Otolaryngology Head and Neck Surgery

Otolaryngology Head and Neck Surgery

Highlights from the Current Issue: October 2019

01-10-2019 – John H. Krouse

Journal Article

Understanding the Minimal Clinically Important Difference (MCID) of Patient-Reported Outcome Measures

04-06-2019 – Ahmad R. Sedaghat

Journal Article

The minimal clinically important difference (MCID) of a patient-reported outcome measure (PROM) represents a threshold value of change in PROM score deemed to have an implication in clinical management. The MCID is frequently used to interpret the significance of results from clinical studies that use PROMs. However, an understanding of the many caveats of the MCID, as well as its strengths and limitations, is necessary. The objective of this article is to provide a review of the calculation, interpretation, and caveats of MCID. MEDLINE and PubMed Central. Literature search-including primary studies, review articles, and consensus statements-pertinent to the objectives of this review using PubMed. The MCID of a PROM may vary depending on the patients and clinical context in which the PROM is given. The primary approaches for calculating MCID are distribution-based and anchor-based methods. Each methodology has strengths and limitations, and the ideal determination of a PROM MCID includes synthesis of results from both approaches. The MCID of a PROM is also not perfect in detecting patients experiencing a clinically important improvement, and this is reflected in its accuracy (eg, sensitivity and specificity). Interpretation or application of MCID requires consideration of all caveats underlying the MCID, including the patients in whom it was derived, the limitations of the methodologies used to calculate it, and its accuracy for identifying patients who have experienced clinically significant improvement.

Systematic Review of Validated Quality of Life and Swallow Outcomes after Transoral Robotic Surgery

23-04-2019 – Alexa Castellano,Arun Sharma

Journal Article

To systematically review the available evidence on the effects of transoral robotic surgery (TORS) on the posttreatment quality of life (QOL) and swallow function of patients with head and neck cancer. PubMed and Ovid electronic databases were searched from inception to July 6, 2016. Specific database functions were applied to maximize the search. Articles in the database were reviewed for inclusion by 2 independent reviewers according to predetermined eligibility criteria. The references of relevant articles were then hand-searched to identify additional manuscripts. For included articles, the study characteristics and relevant data were extracted. Of 103 articles screened, 20 reporting validated measures of QOL and/or swallow outcomes for 659 patients were eligible for inclusion. Fourteen were observational studies or case series and did not compare the TORS group with another intervention. Two were prospective nonrandomized clinical trials that compared outcomes between TORS and primary chemoradiation. Four were cohort studies comparing TORS with other treatment approaches and modalities, including open surgical approaches and transoral laser microsurgery. Overall, most patients who underwent TORS ± adjuvant therapy reported a return to baseline QOL and swallow function by 6 to 12 months posttreatment. Several studies demonstrated superior QOL and swallowing outcomes when compared with primary chemoradiation or open approaches. Available evidence suggests that patients who undergo TORS for head and neck cancer have good QOL and swallowing outcomes after treatment, but outcomes are dependent on baseline function, T stage, and adjuvant treatment status.

Complications and Outcomes of Chimeric Free Flaps: A Systematic Review

21-05-2019 – Abhinav R. Ettyreddy,Collin L. Chen,Joseph Zenga,Laura E. Simon,Patrik Pipkorn

Journal Article

Ablations of locally advanced or recurrent head and neck cancer commonly result in large composite orofacial defects. Chimeric flaps represent a unique surgical option for these defects, as they provide diverse tissue types from a single donor site. The purpose of the study was to consolidate the literature on chimeric flaps with regard to postoperative complication rates to help inform surgical decision making. The librarian created search strategies with a combination of keywords and controlled vocabulary in Ovid Medline (1946), Embase (1947), Scopus (1823), Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, and Clinicaltrails.gov (1997). Candidate articles were independently reviewed by 2 authors familiar with the subject material, and inclusion/exclusion criteria were uniformly applied for article selection. Articles were considered eligible if they included patients who received a single chimeric flap for reconstruction of head and neck defects and if they provided data on complication rates. A total of 521 chimeric flaps were included in the study. The major complication rate was 22.6%, while the minor complication rate was 14.0%. There were 7 flap deaths noted in the series. Median operative time and harvest time were 15.0 and 2.5 hours, respectively. Chimeric flaps represent a viable option for reconstruction of complex head and neck defects and have complication rates similar to those of double free flaps and single free flaps with locoregional flap while only modestly increasing total operative time.

The Influence of Cochlear Implantation on Tinnitus in Patients with Single-Sided Deafness: A Systematic Review

07-05-2019 – Nicole Peter,Nuwan Liyanage,Flurin Pfiffner,Alexander Huber,Tobias Kleinjung

Journal Article

This systematic review provides an overview of the available studies (published by January 29, 2018) with descriptive data analysis about the influence of cochlear implantation on tinnitus in patients with single-sided deafness (SSD). PubMed, EMBASE, Web of Science, Cochrane Library, and Google Scholar. Original studies about the influence of cochlear implantation on tinnitus, measured with different tinnitus questionnaires or visual analog scale, in patients with SSD were included. The pre- and postimplantation tinnitus scores of the included studies were extracted for the further systematic review. The systematic search yielded 1028 studies. After evaluating titles, abstracts, and full texts, 1011 of these were dismissed. From the remaining 17 studies, 4 showed a low directness of evidence or high risk of bias and were therefore excluded. Due to the nature of cochlear implantation in SSD, only cohort studies and no randomized trials exist, which limits the evaluation in a systematic review. Generally, the mean tinnitus questionnaire scores decreased after cochlear implantation in these 13 studies with a total of 153 patients. The most widely used tinnitus questionnaire was the Tinnitus Handicap Inventory. In these studies, 34.2% of patients demonstrated complete suppression, 53.7% an improvement, 7.3% a stable value, and 4.9% an increase of tinnitus, and none of the patients reported an induction of tinnitus. This review shows a clear improvement of tinnitus complaints after cochlear implantation in patients with SSD. Therefore, tinnitus might be considered as an additional indication for cochlear implantation in SSD.

The Impact of Post-thyroidectomy Paresis on Quality of Life in Patients with Nodular Thyroid Disease

11-06-2019 – Jesper Roed Sorensen,Trine Printz,Jenny Iwarsson,Ågot Møller Grøntved,Helle Døssing,Laszlo Hegedüs,Steen Joop Bonnema,Christian Godballe,Camilla Slot Mehlum

Journal Article

To investigate the impact of postoperative paresis on disease-specific quality of life (DSQoL) after thyroidectomy in patients with benign nodular thyroid disease. Observational study. University hospital. Patients were evaluated before and 3 weeks and 6 months after surgery in an individual prospective cohort study using videolaryngostroboscopy (VLS), voice range profile, voice handicap index (VHI), multidimensional voice program, maximum phonation time (MPT), and auditory perceptual evaluation. Changes in DSQoL were assessed by the Thyroid-specific Patient-Reported Outcome measure. Cohen’s effect size was used to evaluate changes. Sixty-two patients were included, 55 of whom completed all examinations. Three weeks after surgery, a blinded VLS examination showed signs of paresis of either the recurrent laryngeal nerve or the external branch of the superior laryngeal nerve (RLN/EBSLN) in 13 patients (24%). A paresis corresponded to a 12 ± 28 point increase in VHI ( Signs of RLN/EBSLN paresis after thyroidectomy were associated with less pronounced improvement in goiter symptoms in patients with thyroid nodular disease. However, thyroidectomy was associated with an overall improved DSQoL by 6 months after surgery.

