Should the Contralateral Tonsil Be Removed in Cases of HPV-Positive Squamous Cell Carcinoma of the Tonsil?

TRIO Best PracticeTRIO Best Practice articles are brief, structured reviews designed to provide the busy clinician with a handy outline and reference for day-to-day clinical decision making. The ENTtoday summaries below include the Background and Best Practice sections of the original article. To view the complete Laryngoscope articles free of charge, visit Laryngoscope.

Background

Human papillomavirus-positive (HPV+) head and neck squamous cell carcinomas (SCC) are increasing in incidence worldwide. The palatine tonsils are the most commonly involved anatomical subsite, followed by the base of tongue and then the soft palate. Secondary primary malignancy (SPM) is a well-established phenomenon among patients with head and neck SCC and can present in up to 36% of patients within 20 years of their original diagnosis. Furthermore, synchronous tumors are defined as those that occur simultaneously with the index cancer; these tumors are present in approximately 4% of cases.

SPM is thought to arise secondary to field cancerization, a biological process by which prolonged exposure to carcinogens leads to independent malignant transformation at multiple sites. The prevalence of synchronous bilateral HPV+ SCC of the tonsil (SBTC) is largely unknown, and there is much controversy regarding routinely removing the contralateral tonsil. Fear of increased pain, bleeding, circumferential scarring, and functional impairment have all been cited as reasons to avoid contralateral tonsillectomy in these scenarios. Proponents of contralateral tonsillectomy, however, raise concerns over the potentially fatal consequences of missing occult contralateral disease. Another advantage is the resulting symmetric appearance of the palatal arches, which allows for improved oncologic surveillance and easier detection of tumor recurrence.

Given the important prognostic and therapeutic implications of identifying a SBTC, should the contralateral tonsil routinely be removed in cases of HPV+ squamous cell carcinoma of the tonsil (TSCC)?

Best Practice

The contralateral tonsil should routinely be removed in cases of suspected or known unilateral HPV+ TSCC. Furthermore, preoperative clinical exam findings and imaging studies including PET-CT should not be used to exclude the possibility of SBTC. Although there are reports of significant complications resulting from bilateral radical surgery, performing a routine contralateral tonsillectomy does not appear to increase rates of morbidity or complications, and the resulting symmetric palatal arch could potentially improve oncologic surveillance and detection of recurrence.

Furthermore, identifying a contralateral TSCC can dramatically alter treatment and prognosis. The patient may need further surgery and/or radiation therapy to the contralateral oropharynx and neck, which otherwise would not be indicated in unilateral disease. Although the true incidence of SBTC remains unknown, the oncologic outcome of missing the second primary and delaying treatment can be devastating and even fatal. Future prospective studies should be performed to identify any clinical disparities or differences in tumor characteristics that could improve preoperative identification of SBTC patients (Laryngoscope. 2019;129:1257–1258).

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Is Core Needle Biopsy Effective for Assessment of Head and Neck Lesions?

TRIO Best PracticeTRIO Best Practice articles are brief, structured reviews designed to provide the busy clinician with a handy outline and reference for day-to-day clinical decision making. The ENTtoday summaries below include the Background and Best Practice sections of the original article. To view the complete Laryngoscope articles free of charge, visit Laryngoscope.

Background

Ultrasonography in combination with fine needle aspiration (FNA) has served as the primary line of investigation for head and neck lesions. In the 10% to 15% of cases for which FNAs yield nondiagnostic material, the next option is often excisional biopsy under general anesthesia. In patients who are poor surgical candidates, core needle biopsy (CNB) with a larger gauge needle under ultrasound guidance has emerged as a simple, minimally invasive, and accurate method for the diagnosis of head and neck lesions, especially when conservative treatment is likely. CNB has been shown to yield a higher sensitivity and specificity compared to FNA in head and neck lesions, including malignant lymphoma. Surveys show physicians are reluctant to incorporate this diagnostic method into practice due to concerns regarding bleeding, infection, nerve injury, and tumor cell seeding. This article reviews the evidence for the safety of CNB in the diagnosis of head and neck lesions, with an emphasis on the risk of tumor cell seeding and bleeding.

Best Practice

Based on current studies, ultrasound guided CNB is a minimally invasive and accurate diagnostic option for the assessment of head and neck lesions, including lymphoma. In comparison to FNA, CNB has achieved a higher accuracy in providing specific diagnoses, detecting malignancy, and identifying true neoplasms. CNB should be the procedure of choice in patients with multiple nondiagnostic FNAs prior to excisional biopsy. These studies have shown that CNB has enhanced accuracy and equivalent safety compared to FNA and lower rates of complications as compared to excisional biopsy (Laryngoscope. 2018;129:2669–2670)

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Mild Obstructive Sleep Apnea in Children: What Is the Best Management Option?

TRIO Best PracticeTRIO Best Practice articles are brief, structured reviews designed to provide the busy clinician with a handy outline and reference for day-to-day clinical decision making. The ENTtoday summaries below include the Background and Best Practice sections of the original article. To view the complete Laryngoscope articles free of charge, visit Laryngoscope. May 2019

Background

Pediatric obstructive sleep apnea (OSA) is characterized by upper airway obstruction, poor sleep, and daytime sequelae such as hyperactivity. Although controversy exists regarding the ideal evaluation for children with sleep-disordered breathing, the severity of OSA is currently determined by full-night polysomnogram (PSG). Mild OSA is defined by an apnea-hypopnea index (AHI) > 1 and <5. The majority (approximately 85%) of healthy school-aged children evaluated by otolaryngologists for tonsil hypertrophy and obstructive symptoms have either primary snoring or nonsevere OSA.

