Clinical Practice Guideline: Nosebleed (Epistaxis)
01-01-2020 – David E. Tunkel,Samantha Anne,Spencer C. Payne,Stacey L. Ishman,Richard M. Rosenfeld,Peter J. Abramson,Jacqueline D. Alikhaani,Margo McKenna Benoit,Rachel S. Bercovitz,Michael D. Brown,Boris Chernobilsky,David A. Feldstein,Jesse M. Hackell,Eric H. Holbrook,Sarah M. Holdsworth,Kenneth W. Lin,Meredith Merz Lind,David M. Poetker,Charles A. Riley,John S. Schneider,Michael D. Seidman,Venu Vadlamudi,Tulio A. Valdez,Lorraine C. Nnacheta,Taskin M. Monjur
, also known as The primary purpose of this multidisciplinary guideline is to identify quality improvement opportunities in the management of nosebleeds and to create clear and actionable recommendations to implement these opportunities in clinical practice. Specific goals of this guideline are to promote best practices, reduce unjustified variations in care of patients with nosebleeds, improve health outcomes, and minimize the potential harms of nosebleeds or interventions to treat nosebleeds. The target patient for the guideline is any individual aged ≥3 years with a nosebleed or history of nosebleed who needs medical treatment or seeks medical advice. The target audience of this guideline is clinicians who evaluate and treat patients with nosebleed. This includes primary care providers such as family medicine physicians, internists, pediatricians, physician assistants, and nurse practitioners. It also includes specialists such as emergency medicine providers, otolaryngologists, interventional radiologists/neuroradiologists and neurointerventionalists, hematologists, and cardiologists. The setting for this guideline includes any site of evaluation and treatment for a patient with nosebleed, including ambulatory medical sites, the emergency department, the inpatient hospital, and even remote outpatient encounters with phone calls and telemedicine. Outcomes to be considered for patients with nosebleed include control of acute bleeding, prevention of recurrent episodes of nasal bleeding, complications of treatment modalities, and accuracy of diagnostic measures. This guideline addresses the diagnosis, treatment, and prevention of nosebleed. It focuses on nosebleeds that commonly present to clinicians via phone calls, office visits, and emergency room encounters. This guideline discusses first-line treatments such as nasal compression, application of vasoconstrictors, nasal packing, and nasal cautery. It also addresses more complex epistaxis management, which includes the use of endoscopic arterial ligation and interventional radiology procedures. Management options for 2 special groups of patients-patients with hereditary hemorrhagic telangiectasia syndrome and patients taking medications that inhibit coagulation and/or platelet function-are included in this guideline. This guideline is intended to focus on evidence-based quality improvement opportunities judged most important by the guideline development group. It is not intended to be a comprehensive, general guide for managing patients with nosebleed. In this context, the purpose is to define useful actions for clinicians, generalists, and specialists from a variety of disciplines to improve quality of care. Conversely, the statements in this guideline are not intended to limit or restrict care provided by clinicians based on their experience and assessment of individual patients. The guideline development group made
01-01-2020 – John H. Krouse
Highlights from the Current Issue: January 2020
01-01-2020 – John H. Krouse
Clinical Practice Guideline: Nosebleed (Epistaxis) Executive Summary
01-01-2020 – David E. Tunkel,Samantha Anne,Spencer C. Payne,Stacey L. Ishman,Richard M. Rosenfeld,Peter J. Abramson,Jacqueline D. Alikhaani,Margo McKenna Benoit,Rachel S. Bercovitz,Michael D. Brown,Boris Chernobilsky,David A. Feldstein,Jesse M. Hackell,Eric H. Holbrook,Sarah M. Holdsworth,Kenneth W. Lin,Meredith Merz Lind,David M. Poetker,Charles A. Riley,John S. Schneider,Michael D. Seidman,Venu Vadlamudi,Tulio A. Valdez,Lorraine C. Nnacheta,Taskin M. Monjur
Nosebleed, also known as epistaxis, is a common problem that occurs at some point in at least 60% of people in the United States. While the great majority of nosebleeds are limited in severity and duration, about 6% of people who experience nosebleeds will seek medical attention. For the purposes of this guideline, we define the target patient with a nosebleed as a patient with bleeding from the nostril, nasal cavity, or nasopharynx that is sufficient to warrant medical advice or care. This includes bleeding that is severe, persistent, and/or recurrent, as well as bleeding that impacts a patient’s quality of life. Interventions for nosebleeds range from self-treatment and home remedies to more intensive procedural interventions in medical offices, emergency departments, hospitals, and operating rooms. Epistaxis has been estimated to account for 0.5% of all emergency department visits and up to one-third of all otolaryngology-related emergency department encounters. Inpatient hospitalization for aggressive treatment of severe nosebleeds has been reported in 0.2% of patients with nosebleeds. The primary purpose of this multidisciplinary guideline is to identify quality improvement opportunities in the management of nosebleeds and to create clear and actionable recommendations to implement these opportunities in clinical practice. Specific goals of this guideline are to promote best practices, reduce unjustified variations in care of patients with nosebleeds, improve health outcomes, and minimize the potential harms of nosebleeds or interventions to treat nosebleeds. The target patient for the guideline is any individual aged ≥3 years with a nosebleed or history of nosebleed who needs medical treatment or seeks medical advice. The target audience of this guideline is clinicians who evaluate and treat patients with nosebleed. This includes primary care providers such as family medicine physicians, internists, pediatricians, physician assistants, and nurse practitioners. It also includes specialists such as emergency medicine providers, otolaryngologists, interventional radiologists/neuroradiologists and neurointerventionalists, hematologists, and cardiologists. The setting for this guideline includes any site of evaluation and treatment for a patient with nosebleed, including ambulatory medical sites, the emergency department, the inpatient hospital, and even remote outpatient encounters with phone calls and telemedicine. Outcomes to be considered for patients with nosebleed include control of acute bleeding, prevention of recurrent episodes of nasal bleeding, complications of treatment modalities, and accuracy of diagnostic measures. This guideline addresses the diagnosis, treatment, and prevention of nosebleed. It will focus on nosebleeds that commonly present to clinicians with phone calls, office visits, and emergency room encounters. This guideline discusses first-line treatments such as nasal compression, application of vasoconstrictors, nasal packing, and nasal cautery. It also addresses more complex epistaxis management, which includes the use of endoscopic arterial ligation and interventional radiology procedures. Management options for 2 special groups of patients, patients with hemorrhagic telangiectasia syndrome (HHT) and patients taking medications that inhibit coagulation and/or platelet function, are included in this guideline. This guideline is intended to focus on evidence-based quality improvement opportunities judged most important by the working group. It is not intended to be a comprehensive, general guide for managing patients with nosebleed. In this context, the purpose is to define useful actions for clinicians, generalists, and specialists from a variety of disciplines to improve quality of care. Conversely, the statements in this guideline are not intended to limit or restrict care provided by clinicians based upon their experience and assessment of individual patients. The guideline development group made
Plain Language Summary: Nosebleed (Epistaxis)
01-01-2020 – David E. Tunkel,Sarah M. Holdsworth,Jacqueline D. Alikhaani,Taskin M. Monjur,Lisa Satterfield
This plain language summary explains nosebleeds, also known as epistaxis (pronounced ep-ih-stak-sis), to patients. The summary applies to any individual aged 3 years and older with a nosebleed or history of nosebleed who needs medical treatment or wants medical advice. It is based on the 2020 “Clinical Practice Guideline: Nosebleed (Epistaxis).” This guideline uses research to advise doctors and other health care providers on the diagnosis, treatment, and prevention of nosebleeds. The guideline includes recommendations that are explained in this summary. Recommendations may not apply to every patient but can be used to help patients ask questions and make decisions in their own care.