Factors Associated with Free Flap Failures in Head and Neck Reconstruction

06-08-2019 – Meghan B. Crawley,Larissa Sweeny,Prasanti Ravipati,Ryan Heffelfinger,Howard Krein,Adam Luginbuhl,Richard Goldman,Joseph Curry

Journal Article

To investigate causes of failure of free flap reconstructions in patients undergoing reconstruction of head and neck defects. Case series with chart review. Single tertiary care center. Patients underwent reconstruction between January 2007 and June 2017 (n = 892). Variables included were clinical characteristics, social history, defect site, donor tissue, ischemia time, and postoperative complications. Statistical methods used include univariable and multivariable analysis of failure. The overall failure rate was 4.8% (n = 43). Intraoperative ischemia time was associated with free flap failures (odds ratio [OR], 1.062; 95% confidence interval [CI], 1.019-1.107; Prolonged ischemia time, pedicle revision, and alcohol withdrawal were associated with higher rates of flap failure. Employing strategies to minimize ischemic time may have potential to decrease failure rates. Flaps that require pedicle revision and patients with a history of significant alcohol use require closer monitoring.

The Association between Industry Payments and Brand-Name Prescriptions in Otolaryngologists

24-09-2019 – Elliot Morse,Jonathan Hanna,Saral Mehra

Journal Article

To associate pharmaceutical industry payments to brand-name prescriptions by otolaryngologists. Retrospective cross-sectional analysis. Open Payments Database and the Medicare Part D Participant User File 2013-2016. We identified otolaryngologists receiving nonresearch industry payments and prescribing to Medicare Part D recipients. Records were linked by physician name and state. The value of industry payments and the percentage of brand-name drugs prescribed per hospital referral region (HRR) were characterized as medians. Industry payments were correlated to the rate of brand-name prescription by Kendall’s τ correlation. This was repeated at the individual physician level and stratified by payment type. In total, 8167 otolaryngologists received a median of $434 (interquartile range, $138-$1278) in industry compensation over 11 (3-26) payments. Brand-name drugs made up a median of 12.9% (8.6%-18-4%) of each physician’s drug claims. The number (τ = 0.05, Industry financial transactions are associated with brand-name drug prescriptions in otolaryngologists, and these associations are stronger at the regional level than at the individual physician level. These correlations are of modest strength and should be interpreted cautiously by readers.

Music Therapy for Pain and Anxiety Management in Nasal Bone Fracture Reduction: Randomized Controlled Clinical Trial

11-06-2019 – Alvaro Ortega,Felipe Gauna,Daniel Munoz,Gerardo Oberreuter,Hayo A. Breinbauer,Loreto Carrasco

Journal Article

To evaluate whether listening to music through binaural headphones contributes to the perception of pain and anxiety in patients undergoing closed nasal bone fracture reductions. Randomized controlled trial. We recruited patients from San Juan de Dios Hospital with displaced nasal fractures who required a reduction and assigned them to a control group or a music group. For both groups, a protocolized closed reduction of the nasal fracture with local anesthesia was performed. The music group heard music through headphones during the pre-, intra-, and postprocedural periods of the intervention. Physiological variables (blood pressure and heart rate) were measured. An anxiety survey (State-Trait Anxiety Inventory) and the visual analog scale for measuring pain were also applied. The music group exhibited significantly lower levels of systolic blood pressure ( Listening to music through headphones-a safe and low-cost intervention-appears to aid in pain and anxiety management associated with procedures that are usually uncomfortable, such as the reduction of nasal bone fractures with local anesthesia. We believe that this effect is achieved by the modulation of pain and anxiety on an emotional-affective dimension at a central level. Given its safety, feasibility, and low cost, music therapy should be considered a complementary treatment for pain and anxiety management for nasal fracture reduction performed with local anesthesia, as well as for other medical procedures of similar pain levels conducted without general anesthesia.

Positive Surgical Margins in Submandibular Malignancies: Facility and Practice Variation

04-06-2019 – Liliya Benchetrit,Elliot Morse,Benjamin L. Judson,Saral Mehra

Journal Article

Identify positive margin rate in a national cohort of patients with submandibular carcinoma, identify predictors of positive margins, and associate margins with overall survival. Retrospective cohort. Commission on Cancer-accredited hospitals. We included patients in the National Cancer Database from 2004 to 2014 who were diagnosed with submandibular carcinoma and underwent primary surgical resection. We determined the rate of positive surgical margins and associated patient, tumor, and treatment factors with positive margins via univariable and multivariable logistic regression analysis. We associated margin status with overall survival by Kaplan-Meier curve and Cox proportional hazards regression. We identified 1150 patients with submandibular malignancy undergoing surgical resection. Positive margin rate was 41.0%. Increased odds of positive margins were seen in patients with advanced T stage (vs T1, T3: odds ratio [OR] = 3.04, The national positive margin rate of submandibular carcinoma is 41.0%. Preoperative biopsy and treatment at academic institutions independently decreased the risk of positive margins, and positive margins were independently associated with diminished overall survival. Positive margin rate for submandibular carcinoma may be considered a benchmark for quality of care.

Does Surgical Volume and Complexity Affect Cost and Mortality in Otolaryngology–Head and Neck Surgery?

16-07-2019 – Andrew J. Redmann,Sonia N. Yuen,Douglas VonAllmen,Adam Rothstein,Alice Tang,Joseph Breen,Ryan Collar

Journal Article

(1) To evaluate whether admission volume and case complexity are associated with mortality rates and (2) evaluate whether admission volume and case complexity are associated with cost per admission. Retrospective case series. Tertiary academic hospital. The Vizient database was queried for inpatient admissions between July 2015 and March 2017 to an otolaryngology-head and neck surgery service. Data collected included admission volume, length of stay, intensive care unit (ICU) status, complication rates, case mix index (CMI), and cost data. Regression analysis was performed to evaluate the relationship between cost, CMI, admission volume, and mortality rate. In total, 338 hospitals provided data for analysis. Mean hospital admission volume was 182 (range, 1-1284), and mean CMI was 1.69 (range, 0.66-6.0). A 1-point increase in hospital average CMI was associated with a 40% increase in odds for high mortality. Admission volume was associated with lower mortality, with 1% lower odds for each additional case. A 1-point increase in CMI produces a $4624 higher total cost per case (95% confidence interval, $4550-$4700), and for each additional case, total cost per case increased by $6. For otolaryngology inpatient services at US academic medical centers, increasing admission volume is associated with decreased mortality rates, even after controlling for CMI and complication rates. Increasing CMI levels have an anticipated correlation with higher total costs per case, but admission volume is unexpectedly associated with a significant increase in average cost per case.

Surveillance of Patients with Head and Neck Cancer with an Intensive Clinical and Radiologic Follow-up

09-07-2019 – Martina Imbimbo,Salvatore Alfieri,Laura Botta,Cristiana Bergamini,Annunziata Gloghini,Giuseppina Calareso,Ester Orlandi,Nicola Alessandro Iacovelli,Marco Guzzo,Roberta Granata,Carlo Resteghini,Laura Locati,Chiara Costanza Volpi,Lisa Licitra,Paolo Bossi

Journal Article

There is no consensus on the follow-up modalities in patients with head and neck cancer. This study aims to describe the pattern and survival outcomes of recurrences/second primary cancers in patients undergoing an intensive radiologic and clinical follow-up. Retrospective analysis. Single academic tertiary care center. All patients with stage III-IV head and neck cancer treated with chemoradiotherapy at our institution between 1998 and 2010 were retrospectively reviewed. Persistent/recurrent disease within 6 months since the curative treatment and second primary cancers outside the upper aerodigestive tract were excluded. Data were analyzed by descriptive statistics. Surveillance was planned every 3 months in the first year, then with increasing intervals till the fifth year. A total of 326 patients were included. Out of all detected cancer recurrences (n = 106, 32%), 38 (36%) were locoregional, 44 (41%) were distant, and 24 (23%) were second primary cancers. Approximately 70% of recurrences were clinically and/or radiologically discovered, while 30% were diagnosed due to the patients’ symptoms. Of all clinically and/or radiologically discovered recurrences/second primary cancers (n = 74), 26 (35%) were curatively treated, with respect to 9 of the 32 (28%) diagnosed by symptoms. Median overall survival of recurrent curable cases did not significantly differ according to the detection modality (89 months by clinical/radiologic examination vs 85 by symptoms). Clinical and radiologic follow-up identified more recurrences/second primary cancers than the symptom-driven monitoring, but the curability of cancer recurrence was similar regardless of detection modality. Prospective trials are needed to define the most effective follow-up strategy in head and neck cancer.

