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Objective: Temporal bone squamous cell carcinoma (TBSCC) is a rare malignancy with poor prognosis, and optimal treatment for advanced cases is uncertain. Our systematic literature review aimed to assess 5-year survival outcomes for advanced TBSCC across different treatment modalities., Data Sources: EMBASE, Medline, PubMed, and Web of Science., Review Methods: A systematic literature review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for articles published between January 1989 and June 2023., Results: The review yielded 1229 citations of which 31 provided 5-year survival data for TBSCC. The final analysis included 1289 patients. T classification data was available for 1269 patients and overall stage for 1033 patients. Data for 5-year overall survival (OS) was 59.6%. Five-year OS was 81.9% for T1/2 and 47.5% for T3/4 (P < .0001). OS for T1/T2 cancers did not significantly differ between surgery and radiation (100% vs 81.3%, P  = .103). For advanced-stage disease (T3/T4), there was no statistical difference in OS when comparing surgery with postoperative chemoradiotherapy (CRT) (OS 50.0%) versus surgery with postoperative radiotherapy (XRT) (OS 53.3%) versus definitive CRT (OS 58.1%, P  = .767-1.000). There was not enough data to assess the role of neoadjuvant CRT., Conclusion: Most patients will present with advanced-stage disease, and nodal metastasis is seen in nearly 22% of patients. This study confirms the prognostic correlation of the current T classification system. Our results suggest that OS did not differ significantly between surgery and XRT for early stage disease, and combined treatment modalities yield similar 5-year OS for advanced cancers., (© 2024 American Academy of Otolaryngology–Head and Neck Surgery Foundation.)

Objective: To evaluate the impact of losartan on vestibular schwannoma (VS) growth and related hearing loss during observation., Study Design: Retrospective cohort study., Setting: Tertiary referral center., Patients: Sporadic VS patients undergoing initial observation with at least two magnetic resonance imaging and audiologic examinations., Intervention: Losartan., Main Outcome Measures: Endpoints included VS growth, quantitative audiologic changes, survival free of tumor growth, and survival free of nonserviceable hearing. Patient characteristics and endpoints were compared by losartan use., Results: Seventy-nine patients were included, of which 33% were taking losartan. Tumor growth was observed in 50% of patients in the losartan group and 36% in the non-losartan group (p = 0.329). Survival analysis failed to show a significant difference in the hazard rate of VS growth between groups (hazard ratio, 1.38; 95% confidence interval, 0.70-2.70; p = 0.346). Throughout observation, mean decreases in normalized pure-tone average were 5.5 and 9.3 dB in the losartan and non-losartan groups, respectively (p = 0.908). Mean decreases in normalized word recognition score were 11.0 and 16.6% in the losartan and non-losartan groups, respectively (p = 0.757). Nonserviceable hearing developed in 19% of patients in the losartan group and 28% in the non-losartan group (p = 0.734). Survival analysis did not demonstrate a significant difference in the hazard rate of developing nonserviceable hearing between groups (hazard ratio, 1.71; 95% confidence interval, 0.56-5.21; p = 0.337)., Conclusions: Losartan use may not reduce the risk of VS growth or hearing loss during observation. A randomized trial would be ideal to further identify the true effect on growth and hearing., Competing Interests: Conflicts of interest: M.E.N. reports stock ownership in 3M, Amgen, Cardinal Health, Johnson & Johnson, Medtronic, and Pfizer. P.W.G. reports stock ownership in Amgen, Eli Lily, Merck, Medtronic, Novartis, Pfizer, and Roche. There are no conflicts of interest to declare for the remaining authors., (Copyright © 2024, Otology & Neurotology, Inc.)

Objective: To determine if cochlear implant (CI) is safe and effective in patients with radiation therapy (XRT)-induced sensorineural hearing loss and to discuss considerations in this population through a retrospective cohort review, systematic review, and meta-analysis., Databases Reviewed: PubMed, Cochrane Library, and Embase., Methods: We retrospectively reviewed all CI cases after head and neck (HN) XRT at our institution, noting intraoperative findings, postoperative complications, and hearing outcomes. Change in speech discrimination scores (SDSs) was the primary outcome measure. Systematic review was performed to identify all cases of CI after HNXRT. A meta-analysis was performed to assess SDS change., Results: The retrospective cohort review identified 12 patients who underwent CI after HNXRT. One patient with HN cancer (HNC) and one with central nervous system pathology (CNSP) received bilateral implants. Six had HNC, three had CNSP, and one had Langerhans cell histiocytosis. Eleven had abnormal findings during CI. There were no postoperative complications. Twenty articles with an additional 97 patients were suitable for systematic review inclusion. Of the 109 patients, 67 (61.5%) had HNC and 18 (16.5%) had CNSP. Abnormal intraoperative findings were common (30.3%), most frequently in the mastoid (66.7%). Postoperative complications, including wound dehiscence and infection with some requiring explantation, occurred in 10.1% of patients. Sixty-six patients were included in the meta-analysis. All demonstrated SDS improvement (mean increase, 56.2%)., Conclusion: Patients with prior HNXRT benefit from CI. Paying careful attention to surgical planning and technique, postoperative care, and patient expectations is imperative, as complications are not uncommon., Competing Interests: Conflicts of interest and disclosures: M.E.N. reports stock ownership in 3M, Amgen, Cardinal Health, Johnson & Johnson, Medtronic, and Pfizer., (Copyright © 2024, Otology & Neurotology, Inc.)

Chronic myelomonocytic leukemia is a myeloid stem cell disease characterized by an abnormal production and accumulation of monocytic cells in association with other signs of myeloproliferation. Extramedullary manifestations of CMML are common and can affect the spleen, liver skin, and lymph nodes. However, otologic manifestations are extremely rare and could have occurred from either direct leukemic infiltration, hemorrhage of the cochlea, labyrinth, leukostasis, or infection. There is no standard treatment protocol for sensorineural hearing loss in CMML patients. More research is needed to improve the understanding of the pathogenesis of this condition, in order to provide better treatment options., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Objectives: To systematically review and evaluate metformin's potential impact on vestibular schwannoma (VS) growth., Data Sources: PubMed, Cochrane Library, and Embase., Review Methods: A retrospective cohort study was performed on sporadic VS patients undergoing initial observation who had at least two magnetic resonance imaging studies. Patients were stratified by metformin use during the observation period. Primary endpoint was VS growth, defined as at least a 2 mm increase in diameter. Survival free of tumor growth was evaluated between groups. Systematic review and meta-analysis were performed to produce a pooled odds ratio [OR]. Study heterogeneity was assessed and post-hoc power analysis was performed., Results: A total of 123 patients were included, of which 17% were taking metformin. Median patient age was 56.6 years (range, 25.1-84.5). There were no statistically significant differences between the groups. Survival analysis did not demonstrate a statistically significant difference in time to VS growth between groups (hazard ratio = 0.61, 95% confidence interval [CI] = 0.29-1.29). Furthermore, logistic regression analysis did not demonstrate a statistically significant difference between groups in the odds of VS growth (OR = 0.46, 95% CI = 0.17-1.27). Systematic review identified 3 studies. Meta-analysis suggested that metformin reduces the odds of developing VS growth (pooled OR = 0.45, 95% CI = 0.29-0.71). Studies demonstrated low between-study heterogeneity. Power analysis demonstrated a sample size of 220 patients with equal randomization would be required to prospectively identify a true difference with 80% power., Conclusions: Metformin use may reduce the odds of VS growth. A randomized trial would be ideal to identify an unbiased estimate of metformin's effect on VS growth. Laryngoscope, 133:2066-2072, 2023., (© 2023 The American Laryngological, Rhinological and Otological Society, Inc.)