Hypertension and Epistaxis: Why Is There Limited Guidance in the Nosebleed Clinical Practice Guidelines?
01-01-2020 – Spencer C. Payne,David Feldstein,Samantha Anne,David E. Tunkel
Hypertension has long been thought to influence the risk and severity of epistaxis. However, evaluation of the relevant literature reveals articles with methodologic concerns or limited quality. In many instances, these studies are not adequately controlled, and lack of multivariate analyses calls into question any noted association between epistaxis and hypertension. The goal of this commentary is to explain why there is limited guidance about the management of hypertension and the possible association with nosebleed in the 2020 American Academy of Otolaryngology-Head and Neck Surgery Foundation clinical practice guideline for nosebleeds. Background on the literature that describes the association between hypertension and nosebleeds is provided.
Female Authorship of Opinion Pieces in Leading Otolaryngology Journals between 2013 and 2018
01-01-2020 – Ashley L. Miller,Vinay K. Rathi,Stacey T. Gray,Regan W. Bergmark
Although women represent an increasing proportion of the physician workforce, barriers to the professional advancement of women persist, particularly within surgical fields such as otolaryngology. Authorship of scientific opinion articles serves as an important opportunity for professional development. We conducted a retrospective cross-sectional study to characterize the authorship patterns of scientific opinion articles by gender in leading otolaryngology journals between 2013 and 2018. Outcome measures were the number and proportion of female physician first authors and female last authors as compared with the proportion of the otolaryngology workforce. Between 2013 and 2018, female authors accounted for 24.1% of first of multiple authors, 30.4% of sole authors, and 25.3% of last authors. Women were equitably represented in comparison with the proportion of practicing female otolaryngologists (17.1% in 2017). The proportion of female first authorship increased from 20.0% in 2013 to 32.0% in 2018. Additional efforts are necessary to support the equitable advancement of women in otolaryngology.
Ethical Considerations in the Advent of Artificial Intelligence in Otolaryngology
01-01-2020 – Alexandra M. Arambula,Andrés M. Bur
Artificial intelligence (AI) is quickly expanding within the sphere of health care, offering the potential to enhance the efficiency of care delivery, diminish costs, and reduce diagnostic and therapeutic errors. As the field of otolaryngology also explores use of AI technology in patient care, a number of ethical questions warrant attention prior to widespread implementation of AI. This commentary poses many of these ethical questions for consideration by the otolaryngologist specifically, using the 4 pillars of medical ethics-autonomy, beneficence, nonmaleficence, and justice-as a framework and advocating both for the assistive role of AI in health care and for the shared decision-making, empathic approach to patient care.
Effectiveness of Canal Occlusion for Intractable Posterior Canal Benign Paroxysmal Positional Vertigo: A Systematic Review
01-01-2020 – Britta D. P. J. Maas,Hester J. van der Zaag-Loonen,Peter Paul G. van Benthem,Tjasse D. Bruintjes
A last resort for therapy for intractable benign paroxysmal positional vertigo (BPPV) is mechanical occlusion of the posterior semicircular canal. The aim of this review was to assess the effect of posterior canal occlusion for intractable posterior canal BPPV on vertigo and to determine the risk of loss of auditory or vestibular function. A systematic literature search according to the PRISMA statement was performed on PubMed, the Cochrane Library, Embase, Web of Science, and CINAHL. The last search was conducted in June 2018. Cohort studies with original data and case reports describing >5 cases were included if they analyzed the effect of posterior semicircular canal obliteration in adults with intractable posterior BPPV on vertigo. Two authors screened titles and abstracts for eligibility. The first author screened full texts and analyzed the data. Eight retrospective studies met the eligibility criteria. The quality of all individual studies was rated fair. Canal occlusion was performed on 196 patients. All studies reported complete resolution of BPPV in all patients (100%). Among postoperatively tested patients, total loss of auditory function and vestibular function was reported in 2 of 190 (1%) and 9 of 68 (13%), respectively. Posterior semicircular canal plugging resulted in 100% resolution of BPPV in patients with intractable BPPV in all studies. However, the strength of evidence was weak. Potential serious complications, such as deafness and loss of vestibular function, should be taken into account.
Recognizing Persistent Disease in Well-Differentiated Thyroid Cancer and Association with Lymph Node Yield and Ratio
01-01-2020 – Julia E. Noel,Lisa A. Orloff
To establish the association between lymph node yield and ratio in neck dissection for well-differentiated thyroid cancer and risk for persistent postoperative disease. Retrospective cohort study of patients undergoing lymphadenectomy for thyroid carcinoma. Tertiary referral center. Included patients underwent central and/or lateral neck dissection for papillary thyroid carcinoma at our institution between 1994 and 2015. They were divided into a persistent disease group with biochemical and structural disease (49 patients) and a disease-free group with no disease after a minimum 2 years of follow-up (175 patients). Demographic characteristics, adjuvant therapy, tumor, and lymph node features were compared. There were no significant differences in demographic characteristics between the groups. The mean nodal yield of patients with central and lateral neck persistence was significantly lower than that of patients remaining disease free (4.8 vs. 11.9: odds ratio [OR] 0.69; 95% CI, 0.59 to 0.8; Lower lymph node yield and higher node ratio from cervical lymph node dissections are associated with persistent disease and have potential applications in surgical adequacy.
US Medical Trainees’ Knowledge of Human Papilloma Virus and Head and Neck Cancer
01-01-2020 – Benjamin M. Laitman,Lukas Ronner,Kristin Oliver,Eric Genden
Given the increasing incidence of human papilloma virus (HPV)-positive head and neck cancers (HNCs), discussion of this oncologic outcome should be incorporated into HPV vaccine counseling practices. Yet, preliminary evidence shows that knowledge of the association between HPV and HNC is lacking among most medical trainees. To better characterize this deficit, we nationally assessed knowledge of HPV’s association with HNC among medical students and residents across 4 specialties (pediatrics, obstetrics and gynecology, family medicine, and otolaryngology). A total of 3141 responses from 46 states were obtained (n = 402 pediatric residents, n = 346 obstetrics/gynecology residents, n = 260 family medicine residents, n = 87 otolaryngology residents, and n = 2045 medical students). Only 40.3% of surveyed medical students and 56.1% of surveyed obstetrics/gynecology, pediatrics, and family medicine residents identified associations between persistent HPV infection and HNC. When counseling on the vaccine, nonotolaryngology residents more often discussed cervical cancer (99.8%) as compared with HNC (39.7%), commonly because of less HNC knowledge (61.5%). These results suggest that it is imperative to develop educational interventions targeted at medical students and resident trainees on the front line of HPV vaccine counseling and administration.
Approximate Weight of 1:1000 Topical Epinephrine on Wrung-Out Epinephrine-Soaked Pledgets
01-01-2020 – Hannah N. Kuhar,Xiaoxia Han,Donald H. Penning,John R. Craig
Topical 1:1000 epinephrine solution is commonly applied intranasally with cottonoid pledgets in endoscopic sinonasal surgery for local vasoconstriction and hemostasis. Pledgets are typically submerged in epinephrine solution and applied without measurement. Hemodynamic complications have been reported when pledgets have been saturated and not wrung out. The amount of epinephrine absorbed per pledget has not been studied methodically. The purpose of this study was to determine the amount of topical 1:1000 epinephrine remaining on a cottonoid pledget after wringing out the pledget, to simulate intraoperative application.
Tertiary care center.
