Seven Pearls from the Winston-Salem Area ENT Surgery Journal Club

Last month, ENT surgeons gathered together to discuss the latest research on chemotherapy de-escalation for oropharyngeal cancer, surgical outcomes for head and neck microvascular reconstruction, surgical options for sleep apnea, and cochlear implants for single-sided hearing loss. We’ve rounded up some key takeaways, plus links to the original journal articles.

 

‘Journal Club’ is an opportunity for ENT surgeons at Wake Forest University and surgeons in private practice throughout the Triad to come together, says organizer Jamey Cost, MD  of  Carolina Ear Nose & Throat. The doctors discuss insights from recent clinical research that can help them achieve even better surgical outcomes for their patients. “It’s also a time for Triad-area ENT doctors to get to know Wake Forest faculty whom they might be referring patients to,” says Dr. Cost. Her co-organizer is Dr. Dale Brown.

 

The Journal Club hasn’t gathered together face-to-face since the COVID-19 pandemic began, and the doctors seemed happy to reconnect personally. To celebrate, we teamed up with Chris Horton at Hemostasis and Carol Seago at Grace Medical to host a midweek Mexican fiesta. Here’s a taste of the hot research topics the doctors discussed over sizzling hot fajitas.

 

Chemoradiation De-Escalation after Surgery for Oropharyngeal Cancer

First up, Dr. Adam Zanation of Carolina Ear Nose & Throat, who reviewed Phases 2 and 3 of clinical trials conducted by researchers at Mayo Clinic and recently published in the International Journal of Radiation Oncology Biology Physics.

ENT Background

In the past, most people who got oropharyngeal cancer were long-term smokers who were old. Now, younger people sometimes get oropharyngeal cancer because of the sexually transmitted human papillomavirus (HPV). Treatment outcomes for about 95 percent of oropharyngeal cancer patients are good. Care teams typically remove the cancer with a minimally invasive surgery called transoral robotic surgery (TORS) and follow up with chemotherapy and radiation. But the radiation treatment has side effects like “dry mouth, throat pain, swallowing difficulty and taste changes, which can lead to emergency room visits, hospitalization and significantly decreased quality of life,” explains a Mayo Clinic article. Now that younger people with many years to live are getting HPV-associated oropharyngeal cancer, “radiation oncologists are focusing more than ever on making the therapy less painful and less detrimental to quality of life,” the article continues.

Clinical Research Question

Mayo Clinic researchers wanted to know if lower doses of radiation and chemotherapy than are typically administered post-surgery would successfully treat the cancer and result in fewer toxic side effects. Some patients received 1.5-Gy fractions twice per day over 2 weeks with weekly docetaxel (15 mg/m2) and others received 36 Gy in 1.8-Gy fractions twice per day over 2 weeks with the same chemotherapy, depending on what kind of treatment their case required post surgery. Doctors call the smaller doses “DART,” which stands for De-Escalated Adjuvant Radiation Therapy. 

Study Results & Insights

The lower chemoradiation both treated the cancer and resulted in fewer toxic side effects and better quality of life. In light of this study, treating patients with HPV-positive oropharyngeal cancer should involve a “decision tree” that factors in whether they have 40 or 50 years left to live, Dr. Zanation told the journal club. And, deploying DART in younger patients would give doctors more leeway to treat the same patients with higher doses of chemoradiation should the cancer return, he pointed out.

 

Improving Head and Neck Microvascular Reconstruction Surgery Outcomes

The next presenter was Dr. Allison Slijepcevic, Assistant Professor of Otolaryngology at Wake Forest University School of Medicine. She was a co-author of the “Factors Impacting Discharge Destination Following Head and Neck Microvascular Reconstruction,” a retrospective study published earlier this year in The Laryngoscope.

ENT Background

Sometimes, surgeons must remove tissue from the head and neck that has been damaged by trauma or cancer. Once they remove the damaged tissue, they must restore blood supply to the surgical site. To accomplish this, they often perform microvascular free flap reconstruction, a technique that involves taking a small piece of tissue from a completely different part of the body (such as the thigh or abdomen) and transplanting it to the head and neck area. It is a delicate surgical procedure that requires specialized training and expertise.

Clinical Research Question

Researchers wanted to know whether doing a flap procedure affects surgical outcomes, and what other variables might be involved. To do this, they did a retrospective study of 1,972 patients who had undergone microvascular free flap reconstruction over 10 years. Researchers used “discharge destination” (home, skilled nursing facility, or an inpatient rehab facility) as an indicator of post-op outcomes. 

Study Results & Insights

Simply put, “You can’t blame the flap,” Dr. Slijepcevic told the journal club. “There was no correlation with the anatomic site, free flap donor selection, or free flap survival and discharge destination,” the study concludes. “Patient age, operative duration, and occurrence of a medical complication postoperatively did correlate with discharge destination.”