Sinonasal cancer is a heterogeneous orphan disease of diverse histologies, each with distinct clinical, oncologic, and toxicity profiles. Because of the comparative rarity of these cancers, sinonasal cancers are treated as a grouped diagnosis despite their clinical and biological heterogeneity. Multimodality treatment with a combination of surgery, chemotherapy, and/or radiotherapy is the standard-of-care for advanced-stage patients but there are few surveillance or follow-up practice guidelines or formalized survivorship care pathways. A scoping literature review was conducted via PubMed, EMBASE, and Google Scholar. A total of 112 studies were included, which were grouped along the following topics: surveillance, second primary tumors, quality of life, and symptom burden. Sinonasal cancer tends to exhibit a higher rate of local failure and occur in a delayed fashion compared to mucosal malignancies of the head and neck. Moreover, the site of failure and time-varying risk of recurrence is histology-specific. Following multimodality treatment of the skull base, patients may experience endocrine, visual, auditory, sinonasal, olfactory, and neurocognitive deficits, as well as psychosocial impairments that impact multiple physical and neuropsychological domains, resulting in diminished quality of life. Sinonasal cancer patients would benefit from tailored, histology-specific survivorship programs to address the recurrence, second primary, and functional impairments resulting from disease and treatment toxicity., (© 2023 Wiley Periodicals LLC.)

Infratemporal fossa (ITF) tumors are difficult to access surgically due to anatomical constraints. Moreover, aggressive ITF carcinomas and sarcomas necessitate aggressive treatment strategies that, along with tumor-related symptoms, contribute to decreases in patient performance status. To assess factors that predict postoperative performance in patients undergoing surgery for ITF tumors. We reviewed medical records for all patients surgically treated for an ITF malignancy between January 1, 1999, and December 31, 2017, at our institution. We collected patient demographics, preoperative performance, tumor stage, tumor characteristics, treatment modalities, pathological data, and postoperative performance data. The 5-year survival rate was 62.2%. Higher preoperative Karnofsky Performance Status (KPS) score (n = 64; p < 0.001), short length of stay (p = 0.002), prior surgery at site (n = 61; p = 0.0164), and diagnosis of sarcoma (n = 62; p = 0.0398) were predictors of higher postoperative KPS scores. Percutaneous endoscopic gastrostomy (PEG) (n = 9; p = 0.0327), and tracheostomy tube placement (n = 20; p = 0.0436) were predictors of lower postoperative KPS scores, whereas age at presentation (p = 0.72), intracranial tumor spread (p = 0.8197), and perineural invasion (n = 40; p = 0.2195) were not. Male patients and patients with carcinomas showed the greatest decreases in KPS scores between pretreatment and posttreatment. Higher preoperative KPS score and short length of stay were the best predictors of higher postoperative KPS scores. This work provides treatment teams and patients with better information on outcomes for shared decision-making., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Objectives/hypothesis: Mycosis Fungoides (MF) is the most common subtype of cutaneous T-cell lymphoma. Disease involvement of specific locations may be more significant than simply the symptoms associated with that site; it is possible that involvement of certain sites could be associated with poor prognosis. We aimed to evaluate the outcomes of patients with MF with documented involvement of the EAC and external ear., Study Design: Retrospective analysis., Methods: We retrospectively reviewed 40 patients with MF that were treated by otologists between 2012 and 2021., Results: We report the largest series of patients with MF involving the external ear and EAC. Of the 40 patients included in this study, 17 presented with Mycosis Fungoides in the otologic region (MFO). Of these 17 MFO patients, 2/17 had involvement of the external ear only, 3/17 of the EAC only, 11/17 of both the external ear and EAC, and 1/17 of the periauricular skin. Of note, 11/14 (79%) patients presenting with EAC disease died compared to11/26 (42%) of patients without involvement. In addition, eight of the 13 (62%) patients with external ear involvement died compared to 14/27 (52%) of patients without involvement. Ear canal involvement was associated with a statistically significant shorter overall survival duration in patients with MF (p = 0.03). Furthermore, disease in the EAC was found to have a hazard ratio value of 2.565 (CI 1.102-5.970)., Conclusions: Involvement of the EAC by MF portends a poor prognosis. This finding highlights the need for a more in-depth otologic evaluation of patients with MF., Level of Evidence: 4 Laryngoscope, 133:1486-1491, 2023., (© 2022 The American Laryngological, Rhinological and Otological Society, Inc.)

Competing Interests: Conflicts of interest: MEN reports stock ownership in 3M, Amgen, Cardinal Health, Johnson & Johnson, Medtronic, and Pfizer. No conflicts of interests to declare for the remaining author.

Background: This study investigated the association of hearing loss and tinnitus with overall health-related quality of life (HRQoL) among long-term oropharyngeal cancer (OPC) survivors., Methods: This study included OPC survivors treated between 2000 and 2013 and surveyed from September 2015 to July 2016. Hearing loss and tinnitus were measured by asking survivors to rate their "difficulty with hearing loss and/or ringing in the ears" from 0 (not present) to 10 (as bad as you can imagine). Hearing loss and tinnitus scores were categorized as follows: 0 for none, 1-4 for mild, and 5-10 for moderate to severe. The primary outcome was the mean score of MD nderson Symptom Inventory Head & Neck module interference component as a HRQoL surrogate dichotomized as follows: 0 to 4 for none to mild and 5 to 10 for moderate to severe interference., Results: Among 880 OPC survivors, 35.6% (314), reported none, 39.3% (347) reported mild, and 25.1% (221) reported moderate to severe hearing loss and tinnitus. On multivariable analysis, mild (OR, 5.83; 95% CI; 1.48-22.88; p = 0.012) and moderate (OR, 30.01; 95% CI; 7.96-113.10; p < 0.001) hearing loss and tinnitus were associated with higher odds of reporting moderate to severe symptom interference scores in comparison to no hearing loss and tinnitus. This association of hearing dysfunction was consistent with all domains of HRQoL., Conclusions: Our findings provide preliminary evidence to support the need for continued audiological evaluations and surveillance to detect hearing dysfunction, to allow for early management and to alleviate the long-term impact on QoL., (© 2022 The Authors. Cancer Medicine published by John Wiley & Sons Ltd.)