Sixty 0.5-in × 3-in cottonoid pledgets were submerged in canisters filled with 1:1000 epinephrine solution (1 mg/m
L). Weights of the epinephrine-filled canisters were measured before submerging the pledgets and then after removing and wringing out the pledgets. Measurements were recorded for each pledget after being submerged for 0, 1, and 5 minutes and then wrung out. Mean weights were calculated and compared between the submersion durations. The mean overall weight of epinephrine on a wrung-out pledget was 0.931 mg. Mean weights of epinephrine absorbed onto wrung-out pledgets after submersion for 0, 1, and 5 minutes were 0.914, 0.913, and 0.967 mg, respectively. There were no significant differences in weights based on submersion duration ( Approximately 1 mg of epinephrine was absorbed onto 0.5-in × 3-in cottonoid pledgets when pledgets were wrung out after being submerged in 1:1000 epinephrine, whether being removed from solution immediately or after up to 5 minutes.
Impact of Neck Disability on Health-Related Quality of Life among Head and Neck Cancer Survivors
01-01-2020 – Marci L. Nilsen,Lingyun Lyu,Michael A. Belsky,Leila J. Mady,Dan P. Zandberg,David A. Clump,Heath D. Skinner,Shyamal Das Peddada,Susan George,Jonas T. Johnson
Although neck impairment has been described following surgical resection, limited studies have investigated its prevalence in nonsurgical treatment. The purpose of this study is to determine the prevalence and predictors of neck disability following head and neck cancer (HNC) treatment and to explore its association with quality of life (QOL). Cross-sectional study. HNC survivorship clinic. We identified 214 survivors who completed treatment ≥1 year prior to evaluation in the clinic. Self-reported neck impairment was measured using the Neck Disability Index. QOL was measured using the University of Washington QOL Questionnaire, with physical and social subscale scores calculated. Regression analysis and trend tests were employed to explore associations. Over half of survivors (54.2%) reported neck disability. The odds of neck disability in survivors who received nonsurgical treatment and those who received surgery plus adjuvant treatment were 3.46 and 4.98 times higher compared to surgery alone ( This study revealed a high prevalence of neck disability following nonsurgical treatment. While neck disability is an established sequela of surgical resection, the impact of nonsurgical treatment has gone unrecognized. Early identification and intervention to prevent progression of neck disability are crucial to optimize QOL.
Patient and Provider Perspectives Regarding Enrollment in Head and Neck Cancer Research
01-01-2020 – Andrew G. Shuman,Michele C. Gornick,Collin Brummel,Madison Kent,Kayte Spector-Bagdady,Elliot Biddle,Carol R. Bradford,J. Chad Brenner
The advent of precision oncology complicates how clinicians and participants understand how clinical care and research interface. Here we examine how key stakeholders perceive the utility of, and evaluate the decision to participate in, genomic sequencing head and neck cancer research. The goal of this study was to highlight unique considerations for our community as this type of research proliferates across the country. Prospective multimethod qualitative and quantitative embedded ethics protocol. Single-institution National Cancer Institute-designated academic cancer center. Multimethod study using paired surveys and semistructured interviews among patients and providers involved in a prospective precision head and neck oncology sequencing protocol (116 survey patient-participants, response rate 82%) with 18 interviewees. Participants were generally enthusiastic about enrollment in research, both to help future patients and as a way of giving back to the community. They described reliance on information from and trust in their cancer doctor regarding the decision to participate in research, but paradoxically there was discordance in how doctors and patients reported their respective influence in the decision-making process. Clinicians also stressed the importance in separating clinical and research-informed consent processes, although patients did not describe this tension. As we enter an era of increasing personalized medicine and targeted therapies, the relationship between clinicians, scientists, and patients plays a larger role in how we individualize and contextualize cancer research. Our data are another step toward the ultimate goal of respecting and protecting patients as participants in head and neck translational oncology.
Risks of Neoplasia and Malignancy in Surgically Resected Cystic Parotid Lesions
01-01-2020 – Brian C. Boursiquot,Nancy J. Fischbein,Davud Sirjani,Uchechukwu C. Megwalu
To evaluate the risks of neoplasm and malignancy in surgically treated cystic parotid masses compared with solid or mixed lesions and to evaluate the performance of fine-needle aspiration (FNA) in parotid cysts. Retrospective cross-sectional study. Single-institution academic tertiary care center. Patients without a history of human immunodeficiency virus or head and neck cancer who underwent parotidectomy for parotid masses and had preoperative imaging to characterize lesions as cystic, solid, or mixed (ie, partially cystic and partially solid). We assessed the risks of neoplasia and malignancy, adjusting for age, sex, race/ethnicity, facial nerve weakness, and history of malignancy. We also evaluated the sensitivity and specificity of FNA. We included 308 patients, 27 of whom had cystic parotid masses (5 simple and 22 complex). Cystic masses were less likely to be neoplastic compared to solid or mixed masses (44% vs 97%; odds ratio [OR], 0.03; 95% confidence interval [CI], 0.01-0.07); however, there was no difference in the risk of malignancy (22% vs 26%; OR, 0.81; 95% CI, 0.32-2.10). Cystic masses were more likely to yield nondiagnostic FNA cytology results, but for diagnostic samples, FNA was 86% sensitive and 33% specific for diagnosing neoplasia and 75% sensitive and 83% specific for diagnosing malignancy. In our population, cystic masses undergoing surgery were less likely to be neoplastic but had a similar risk of malignancy as solid masses. The risk of malignancy should be considered in the management of cystic parotid masses.
Preoperative Stellate Ganglion Block for Perioperative Pain in Lateralized Head and Neck Cancer: Preliminary Results
01-01-2020 – Daniel Sharbel,Paramvir Singh,Daniel Blumenthal,James Sullivan,Anterpreet Dua,W. Greer Albergotti,Michael Groves,J. Kenneth Byrd
Patients with head and neck cancer represent a vulnerable population at particular risk of opioid dependence due to frequent histories of substance abuse, requirement of extensive surgery, and the synergistic toxicity of multimodal therapy. Regional anesthetic techniques have been used by other surgical disciplines to facilitate early recovery after surgery and decrease postoperative patient narcotic requirements. This pilot study investigates the efficacy of a preoperative regional analgesia using stellate ganglion block in lateralized head and neck cancer surgery. From our early results, stellate ganglion blockade may hold promise as an effective preoperative intervention for controlling early postoperative pain, lessening narcotic requirements, and improving quality of life.
The First Pull-through Approach to a Tongue Tumor by Giorgio Regnoli in 1838
01-01-2020 – Riccardo F. Mazzola,Giovanna Cantarella
The aim of this article is to describe the first report of a “pull-through” submental approach for excision of a tongue tumor, performed by Giorgio Regnoli in 1838 on a 14-year-old girl affected by a huge swelling of the tongue, which obstructed the upper airway and hindered swallowing and speech. Regnoli made a midline submental incision, divided the mylohyoid muscle and the oral mucosa, and entered the floor of the mouth. The tongue was pulled into the neck through the newly created opening, and the tumor was circumscribed by thread loops to prevent bleeding and was excised. Then the tongue stump was repositioned in the oral cavity. The skin margins were approximated by bandages. Despite limited armamentarium, the operation was successful. The described approach, subsequently named “pull-through,” is still utilized nowadays for selected cases of tongue neoplasms when mandibular splitting is not required.
Surgical Explantation of Bone-Anchored Hearing Devices: A 10-year Single Institution Review
01-01-2020 – Christian G. Fritz,Dennis I. Bojrab,Kenny F. Lin,Christopher A. Schutt,Seilesh C. Babu,Robert S. Hong
To identify clinical variables associated with the decision to surgically discontinue bone-anchored hearing device function. Retrospective chart review. Tertiary neurotology referral center. This study examines surgical interventions performed on existing bone-anchored hearing devices at a single institution from 2008 to 2018. Patient characteristics, indications for implantation, and complications prompting surgical intervention were assessed. Seventy-seven cases were included in this study. Among patients in the younger cohort (<37 years old), 100% (13 of 13) of those discontinuing their device had a contralateral normal-hearing ear. Conversely, 0% (0 of 14) of the younger patients with bilateral hearing loss surgically discontinued their devices. Within the older cohort (≥37 years old), female patients ( Surgical discontinuation is associated with several clinical variables. Targeted interventions that are viable alternatives to removal, such as device relocation, should be presented to younger patients with a contralateral normal-hearing ear who experience persistent complications. Patients with persistent infection in the absence of soft tissue overgrowth would especially benefit from enhanced counseling on proper hygiene.
