) Clinicians may use irrigation in the management of cerumen impaction. (3) Clinicians may use manual removal requiring instrumentation in the management of cerumen impaction. (4) Last, clinicians may educate/counsel patients with cerumen impaction or excessive cerumen regarding control measures.

Concepts: Hospital, Evidence-based medicine, Auditory system, Ear, Otitis externa, Eardrum, Earwax, Ear pick


Objective To determine a new therapeutic approach using granulocyte monocyte-colony-stimulating factor (GM-CSF) and pegylated interferon alpha 2a (Peg-IFNα-2a) as adjuvant therapy in patients with adult recurrent respiratory papillomatosis. Study Design Descriptive observational clinical trial. Setting Departments of Otolaryngology and Immunology. Methods Fourteen patients with adult recurrent respiratory papillomatosis were examined regarding medical history and number of operations before and after treatment. Voice disorder and glottal stop were evaluated using the Voice-Related Quality-of-Life instrument. Papilloma staging was determined using the Coltera/Derkay diagram. The patients received Peg-IFNα-2a at 180 mcg weekly for 6 months. In the third month, the patients began GM-CSF treatment at 400 mcg weekly for 2 months. The patients were observed for 12 months after treatment ended. Results Eleven patients met the study criteria; 3 patients had tracheotomies before treatment, and they were decannulated after treatment. Before treatment, the scale of voice quality ranged from 34 to 45 points (mean, 38.31). After treatment, the range was 12 to 35 points (mean, 21.09; P < .001). Prior to therapy, the glottal stop ranged from 50% to 90% (average, 62.27%). After therapy, the range decreased to 0% to 15% (mean, 4.63%; P < .001). The number of surgical interventions decreased. Two patients each had 1 surgical intervention after treatment began. Conclusion A new adjuvant treatment based on immunogenetic mechanisms against human laryngeal papilloma virus, with expectations of reducing disease aggressiveness and the number of operations, avoids the risks of surgery. Implication for Practice Peg-IFNα-2a and GM-CSF is an adjuvant therapy for treating adult recurrent respiratory papillomatosis.

Concepts: Human papillomavirus, Interferon, Laryngeal papillomatosis, Papilloma


Balloon dilation may offer a more expedient and cost-effective treatment method compared with traditional endoscopic sinus surgery for chronic maxillary atelectasis. We sought to demonstrate the feasibility of balloon dilation of the maxillary os as a treatment modality for patients with chronic maxillary atelectasis by investigating the short-term outcomes in a retrospective case series of 4 patients representing 5 sinuses treated between 2011 and 2013. All sinuses were successfully balloon dilated without complications. Follow-up ranged from 1 week to 4 months. Aeration of the treated sinuses without restenosis was confirmed by postoperative endoscopy, sinus computed tomography, or both. All patients reported subjective symptomatic improvement. Balloon dilation of the maxillary os may be a feasible treatment option for maxillary sinus atelectasis. Longer follow-up and a larger study sample will be needed to validate the safety of this technique and determine the rate of restenosis.

Concepts: Sinusitis, Retrospective, Maxillary sinus, Endoscopy, Case series, Dilation, Cervical dilation


ObjectiveNasal polyps can be categorized as eosinophilic or non-eosinophilic, depending on inflammatory cell infiltration. There are geographical differences in the prevalence of types of pathologic polyps. The aim of this study was to evaluate the change in the prevalence of histological subtypes of polyps over time in a Korean population.Study DesignA retrospective cross-sectional study with histologic analysis.SettingA single academic medical center.Subjects and MethodsA total of 230 patients with nasal polyps were enrolled between 1993-1994 (group A) and 2010-2011 (group B). Specimens were fixed in formalin and embedded into paraffin blocks. Slides were stained with hematoxylin-eosin (H&E) and were subsequently reviewed by 2 of the authors. The numbers of eosinophils per high power field (HPF), as well as other cellular, epithelial, and stromal markers, were recorded.ResultsWe compared nasal polyp eosinophil counts according to time period. The average eosinophil count/HPF increased from 6.8 in group A to 19.3 in group B (P = .006). The prevalence of eosinophilic polyps also increased from 24.0% in group A to 50.9% in group B (P < .001). Among other histologic markers, lymphocytes, basement membrane thickening, and gland hyperplasia showed significant differences between groups.ConclusionAfter comparison of histopathologic findings of nasal polyps from 1993 and 2011 at 1 academic medical center in Korea, the prevalence of eosinophilic nasal polyps, which are known to be rare among Asians, has significantly increased.

Concepts: Immune system, White blood cell, Anatomical pathology, Histology, Histopathology, Eosin, Korea, Eosinophil granulocyte


The aim of this prospective study is to establish whether ductoplasty is necessary to repair the Wharton’s duct after a combined endoscopic and external approach to remove large submandibular gland stones or if simple suturing of the oral floor mucosa after stent placement may be sufficient to achieve proper duct healing. Ten patients were enrolled. Ductoplasty was performed in 6 cases, whereas in 4 cases, only the mucosa of the oral floor was sutured. The stent was removed about 3 weeks after surgery. Sialoliths were completely removed in all cases. During follow-up, patient symptom evaluation, ultrasound, and physical examination showed no signs of recurrence or complications. In our limited experience, ductoplasty after the combined approach was not necessary. After stent placement, the mere suture of the oral mucosa overlying the damaged ductal wall allowed a correct recanalization of the ductal lumen as commonly observed after careful ductoplasty.