Background: Recurrent skull base chondrosarcomas (CSA) are difficult to treat, and limited data are available to help guide subsequent therapy., Objective: To further characterize the natural history of CSA and identify treatment modalities that were most effective in prolonging progression-free (PFS) and disease-specific survival (DSS)., Methods: We conducted a single-institution retrospective review of patients with recurrent skull base CSA from 1993 to 2021. Kaplan-Meier survival analyses for PFS and DSS were completed. Univariable and multivariable Cox proportional hazards regression models were used to identify patient-related, treatment-related, and disease-related factors that predicted PFS and DSS., Results: A total of 28 patients and 84 episodes of recurrence were included. One-year PFS was 70.6%, 5-year PFS was 28.9%, and 10-year DSS was 78.5%. The median time to first progression was 23.9 months (range, 2.8-282 months). In univariable Cox proportional hazards regression, male sex, higher grade histology, fourth or greater progression episode status, distal pattern of recurrence, and treatment of recurrence without surgery or with chemotherapy alone predicted worse PFS. Multivariable regression predicted shortened DSS in male patients (hazard ratio [HR] 0.16; P = .021) and higher-grade tumors (HR 0.22; P = .039). Treatment of recurrence with surgery was associated with, but did not significantly predict, improved DSS (HR 1.78; P = .11)., Conclusion: Several patient and disease-specific factors were associated with shorter PFS and DSS in recurrent skull base chondrosarcoma. For recurrences amenable to resection, surgery is recommended for treatment of recurrent CSA. Local recurrence management without surgery results in shorter PFS and DSS., (Copyright © Congress of Neurological Surgeons 2022. All rights reserved.)

Background: The management of sub-totally resected sporadic vestibular schwannoma (VS) may include observation, re-resection or irradiation. Identifying the optimal choice can be difficult due to the disease's variable progression rate. We aimed to define an immune signature and associated transcriptomic fingerprint characteristic of rapidly-progressing VS to elucidate the underpinnings of rapidly progressing VS and identify a prognostic model for determining rate of progression., Methods: We used multiplex immunofluorescence to characterize the immune microenvironment in 17 patients with sporadic VS treated with subtotal surgical resection alone. Transcriptomic analysis revealed differentially-expressed genes and dysregulated pathways when comparing rapidly-progressing VS to slowly or non-progressing VS., Results: Rapidly progressing VS was distinctly enriched in CD4 + , CD8 + , CD20 + , and CD68 + immune cells. RNA data indicated the upregulation of anti-viral innate immune response and T-cell senescence. K - Top Scoring Pair analysis identified 6 pairs of immunosenescence-related genes (CD38-KDR, CD22-STAT5A, APCS-CXCR6, MADCAM1-MPL, IL6-NFATC3, and CXCL2-TLR6) that had high sensitivity (100%) and specificity (78%) for identifying rapid VS progression., Conclusion: Rapid progression of residual vestibular schwannoma following subtotal surgical resection has an underlying immune etiology that may be virally originating; and despite an abundant adaptive immune response, T-cell immunosenescence may be associated with rapid progression of VS. These findings provide a rationale for clinical trials evaluating immunotherapy in patients with rapidly progressing VS., (© 2022. The Author(s).)

Introduction: Audiovestibular toxicity secondary to immunotherapy has only rarely been reported in the literature. Herein, we examine our experience diagnosing and managing audiovestibular immune-related adverse events (irAEs) in patients undergoing immunotherapy., Methods: Four patients who experienced irAEs were included. Demographics, immunotherapy regimen, diagnostic tests, treatment, and outcomes were recorded in a retrospective chart review., Results: The cases of three patients with metastatic melanoma and one patient with metastatic renal cell carcinoma are presented. Hearing loss and tinnitus were the most common presenting symptoms. Immune checkpoint inhibitors (ICIs) were implicated in three cases and T-cell therapy in one case. Two of three patients (67%) treated with steroids had substantial improvements in hearing., Conclusions: Audiovestibular irAEs are a rare complication of immunotherapy. Suspicion for symptoms including hearing loss, tinnitus, and/or vertigo should prompt an expedient referral to the otolaryngologist for evaluation, as symptoms may improve with corticosteroid use. Hearing and/or vestibular deficits can have a substantial impact on the quality of life for affected patients, but rehabilitation options do exist., Competing Interests: Conflict of Interest: Marc-Elie Nader: Stock ownership in 3M, Amgen, Cardinal Health, Johnson & Johnson, Medtronic, and Pfizer. Paul W. Gidley: Stock ownership in Amgen, Eli Lily, Merck, Medtronic, and Pfizer. Joshua C. Page: None.

Objective: To introduce a minimally invasive and image-guided technique for staged placement of a percutaneous abutment after osseointegrated implantation., Patients: Adults undergoing temporal bone resection at two academic medical centers., Interventions: Ultrasound-guided percutaneous installation of a bone conduction hearing device abutment. All patients had lateral temporal bone resection with osseointegrated implantation. Abutment placement followed as a planned staged procedure 3 to 6 months later depending on the use of radiotherapy., Main Outcome Measures: Ability to use a bone conduction hearing device and occurrence of skin reactions or wound complications., Results: Twelve patients successfully underwent abutment installation through a 5 mm skin biopsy punch incision, nine of which had minimal to no skin reaction surrounding the abutment. Two patients developed Holgers grade 1 skin reaction (redness with slight swelling). One patient experienced an osseointegration failure 152 days after abutment placement., Conclusions: Ultrasound is a widely available imaging modality that can be used to precisely localize subcutaneous osseointegrated implants, allowing for minimally invasive percutaneous placement of an abutment under local or general anesthesia., Competing Interests: The authors disclose no conflicts of interest., (Copyright © 2021, Otology & Neurotology, Inc.)