Appropriateness of Otic Quinolone Use among Privately Insured US Patients
01-01-2020 – Phuong T. Tran,Almut G. Winterstein,Xi Wang,Kiyon Rhew,Patrick J. Antonelli
Considering emerging safety concerns involving otic quinolones, we assessed the extent of otic quinolone use for questionable indications.
Descriptive cross-sectional study of a national sample of privately insured patients.
Outpatient encounters in the United States.
Children and adults with outpatient pharmacy-dispensing claims for new prescriptions of otic or ophthalmic quinolones in 2017 were identified within the IBM Market
Scan Commercial Claims & Encounters and the Medicare Supplemental Database. Each dispensing ≥30 days apart constituted a unique episode. Only claims with supporting ear-related diagnoses on outpatient encounters ±3 days of dispensing were considered. Ophthalmic drops were excluded if eye-related diagnoses were found ±30 days. Prescribing was classified as appropriate, questionable, or undetermined. We found 214,897 episodes in 200,270 patients. Adults were twice as likely as children to have otic treatment with questionable indications (6.2% vs 3.0%). Sensitivity analyses with broader time windows to ascertain diagnoses showed similar proportions of questionable use. Otalgia and cerumen impaction constituted 90% of questionable indications. Family physicians (6.8%) and internists (8.0%) had higher percentages of questionable use than other specialties. Based on the demonstrated risks of quinolone ear drops, opportunities exist to decrease otic quinolone use, especially in adults.
Association between Smoking and 30-Day Outcomes in Otologic Surgery
01-01-2020 – Emily Kay-Rivest,Marco Mascarella,Maida J. Sewitch,François Cloutier,Tamara Mijovic
To determine the effect of current smoking status on 30-day postoperative adverse events in patients undergoing otologic surgery. Retrospective cohort study. Database of the American College of Surgeons National Surgical Quality Improvement Program from 2006 to 2016. Adult patients undergoing middle ear and mastoid surgery were included. Preoperative smoking status was determined, and adverse events within 30 days of surgery were recorded. Descriptive statistics were used to characterize the study sample. Multivariable logistic regression was performed to identify the association between sociodemographic and clinical variables and postoperative adverse events. Population-attributable fractions were then calculated. A total of 10,684 patients who underwent otologic surgery were included, of whom 2036 (19.1%) were smokers. The most commonly performed surgery was tympanoplasty with and without ossicular chain reconstruction, followed by canal wall up tympanomastoidectomy. Adverse events occurred in 221 (2.1%) patients; the most common was superficial wound infections (n = 99, 0.9%). In smokers, the odds ratio for any adverse event was 1.97 (95% CI, 1.42-2.71). The odds ratios (95% CIs) for superficial wound infections, wound dehiscence, and 30-day readmission among smokers were 1.89 (1.32-2.86), 3.92 (1.26-11.60), and 1.84 (1.15-2.87), respectively. The population-attributable fraction for any adverse event in smokers was 15.5%. In patients undergoing otologic surgery, smokers are more likely than nonsmokers to have postoperative adverse events-in particular, wound infections, wound dehiscence, and readmission to hospital.
Should You Follow the Better-Hearing Ear for Congenital Cytomegalovirus Infection and Isolated Sensorineural Hearing Loss?
01-01-2020 – Vanessa Torrecillas,Chelsea M. Allen,Tom Greene,Albert Park,Winnie Chung,Tatiana M. Lanzieri,Gail Demmler-Harrison
To describe the progression of sensorineural hearing loss (SNHL) in the better- and poorer-hearing ears in children with asymptomatic congenital cytomegalovirus (CMV) infection with isolated SNHL. Longitudinal prospective cohort study. Tertiary medical center. We analyzed hearing thresholds of the better- and poorer-hearing ears of 16 CMV-infected patients with isolated congenital/early-onset or delayed-onset SNHL identified through hospital-based CMV screening of >30,000 newborns from 1982 to 1992. By 12 months of age, 4 of 7 patients with congenital/early-onset SNHL developed worsening thresholds in the poorer-hearing ear, and 1 had an improvement in the better-hearing ear. By 18 years of age, all 7 patients had worsening thresholds in the poorer-hearing ear and 3 patients had worsening thresholds in the better-hearing ear. Hearing loss first worsened at a mean age of 2 and 6 years in the poorer- and better-hearing ears, respectively. Nine patients were diagnosed with delayed-onset SNHL (mean age of 9 years vs 12 years for the poorer- and better-hearing ears), 6 of whom had worsening thresholds in the poorer-hearing ear and 1 in both ears. In most children with congenital CMV infection and isolated SNHL, the poorer-hearing ear worsened earlier and more precipitously than the better-hearing ear. This study suggests that monitoring individual hearing thresholds in both ears is important for appropriate interventions and future evaluation of efficacy of antiviral treatment.
Epidemiology of Pediatric Tracheostomy and Risk Factors for Poor Outcomes: An 11-Year Single-Center Experience
01-01-2020 – Aletheia Z. H. Chia,Zhi Min Ng,Yu Xian Pang,Annette H. C. Ang,Cristelle C. T. Chow,Oon Hoe Teoh,Jan Hau Lee
Children with long-term tracheostomies are at higher risk of complications. This study aims to describe the epidemiology, outcomes, and factors associated with successful decannulation in children undergoing tracheostomy. Case series with chart review. Tertiary hospital. A retrospective analysis was conducted on pediatric tracheostomies performed from 2006 to 2016. Demographics, preexisting comorbidities, indications for tracheostomy, and pretracheostomy ventilatory requirements were collected. A multivariate regression model with covariates of age, failure to thrive (FTT), and comorbidities was used to identify factors associated with successful decannulation. Secondary outcomes were ventilation and oxygen requirements at hospital discharge, hospital and intensive care unit length of stay, and complications. In total, 105 patients received a tracheostomy at a median age of 8.0 months (interquartile range, 2.0-45.0). The most common indication was anatomic airway obstruction (55 of 105, 52.5%). Forty-four (41.9%) patients had preexisting FTT. In-hospital mortality was 14 of 105 (13.3%). None were directly related to tracheostomy. At discharge, 40 of 91 (44.0%) and 12 of 91 (13.2%) required home mechanical ventilation and supplemental oxygen, respectively. Forty-one (39%) patients underwent successful decannulation at a median 408 days (interquartile range, 170-1153) posttracheostomy. On adjusted analysis, unsuccessful decannulation was more common in patients with FTT and neurologic comorbidities. Postoperative complications were more common in younger patients and those with a longer time to decannulation. Neurologic comorbidities and FTT were risk factors for unsuccessful decannulation after pediatric tracheostomy. Nutritional interventions may have a role in improving long-term outcomes following pediatric tracheostomies and should be investigated in future studies.