Factors that did influence discharge destination included:

• • Age

• • Whether the operation lasted more than 10 hours

• • History of cardiac disease

• • Alcohol withdrawal

• • Thromboembolism

• • Pulmonary complication

• • Cardiac complication

• • Cerebral vascular event 

What does this mean for primary care doctors and surgical teams planning for post-operative care? Study results show that you can plan based on the patient’s medical history prior to the procedure. For example, if you see a patient in their 80s who has a history of stroke, study results indicate that you can be pretty sure they’ll need to go to an inpatient rehab facility or a SNF after the surgery, Dr. Slijepcevic told journal club attendees. Patients who had flaps from large donor sites had a slightly higher incidence of discharge to facilities, she noted.

 

Tonsillectomy vs Modified UPPP for Obstructive Sleep Apnea

“I’m a general ENT, so I’m going to take this discussion down a level,” joked the next presenter, Dr. William Falls of Carolina Ear Nose & Throat. Dr. Falls reviewed “Effectiveness of Tonsillectomy vs Modified Uvulopalatopharyngoplasty in Patients With Tonsillar Hypertrophy and Obstructive Sleep Apnea,” which appeared in JAMA late last year.

ENT Background

Obstructive sleep apnea (OSA) happens when the muscles at the back of the throat fail to keep the airway open while a person is sleeping. As a result, the sleeper’s breathing repeatedly stops and starts as blood oxygen levels fall and the sleeper gasps for breath. A person who endures severe OSA never gets a good night’s sleep, which can cause long-term health problems like tiredness during the day, high blood pressure, type 2 diabetes, and heart disease.

Sometimes, lifestyle changes or a Continuous Positive Airway Pressure (CPAP) machine remedy OSA, but sometimes surgery is required to solve the problem. This paper caught  Dr. Falls’ attention because, as a Navy surgeon, he served as an ENT surgeon aboard the amphibious assault ship U.S.S. Nassau and in naval hospitals. In this role, he treated sailors and soldiers who had sleep apnea and for whom a CPAP machine was impractical. At the time, the protocol for treating OSA was modified uvulopalatopharyngoplasty (mUPPP), and Dr. Falls performed many of these procedures.

“There is a lot of pain associated with UPPP, much worse than tonsillectomy,” Dr. Falls told the journal club.     

Clinical Research Question

Researchers wanted to learn which surgery was most effective for treating OSA: tonsillectomy (TE) or mUPPP. During a randomized clinical trial of 93 OSA patients, some had mUPPP and some had TE alone. Researchers hypothesized that mUPPP would be a superior strategy to TE for resolving OSA. 

Study Results & Insights

Welp. It wasn’t. The study revealed that mUPPP wasn’t superior to TE. “At the very least, I would look at this [study] and say that tonsillectomy is a very viable, much less painful option for solving the sleep apnea problem,” Dr. Falls told his ENT colleagues.

Limitations: The study didn’t consider multi-level obstruction, Dr. Falls noted, and medicine in general lacks first-rate diagnostic tools for determining the best way to treat OSA. The world needs more ENT specialists working in sleep medicine, he noted, and it’s a great practice area for young doctors just starting out.

 

Do Cochlear Implants Have Beneficial Effects on Single-Sided Hearing Loss?

Wrapping up our ENT evening was Dr. Pedrom Sioshansi, assistant professor of otolaryngology at Wake Forest University School of Medicine. He reviewed “Cochlear Implantation in Adults With Single-Sided Deafness: A Systematic Review and Meta-analysis,” which appeared in Otolaryngology Head and Neck Surgery earlier this year.

ENT Background

Since the early 1980s, otologists have used cochlear implants to treat hearing loss so severe that conventional hearing aids can’t help. Surgeons implant the device’s internal component behind the ear and thread an electrode array into the inner ear’s cochlea to directly stimulate the auditory nerve. A person with cochlear implants is still hearing-impaired and struggles with challenges hearing people do not, but they often help with overall communication.

For more than 40 years, FDA has approved cochlear implants for double-sided deafness only, so their capacity to help with single-sided deafness hasn’t been studied. In 2019, FDA approved the practice of placing one cochlear implant in cases of single-sided deafness (SSD). People with SSD can hear out of one ear, but they struggle with localizing sounds and communicating in noisy environments.       

Clinical Research Question

Researchers conducted a journal article review to determine whether ipsilateral cochlear implants–devices placed on one side only–helped patients with SSD.

Study Results & Insights

“To cut to the chase, they did improve SSD in the four measurement areas researchers looked at: speech perception, tinnitus control, sound localization, and quality of life,” Dr. Sioshansi told the journal club. 

He thinks the article underestimates the benefits, which doctors will be able to show more clearly with further studies. The bad news is that some insurers haven’t approved ipsilateral implants for single-sided deafness, which means that some patients don’t have access to the treatment. One journal club attendee said that he and other doctors are working to change that in North Carolina by sending data to insurers and sitting on peer review boards to improve patient access to good hearing health care.