Rates of Dysphagia-Related Diagnoses in Long-Term Survivors of Head and Neck Cancers

11-06-2019 – Alana Aylward,Sarah Abdelaziz,Jason P. Hunt,Luke O. Buchmann,Richard B. Cannon,Shane Lloyd,Ying Hitchcock,Mia Hashibe,Marcus M. Monroe

Journal Article

To estimate long-term prevalence of new dysphagia-related diagnoses in a large cohort of head and neck cancer survivors. Retrospective cohort. Population based. In total, 1901 adults diagnosed with head and neck cancer between 1997 and 2012 with at least 3 years of follow-up were compared with 7796 controls matched for age, sex, and birth state. Prevalence of new dysphagia-related diagnoses and procedures and hazard ratio compared to controls were evaluated in patients 2 to 5 years and 5 years and beyond after diagnosis. Risk factors for the development of these diagnoses were analyzed. Prevalence of new diagnosis and hazard ratio compared to controls remained elevated for all diagnoses throughout the time periods investigated. The rate of aspiration pneumonia was 3.13% at 2 to 5 years, increasing to 6.75% at 5 or more years, with hazard ratios of 9.53 (95% confidence interval [CI], 5.08-17.87) and 12.57 (7.17-22.04), respectively. Rate of gastrostomy tube placement increased from 2.82% to 3.32% with hazard ratio remaining elevated from 51.51 (13.45-197.33) to 35.2 (7.81-158.72) over the same time period. The rate of any dysphagia-related diagnosis or procedure increased from 14.9% to 26% with hazard ratio remaining elevated from 3.32 (2.50-4.42) to 2.12 (1.63-2.75). Treatment with radiation therapy and age older than 65 years were associated with increased hazard ratio for dysphagia-related diagnoses. Our data suggest that new dysphagia-related diagnoses continue to occur at clinically meaningful levels in long-term head and neck cancer survivors beyond 5 years after diagnosis.

Outcomes of Prophylactic Epiglottic Petiole Suspension at the Time of Complete Laryngofissure

11-06-2019 – Mathieu Bergeron,Alessandro de Alarcon,Catherine K. Hart,Michael J. Rutter

Journal Article

To compare the clinical outcomes of patients with prophylactic petiole suspension (PPS) at the time of laryngofissure and patients without PPS. Retrospective case series. Tertiary pediatric hospital from May 2003 to August 2017. Patients included those undergoing airway reconstruction with complete laryngofissure. Patients in the study group had PPS at the time of laryngofissure, while control group patients did not. Eighty-one patients underwent complete laryngofissure (22 study patients, 59 controls) at a median age of 4.8 years (interquartile range, 2.1-9.7). Patients in the control group were younger at the time of the surgery (3.7 vs 6.5 years, Patients with PPS had significantly fewer symptoms after complete laryngofissure as compared with patients without PPS. PPS should be considered when a complete laryngofissure is being performed during airway reconstruction.

Human Otopathology of Cochlear Implant Drill-out Procedures

07-05-2019 – Danielle R. Trakimas,Reuven Ishai,Elliott D. Kozin,Joseph B. Nadol,Aaron K. Remenschneider

Journal Article

Human otopathology following drill-out procedures for cochlear implantation (CI) in cases with labyrinthitis ossificans (LO) has not been previously described. This study uses the high sensitivity of histopathology to (1) evaluate surgical drill-out technique with associated intracochlear findings and (2) quantify spiral ganglion neuron populations in a series of patients with LO who underwent CI. Retrospective otopathology study. Otopathology laboratory. Temporal bone (TB) specimens from cases with evidence of preoperative intracochlear fibroossification that required a drill-out procedure for CI electrode array insertion were included. All cases were histopathologically evaluated and 3-dimensional reconstructions of the cochleae were performed to interpret drilling paths and electrode trajectories. Five TB specimens were identified, of which 4 underwent drill-out of the basal turn of the cochlea and 1 underwent a radical cochlear drill-out. In multiple TBs, drilling was imprecise with resultant damage to essential structures. Two TBs showed injury to the modiolus, which was associated with substantially decreased or even absent neuronal populations within these areas. In addition, 2 cases with inadequate drill-out or extensive LO of the basal turn resulted in extracochlear placement of electrode arrays into the vestibule due to persistent obstruction within the basal turn. Otopathology highlights the challenges of drill-out procedures in cases of LO. Imprecise drilling paths, due to distortion of normal cochlear anatomy, risk injury to the modiolus and adjacent neurons as well as extracochlear placement of electrode arrays, both of which may contribute to poorer hearing outcomes.

Feasibility of High-Resolution Computed Tomography Imaging for Obtaining Ear Impressions for Hearing Aid Fitting

07-05-2019 – Chin-Kuo Chen,Li-Chun Hsieh,Yuan-Chuan Chiang,Wei-De Cheng

Journal Article

This study investigated the feasibility of obtaining ear impressions for hearing aids by using 3-dimensional high-resolution computed tomography (HRCT) images. Case series. One referral tertiary center. Hearing-impaired adults who were fitted with 1 or 2 behind-the-ear hearing aid(s) and had undergone temporal bone HRCT for various ear pathologies were enrolled in this study. Earmolds were fabricated from the impressions obtained using the conventional ear canal silicone injection technique and the HRCT reconstructed technique. Outer ear canal resonance frequencies and amplitude in open ears and those measured with silicon and HRCT reconstructed earmolds were determined through real-ear gain measurements, including real-ear unaided gain (REUG) and real-ear occluded gain (REOG), for comparison. A total of 50 HRCT reconstructed earmolds were compared with 50 conventional silicon injection earmolds. The average value of open ear canal resonance amplitude (REUG) for each ear was 0.41 to 16.76 d
B. No statistically significant difference in resonance amplitude (REOG) was observed between silicon and reconstructed earmolds (paired According to our real-ear measurements, acoustic characteristics of the HRCT reconstructed earmolds were compatible with those of the silicone injection earmolds. Despite concerns about increased cost and radiation exposure, the HRCT reconstructed technique is a clinically useful and applicable method and can reduce potential safety complications for difficult cases.

Expanding Access: Cost-effectiveness of Cochlear Implantation and Deaf Education in Asia

18-06-2019 – Susan D. Emmett,Chad K. Sudoko,Debara L. Tucci,Wenfeng Gong,James E. Saunders,Nasima Akhtar,Mahmood F. Bhutta,Sokdavy Touch,Rabindra Bhakta Pradhananga,Nadeem Mukhtar,Norberto Martinez,Frances Dianne Martinez,Hubert Ramos,Mohan Kameswaran,Raghu Nandhan Sampath Kumar,Soekirman Soekin,Narayanan Prepageran

Journal Article

To determine the cost-effectiveness of cochlear implantation (CI) with mainstream education and deaf education with sign language for treatment of children with profound sensorineural hearing loss in low- and lower-middle income countries in Asia. Cost-effectiveness analysis. Bangladesh, Cambodia, India, Indonesia, Nepal, Pakistan, Philippines, and Sri Lanka participated in the study. Costs were obtained from experts in each country with known costs and published data, with estimation when necessary. A disability-adjusted life-years model was applied with 3% discounting and 10-year length of analysis. A sensitivity analysis was performed to evaluate the effect of device cost, professional salaries, annual number of implants, and probability of device failure. Cost-effectiveness was determined with the World Health Organization standard of cost-effectiveness ratio per gross domestic product (CER/GDP) per capita <3. Deaf education was cost-effective in all countries except Nepal (CER/GDP, 3.59). CI was cost-effective in all countries except Nepal (CER/GDP, 6.38) and Pakistan (CER/GDP, 3.14)-the latter of which reached borderline cost-effectiveness in the sensitivity analysis (minimum, maximum: 2.94, 3.39). Deaf education and CI are largely cost-effective in participating Asian countries. Variation in CI maintenance and education-related costs may contribute to the range of cost-effectiveness ratios observed in this study.