Quality of Life in Children with Sensorineural Hearing Loss
01-01-2020 – Evette A. Ronner,Liliya Benchetrit,Patricia Levesque,Razan A. Basonbul,Michael S. Cohen
To assess quality of life (QOL) in pediatric patients with sensorineural hearing loss (SNHL) with the Pediatric Quality of Life Inventory 4.0 (Peds
QL 4.0) and the Hearing Environments and Reflection on Quality of Life 26 (HEAR-QL-26) and HEAR-QL-28 surveys. Prospective longitudinal study. Tertiary care center. Surveys were administered to patients with SNHL (ages 2-18 years) from July 2016 to December 2018 at a multidisciplinary hearing loss clinic. Patients aged >7 years completed the HEAR-QL-26, HEAR-QL-28, and Peds
QL 4.0 self-report tool, while parents completed the Peds
QL 4.0 parent proxy report for children aged ≤7 years. Previously published data from children with normal hearing were used for controls. The independent In our cohort of 100 patients, the mean age was 7.7 years (SD, 4.5): 62 participants had bilateral SNHL; 63 had mild to moderate SNHL; and 37 had severe to profound SNHL. Sixty-eight patients used a hearing device. Mean (SD) total survey scores for the Peds
QL 4.0 (ages 2-7 and 8-18 years), HEAR-QL-26 (ages 7-12 years), and HEAR-QL-28 (ages 13-18 years) were 83.9 (14.0), 79.2 (11.1), 81.2 (9.8), and 77.5 (11.3), respectively. Mean QOL scores for patients with SNHL were significantly lower than those for controls on the basis of previously published normative data ( It is feasible to collect QOL data from children with SNHL in a hearing loss clinic. Children with SNHL had significantly lower scores on validated QOL instruments when compared with peers with normal hearing.
Adverse Events Associated with Balloon Sinuplasty: A MAUDE Database Analysis
01-01-2020 – Kevin Hur,Marshall Ge,Jeehong Kim,Elisabeth H. Ference
Balloon sinuplasty utilization has increased significantly since its introduction over a decade ago. However, the most common associated complications are still unknown. The objective of this study was to analyze adverse events related to balloon sinuplasty. Retrospective cross-sectional analysis. Food and Drug Administration’s MAUDE database (Manufacturer and User Facility Device Experience; 2008-2018). The MAUDE database was searched for all reports on adverse events involving balloon sinuplasty devices from the 3 leading manufacturers: Acclarent, Entellus, and Medtronic. Reported events were reviewed and categorized. During the study period, there were 211 adverse events from 208 reports divided into the following categories: patient related (n = 102, 48.3%), device related (n = 101, 47.9%), and packaging related (n = 8, 3.8%). Four periprocedural deaths were reported but were not clearly associated with technical complications. The most common device-related complications were guide catheter malfunction (39.6%), balloon malfunction (38.6%), and imprecise navigation (17.8%). The most common patient-related complications were cerebrospinal fluid leak (36.3%), eye swelling (29.4%), and epistaxis (11.8%). A lateral canthotomy was performed in 30.0% of eye-swelling complications. Sixty percent of eye complications occurred during balloon dilation of the maxillary sinus. The years 2014 (n = 48) and 2012 (n = 32) had the highest number of adverse events reported as compared with all other years. The most common adverse events associated with balloon sinuplasty include balloon malfunction, guide catheter malfunction, cerebrospinal fluid leak, and significant eye swelling. Health care providers should discuss these possible complications when consenting patients for balloon sinuplasty.
PHQ-9 and SNOT-22: Elucidating the Prevalence of Depression in Chronic Rhinosinusitis
01-01-2020 – Laura J. Vandelaar,Zi Yang Jiang,Alok Saini,William C. Yao,Amber U. Luong,Martin J. Citardi
Chronic rhinosinusitis (CRS) has been associated with comorbid depression, yet the prevalence of depression among all patients with CRS is not well described. The Patient Health Questionnaire-9 (PHQ-9), a validated instrument for diagnosing depression, has been used to assess depression in a variety of clinical settings. PHQ-9 scores ≥10 are the threshold for a depression diagnosis. The purpose of this study was to assess the prevalence of depression in a rhinology practice and compare the PHQ-9 with the 22-item Sinonasal Outcome Test (SNOT-22). Retrospective chart review. Tertiary rhinology practice. During the 2-month period ending April 30, 2018, all rhinology patients were asked to complete the PHQ-9 and SNOT-22. Among 216 patients, 46 (21.3%) had a self-reported history of depression, and 39 (18.1%) had a PHQ-9 score ≥10. Of the 39 patients screening positive for depression, 18 (41.9%) had no history of depression. Comparison of PHQ-9 with overall SNOT-22 score had a Pearson’s coefficient of 0.632 ( Depression rates (estimated by PHQ-9 responses) among rhinology patients are similar to chronic disease populations; depression may be underdiagnosed in rhinology patients. Higher SNOT-22 scores were associated with higher PHQ-9 scores. Further studies are warranted to understand the impact of comorbid conditions of depression and CRS in patient quality of life.
Five-Year Objective and Subjective Outcomes of Velopharyngeal Surgery for Patients with Obstructive Sleep Apnea
01-01-2020 – Guoping Yin,Mu He,Xin Cao,Jinkun Xu,Yuhuan Zhang,Dan Kang,Jingying Ye
To assess the long-term effects of velopharyngeal surgery on objective and subjective symptoms in patients with obstructive sleep apnea (OSA). Prospective cohort study. University medical center. Eighty-six patients with OSA underwent velopharyngeal surgery, which consisted of revised uvulopalatopharyngoplasty with uvula preservation, with or without concomitant transpalatal advancement pharyngoplasty. The results from polysomnography and the Epworth Sleep Scale after 6 months and 5 years were compared with baseline. Baseline variables were compared between responders and nonresponders. Sixty-three patients were successfully followed up at the end of study. The surgical success rate after 6 months and 5 years was 66.67% (42 of 63) and 60.32% (38 of 63), respectively, with no significant difference ( Velopharyngeal surgery was effective in improving nocturnal respiration and excessive daytime sleepiness in patients with OSA at 6-month and 5-year follow-up. Tonsil size and CT90 could be predictors for surgery responders.
Improving On-time Discharge in Otolaryngology Admissions
08-01-2020 – Steven A. Gordon,David Garber,Zahrah Taufique,Qianhui Shao,Milan R. Amin,J. Thomas Roland,Babak Givi
We conducted a quality improvement project to increase the rate of discharges before noon (DBN) in the otolaryngology department at a tertiary care center. Based on a Plan-Do-Study-Act framework, monthly discharge data and observed-to-expected (O:E) length of stay were collected and shared with the department members monthly. A target of 43% DBN was predetermined by the center (Plan). The following interventions were implemented (Do): discharge planning starting at the time of admission, focus on early attending-to-resident team communication, placement of discharge order prior to rounding, and weekly reminders to the entire department. Discharges were monitored for 3 years. For the year prior to this study, a minority of patients were discharged before noon (12 months: 75 of 190, 36%). During the first 6 months of monitoring (Study), no significant improvement was identified (34 of 95, 36%). After interventions, performance significantly improved (31 months: 250 of 548, 68%). The performance was consistently above the predetermined target of 43%. During the study time, O:E length of stay remained below the predetermined target (O:E ratio, 0.90; hospital target, 0.93). Comprehensive discharge planning beginning at the time of admission, weekly reminders, and improved communication (Act) can help to prioritize DBN and increase the percentage of discharges before noon. By utilizing a quality improvement framework, significant improvements in timely discharge can be achieved and sustained with changes in workflow and departmental culture. These changes can be achieved without increases in resources or prolonging the length of stay.