Objective: To determine recurrence patterns in patients with head and neck cancers requiring facial nerve sacrifice and to determine the optimal management of the positive proximal facial nerve margin., Study Design: Case series with chart review., Setting: Tertiary care center., Patients: One hundred fifty-five patients with head and neck malignancies who underwent sacrifice of the facial nerve between March 1, 1999 and October 31, 2020. Demographics, preoperative facial nerve function, prior oncologic treatment, histologic type, operative details, adjuvant treatment, recurrence patterns, and overall survival were reviewed., Main Outcome Measures: Recurrence rates and recurrence location., Results: Thirteen patients (8%) had positive proximal margins on final pathologic evaluation. Six of 13 (46%) experienced disease recurrence. No disease recurred proximally along the facial nerve. The recurrence rate was 26% for negative proximal facial nerve margins. Segments of the facial nerve biopsied included: extratemporally (n = 78), at the stylomastoid foramen (36), mastoid segment (22), second genu (7), tympanic (6), geniculate (3), labyrinthine (1), and IAC (2). Median patient follow-up was 30.3 months., Conclusions: Our data suggest that a conservative approach to a positive proximal facial nerve margin is optimal with respect to operative planning, patient morbidity, and disease recurrence patterns. Recurrence proximally along the facial nerve is an exceedingly rare event and the necessity of biopsy proximal to the geniculate ganglion, and in some cases even to the second genu, is called into question., (Copyright © 2021, Otology & Neurotology, Inc.)

Objectives/hypothesis: To report the largest single-institution review of temporal bone osteoradionecrosis (TBORN), and characterize the disease's natural history, prognostic factors, management, and outcomes., Study Design: Retrospective chart review., Methods: Retrospective review was conducted to identify patients with TBORN. Pertinent data were extracted. Descriptive statistics were used to summarize patient, tumor, and treatment characteristics. Multivariable analyses were conducted to explore associations between these characteristics and time to TBORN diagnosis and risk of developing diffuse disease., Results: TBORN was identified in 145 temporal bones from 128 patients. Mean age at diagnosis was 62 years, and mean time to diagnosis after radiotherapy was 10 years. Age greater than 50 years was associated with earlier diagnosis. According to the Ramsden criteria, 76% of TBs had localized and 24% had diffuse disease at initial diagnosis; 37% had diffuse disease at last follow-up. On multivariable analysis, diabetes, three-dimensional conformal radiotherapy (3D-CRT), and periauricular skin malignancy were significant risk factors for developing diffuse disease. Localized disease was successfully managed with conservative measures, whereas surgery was often necessary for diffuse disease. When TBORN spread outside the mastoid or infratemporal fossa, conservative measures were always unsuccessful., Conclusions: TBORN occurs earlier in older patients. While diffuse disease is less common than localized disease, it occurs more frequently in patients with diabetes, history of 3D-CRT, and periauricular skin malignancies. Conservative management is appropriate for localized disease, while surgery is often necessary for diffuse disease. The prognostic factors identified helped propose a TBORN staging system and treatment guidelines which may improve patient risk stratification and disease management., Level of Evidence: 4 Laryngoscope, 131:2578-2585, 2021., (© 2021 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: Examine the presentation and management characteristics of seven patients with melanoma of the external auditory canal (EAC)., Study Design: Retrospective case series and review of the relevant literature., Methods: Records of seven patients from 2003 to 2017 with melanoma of the EAC were reviewed for characteristics of presentation, subsequent management, and outcomes. A thorough review of relevant literature is presented., Results: The median age is 52 years, with four females. The average Breslow depth was 3.6 mm, with five patients having a Clark level IV or greater on presentation. Six patients underwent lateral temporal bone resection, and one patient underwent wide local excision of the cartilaginous canal. Sentinel lymph node biopsy (SLNB) was performed in three patients. Three patients experienced distant recurrence an average of 20 months following primary therapy. Median follow-up was 21 months. At last follow-up, four were free of disease, one had active disease, and two were deceased from melanoma., Conclusions: This is the largest series and the first to report the use of SLNB for patients with EAC melanoma in the peer-reviewed literature. Patients with external auditory canal melanoma present with higher Breslow thickness and stage relative to all external ear melanomas. Management should include wide local excision, which entails lateral temporal bone resection when the bony ear canal is involved. SLNB has a critical role in identifying patients with early metastatic disease. Postoperative radiation therapy should be considered for patients with high-risk features to reduce the risk of locoregional relapse. Chemotherapy, and especially immunotherapy, has an emerging role for this disease., Level of Evidence: 4 Laryngoscope, 131:165-172, 2021., (© 2020 The American Laryngological, Rhinological and Otological Society, Inc.)

Emerging immunotherapeutic agents, including immune checkpoint inhibitors targeting cytotoxic T-lymphocyte-associated antigen-4 (CTLA-4), programmed cell death protein 1 (PD-1), and programmed cell death protein ligand 1 (PD-L1), have revolutionized cancer treatment. The first immune checkpoint inhibitor (ICI) ipilimumab, an anti-CTLA-4, was approved in 2011. Since then, the US Food and Drug Administration (FDA) has approved more than half a dozen immune checkpoint inhibitors to treat various malignancies. These agents are part of a broader class of chemotherapy agents termed immunotherapy, which selectively target different steps in the immune response cascade to upregulate the body's normal response to cancer. While the effects of traditional chemotherapy are well known, the toxicity profile of emerging immune therapies is not fully elucidated. They have been associated with atypical side effects labeled collectively as immune-related adverse events (irAEs)., (© 2021. The Author(s), under exclusive license to Springer Nature Switzerland AG.)

Objective: Temporal bone osteoradionecrosis (TBORN) is a rare, chronic complication of head and neck radiation. Initial treatment consists of conservative management, with surgical resection of necrotic bone indicated for cases of severe, symptomatic, or progressive disease. Pentoxifylline-tocopherol (PENTO) has demonstrated usefulness for osteoradionecrosis of other head and neck subsites. Herein, we report five TBORN cases utilizing this protocol., Study Design: Retrospective case series., Setting: Tertiary referral center., Patients: This case series describes five TBORN cases in which the PENTO protocol was used in conjunction with conservative management. All patients were women and average age was 61 ± 8 years., Intervention: All patients received a daily dose of 800 mg of pentoxifylline and 1 g of tocopherol. Four of the five patients received systemic and/or ototopical antibiotics as an antimicrobial regimen before and/or during the PENTO protocol., Main Outcome Measures: Details regarding the total duration of protocol, improvement in symptoms, exposed bone and radiographic changes, and duration until first improvement of exposed bone were collected retrospectively., Results: The average duration of PENTO protocol was 302 ± 166 days. Four of the five (80%) patients demonstrated a decrease in exposed ear canal bone. Three of the five (60%) patients had stable or improvement in otologic symptoms of TBORN. One patient progressed to diffuse TBORN. The average duration until first improvement in exposed bone was 193 ± 137 days., Conclusions: The PENTO protocol may be a useful adjunct to conservative measures in the management of localized TBORN. We recommend trialing the protocol for at least 12 months.