Balloon Sinuplasty Utilization in the Pediatric Population: A National Database Perspective

11-06-2019 – Gerard Thong,Natasha D. Dombrowski,Kosuke Kawai,Michael J. Cunningham,Eelam A. Adil

Journal Article

Balloon sinuplasty (BS) is a surgical management option in the treatment of chronic rhinosinusitis. The purpose of this study was to examine BS utilization among children with a national database. Retrospective review. National pediatric database. All cases of children aged ≤18 years who underwent BS or traditional endoscopic sinus surgery (ESS) 5 years before and after the introduction of BS billing codes were studied with the Pediatric Health Information System database. We evaluated overall trends, demographics, performing physicians, readmissions, and cost data. A total of 14,079 patients met inclusion criteria: 13,555 underwent traditional ESS and 524 had a BS procedure. There was no significant increase in BS rates between 2011 and 2016. BS was more commonly performed among younger children than ESS (median age [interquartile range], 6 years [4-10] vs 9 years [6-13]; Rates of BS performance in the pediatric population have not increased over time. Results showed no difference in readmission rates between BS and ESS. BS was associated with higher costs as compared with ESS. The role of BS in the pediatric chronic rhinosinusitis population remains unclear.

Endoscopic-Assisted Cochlear Implantation in Children with Malformed Ears

04-06-2019 – Marco Carner,Andrea Sacchetto,Luca Bianconi,Davide Soloperto,Luca Sacchetto,Livio Presutti,Daniele Marchioni

Journal Article

Complex middle and inner ear malformations are considered an important limitation for cochlear implant (CI) with traditional microscopic techniques. The aim of the present study is to describe the results of the endoscopic-assisted CI procedure in children with malformed ears. Case series with chart review of consecutive patients. Two tertiary referral centers: University Hospital of Verona and University Hospital of Modena, Italy. In total, 25 children underwent endoscopic-assisted cochlear implantation between January 2013 and January 2018. The audiologic and neuroradiologic assessment showed profound hearing loss and malformation of the middle and inner ear in all children. A complete review of anatomic features, surgical results, and audiologic outcomes was performed. The surgical technique is described step-by-step, and the outcomes are detailed. All patients (mean age, 3.6 years; range, 2.8-9 years) underwent a transattical/endoscopic-assisted CI procedure. All children showed varying degrees of auditory benefit, as measured by routine audiometry, speech perception tests, and Categories of Auditory Performance scores (mean, 6). No immediate or late postoperative complications were noted. The endoscopic-assisted approach proved to be successful in cochlear implantation. The direct visualization and magnification allow (1) exploration of the tympanic cavity; (2) confirmation of all anatomic features, with strict control of the course of the facial nerve, round window area, and inner ear; and (3) performance of the cochleostomy with adequate insertion of the array.

Polysomnography Outcomes after Supraglottoplasty in Children with Obstructive Sleep Apnea

23-04-2019 – Bharat Bhushan,James W. Schroeder,Kathleen R. Billings,Nicholas Giancola,Dana M. Thompson

Journal Article

Laryngomalacia has been reported to contribute to the severity of obstructive sleep apnea (OSA) in children. It is unclear if surgical treatment of laryngomalacia improves polysomnography (PSG) outcomes in these patients. The objective of this study is to report the impact of supraglottoplasty on PSG parameters in children with laryngomalacia-related OSA. Retrospective case series. Tertiary care medical center. Historical cohort study of consecutive children with laryngomalacia who underwent supraglottoplasty and who had undergone overnight PSG before and after surgery. Forty-one patients were included in the final analysis: 22 (53.6%) were male, and 19 (46.3%) were female. The mean ± SEM age of patients at preoperative PSG was 1.3 ± 0.89 years (range, 0.003-2.9). In entire cohort, the mean obstructive apnea-hypopnea index score was reduced from 26.6 events/h before supraglottoplasty to 7.3 events/h after surgery ( Overall, supraglottoplasty significantly improved several PSG outcomes in children with laryngomalacia. However, mild to moderate OSA was still present postoperatively in most children. This suggested a multifactorial cause for OSA in this population.

A Cross-sectional Analysis of Pediatric Ambulatory Tonsillectomy Surgery in the United States

23-04-2019 – Yann-Fuu Kou,Ron B. Mitchell,Romaine F. Johnson

Journal Article

To report nationwide estimates of ambulatory tonsillectomies performed in hospitals and ambulatory surgery centers in the United States. Cross-sectional survey. National databases. We analyzed the 2010 National Hospital Ambulatory Medical Care Survey of hospitals and ambulatory surgery centers for pediatric patients undergoing tonsillectomy with or without adenoidectomy. We determined estimations of the number of procedures, demographics, and outcomes. A tonsillectomy cohort from the 2009 National Inpatient Sample served as a comparison group. In 2010, there were an estimated 339,000 (95% CI, 288,000-391,000) ambulatory tonsillectomies in the United States. The mean age was 7.8 years (SD, 5.1), and 71,000 (21.0%) were <3 years old. The male:female ratio was even (51% vs 49%). The racial makeup mirrored the US census (69% white, 18% Hispanic, and 12% black). Obstructive sleep-disordered breathing was reported in 48%. Perioperative events such as apnea, hypoxia, or bleeding occurred 7.8% of the time. Approximately 9% of patients could not be discharged home. When compared with cases of inpatient tonsillectomies, ambulatory cases comprised older patients (7.8 vs 5.9 years, Tonsillectomy was one of the most common ambulatory surgical procedures in 2010 in the United States. The majority of patients were low risk, but some at higher risk were included (age ≤3 years and obstructive sleep apnea). The National Hospital Ambulatory Medical Care Survey estimates provide useful baseline data for future research on quality measures and outcomes.

Use of 3D-Printed and 2D-Illustrated International Frontal Sinus Anatomy Classification Anatomic Models for Resident Education

09-07-2019 – Christopher M. Low,Jonathan M. Morris,Jane S. Matsumoto,Janalee K. Stokken,Erin K. O’Brien,Garret Choby

Journal Article

To examine the impact of 2-dimensional (2D) illustrations and 3-dimensonal (3D)-printed anatomic models of the frontal sinuses according to the International Frontal Sinus Anatomy Classification in the education of otolaryngology and radiology residents. A crossover study design with half of the study participants randomized to the 2D illustration intervention first and the other half randomized to the 3D-printed model first. Regularly scheduled resident didactic lectures at a tertiary care center. Forty-one otolaryngology and radiology residents were assessed with pre- and postintervention questionnaires that included subjective and objective methods of assessment. Overall, there was a statistically significant improvement in total number of answers correct and in confidence score between the pre- and postintervention assessments ( There is no difference between 2D-illustrated and 3D-printed International Frontal Sinus Anatomy Classification anatomic models in overall educational outcome, despite the preference of learners. Together, these models can be used as helpful tools in frontal sinus education for otolaryngology and radiology trainees.