Global Burden of Head and Neck Cancer: Economic Consequences, Health, and the Role of Surgery
08-01-2020 – Rolvix H. Patterson,Victoria G. Fischman,Isaac Wasserman,Jennifer Siu,Mark G. Shrime,Johannes J. Fagan,Wayne Koch,Blake C. Alkire
We aimed to describe the mortality burden and macroeconomic effects of head and neck cancer as well as delineate the role of surgical workforce in improving head and neck cancer outcomes. Statistical and economic analysis. Research group. We conducted a statistical analysis on data from the World Development Indicators and the 2016 Global Burden of Disease study to describe the relationship between surgical workforce and global head and neck cancer mortality-to-incidence ratios. A value of lost output model was used to project the global macroeconomic effects of head and neck cancer. Significant differences in mortality-to-incidence ratios existed between Global Burden of Disease study superregions. An increase of surgical, anesthetic, and obstetric provider density by 10% significantly correlated with a reduction of 0.76% in mortality-to-incidence ratio ( The mortality burden of head and neck cancer is increasing and disproportionately affects those in low- and middle-income countries and regions with limited surgical workforces. This imbalance results in large and growing economic losses in countries that already face significant resource constraints. Urgent investment in the surgical workforce is necessary to ensure access to timely surgical services and reverse these negative trends.
Temporal Trajectory of Body Image Disturbance in Patients with Surgically Treated Head and Neck Cancer
08-01-2020 – Evan M. Graboyes,Elizabeth G. Hill,Courtney H. Marsh,Stacey Maurer,Terry A. Day,Joshua D. Hornig,Eric J. Lentsch,David M. Neskey,Judith Skoner,Katherine R. Sterba
To characterize the temporal trajectory of body image disturbance (BID) in patients with surgically treated head and neck cancer (HNC). Prospective cohort study. Academic medical center. Patients with HNC who were undergoing surgery completed the Body Image Scale (BIS), a validated patient-reported outcome measure of BID, pretreatment and 1, 3, 6, 9, and 12 months posttreatment. Changes in BIS scores (ΔBIS) relative to pretreatment (primary endpoint) were analyzed with a linear mixed model. Associations between demographics, clinical characteristics, psychosocial attributes, and persistently elevated BIS scores and increases in BIS scores ≥5 points relative to pretreatment (secondary endpoints) were analyzed through logistic regression. Of the 68 patients, most were male (n = 43), had oral cavity cancer (n = 37), and underwent microvascular reconstruction (n = 45). Relative to baseline, mean ΔBIS scores were elevated at 1 month postoperatively (2.9; 95% CI, 1.3-4.4) and 3 (3.2; 95% CI, 1.5-4.9) and 6 (1.8; 95% CI, 0.02-3.6) months posttreatment before returning to baseline at 9 months posttreatment (0.9; 95% CI, -0.8 to 2.5). Forty-three percent of patients (19 of 44) had persistently elevated BIS scores at 9 months posttreatment relative to baseline, and 51% (31 of 61) experienced an increase in BIS scores ≥5 relative to baseline. In this cohort of patients surgically treated for HNC, BID worsens posttreatment before returning to pretreatment (baseline) levels at 9 months posttreatment. However, 4 in 10 patients will experience a protracted course with persistent posttreatment body image concerns, and half will experience a significant increase in BIS scores relative to pretreatment levels.
Navigating the Informed Consent Process When Using Innovative Surgery
25-12-2019 – Daniel Wehrmann,Glenn E. Green,Kevin J. Weatherwax,Andrew G. Shuman
The Utility of Facial Nerve Ultrasonography in Bell’s Palsy
25-12-2019 – Seol-Hee Baek,Yoo Hwan Kim,Ye-Ji Kwon,Joo Hye Sung,Myeong Hun Son,Jung Hun Lee,Byung-Jo Kim
This study aimed to investigate the utility of facial nerve ultrasonography in the functional and structural assessment of early-stage Bell’s palsy and the prognostic value of facial nerve ultrasonography in Bell’s palsy. Prospective longitudinal study. Single center, a university-affiliated neurology clinic. Patients with unilateral Bell’s palsy who had visited our clinic within 3 days of symptom onset were enrolled in this study. Demographic information and House-Brackmann grade were collected. Electrophysiologic studies and facial nerve ultrasonography were then performed. The facial nerves on each side were scanned longitudinally with a 5- to 12-MHz probe. The diameter of the facial nerves with and without the sheath was measured at the proximal and distal portions. Follow-up examinations, including House-Brackmann grade analysis, electrophysiologic studies, and facial nerve ultrasonography, were performed after 2 months. Fifty-four patients with unilateral Bell’s palsy were enrolled, and 22 underwent the follow-up examinations. The diameters of the facial nerves were larger on the affected side than on the unaffected side at the proximal and distal portions ( Ultrasonography could be a useful tool for evaluating the facial nerve in Bell’s palsy. Nevertheless, further studies are needed to demonstrate its prognostic value.
Endoscopic Evidence of Canalicular-Lacrimal Sac Mucosal Folds Mimicking Common Canalicular Obstructions
18-12-2019 – Mohammad Javed Ali
Laryngeal Web in the Pediatric Population: Evaluation and Management
18-12-2019 – Claire M. Lawlor,Natasha D. Dombrowski,Roger C. Nuss,Reza Rahbar,Sukgi S. Choi
To discuss the presentation, evaluation, and management of pediatric laryngeal web. Retrospective case series. Single tertiary care center. All patients with laryngeal web at Boston Children’s Hospital in the past 22 years. No exclusion criteria. Charts mined for age at presentation, presenting symptoms, degree/location of web, associated syndromes, number/type of surgical procedures, and postoperative outcomes. Thirty-seven patients were included (13 male, 24 female). Average age at diagnosis was 3.7 years (0-19.5 years). Mean follow-up was 4.4 years (range, 0-16.4 years). There were 26 congenital webs (70.2%) and 11 acquired webs (29.8%). Presenting symptoms were vocal (29 patients, 78.4%) and respiratory (22 patients, 60%). Underlying syndromes or synchronous airway lesions included the following: premature (n = 5), congenital heart disease (n = 18), subglottic stenosis (n = 5), 22q11.2 deletion syndrome (n = 10), and recurrent respiratory papillomatosis (n = 4). There were 20 type 1 webs, 6 type 2 webs, 8 type 3 webs, and 3 type 4 webs; 10 had subglottic extension of the laryngeal web. Twelve patients were managed conservatively with observation. Eighty-four interventions were performed: 18 open and 66 endoscopic (sharp division, 32; dilation, 33; mitomycin C, 14; laser, 5; keel, 6; triamcinolone injection, 8; stent, 15; removal of granulation tissue, 5). Tracheotomy was required in 11 patients, and 5 patients were decannulated. Voice improved in 12 patients, with respiratory symptoms in 12 patients. Web recurred in 17 patients. One patient died due to airway complications. Pediatric laryngeal web is an uncommon but challenging lesion. Patients need to be evaluated for comorbid syndromes and synchronous airway lesions. Management includes open and endoscopic procedures. Procedures should be tailored to the child’s presentation.
Location of Small Intracanalicular Vestibular Schwannomas Based on Magnetic Resonance Imaging
18-12-2019 – Nicholas Koen,Chandler Shapiro,Elliott D. Kozin,Mary E. Cunnane,Aaron K. Remenschneider,Michael J. McKenna,David H. Jung
Vestibular schwannomas (VSs) were proposed to arise from the glial-Schwann cell junction within the internal auditory canal (IAC). However, otopathology studies indicate that VS may arise anywhere along the course of the vestibular nerve. Recent studies suggested that the majority of tumors are located centrally within the IAC with an equal distribution near the porus acusticus and the fundus. However, these studies analyzed tumors of all sizes, obscuring their precise origin. Herein, we aim to quantify the position of small intracanalicular tumors (<5 mm), assessing hearing outcomes and growth patterns in relation to tumor position. Of the 38 small intracanalicular tumors analyzed, 61% originated closest to the fundus, 34% at the midpoint, and only 5% closest to the porus acusticus. Tumors were observed with serial magnetic resonance imaging for 3.37 ± 2.65 years (mean ± SD) without intervention. Our findings indicate a lateral predominance of small VS within the IAC, an independence between tumor location and hearing outcomes, and further support the slow natural progression of VS.