Background: Skull base osteoradionecrosis (ORN) is a challenging treatment-related complication sometimes seen in patients with cancer. Although ORN management strategies for other anatomic sites have been reported, there is a paucity of data guiding the management of skull base ORN., Objective: To report a single-center tertiary care series of skull base ORN and to better understand the factors affecting ORN recurrence after surgical management., Methods: We conducted a retrospective cohort study of patients with skull base ORN treated at our center between 2003 and 2017. Univariate and multivariate binary logistic regressions were performed to identify predictors of recurrence., Results: A total of 31 patients were included in this study. The median age at ORN diagnosis was 61.1 yr (range, 32.8-84.9 yr). Of these 31 patients, 15 (48.4%) patients were initially treated medically. All 31 patients underwent surgery. Three (14.3%) of 21 patients treated with a free flap and 4 (50.0%) of 8 patients who underwent primary closure experienced recurrence. Cox regression analysis revealed that reconstruction with local tissue closure (P = .044) and ongoing treatment for active primary cancer (P = .022) were significant predictors of recurrence. The median overall survival from index surgery for ORN treatment was 83.9 mo. At 12-mo follow-up, 78.5% of patients were alive., Conclusion: In this study, we assess the outcomes of our treatment approach, surgical debridement with vascularized reconstruction, on recurrence-free survival in patients with skull base ORN. Further studies with larger cohorts are needed to assess current treatment paradigms., (Copyright © 2020 by the Congress of Neurological Surgeons.)

Objective: Infratemporal fossa (ITF) tumors are unique in histological characteristics and difficult to treat. Predictors of patient outcomes in this context are not known. The objective of this study was to identify independent predictors of outcome and to characterize patterns of failure in patients with ITF carcinoma., Methods: All patients who had been surgically treated for anterolateral skull base malignancy between 1999 and 2017 at the authors' institution were retrospectively reviewed. Patient demographics, preoperative performance status, tumor stage, tumor characteristics, treatment modalities, and pathological data were collected. Primary outcomes were disease-specific survival (DSS) and local progression-free survival (LPFS) rates. Overall survival (OS) and patterns of progression were secondary outcomes., Results: Forty ITF malignancies with skull base involvement were classified as carcinoma. Negative margins were achieved in 23 patients (58%). Median DSS and LPFS were 32 and 12 months, respectively. Five-year DSS and OS rates were 55% and 36%, respectively. The 5-year LPFS rate was 69%. The 5-year overall PFS rate was 53%. Disease recurrence was noted in 28% of patients. Age, preoperative performance status, and margin status were statistically significant prognostic factors for DSS. Lower preoperative performance status and positive surgical margins increased the probability of local recurrence., Conclusions: The ability to achieve negative margins was significantly associated with improved tumor control rates and DSS. Cranial base surgical approaches must be considered in multimodal treatment regimens for anterolateral skull base carcinomas.

Background: COVID-19 pandemic has strained human and material resources around the world. Practices in surgical oncology had to change in response to these resource limitations, triaging based on acuity, expected oncologic outcomes, availability of supportive resources, and safety of health care personnel., Methods: The MD Anderson Head and Neck Surgery Treatment Guidelines Consortium devised the following to provide guidance on triaging head and neck cancer (HNC) surgeries based on multidisciplinary consensus. HNC subsites considered included aerodigestive tract mucosa, sinonasal, salivary, endocrine, cutaneous, and ocular., Recommendations: Each subsite is presented separately with disease-specific recommendations. Options for alternative treatment modalities are provided if surgical treatment needs to be deferred., Conclusion: These guidelines are intended to help clinicians caring for patients with HNC appropriately allocate resources during a health care crisis, such as the COVID-19 pandemic. We continue to advocate for individual consideration of cases in a multidisciplinary fashion based on individual patient circumstances and resource availability., (© 2020 Wiley Periodicals, Inc.)

Emerging immunotherapy agents, such as immune checkpoint inhibitors, have shown remarkable promise in the treatment of various malignancies. These drugs selectively target different steps in the immune response cascade to upregulate the body's normal response to cancer. Due to the novelty of these therapeutic agents, their toxicity profile is less well understood.Meta-analysis results reveal that the overall prevalence of oral mucositis, stomatitis, and xerostomia is lower with checkpoint inhibitors compared to conventional chemotherapy, and head and neck radiation therapy. However, the widespread use of immunotherapy reveals new oral mucosal barrier adverse events, including bullous pemphigoid, mucous membrane pemphigoid, and lichenoid mucositis. Audiovestibular dysfunction can occur from autoimmune-mediated pathways of immunotherapy (adoptive cell) with limited treatment options. Such auditory complications can lead to speech recognition deficits and sensorineural hearing loss. Ocular toxicities are among the most common adverse events resulting from the use of these agents. The majority of ocular immune-related adverse events (irAEs) are mild, low-grade, non-sight threatening, such as blurred vision, conjunctivitis, and ocular surface disease. Serious and sight-threatening events, including corneal perforation, optic neuropathy, and retinal vascular occlusion, can occur but are infrequent. In this chapter, we review the current evidence on the clinical manifestations of oral, audiovestibular, and ocular immune-related adverse events (i.e., irAEs).

Background: Skull base osteosarcomas are aggressive neoplasms characterized by bony invasion and extracompartmental/extra-osseous soft tissue extension that pose obstacles to achieving complete resection. Management is further complicated by the paucity of data regarding the efficacy of surgery within the treatment paradigm., Objective: To identify the impact of margin status on local progression free survival (PFS) and disease specific survival (DSS)., Methods: A retrospective review was performed of 36 patients with osteosarcoma who underwent gross total resection with negative margins (R0), or positive margins (R1). Patient demographics, prior treatments, relapse patterns, and survival were collected. Univariate analysis was performed to determine the impact of margin status on the PFS (primary outcome) and DSS (secondary outcome)., Results: R0 resection was achieved in 67%, 25% patients had local recurrence, and 19.4% patients had distant metastasis. In assessing the entire cohort, R0 resections had improved DSS (P = .002) and PFS (P = .04). In chemotherapy-naïve patients, R0 resections also had improved impact on PFS (P = .04) and DSS (P = .027). For radiation-naïve patients, improvements in PFS (P = .026) and DSS (P = .031) were also noted., Conclusion: Skull base osteosarcomas present management challenges in which both local and systemic disease progression is the cause of mortality. Achieving R0 resections significantly improves PFS and DSS in treatment-naïve patients within multimodality treatment paradigms. Salvage surgery may benefit in patients after failing previous radiation and chemotherapy treatments. Further work is needed to determine optimal treatment strategies. These data represent the largest series reported to date., (Copyright © 2019 by the Congress of Neurological Surgeons.)