Upper Airway Stimulation Response in Older Adults with Moderate to Severe Obstructive Sleep Apnea

14-05-2019 – Kirk Withrow,Sean Evans,John Harwick,Eric Kezirian,Patrick Strollo

Journal Article

To evaluate the impact of age on safety, efficacy, and usage of upper airway stimulation (UAS). Multicenter observational study. Thirteen US hospitals and 3 German hospitals. The ADHERE registry is a multicenter database enrolling patients undergoing UAS implantation from October 2016 to April 2018. Outcome measures included the Epworth Sleepiness Scale, apnea-hypopnea index (AHI), therapy usage, and complications. Data were segmented by age (<65 vs ≥65 years). Younger adults (n = 365) were a mean ± SD 52.7 ± 7.9 years old and 82% male, with a body mass index of 29.6 ± 3.8. Older adults (n = 235) were 71.1 ± 4.8 years old and 71% male, with a body mass index of 28.8 ± 3.8. Baseline AHI was similar (younger, 36.2 ± 15.9; older, 36.1 ± 14.8). Both groups had lower AHI at 12 months versus baseline ( AHI reduction and therapy usage were found to be somewhat higher among patients aged ≥65 years who were treated with UAS. Surgical complications were low, in contrast to traditional sleep surgery.

Antacid Tablets Oral Treatment Causing Respiratory Distress: An Uncommon Cause of Dyspnea

14-05-2019 – François Thibouw,Mireille Folia

Journal Article

Effectiveness of Canal Occlusion for Intractable Posterior Canal Benign Paroxysmal Positional Vertigo: A Systematic Review

15-10-2019 – Britta D. P. J. Maas,Hester J. van der Zaag-Loonen,Peter Paul G. van Benthem,Tjasse D. Bruintjes

Should You Follow the Better-Hearing Ear for Congenital Cytomegalovirus Infection and Isolated Sensorineural Hearing Loss?

08-10-2019 – Vanessa Torrecillas,Chelsea M. Allen,Tom Greene,Albert Park,Winnie Chung,Tatiana M. Lanzieri,Gail Demmler-Harrison

Journal Article

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.

Plasma Ablation–Assisted Endoscopic Management of Postintubation Laryngotracheal Stenosis: An Alternate Tool for Management

08-10-2019 – Ramandeep Singh Virk,Sandeep Bansal,Gyanaranjan Nayak,Lokesh P

Journal Article

The current study was conducted to highlight the use of plasma ablation as a promising method in management of adult laryngotracheal stenosis. We present our institutional experience with a minimum follow-up of 6 months. Seventy adult patients with acquired postintubation laryngotracheal stenosis were included. Efficacy and clinical outcomes of plasma ablation in endoscopic management and eventual decannulation rate were studied. Number of patients with Myer-Cotton stenosis grades 1, 2, 3, and 4 were 20, 25, 18, and 7, respectively. The mean number of surgical interventions required in each grade of stenosis were 1, 2, 3.8, and 4, respectively. Overall, 47 patients (67%) were without tracheotomy by the end of 6 months. Plasma ablation is an effective treatment option for adult laryngotracheal stenosis, with a better success rate for lower-grade stenosis. It has lesser complications and requires fewer surgical interventions.

Effects of OSA Surgery on Leptin and Metabolic Profiles

01-10-2019 – Chien-Hung Chin,Pei-Wen Lin,Hsin-Ching Lin,Michael Friedman,Meng-Chih Lin

Journal Article

This study is designed to investigate the effects of obstructive sleep apnea/hypopnea syndrome (OSA) surgery on serum leptin levels and metabolic disturbances, both of which contribute to the risk of cardiovascular diseases. Case series with planned data collection. Tertiary referral medical center. A retrospective chart review of 101 consecutive patients with OSA who refused or failed conservative therapy and who then underwent upper airway surgery for OSA treatment was conducted. The personal medical history, anthropometric measurements, subjective symptoms, and objective polysomnographic parameters and fasting morning blood samples for leptin and metabolic biomarkers measurements were collected preoperatively and at a minimum of 3 months postoperatively. Eighty patients with OSA (69 men and 11 women; mean [SD] age of 42.2 [10.2] years) with complete data were included in the final analysis. At least 3 months after surgery, serum leptin, low-density lipoprotein cholesterol (LDL-C), and triglyceride levels and the mean systolic blood pressure (SBP) (night and morning) significantly decreased. According to the classical definition of surgical success, 40 subjects had successful surgery and were categorized as surgical responders, and the other 40 patients who failed surgery were categorized as surgical nonresponders. Significant reductions in serum leptin, total cholesterol, LDL-C, and triglyceride levels and improvement of mean SBP (morning) occurred in surgical responders but not in nonresponders. Effective OSA surgery improves serum leptin, lipid profiles, and SBP. Further studies are needed to investigate the role of serial measurements of these biomarkers in monitoring surgical outcome of OSA treatment.

Surgical Explantation of Bone-Anchored Hearing Devices: A 10-year Single Institution Review

01-10-2019 – Christian G. Fritz,Dennis I. Bojrab,Kenny F. Lin,Christopher A. Schutt,Seilesh C. Babu,Robert S. Hong

Journal Article

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.

Patient Safety/Quality Improvement Primer, Part II: Prevention of Harm Through Root Cause Analysis and Action (RCA2)

01-10-2019 – Karthik Balakrishnan,Michael J. Brenner,John W. Gosbee,Cecelia E. Schmalbach

Journal Article

With increasing emphasis on patient safety/quality improvement, health care systems are mirroring industry in the implementation of root cause analysis (RCA) for the identification and mitigation of errors. RCA uses a team approach with emphasis on the system, as opposed to the individual, to accrue empirical data on what happened and why. While many otolaryngologists have a broad understanding of RCA, practical experience is often lacking. Part II of this patient safety/quality improvement primer investigates the manner in which RCA is utilized in the prevention of medical errors. Attention is given to identifying system errors, recording adverse events, and determining which events warrant RCA. The primer outlines steps necessary to conduct an effective RCA, with emphasis placed on actions that arise from the RCA process through the

Office-Based Stapes Surgery

01-10-2019 – Béatrice Voizard,Anastasios Maniakas,Issam Saliba

Journal Article

The objective of this study was to provide a proof of concept and to assess the success and safety of stapes surgery for otosclerosis under local anesthesia in an office-based setting (OBS) as compared with a hospital operating room setting (ORS). Retrospective cohort study. We reviewed all patients who underwent stapes surgery by the same surgeon from October 2014 to January 2017 at our tertiary care center (ORS, n = 36, 52%) and in an OBS (n = 33, 48%). The surgical technique was identical in both groups. All patients had a temporal bone computed tomography scan and audiogram within the 6 months prior to surgery. Air-bone gaps (ABGs), bone conduction, and air conduction pure tone average values were calculated. Preoperative results for pure tone average, bone conduction, ABG, and word recognition scores were compared with early (4 months) and late (12 months) follow-up audiograms. Intra- and postoperative complications were compared. Both groups were comparable in terms of demographic characteristics and severity of disease. The mean 1-year postoperative ABG was 5.66 d
B (95% CI = 4.42-6.90) in the ORS group and 6.30 d
B (95% CI = 4.50-8.10) in the OBS group ( In this small group of patients, the success of stapes surgery performed in an OBS and its complications were comparable to those of an ORS, thus providing an alternative to patients on long operating room waiting lists.

Establishing an Animal Model of Single-Sided Deafness in Chinchilla lanigera

01-10-2019 – Renee M. Banakis Hartl,Nathaniel T. Greene,Victor Benichoux,Anna Dondzillo,Andrew D. Brown,Daniel J. Tollin

Journal Article

(1) To characterize changes in brainstem neural activity following unilateral deafening in an animal model. (2) To compare brainstem neural activity from unilaterally deafened animals with that of normal-hearing controls. Prospective controlled animal study. Vivarium and animal research facilities. The effect of single-sided deafness on brainstem activity was studied in Four animals underwent chemical deafening, with 2 normal-hearing animals as controls. ABRs confirmed unilateral loss of auditory function. Deafened animals demonstrated symmetric local field potential responses that were distinctly different than the contralaterally dominated responses of the inferior colliculus seen in normal-hearing animals. We successfully developed a model for unilateral deafness to investigate effects of single-sided deafness on brainstem plasticity. This preliminary investigation serves as a foundation for more comprehensive studies that will include cochlear implantation and manipulation of binaural cues, as well as functional behavioral tests.