Psychometric Evaluation of the Nasal Obstruction Symptom Evaluation Scale for Pediatric Patients
11-12-2019 – Hena Din,Nour Bundogji,Shelby C. Leuin
To evaluate the psychometric properties of the nasal obstruction symptom scale within a sample of pediatric patients undergoing septoplasty or functional septorhinoplasty. This was a prospective study with nasal obstruction symptom scale evaluations conducted pre- and postoperatively. A tertiary care pediatric hospital. Pediatric patients underwent septoplasty or functional septorhinoplasty (FSR) from January 2013 to January 2017. Reliability of the scale was assessed through measures of internal consistency. In addition, item response models of each item were evaluated to assess how well each item captured individuals with varying levels of nasal obstruction. Study authors assessed face validity, and construct validity was assessed by correlation measures between items and exploratory factor analysis. A total of 136 patients, ages 8 to 18 years with a mean age of 15.7 ± 2.1 years, completed pre- and postoperative evaluations. Internal consistency of the scale was high (Cronbach’s α = 0.83). Predominantly a unidimensional scale resulted from exploratory factor analyses. Item response models indicate questions capture low to moderate levels of nasal obstruction within this population. Additional analyses show the scale functions similarly between septoplasty and FSR patients. The Nasal Obstruction Symptom Evaluation scale is a robust tool that may be incorporated as a subjective evaluation of severity of nasal obstruction among pediatric patients undergoing a septoplasty or functional septorhinoplasty.
Evaluation of Tonsillotomy Effects on Pharyngeal Volume and Compliance in Children
11-12-2019 – Abeer Al Ali,Emilie Bois,Imene Boujemla,Natacha Teissier,Thierry Van den Abbeele,Christophe Delclaux,Plamen Bokov
Our objective was to assess whether adenotonsillotomy improved pharyngeal compliance, which is a risk factor for sleep-disordered breathing. Otherwise healthy children underwent Obstructive Sleep Apnea (OSA)-18 questionnaire and a pre- and postoperative acoustic pharyngometry in both sitting and supine positions, allowing the measurement of the volume of the palatine tonsil region and pharyngeal compliance. Thirty-five children (median age 5.3 years) were enrolled; they were reevaluated at a median of 18 days (25th-75th percentiles, 15-25) after surgery. Participants were compared according to a normal (n = 18) or an increased (n = 17) preoperative pharyngeal compliance. Surgery was associated with a significant decrease in OSA-18 and Brodsky scores, with a median increase in palatine volume of 0.13 cm
Adenotonsillectomy for the Treatment of Obstructive Sleep Apnea in Children with Prader-Willi Syndrome: A Meta-analysis
11-12-2019 – Chia-Hsuan Lee,Wei-Chung Hsu,Jenq-Yuh Ko,Te-Huei Yeh,Ming-Tzer Lin,Kun-Tai Kang
Adenotonsillectomy outcomes in obstructive sleep apnea (OSA) treatment among children with Prader-Willi syndrome (PWS) remain unclear. This study aimed to elucidate the effectiveness of adenotonsillectomy in OSA treatment among children with PWS. PubMed, MEDLINE, Embase, and Cochrane Review up to February 2019. The registry number of the protocol published on PROSPERO was CRD42015027053. Two authors independently searched the relevant database. Polysomnography outcomes in these children were examined, including net postoperative changes in the apnea-hypopnea index (AHI), net postoperative changes in the minimum and mean oxygen saturation, the overall success rate for a postoperative AHI <1, and the overall success rate for a postoperative AHI <5. Six studies with 41 patients were analyzed (mean age, 5.0 years; 55% boys; mean sample size, 6.8 patients). All children had PWS and received adenotonsillectomy for the treatment of OSA. The AHI was 13.1 events per hour (95% CI, 11.0-15.1) before surgery and 4.6 events per hour (95% CI, 4.1-5.1) after surgery. The mean change in the AHI was a significant reduction of 8.0 events per hour (95% CI, -10.8 to -5.1). The overall success rate was 21% (95% CI, 11%-38%) for a postoperative AHI <1 and 71% (95% CI, 54%-83%) for a postoperative AHI <5. Some patients developed velopharyngeal insufficiency postoperatively. Adenotonsillectomy was associated with OSA improvement among children with PWS. However, residual OSA was frequently observed postoperatively in these patients.
Outcomes of Overlapping Surgery in Otolaryngology
11-12-2019 – Pedrom C. Sioshansi,Robert K. Jackler,Edward J. Damrose
To compare outcomes in otolaryngology between overlapping and nonoverlapping surgeries. Retrospective cohort study. Tertiary referral center. All patients undergoing otolaryngologic procedures at Stanford University Hospital between January 2009 and June 2016 were included (n = 13,479). Cases were divided into 2 cohorts: overlapping (n = 1806, 13.4%) vs nonoverlapping (n = 11,673, 86.6%). Variables reviewed were type of operation performed, multidisciplinary team involvement, complications, reoperations, readmissions, and deaths. The total complication rate over 7.5 years studied was 3.3% (n = 450). Complication rates were lower for overlapping cases (0.77%) compared to nonoverlapping cases (3.73%) with an odds ratio of 0.2014, which was statistically significant ( Patients undergoing overlapping surgery had lower overall complication rates, lower reoperation rates, lower readmission rates, and no mortalities. The institutional experience presented provides evidence that with appropriate patient and case selection, otolaryngologists may safely perform overlapping surgery without increased risk of adverse patient outcomes.
Distance Traveled to Head and Neck Cancer Provider: A Measure of Socioeconomic Status and Access
04-12-2019 – Sean T. Massa,Adam P. Liebendorfer,Jose P. Zevallos,Angela L. Mazul
Improved head and neck cancer survival has been associated with traveling farther distances for treatment, potentially due to patients seeking higher-quality facilities. This study investigates the role of both facility and confounding patient factors on this relationship. Review of national registry data. National Cancer Database. Adults with head and neck cancer diagnosed from 2004 to 2014 were identified. Overall survival was compared among distance-to-facility quartiles via univariate and multivariate survival models. Then, the analysis was stratified by facility and patient factors, and the association between distance and survival was compared among strata. Overall survival was worst in the shortest-distance quartile (<5 miles; median survival, 80.7 months; 95% CI, 79.2-82.3), while other distance groups showed similar survival (range, 96.4-104 months). This finding remained in the multivariate model (adjusted hazard ratio vs first distance quartile: 0.88; 95% CI, 0.87-0.89). The association between survival and distance persisted in all subgroups when stratified by facility volume and type (adjusted hazard ratio range, 0.82-0.91), suggesting that facility quality does not fully account for this association. When stratified by income, distance remained statistically associated with survival but with a smaller effect size than that of income. The association between distance to treating facility and head and neck cancer survival is limited to patients with worse survival outcomes living within 5 miles of the facility and is not fully explained by measures of facility quality.