Objectives: To determine the sensitivity and specificity of magnetic resonance imaging (MRI) for the detection of perineural spread (PNS) along the intratemporal facial nerve (ITFN) in patients with head and neck cancers., Study Design: Case series with chart review., Setting: Tertiary care center., Subjects and Methods: We included 58 patients with head and neck malignancies who underwent sacrifice of the ITFN between August 1, 2002, and November 30, 2015. Demographics, preoperative facial nerve function, prior oncologic treatment, and timing between MRI and surgery were recorded. Histopathology slides and preoperative MRI were reviewed retrospectively by a neuropathologist and a neuroradiologist, respectively, both blinded to clinical data. The mastoid segment of the facial nerve (referred to as the descending facial nerve [DFN]) and stylomastoid foramen (SMF) were evaluated separately. A grading system was devised when radiographically assessing PNS along the DFN., Results: Histopathologic evidence of PNS was found in 21 patients (36.2%). The sensitivity and specificity of MRI in detecting PNS to the DFN were 72.7% and 87.8%, respectively. MRI showed higher sensitivity but slightly lower specificity when evaluating the SMF (80% and 82.8%, respectively). Prior oncologic treatment did not affect the false-positive rate ( P = .7084). Sensitivity was 100% when MRI was performed within 2 weeks of surgery and was 62.5% to 73.3% when the interval was greater than 2 weeks. This finding was not statistically significant (SMF, P = .7076; DFN, P = .4143)., Conclusion: MRI shows fair to good sensitivity and good specificity when evaluating PNS to the ITFN.

Radiation and chemotherapy are frequently used in the treatment of head and neck malignancies. Ototoxicity is a common adverse effect of these treatment modalities. This article discusses the patterns of hearing loss following chemotherapy and radiation therapy. Specific issues related to hearing rehabilitation in oncological patients will also be covered, such as controversies regarding treatment of radiation-induced serous otitis media, risks of otologic surgery, and the use of osseointegrated hearing aids and cochlear implants.

Objective: (1) To assess the correlation between preoperative high-resolution CT (HRCT) imaging measurement from the long process of the incus to the footplate and the length of intraoperative selected prosthesis. (2) To determine if HRCT has a predictive value of prolapsed facial nerve during stapedotomy., Materials and Methods: We evaluated in our tertiary care center, in a retrospective case series, 94 patients undergoing primary stapedotomy. Preoperative temporal bone HRCT scans were reformatted in the plane of the stapes to measure on the same section the distance between the long process of the incus and the footplate. Measurement was performed by otolaryngology resident and neurotologist. We analyze the interobserver correlation and the mean length measured on the HRCT to the selected prosthesis size intraoperatively., Results: Mean HRCT measurement of the incus long process/footplate distance assessed by the otolaryngology resident and neurotologist was 4.34 and 4.38 mm, respectively. Interobserver correlation was statistically significant [intraclass correlation coefficient (ICC) of 0.679 (p < 0.001)]. Mean selected prosthesis length intraoperatively was 4.36 mm. Correlation between the mean selected length prosthesis and the mean HRCT measurement was also statistically significant [ICC of 0.791 (p < 0.001)]. Postoperatively, a statistical improvement was shown in air conduction (p < 0.001), bone conduction (p < 0.001) and air-bone gap reduction (p < 0.001). 2 cases of facial nerve covering one-half of the oval window were identified by HRCT and confirmed intraoperatively., Conclusion: HRCT is a valuable tool to predict preoperatively the length of the stapedotomy prosthesis. Moreover, it might be helpful to identify a potential prolapsed facial nerve, to confirm the diagnosis of otosclerosis and to rule out other abnormalities. Ultimately, it may optimize the stapedotomy procedure planning.

Background: This study aims to assess the effectiveness of delayed facial nerve decompression for Bell's palsy (BP)., Methods: We performed a retrospective case review of all patients having undergone facial nerve decompression for severe refractory BP between 1984 and 2009 at our tertiary referral center. Demographics, timing between onset of symptoms and surgical decompression, degree of facial nerve dysfunction pre- and post-operatively, follow-up length after surgery and postoperative complications were recorded. Facial nerve dysfunction was assessed using the House-Brackmann (HB) scale. Electroneuronography, electromyography and imaging results were assessed when available., Results: Eighteen patients had surgery between 21 and 60 days after onset of BP (group I), and 18 patients had surgery more than 60 days after onset of symptoms (group II). In group II, 11 patients had surgery between 61 and 89 days and 7 patients after 90 days. Groups I and II showed similar functional gain and rates of improvement to HB 3 or better (11/18 vs. 11/18, p > 0.05). In group II, patients operated 60 to 89 days after onset of BP showed a significantly higher rate of improvement to HB 3 or better (9/11 vs. 2/6, p = 0.049) with higher functional gain compared to those operated after 90 days (p = 0.0293)., Conclusions: When indicated, facial nerve decompression for BP is usually recommended within the first 2 weeks of onset of facial paralysis. Nonetheless, our results suggest that patients with severe BP could benefit from decompression surgery within 90 days after onset of symptoms in the absence of an opportunity to proceed earlier to surgery. Further investigation is still required to confirm our findings., Trial Registration: Retrospective registered. IRB# 2016-6154, CE 15.154 - CA.

Objective: 1) To determine if unexplained ear fullness might be a symptom of endolymphatic hydrops (EH) by using Electrocochleography (ECochG) SP/AP area and amplitude ratios. 2) To assess if individuals with unexplained ear fullness without vertigo differ significantly from individuals with ear fullness due to Ménière's disease (MD)., Materials and Methods: In a case-control study in our tertiary care center, we evaluated 62 ears across 49 patients, including 18 normal healthy ears across 12 control patients, 26 ears with unexplained ear fullness across 20 patients (6 had bilateral symptoms of ear fullness), and 18 ears with definite MD across 17 patients (1 bilateral disease). Outcome measures were SP/AP amplitude and area ratio, hearing threshold, and air-bone gap., Results: The analysis of auditory thresholds revealed a significant group effect for air conduction [F(2,50)=49.627; p<0.001] and for bone conduction [F(2,50)=45.625; p<0.001]. We observed significant differences between MD (36.36±4.87) and control patients (19.85±2.55) (p=0.015) for amplitude ratio. Moreover, significant differences were noted between MD (5.32±1.06) and controls (1.36±0.07) (p=0.035) and between ear fullness (5.16±1.17) and controls (p=0.026) for the area ratio parameter. No significant correlation was observed between SP/AP area or amplitude ratios and air-bone gap at any of the tested frequencies. The amplitude ratio was not significantly different between the ear fullness and control groups (p=0.406). The area and amplitude ratios did not reveal significant differences between MD and ear fullness (p=1.00)., Conclusion: EH can be present even in the absence of vertigo and when patients report unexplained ear fullness. This study, to our knowledge, is the first to possibly allow early identification of cochlear EH in patients suffering from ear fullness without vertigo.