Concepts: Oral mucosa, Patient, Physical examination, Exocrine gland, Necessary and sufficient condition


ObjectiveTo compare the efficacy, relapse, and adverse effects between intralesional injection and mouth rinse of triamcinolone acetonide (TA) in patients with oral lichen planus (OLP).Study DesignA randomized controlled study.SettingCollege medical center.Subjects and MethodsForty consecutive patients, who had been diagnosed with OLP, were recruited. Participants were randomly divided into 2 groups using intralesional injection or mouth rinse of TA. The severity of pain and burning sensation on a 10-cm visual analog scale (VAS) and the Oral Health Impact Profile-14 (OHIP-14) were assessed at weeks 0, 1, 2, 3, 4, and 6. The signs of OLP were quantified using a special scoring system for OLP. The rate of relapse and the adverse effects were compared between both groups.ResultsThe VAS scores for pain and burning mouth sensation and objective scoring for OLP were significantly improved at 1, 2, 3, 4, and 6 weeks in both groups. The changes in the VAS for burning mouth sensation, OHIP-14, and objective scoring for OLP were similar between both groups. The change in the VAS for pain from baseline to week 1 in the intralesional injection group was significantly higher than in the mouth rinse group. The rate of adverse effects was significantly higher in the mouth rinse group than in the intralesional injection group (44.4% vs 5.0%).ConclusionThe efficacies of both treatments were similar. The rate of adverse effects was significantly lower for intralesional injection of TA than mouth rinse of TA.

Concepts: Randomized controlled trial, Randomness, Eczema, Triamcinolone acetonide, Lichen planus, Mucosal lichen planus


This update of a 2004 guideline codeveloped by the American Academy of Otolaryngology-Head and Neck Surgery Foundation, the American Academy of Pediatrics, and the American Academy of Family Physicians, provides evidence-based recommendations to manage otitis media with effusion (OME), defined as the presence of fluid in the middle ear without signs or symptoms of acute ear infection. Changes from the prior guideline include consumer advocates added to the update group, evidence from 4 new clinical practice guidelines, 20 new systematic reviews, and 49 randomized control trials, enhanced emphasis on patient education and shared decision making, a new algorithm to clarify action statement relationships, and new and expanded recommendations for the diagnosis and management of OME.

Concepts: Medicine, Medical terms, Evidence-based medicine, Systematic review, Randomized controlled trial, Physician, Otitis media


The purpose of the current study was to compare outcomes and complication rates of sialolithiasis treated with intracorporeal holmium laser lithotripsy in conjunction with salivary endoscopy with those treated with simple basket retrieval or a combined endoscopic/open procedure.

Concepts: The Current, Basket


Objective To understand whether the impact of smoking on chronic rhinosinusitis (CRS) is reversible after smoking cessation. Study Design Cross-sectional study. Setting Academic tertiary care rhinology clinic. Subjects and Methods A total of 103 former-smoker CRS patients and 103 nonsmoker CRS patients were prospectively recruited. The primary outcome measure was sinonasal symptom severity measured with the 22-item Sinonasal Outcomes Test (SNOT-22), and secondary outcome measures were general health-related quality of life (QOL) measured with the 5-dimensional EuroQol visual analog scale (EQ-5D VAS) and patient-reported CRS-related antibiotic and oral corticosteroid usage in the past year. Outcome measures were compared between cohorts and checked for association with time since cessation of smoking for former smokers. Results Compared with nonsmokers, former smokers had worse SNOT-22 score ( P = .019) and EQ-5D VAS score ( P = .001) and reported using more CRS-related antibiotics ( P = .003) and oral corticosteroids in the past year ( P = .013). In former smokers, every year was associated with a statistically significant improvement in SNOT-22 score (β = -0.48; 95% CI, -0.91 to -0.05; P = .032), EQ-5D VAS score (β = 0.46; 95% CI, 0.02-0.91; P = .046), and CRS-related oral corticosteroid use (relative risk = 0.95; 95% CI, 0.91-0.98; P = .001). Given the differences in our study outcome measures between former smokers and nonsmokers, we estimate that the reversible impacts of smoking on CRS may resolve after 10 to 20 years. Conclusions CRS patients who are former smokers have worse sinonasal symptomatology, QOL, and CRS-related medication usage than nonsmokers. Every year since cessation of smoking is associated improvements in sinonasal symptomatology, QOL, and CRS-related oral corticosteroid use, potentially reaching nonsmoker levels after 10 to 20 years.

Concepts: Antibiotic resistance, Smoking, Tobacco, Passive smoking, Nicotine, Smoking cessation, Corticosteroid, Vaporizer


To report patient/family experiences and outcomes after tracheostomy STUDY DESIGN: International survey of patients and families with tracheostomy.