The Role for Imaging in the Investigation of Isolated Objective Vestibular Weakness

01-10-2019 – Deanna Gigliotti,Brian Blakley,Paige Moore,Jordan Hochman

Journal Article

Unilateral vestibular weakness has considerable potential etiologies. One source is a vestibular schwannoma. This article evaluates, in the absence of other symptoms and signs, if unilateral vestibular weakness is an analogue to asymmetric sensorineural hearing loss and serves as an indication for lateral skull base imaging. Retrospective chart review. Academic tertiary center. All patients undergoing caloric assessment between January 1, 2012, and June 30, 2018, were investigated. Patients with unilateral vestibular weakness (a left-right difference >25% on electronystagmography) were included in the study. A provincial encompassing image library was surveyed for potential adequate imaging (computed tomography internal auditory canal infused, magnetic resonance imaging [MRI] brain, MRI internal auditory canal) of the target population within the preceding 5 years. Presence/absence of vestibular schwannoma on imaging was determined. Of the 3531 electronystagmography reports reviewed during the period, 864 patients were identified with unilateral vestibular weakness. Of these, 542 had sufficient imaging, and 14 vestibular schwannomas were identified. Only 1 individual had a vestibular weakness in isolation, while the remaining 13 patients also suffered from documented sensorineural hearing loss that would have mandated MRI scanning. The results of our study suggest that, in isolation, vestibular weakness is an insufficient indicator for lateral skull base imaging.

Accuracy of a Modern Intraoperative Navigation System for Temporal Bone Surgery in a Cadaveric Model

24-09-2019 – Zachary G. Schwam,Vivian Z. Kaul,Maura K. Cosetti,George B. Wanna

Journal Article

To determine the accuracy of a modern navigation system in temporal bone surgery. While routine in other specialties, navigation has had limited use in the temporal bone due to issues of accuracy, perceived impracticality, and value. Prospective observational study. Temporal bone laboratory. Eighteen cadaveric specimens were dissected after rigid fiducials were implanted and computed tomography scans were obtained. Target registration and target localization errors were then measured at various points. The mean overall target registration error was 0.48 ± 0.29 mm. The mean target localization error was 0.54 mm at the sinodural angle, 0.48 mm at the lateral semicircular canal, 0.55 mm at the round window, 0.39 mm at the oval window, and 0.52 mm at the second genu of the facial nerve. A modern navigation system demonstrated submillimeter accuracy for all points of interest. Its use in clinical as well as training settings has yet to be fully elucidated.

Optimal Head Position Following Intratympanic Injections of Steroids, As Determined by Virtual Reality

24-09-2019 – Omer J. Ungar,Ophir Handzel,Limor Haviv,Solomon Dadia,Oren Cavel,Dan M. Fliss,Yahav Oron

Journal Article

To study optimal head position after intratympanic steroid injections to enhance drug bioavailability. Application of virtual and in vitro models of the intratympanic anatomy. The surgical 3-dimensional printing laboratory of a tertiary academic medical center. A high-resolution computerized tomographic scan of healthy temporal bone and surrounding soft tissue was segmented and reconstructed to a 3-dimensional model. The tympanic membrane was perforated in the posterior-inferior quadrant. Methylene blue-stained 10-mg/m
L dexamethasone was administered to the middle ear cleft, after which a 3-dimensional rotation in space was performed to hypothesize the optimal position in relation to gravity. The same stereolithography file used for the actual model was used for a digital virtual liquid flow simulation. The optimal head position was defined as the one with the maximum vertical distance between the round window membrane and the plane of the aditus ad antrum and eustachian tube orifice. The virtual model yielded the following position of the head as optimal: 53º rotation away from the injected ear in the vertical axis (yaw), 27º rotation toward the noninjected ear in the longitudinal axis (roll), and 10º neck extension in the transverse axis (pitch). Virtual imaging determined that 53º and 27º yaw and roll, respectively, away and 10º pitch were the optimal position for drug delivery after intratympanic injection to the middle ear and that an erect head position provided optimal passage of steroids from the middle ear to the inner ear.

Application-Based Translaryngeal Ultrasound for the Assessment of Vocal Fold Mobility in Children

24-09-2019 – Zahra Sayyid,Varun Vendra,Kara D. Meister,Catherine D. Krawczeski,Noah J. Speiser,Douglas R. Sidell

Journal Article

To compare the evaluation of vocal fold mobility between flexible nasal laryngoscopy (FNL) and a handheld application-based translaryngeal ultrasound (TLUS) platform. Prospective analysis included patients with unknown vocal fold mobility status who underwent FNL and TLUS. Tertiary referral center. TLUS was performed on 23 consecutive children (<18 years old) presenting for laryngoscopy due to unknown vocal fold mobility status. After the recording of three 10-second TLUS videos as well as FNL, the study was divided into 2 parts: parental assessment of laryngeal ultrasound at the time of patient evaluation and random practitioner assessment of ultrasound videos. We describe 23 patients who underwent TLUS and FNL. Ten patients (43.5%) had normal vocal fold function bilaterally, and 13 (56.5%) had either left or right vocal fold immobility. Family members and physicians correctly identified the presence and laterality of impaired vocal fold mobility in 22 of 23 cases (κ = 0.96). The sensitivity, specificity, positive predictive value, and negative predictive value of FLUS in diagnosing vocal fold immobility were 92.3%, 100%, 100%, and 90.9%, respectively. Random practitioners accurately identified the presence and laterality of vocal fold immobility under all circumstances. A handheld application-based ultrasound platform is both sensitive and specific in its ability to identify vocal fold motion impairment. Portable handheld TLUS has the potential to serve as a validated screening examination, even by inexperienced providers, and in specific cases may obviate the need for an invasive transnasal laryngoscopy.

Acoustic Nanomotors for Detection of Human Papillomavirus–Associated Head and Neck Cancer

24-09-2019 – Jesse R. Qualliotine,Gulcin Bolat,Mara Beltrán-Gastélum,Berta Esteban-Fernández de Ávila,Joseph Wang,Joseph A. Califano

Journal Article

Human papillomavirus (HPV)-associated oropharyngeal cancer (OPC) is a lethal disease with increasing incidence; however, technologies for early detection are limited. Nanomotors are synthetic nanostructures that can be powered by different mechanisms and functionalized for specific applications, such as biosensing. The objective of this investigation was to demonstrate an in vitro proof of concept for a novel nanomotor-based cancer detection approach toward in vivo detection of HPV-OPC. In vitro cell line incubated with ultrasound-propelled nanomotors. Basic science and engineering laboratories. Ultrasound-powered gold nanowire nanomotors were functionalized with graphene oxide and dye-labeled single-stranded DNA for the specific intracellular detection of HPV16 Nanomotors incubated with RNA extracted from HPV-positive OPC cells resulted in 60.7% of maximal fluorescence recovery, while incubation with RNA extracted from HPV-negative cells produced negligible fluorescence. Nanomotor incubation with intact HPV-negative cells produced minimal fluorescence (0.01 au), while incubation with HPV-positive cells produced a detectable signal (0.43 au) under static conditions and had 2.3-times greater intensity when powered with ultrasound. Acoustically powered nanomotors can successfully identify HPV16

Submental Island Flap versus Free Flap Reconstruction for Complex Head and Neck Defects

10-09-2019 – Mads Gustaf Jørgensen,Siavosh Tabatabaeifar,Navid Mohamadpour Toyserkani,Jens Ahm Sørensen

Journal Article

Complex soft tissue reconstruction of the head and neck requires a viable, versatile, and dependable flap. Free flaps, such as the radial forearm and anterolateral thigh flap, have been the mainstay of complex head and neck reconstruction. However, a local pedicled flap, such as the submental island flap (SIF), could be a more effective and less demanding alternative. This systematic review and meta-analysis aim to compare free tissue transfer (FTT) with the SIF for head and neck reconstruction. We performed a systematic search in PubMed and EMBASE databases. Meta-analysis was performed on outcomes reported in ≥3 studies. Candidate articles were assessed for eligibility by 2 authors. Three authors performed data extraction and methodological quality of the included studies using the Newcastle-Ottawa Quality Assessment Form for Cohort Studies. The search strategy resulted in 450 studies, of which 7 were included in the analysis, yielding 155 SIF and 198 FTT cases. Operating time and length of stay were significantly lower for the SIF than for FTT ( These results suggest that the SIF reduces length of stay and operating time as compared with FTT in head and neck reconstruction. These findings suggest that the SIF can be considered an alternative reconstructive option to FTT when evaluating intraoral, lateral facial, skull base, and parotidectomy defects, given comparable defect size and tumor biology.