Background: Methylene blue is widely used in the medical field, especially as a blue dye for staining. It is also used as a photosensitizing agent in antimicrobial photodynamic therapy, which once photoactivated is effective for the eradication of several multi-resistant bacteria. The objective of this study was to investigate the ototoxic potential of methylene blue and precise its use in otology., Methods: It was a prospective animal study performed on guinea pigs in our tertiary medical center. We divided the animals into two groups: an experimental group and a control group, who underwent a series of three intratympanic (IT) injections. In the control group (n = 10), they received injections of gentamicin in one ear (positive control) and normal saline in the contralateral ear (negative control). The experimental group (n = 10) received injections of methylene blue in one ear, compared to injections of normal saline in the contralateral ear. We conducted auditory-evoked brainstem response (ABR) before and 1 week after the injection series. Once this is completed, the cochlea was dissected and caspase-3 was analyzed by immunohistochemistry., Results: The mean difference of hearing loss in the methylene blue group compared to normal saline was 1.50 dB, and it was not shown to be statistically significant (P = 0.688). For the positive control group, which received IT injections of gentamicin, the mean threshold of hearing loss difference for all the frequencies combined was 66.25 dB (P < 0.001). Furthermore, uptake of caspase-3 by immunohistochemistry (apoptotic marker) was negative in our group, which received injections of methylene blue., Conclusion: In light of our results, IT injections of methylene blue did not demonstrate an ototoxic potential. We recommend further studies to precise its use in the otologic field., Competing Interests: None.

Objective: Adenocarcinoma of the middle ear is a rare entity that must be distinguished from other adenomatous tumors of the temporal bone. We present the first patient of an intestinal-type adenocarcinoma originating from the middle ear., Patients: A 58-year-old woman presented with an 8-year history of left otorrhea. Her middle ear effusions were quite thick and gummy. She underwent eight sets of pressure-equalization tubes within 3 years. In 2011, her physical examination identified a middle ear mass, and she underwent mastoidectomy. A middle ear adenoma was resected. She underwent an additional three mastoidectomies for recurrence, with pathology from the 4th mastoidectomy revealing a diagnosis of adenocarcinoma. Imaging, at that time, showed an extensive temporal bone and Eustachian tube tumor., Interventions: She underwent a left subtotal temporal bone resection, parotidectomy, infratemporal fossa resection, dural resection, and microvascular free flap reconstruction followed by postoperative proton beam radiotherapy., Main Outcome Measures: The final pathology report revealed intestinal-type adenocarcinoma., Results: Treatment was successful and the patient remains disease free 4 years later., Conclusion: This is the first report of an intestinal-type adenocarcinoma of the middle ear and temporal bone. This patient also illustrates the difficulty of accurate histologic diagnosis of adenomatous tumors of the middle ear.

Immune checkpoint inhibitors have emerged as a promising therapeutic option for metastatic cancers. However, they have been associated with inflammatory adverse reactions in various organ systems. A recent article reported a case of sudden bilateral hearing loss that occurred in a patient with metastatic melanoma being treated with pembrolizumab. The authors attributed that complication to an autoimmune reaction secondary to the treatment. This commentary discusses the importance of considering the diagnosis of leptomeningeal metastasis in patients with metastatic melanoma who present with new cranial nerve deficits.

Objectives/hypothesis: To compare the complication rate for osseointegrated hearing aids (OIHA) in patients with or without irradiation., Study Design: Retrospective case review., Methods: We studied patients with OIHAs implanted between January 1, 2005, and July 15, 2013 in a tertiary university center with a referral otology and neurotology practice. Demographics, history of oncologic surgery, follow-up length after OIHA implantation, radiation history and dosage, postoperative complications, and chronologic relationship between oncologic resection, OIHA implantation, and irradiation were reviewed to collect information. Soft tissue complications were graded according to a modified Holgers classification., Results: The study included 48 patients. Twenty-nine patients (32 implants) did not undergo radiotherapy and 19 patients (19 implants) did. In the radiotherapy group, six patients had OIHAs implanted before radiotherapy, and 13 had OIHAs implanted in irradiated bone. Of these 13 patients, one had OIHA implanted during primary oncologic surgery; 11 had OIHA implanted during secondary surgery; and one patient did not have oncologic surgery. Patients with both OIHA implantation and radiotherapy had more complications than patients without radiotherapy (31.6% vs. 24.1%, P > 0.05) and more major complications than patients without radiotherapy (26.3% vs. 3.4%, P > 0.05). Patients with OIHAs implanted before radiotherapy did not have any complications. There were significantly fewer and less severe complications in patients with OIHAs implanted during primary oncologic resection than in patients with OIHAs implanted secondarily (0/8 vs. 8/11, P < 0.05)., Conclusions: The rate and severity of complications of OIHAs can be minimized by implanting the device before irradiation, ideally at the time of primary oncologic surgery., Level of Evidence: 4. Laryngoscope, 126:1187-1192, 2016., (© 2015 The American Laryngological, Rhinological and Otological Society, Inc.)

Lactobacillus curvatus is one of the most prevalent lactic acid bacteria found in fermented meat products. Here, we present the draft genome sequence of Lactobacillus curvatus CRL705, a bacteriocin producer strain isolated from an Argentinean artisanal fermented sausage, which consists of 1,833,251 bp (GC content, 41.9%) and two circular plasmids of 12,342 bp (pRC12; GC, 43.9%) and 18,664 bp (pRC18; GC, 34.4%).

Objective: To assess the benefits in terms of sound localization, to evaluate speech discrimination in noise, to appraise the prosthesis benefit and to identify outcome in right and left handed patients when BAHA are implanted on the right or on the left deaf side., Methods: Two years prospective study in a tertiary referral center. Tests consist on Hearing in Noise Test (HINT) and sound localization after 6 months of BAHA use. Quality of life was assessed by the Abbreviated Profile of Hearing Aid Benefit (APHAB) questionnaire. The paired T-test and the analysis of variance were used for the statistical measures., Results: Twenty-one subjects participated in this study. HINT: patients score better when speech and noise are spatially separated and noise is not presented to the healthy ear. In the right-handed group (left dominant brain), unaided left-implanted patients performed better than right-implanted patient when speech is in front and noise to the good ear; when speech is presented to the good ear and noise to the front, aided right-implanted patients performed better than aided left-implanted patients. Sound localization: correct answers attain 35% at best. No statistical difference between the frequencies was found, neither between the left and right implanted patients. APHAB: the score improvement is statistically significant for the global score, the background noise subscale at 5 weeks and for the reverberation subscale at 6 months., Conclusion: It seems that left dominant hemisphere is able to filter crossed noise better than the right hemisphere. Results of uncrossed speech to the dominant left brain are better than the uncrossed speech to the non-dominant right brain., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