Dysphagia Screening for Pneumonia Prevention in a Cancer Hospital: Results of a Quality/Safety Initiative
04-12-2019 – Barbara Ebersole,Miriam Lango,John Ridge,Elizabeth Handorf,Jeffrey Farma,Sarah Clark,Nausheen Jamal
Hospital-acquired aspiration pneumonia remains a rare but potentially devastating problem. The best means by which to prevent aspiration in a cancer hospital population has not been evaluated. The aim of this study was to evaluate the impact of dysphagia screening on aspiration pneumonia rates in an acute care oncology hospital. A prospective single-institution quality improvement dysphagia screening protocol at a comprehensive cancer center. Effect of dysphagia screening implemented in 2016 on hospital-acquired aspiration pneumonia rates coded “aspiration pneumonitis due to food/vomitus” was compared with rates from 2014 to 2015 prior to implementation. Screening compliance, screening outcomes, patient demographics, and medical data were reviewed as part of a post hoc analysis. Of 12,392 admissions in 2014 to 2016, 97 patients developed aspiration pneumonia during their hospitalization. No significant change in aspiration pneumonia rate was seen during the dysphagia screening year when compared to prior years (baseline, 7.36; screening year, 8.78 per 1000 discharges; Nursing-initiated dysphagia screening did not decrease aspiration pneumonia rates. The causes of aspiration-associated pneumonia were heterogeneous. Aspiration of intestinal contents is a more common source of hospital-acquired pneumonia than oropharyngeal dysphagia.
Cytotoxicity of Ear Drop Excipients in Human and Mouse Tympanic Membrane Fibroblasts
04-12-2019 – Carolyn O. Dirain,David N. Karnani,Patrick J. Antonelli
Commercial ear drops contain ingredients reported to be inactive. We sought to evaluate such excipients for possible cytotoxicity on human and mouse tympanic membrane (TM) fibroblasts. Prospective, in vitro. Tertiary academic center. Mouse and human TM fibroblasts were treated with 1:10 dilutions of benzalkonium chloride (BKC) 0.0025%, 0.006%, or 0.01%; benzyl alcohol 0.9%; polysorbate 80 (PSB) 2.5%; glycerin 2.4%; povidone 0.2%; or water (control), twice within 24 hours or 4 times within 48 hours, for 2 hours each time. Cells were placed back in growth media after the treatments. Cells were observed with phase-contrast microscopy until the cytotoxicity assay was performed. Mouse fibroblasts had lower survival in only the PSB-treated cells compared to the control ( Polysorbate 80 and benzalkonium chloride, at concentrations found in commercial ear drops, may be cytotoxic to human and mouse TM fibroblasts. “Inactive” ingredients may need to be considered when evaluating clinical outcomes with commercial ear drops.
Laryngotracheal Stenosis in Early vs Late Tracheostomy: A Systematic Review
27-11-2019 – Steven D. Curry,Paul J. Rowan
For critically ill patients undergoing long-term mechanical ventilation, to determine whether early conversion from endotracheal intubation to tracheostomy reduces the incidence of laryngotracheal stenosis. MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, and the Cumulative Index to Nursing and Allied Health Literature. A systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and an assessment of bias were performed. Included studies reported outcomes of patients who were converted from endotracheal intubation to tracheostomy, compared early vs late tracheostomy, and reported the incidence of laryngotracheal stenosis and details of postoperative surveillance. Data were also collected for intensive care setting, method of tracheostomy, and timing of tracheostomy. Seven articles met inclusion criteria: 2 randomized trials, 2 quasi-randomized trials, 1 prospective cohort, and 2 retrospective cohorts. A total of 966 patients were included in this analysis (496 in the early tracheostomy group and 470 in the late tracheostomy group). The mean incidence of laryngotracheal stenosis was 8.9% (range, 0%-20.8%), with a mean incidence of 8.1% in early tracheostomy groups and 10.9% in late tracheostomy groups. In studies with the least risk of bias, there were no differences in the incidence of laryngotracheal stenosis in patients who underwent early vs late tracheostomy. In critically ill patients undergoing long-term mechanical ventilation, early conversion to tracheostomy within 7 days of intubation does not significantly decrease the risk of laryngotracheal stenosis compared to later conversion as defined by the included studies.
The Role of Genioglossus Activity in Predicting Uvulopalatopharyngoplasty Outcomes
27-11-2019 – Di Zhao,Yanru Li,Yue Qu,Junbo Zhang,Xin Cao,Jingying Ye
The aim of this study was to evaluate the association between genioglossus activity during sleep onset and the outcome of uvulopalatopharyngoplasty (UPPP) in patients with obstructive sleep apnea. Case series with planned data collection. Sleep medical center. Forty-four patients with obstructive sleep apnea underwent overnight polysomnography with synchronous genioglossus electromyography (GGEMG) with intraoral electrodes. In addition, all patients underwent revised UPPP with uvula preservation and were followed up with polysomnography at least 3 months after surgery. Twenty-five patients (56.8%) were responders. Multiple regression analysis revealed that increasing tonsil size (odds ratio [OR], 0.086; Sleep-onset GGEMG and tonsil size are both important in deciding outcomes of UPPP. Patients with tonsil size III or IV and higher sleep onset may be more suitable candidates for UPPP because of the higher probability of surgical success.
Prevalence of Pediatric Dizziness and Imbalance in the United States
07-11-2019 – Jacob R. Brodsky,Sophie Lipson,Neil Bhattacharyya
Understand the prevalence of vestibular symptoms in US children. Cross-sectional analysis. 2016 National Health Interview Survey. Responses from the 2016 National Health Interview Survey for children ages 3 to 17 years were examined to determine the prevalence of vestibular symptoms and provider-assigned diagnoses. Dizziness or imbalance was reported in 3.5 (95% confidence interval, 3.1-3.9) million patients (5.6%) with a mean age of 11.5 years. Dizziness was reported in 1.2 million patients (2.0%) with a mean age of 12.7 years and balance impairment in 2.3 million patients (3.7%) with a mean age of 10.6 years. Prevalence of dizziness and imbalance did not vary by sex ( The national prevalence of childhood vestibular symptoms is more common than previously thought. Reported diagnoses varied greatly from the literature, suggesting a need for increased awareness of causes of vestibular symptoms in children.
Reflections: Starting an Otolaryngology Medical Student Interest Group
07-11-2019 – Amanda Hu
A decline in applicants for otolaryngology residency spots has been reported. Several possible factors include the lack of exposure to otolaryngology, the lack of role models, work-life balance, and the competitiveness of otolaryngology as a deterrent. Our institution started a medical student interest group to address several of these factors. Key stakeholders who were engaged in this process included medical students, otolaryngology residents, and faculty members. Sustainability of the interest group was investigated with funding and succession planning. Early exposure to otolaryngology through shadowing in the operating room and research projects were initiated with a database on a website. Logistics of starting a club and organizing a clinical skills session were discussed. Awareness of our specialty and branding of the interest group as otolaryngology versus ear, nose, and throat were debated. Starting a medical student interest group in otolaryngology may be an excellent way to foster interest in our specialty.
Surgical Instrument Optimization to Reduce Instrument Processing and Operating Room Setup Time
23-10-2019 – Lauren Crosby,Eric Lortie,Brian Rotenberg,Leigh Sowerby
As health care expenditures rise, novel ways to increase efficiency are sought. The operating room (OR) represents an area where there is opportunity to optimize work flow and supply use. Evidence suggests that instrument redundancy in the OR tends to be high and that direct cost savings can be achieved by “optimizing” surgical trays. The purpose of this study was to quantify the potential time savings associated with surgical tray optimization. Instrument utilization was reviewed for 4 procedures: tonsillectomy, sinus surgery, septoplasty, and septorhinoplasty. Instruments used in <20% of cases were excluded. Data on tray assembly time in the central processing department and instrument setup time in the OR were prospectively collected over a 3-month period before and after tray optimization. Student's Tray assembly times were found to be significantly shorter following optimization, with percentage reduction in time ranging from 58% to 66% ( Tray optimization may reduce stress and adverse events and allow managers to better estimate staffing requirements. Cost-benefits could not be determined given a limited understanding of how departments choose to redistribute time savings. Measurable and significant time savings can be achieved by assessing instrument utilization rates and reducing tray redundancy, leading to lower performance variability and improved efficiency.