Rhinosinusitis in Pediatric Primary Ciliary Dyskinesia: Impact of Disease

10-09-2019 – Jay M. Bhatt,Ethan G. Muhonen,Maxene Meier,Scott D. Sagel,Kenny H. Chan

Journal Article

Primary ciliary dyskinesia (PCD) is a genetic disorder characterized by abnormal respiratory cilia ultrastructure and/or function causing defective mucociliary clearance. We investigated the extent and severity of rhinosinusitis in a large cohort of children with PCD and explored associations among risk factors, including genotype and sinus disease. Retrospective chart review. Tertiary academic children’s hospital. A review was conducted with a patient registry at the PCD Foundation Center at our institution. Demographic, imaging, clinical, and operative data were reviewed through the institutional electronic health record system. Fifty-four subjects were identified with mean and median age at diagnosis of 5.2 and 4.0 years. The male:female ratio was 35%:65%. Sinus symptoms were present in 46 (85%) subjects, 22 of whom had chronic rhinosinusitis. Nineteen (35%) subjects underwent operative intervention, consisting of endoscopic sinus surgery (ESS; 16 patients) and maxillary lavage (3 patients). Nineteen subjects underwent adenoidectomy for PCD-related indications. Five sinus-related admissions in 3 subjects were noted during the study period, and no complication of rhinosinusitis occurred in the cohort. Genetic test results were available in 27 subjects, in whom 23 (85%) had biallelic mutations in a PCD gene. Demographic factors, Lund-Mackay score, and PCD genotype were not found to be predictors for ESS or hospitalization in our cohort. While rhinosinusitis was common in our PCD cohort, most patients did not require ESS. Since complications of rhinosinusitis were uncommon, we recommend judicious surgical management tailored to the patient’s symptoms.

Analysis of Potential Conflicts of Interest among Otolaryngologic Patient Advocacy Organizations in 2016

03-09-2019 – Neil S. Kondamuri,Vinay K. Rathi,Matthew R. Naunheim,Rosh V. Sethi,Ashley L. Miller,Mark A. Varvares

Journal Article

Patient advocacy organizations (PAOs) are nonprofits dedicated to benefiting patients and their families through activities such as education/counseling and research funding. Although medical drug/device companies may serve as important partners, industry donations may bias the efforts of PAOs. We conducted a retrospective cross-sectional analysis of the Kaiser Health News nonprofit database to identify and characterize otolaryngologic PAOs (n = 32) active in 2016. Among these PAOs, half (n = 16, 50.0%) focused on otologic diseases, and mean total annual revenue was $3.1 million. Among the 15 PAOs (46.9%) with publicly available donor lists, 10 (66.7%) received donations from industry. Few PAOs publicly reported the total amount donated by industry (n = 3, 9.4%) or published policies for mitigating potential financial conflicts of interest with donors (n = 3, 9.4%). Requiring drug and device companies to publicly report donations to PAOs may help patients, providers, and policy makers to better understand advocacy by these influential stakeholders.

Esophageal Transit Times Vary with Underlying Comorbid Disease

03-09-2019 – Anna Miles,Kirany Bennett,Jacqui Allen

Journal Article

Little is known about esophageal transit times (ETT) in relation to underlying comorbid disease or aspiration risk. Our study evaluated liquid ETT in patients relative to underlying comorbid disease and compared this with ETT in healthy adults. We examined whether prolonged ETT was associated with swallow risk. Prospective observational study. Radiology department. Patients included those referred to speech pathology for a videofluoroscopic study of swallowing (VFSS) within a tertiary hospital. A total of 617 patients (49% female; mean ± SD age, 77 ± 15 years) and 139 healthy adults (56% female; age, 59 ± 22 years) were included. All patients underwent a standardized VFSS with esophageal screening. Patients were categorized by chief underlying disorder: previous stroke (n = 207), other neurologic condition (n = 188), respiratory conditions (n = 91), or gastroenterology conditions (n = 131). All VFSSs were analyzed with objective measures. ETT and penetration-aspiration scores were compared between groups. Advancing age was significantly associated with increased ETT ( Liquid ETTs differ among patients with different underlying primary diagnoses. Patients following stroke show significantly prolonged ETT and increased risk of aspiration. Prolonged ETT may influence symptom complaint and warrants consideration.

Margins in Laryngeal Squamous Cell Carcinoma Treated with Transoral Laser Microsurgery: A National Database Study

03-09-2019 – Jonathan Hanna,Philip R. Brauer,Elliot Morse,Saral Mehra

Journal Article

To determine national positive margin rates in transoral laser microsurgery, to compare patients with positive and negative margins, and to identify factors associated with positive margins. Retrospective review of the National Cancer Database. Population based. Patients included those with TIS-T3 laryngeal squamous cell carcinoma (2004-2014). Univariable and multivariable logistic regression were used to identify predictors. A total of 1959 patients met inclusion criteria. The national positive margin rate was 22.3%. Sixty-five percent of patients had T1 disease; 94.3% were N-negative; and 74.0% had glottic tumors. Fifty-eight percent of patients were treated at academic centers, and 60.6% were treated at facilities performing <2 cases per year. On multivariable analysis, factors associated with margin status included facility volume (odds ratio [95% CI]; in cases per year: 0.93 [0.89-0.97], The national positive margin rate for laryngeal laser surgery is 22%, which is concerning given the equivalent survival benefit offered by surgery and primary radiation and the increased likelihood of bimodal therapy in the situation of positive margins. Cases treated at nonacademic centers and those with lower caseloads had a higher likelihood of positive margins. There was a linear association between T-stage and likelihood of positive margins, with T3 tumors being 5 times as likely as T1 to yield positive margins. This study highlights the importance of proper patient selection for transoral laser microsurgery resections.

Postoperative Analgesic Requirement and Pain Perceptions after Nonaerodigestive Head and Neck Surgery

03-09-2019 – Elizabeth D. Stephenson,Zainab Farzal,Maryam Jowza,Trevor Hackman,Adam Zanation,Eugenie Du

Journal Article

Little data exist on associations between patient factors and postoperative analgesic requirement after head and neck (H&N) surgeries. Such information is important for optimizing postoperative care considering concerns regarding opioid misuse. We analyzed factors associated with narcotic use and pain perception following H&N surgery sparing the upper aerodigestive tract. Prospective cohort. Tertiary referral center. From May to October 2017, data were collected for patients undergoing nonaerodigestive H&N procedures requiring hospitalization. Patients completed a preoperative survey querying chronic pain history, narcotic usage, and postoperative pain expectation. Demographics, surgical data, postoperative narcotic use defined by morphine milligram equivalents (MME), pain scores, and Overall Benefit of Analgesia Score (OBAS) were analyzed. Seventy-six patients, 44 (57.9%) females and 32 (42.1%) males with a mean age of 54.0 years, met inclusion criteria. The most common procedures were parotidectomy (27.6%) and total thyroidectomy (19.7%). Average cumulative 24-hour postoperative MME and calculated MME per hospital day (MME/HD, cumulative MME for hospitalization divided by length of stay) were 40.5 ± 30.6 and 60.8 ± 60.1, respectively. Average pain score throughout the initial 24 hours after surgery was 3.7/10 ± 2.0. Female sex and prior chronic pain diagnosis were associated with higher OBAS after multivariate linear adjustments. Postoperative narcotic requirement in nonaerodigestive H&N surgery is overall low. Female sex and prior chronic pain diagnosis may be associated with higher postoperative OBAS, a validated assessment of pain and opioid-related side effects. This study may serve as a comparison for future studies evaluating narcotic-sparing analgesia and pain perception in nonaerodigestive H&N surgery.