Objectives/hypothesis: There is no approved agent to prevent cisplatin-induced ototoxicity. Our objectives were to: 1) identify and compare the effect of intratympanic injections of lactate or N-acetylcysteine (NAC) in the prevention of cisplatin-induced ototoxicity, 2) investigate inner ear protection using a scanning electron microscope, and 3) study systemic diffusion of intratympanic NAC., Study Design: Prospective animal study., Methods: Sixteen guinea pigs formed two groups, and respectively received intratympanic lactate and 20% NAC in one ear. The contralateral ears received a control saline solution. After 30 minutes, an intraperitoneal cisplatin injection of 3 mg/kg was performed and repeated eight times, once a week, to achieve 24 mg/kg. Auditory brainstem responses (ABRs) were recorded before any injection, after 9 mg/kg and after 24 mg/kg of cisplatin for the frequencies 2, 4, 6 and 8 kHz. Cochleas were analyzed under scanning electron microscope. Systemic diffusion of NAC was studied using high-performance liquid chromatography., Results: For the control ears, ABR thresholds increased uniformly and averaged 28.4 dB. The lactate group showed a lower threshold increase and averaged 17.0 dB. The NAC showed an important threshold increase of 89.0 dB. Lactate showed a significant hearing protection at 2000 Hz (P < .01). Electron microscopy revealed partial preservation of outer hair cell stereocilia for the ears treated with lactate and severe disruption for NAC group. No systemic diffusion of NAC was observed with chromatography., Conclusions: Intratympanic lactate offers significant partial protection against cisplatin-induced ototoxicity at midfrequencies. High-concentration NAC does not seem a viable solution as it causes a considerable inflammatory reaction. NAC does not diffuse systemically.

Objectives: Studies of the genetics of chronic rhinosinusitis offer potential insights into the pathophysiology of this poorly understood condition. However, genetic studies are both expensive and time consuming-hence the importance of establishing beforehand the proper population and target genes. We wished to identify patient factors associated with a proposed definition of severe chronic rhinosinusitis to minimize heterogeneity and maximize the impact of genetic contributions. We therefore wanted to determine if the response to a standardized therapy following endoscopic sinus surgery could be used as a viable phenotypic criterion for subsequent genetic studies., Design: Retrospective chart review., Setting: Tertiary sinus centre., Methods: Seventy-one cases of chronic rhinosinusitis refractory to medical and surgical treatment were studied. They formed two groups according to their response to a standardized treatment protocol. We collected information concerning patients' characteristics and bacteriology on endoscopic culture., Results: 60.5% patients were managed successfully with budesonide irrigations. Atopy was present in 33.8%, asthma in 69.0%, and aspirin sensitivity in 33.3%. The rate of asthma was higher in nonresponders. Bacterial colonization rates showed the presence of Staphylococcus aureus (36.4%), gram-negative rods (29.1%), and Pseudomonas aeruginosa (32.7%)., Conclusions: Patients with refractory chronic rhinosinusitis represent a severely diseased, more homogeneous population in which the genetic contribution(s) to disease may be maximal. Strong associations with asthma, aspirin intolerance, and atopy suggest links between these disorders. Irrigation with budesonide solution appears to be effective in management. Studies of the genetics of chronic rhinosinusitis will include genes known to be involved with both asthma and innate immunity.

Purpose: to identify species of lactobacillus isolated from the vaginal contents of healthy and asymptomatic women, determining the most prevalent species and characterizing them phenotypically., Methods: lactobacillus have been isolated in selective milieu from samples of the vaginal contents of 135 women without complaints of vaginal secretion, and with negative laboratorial diagnosis of vaginal infection, followed up at an outpatient clinic. After being identified by multiplex PCR, the isolates have been submitted to RNAr 16S gene sequencing, when necessary. They have also been evaluated concerning the production of lactic acid, H2O2, bacteriocins and the ability to adhere to epithelial cells., Results: eight-three lactobacillus strains were isolated and identified, L. crispatus (30.1%), L. jensenii (26.5%), L. gasseri (22.9%) e L. vaginalis (8.4%), being the prevalent species. Only 20 of those isolates did not present H2O2 production, in detectable amounts. From the 37 strains selected for the test of adhesion to the epithelial cells, 12 presented 50 to 69% of adhesion, 10 presented 70% or more, and the remaining, little or no adhesion at all. None of the tested strains produced bacteriocins., Conclusions: the lactobacillus species more prevalent in women without vulvovaginitis, isolated in selective culture milieu and identified by molecular methods were L. crispatus, L. jensenii and L. gasseri. Besides the fact of being more prevalent, these strains also presented better production of H2O2, and reached lower pH values in the culture milieu.

Objective: Some clinicians use hydrogen peroxide (H2O2) to clear the lumen of ventilation tubes that become blocked postoperatively. The ototoxicity associated with H2O2 has been controversial., Study Design: We designed an experiment to test if H2O2 damages the cochlear hair cells using a Chinchilla laniger animal model., Methods: Nine chinchillas (18 ears) were included in this study. Each animal was used as its own control. Following the insertion of ventilation tubes in both ears and baseline recordings of the auditory brain stem responses (ABR), we instilled 2 ml of 3 percent H2O2 into their right external auditory canals (experimental ears). H2O2 was left in the external auditory canal for a total of 5 minutes and then was drained. We instilled a normal saline control solution in their left ears (control ears) in a similar fashion. ABR recordings were performed 1 day after the last instillation of H2O2 and 5 days later., Results: There was no statistically significant difference in the ABR thresholds of the experimental and control ears., Conclusion: H2O2 did not appear to cause ototoxicity in chinchilla ears with tympanostomy tubes exposed to H2O2 instillation using a standard clinical protocol.

Objective: To document the most important postoperative adenotonsillectomy morbidities, with an emphasis on prolonged hospitalization and readmissions., Design: Retrospective chart analysis., Methods: We reviewed 2067 cases of adenotonsillectomies performed at our institution over a period of 6 years., Results: Of these cases, 1927 patients had undergone tonsillectomy by electrocautery and adenoidectomy by suction-coagulator, of whom 9.3% required admission. The incidence of admissions owing to bleeding was 1.7%, whereas admissions owing to respiratory and gastrointestinal complications represented 3.7% and 5.2%, respectively. Compared with the literature and our institution's previous results, these morbidity values were found to be either comparable or significantly lower (p < .05)., Conclusion: We attribute this improvement to our use of electrocautery-based techniques not only for tonsillectomy but also for adenoidectomy.

The ultrastructural modifications of the respiratory tract of mice produced by the intranasally inoculated L. fermentum was evaluated. The genus Lactobacillus has been largely studied from the probiotic effect point of view in different ecological systems. Lactobacilli inoculated in 4 intranasal doses (1 x 10(9) CFU/dose) do not produce fundamental changes at the ultrastructural level in the organs of the respiratory tract studied. The most important finding was the presence of a cellular type with intracellular structures surrounded by membranes exhibiting electron dense paracristalline material parallel arranged.