The treatment of mild OSA in children is controversial. There is a lack of data on the natural history of mild sleep apnea. Furthermore, a poor correlation exists between quality of life (QOL) scores and OSA severity; mild OSA in children may have a significant impact on their general health and well-being. High-quality studies comparing observation, medical management, and surgery for mild pediatric OSA are just beginning to emerge. Many of these studies use varied measures to assess outcomes. Thus, it may be difficult for providers treating children with mild OSA to counsel parents on the optimal treatment for their child.

Best Practice

Multiple therapeutic options may be effective for treating mild pediatric OSA including observation, management with anti-inflammatory medications, and surgery (Table 1). Validated instruments that assess symptom burden and the impact of OSA on QOL may be useful in determining which treatment option is most appropriate for the child. Shared decision making between caregiver, child (when appropriate), and physician may be useful in developing a management strategy for mild OSA. Data on the sequelae of mild OSA in children, including the impact of obstruction on cardiovascular parameters and neurocognition, are lacking. Future research is needed to compare long-term outcomes for the different treatment options for mild OSA in children (Laryngoscope. 2018;128:2671–2672).

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Do Preoperative Corticosteroids Benefit Patients with Chronic Rhinosinusitis with Nasal Polyposis?

TRIO Best PracticeTRIO Best Practice articles are brief, structured reviews designed to provide the busy clinician with a handy outline and reference for day-to-day clinical decision making. The ENTtoday summaries below include the Background and Best Practice sections of the original article. To view the complete Laryngoscope articles free of charge, visit Laryngoscope.

Background

Optimizing the surgical field in patients with chronic rhinosinusitis with nasal polyposis (CRSwNP) increases the chances for a safe and efficient surgery. Preoperative medical management, anesthetic choice, patient positioning, and topical vasoconstrictors are methods currently used to mitigate cumbersome bleeding during surgery. Decreased bleeding improves the quality of the optical cavity, thereby enhancing visualization of nearby critical structures.
Pretreatment with corticosteroids is a common practice with the theory that decreased preoperative mucosal inflammation and edema results in less blood loss and better surgical visualization. Several randomized trials have addressed the efficacy of CRSwNP pretreatment with corticosteroids with respect to bleeding loss and surgical field quality.

Best Practice

Preoperative treatment of patients with CRSwNP undergoing endoscopic sinus surgery with corticosteroids is indicated and beneficial. Pretreatment with corticosteroids shortens operative time, likely decreases bleeding, and improves the quality of the surgical field allowing for safe and efficient surgery. There are known risks of administration of systemic corticosteroids, and clinicians must take these into account when evaluating an individual patient. Additionally, future studies are needed to determine the optimal dose and duration of treatment (Laryngoscope. 2019;129:773–774).

Table 1. Summary of Management of Pediatric Obstructive Sleep Apnea

(click for larger image) Table 1. Summary of Management of Pediatric
Obstructive Sleep Apnea

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Is Hearing Preserved Following Radiotherapy for Vestibular Schwannoma?

TRIO Best PracticeTRIO Best Practice articles are brief, structured reviews designed to provide the busy clinician with a handy outline and reference for day-to-day clinical decision making. The ENTtoday summaries below include the Background and Best Practice sections of the original article. To view the complete Laryngoscope articles free of charge, visit Laryngoscope.

Background

A common question by patients with newly diagnosed vestibular schwannomas (VS) is, “Which treatment will best preserve my hearing?” Currently, management of this benign tumor arising from the eighth cranial nerve sheath includes three broad options: observation with serial imaging, microsurgery, and radiotherapy. There are no high-quality, prospective controlled trials comparing outcomes among these three treatment modalities. Therefore, treatment recommendations are largely based on data from single-institution case series. As outcomes of tumor control and facial nerve preservation have improved with modern surgical and radiotherapy techniques, the possibility of hearing preservation (HP) often plays a significant role for patients and physicians making treatment decisions.

The heterogeneity of data poses a major challenge to providing accurate estimates of hearing preservation rates with radiotherapy for VS. Indications for treatment and inclusion criteria vary widely by institution. Radiation may be delivered in a single dose or as many as 30. The radiation source may be cobalt (e.g., GammaKnife surgery [GKS]) or a linear accelerator (e.g., CyberKnife). The methods for reproducing localization differ between techniques as well. Moreover, hearing outcomes are not standardized. For example, some publications simply report the patient’s subjective ability to use the telephone at the first post-treatment visit, whereas other studies utilize audiograms to provide an objective measure of hearing in the treated ear. Traditionally, serviceable hearing has been defined as pure-tone audiometry (PTA) < 50 db with speech discrimination scores (SDS) > 50%, corresponding to American Academy of Otolaryngology–Head and Neck Surgery class A or B, or Garner-Robertson (GR) grade 1 or 2. These differences result in widely varied rates of hearing preservation (between 10% and 90%) after radiotherapy for VS.

Best Practice

The level of evidence of reviewed articles is low. Given that the field involves rapidly developing technology, this is not surprising. Moreover, synthesis of data from case series is vitally important, as controlled studies comparing radiotherapy against microsurgery or conservative management would logistically be very challenging. Evidence from modern, highly conformal, low-dose radiation techniques demonstrate that long-term hearing preservation rates are poor; an approximately 80% hearing preservation rate at two years posttreatment falls to approximately 23% at 10 years. Although radiation therapy provides patients with satisfactory short-term hearing preservation, this treatment modality does not reliably preserve hearing in the long term. It is important when assessing publications in this field to thoroughly scrutinize the methodology, systems of hearing classification, and time to follow-up to provide patients with the most accurate estimations of hearing preservation (Laryngoscope. 2019;129:775–776).

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