Establishing Urinary Leukotriene E4 as a Diagnostic Biomarker for Chronic Rhinosinusitis with Comorbid Asthma and Atopy

27-08-2019 – Griffin D. Santarelli,Kent K. Lam,Joseph K. Han

Journal Article

While urinary leukotriene E Tertiary referral medical center. A prospective case-control study was conducted to compare u
LTE A total of 153 patients (mean age, 47.3; 47.1% female) were included in the study. Patients with CRS demonstrated significantly higher concentrations of u
LTE Urinary LTE

Machine Learning Diagnosis of Peritonsillar Abscess

20-08-2019 – Michael B. Wilson,S. Ahmed Ali,Kevin J. Kovatch,Josh D. Smith,Paul T. Hoff

Journal Article

Peritonsillar abscess (PTA) is a difficult diagnosis to make clinically, with clinical examination of even otolaryngologists showing poor sensitivity and specificity. Machine learning is a form of artificial intelligence that “learns” from data to make predictions. We developed a machine learning classifier to predict the diagnosis of PTA based on patient symptoms. We retrospectively collected clinical data and symptomatology from 916 patients who underwent attempted needle aspiration for PTA. Machine learning classifiers were trained on a subset of the data to predict the presence or absence of purulence on attempted aspiration. The performance of the model was evaluated on a holdout set. The accuracy of the top-performing algorithm, the artificial neural network, was 72.3%. Artificial neural networks can use patient symptoms to exceed human ability to predict PTA in patients with clinical suspicion for PTA. Similar models can assist medical decision making for clinicians who have suspicion of PTA.

Reliability and Construct Validity of the Penetration-Aspiration Scale for Quantifying Pediatric Outcomes after Interarytenoid Augmentation

20-08-2019 – Elizabeth H. Wick,Kaalan Johnson,Kim Demarre,Amy Faherty,Sanjay Parikh,David L. Horn

Journal Article

To assess the reliability and construct validity of the Penetration-Aspiration Scale in children. This was a retrospective cohort study of pre- and postoperative video modified barium swallow studies from children who underwent interarytenoid injection augmentation for unexplained persistent pharyngeal dysphagia. Two pediatric speech and language pathologists reviewed each study twice in a blinded and randomized fashion. Tertiary academic pediatric hospital. Thirty children were identified with adequate pre- and postoperative modified barium swallow studies within 4 weeks of intervention. Children were separated into clinical outcome groups based on ability to advance to thinner diet consistencies postoperatively. Construct validity was assessed with a mixed linear model to test the hypothesis that only the clinically improved group would receive better Penetration-Aspiration Scale scores after surgery. Reliability was assessed by calculating chance-corrected agreement between raters (interrater) and raters’ repeat evaluations (intrarater). Inter- and intrarater reliabilities (Cohen’s κ) were both excellent. Results of the mixed model revealed a significant interaction between outcome group and pre- and postoperative time interval. As hypothesized, this involved a significant improvement in Penetration-Aspiration Scale score only in the improved group. These findings suggest that the Penetration-Aspiration Scale is a reliable and valid measure of clinical response to interarytenoid injection augmentation in children.

Assessments of Otolaryngology Resident Operative Experiences Using Mobile Technology: A Pilot Study

13-08-2019 – Jenny X. Chen,Elliott Kozin,Jordan Bohnen,Brian George,Daniel G. Deschler,Kevin Emerick,Stacey T. Gray

Journal Article

Surgical education has shifted from the Halstedian model of “see one, do one, teach one” to a competency-based model of training. Otolaryngology residency programs can benefit from a fast and simple system to assess residents’ surgical skills. In this quality initiative, we hypothesize that a novel smartphone application called System for Improving and Measuring Procedural Learning (SIMPL) could be applied in an otolaryngology residency to facilitate the assessment of resident operative experiences. The Plan Do Study Act method of quality improvement was used. After researching tools of surgical assessment and trialing SIMPL in a resident-attending pair, we piloted SIMPL across an otolaryngology residency program. Faculty and residents were trained to use SIMPL to rate resident operative performance and autonomy with a previously validated Zwisch Scale. Residents (n = 23) and faculty (n = 17) were trained to use SIMPL using a standardized curriculum. A total of 833 assessments were completed from December 1, 2017, to June 30, 2018. Attendings completed a median 20 assessments, and residents completed a median 14 self-assessments. All evaluations were resident initiated, and attendings had a 78% median response rate. Evaluations took residents a median 22 seconds to complete; 126 unique procedures were logged, representing all 14 key indicator cases for otolaryngology. This is the first residency-wide application of a mobile platform to track the operative experiences of otolaryngology residents. We adapted and implemented a novel assessment tool in a large otolaryngology program. Future multicenter studies will benchmark resident operative experiences nationwide.

Plaut-Vincent’s Ulcerative Gingivitis and Tonsillitis

06-08-2019 – Francesco Maccarrone,Matteo Alicandri-Ciufelli

Journal Article

Outcomes of Cadaveric Allograft versus Autologous Cartilage Graft in Functional Septorhinoplasty

06-08-2019 – Robert Saadi,Justin Loloi,Eric Schaefer,Jessyka G. Lighthall

Journal Article

Our goal was to elucidate the efficacy and outcome profile of cadaveric allografts (homograft costal cartilage) in functional septorhinoplasty as compared with autografts (quadrangular cartilage, conchal cartilage, and autologous costal cartilage). Retrospective chart review. Otolaryngology division of the Penn State Health Milton S. Hershey Medical Center. A chart review of a single surgeon’s practice was conducted with A total of 171 cases were included in our data analysis. On multivariate analysis, there were no significant differences between patients who had autografts and those who had allografts in 3-, 6-, or 12-month postoperative NOSE score. Preoperative NOSE score was the only covariate to demonstrate a significant positive relationship to postoperative NOSE score. Regarding outcomes between autograft and allograft, no significant differences were found in rate of graft resorption (3.4% vs 5.6%, Autologous grafting is often the first choice in septorhinoplasty because of its presumed resistance to infection and resorption. Similar to autologous grafts, allografts are resistant to infection and resorption and demonstrate prolonged efficacy following functional septorhinoplasty.

The Potential of High-Throughput DNA Sequencing of the Paranasal Sinus Microbiome in Diagnosing Odontogenic Sinusitis

06-08-2019 – Asad A. Haider,Michael J. Marino,William C. Yao,Martin J. Citardi,Amber U. Luong

Journal Article

High-throughput DNA sequencing of the paranasal sinus microbiome has potential in the diagnosis and treatment of sinusitis. The objective of this study is to evaluate the use of high-throughput DNA sequencing to diagnose sinusitis of odontogenic origin. Case series with chart review. Single tertiary care academic medical center. A chart review was performed of DNA sequencing results from the sinus aspirates obtained under endoscopic visualization in 142 patients with sinusitis. The identification of any potentially pathogenic bacteria associated with oral flora in a sample was classified as a positive result for sinusitis of odontogenic etiology. The sensitivity, specificity, and predictive values of using high-throughput DNA sequencing to diagnose sinusitis of odontogenic etiology were determined, with the patient’s computed tomography sinus scan as the reference standard. On computed tomography scans, an odontogenic source was determined by the presence of a periapical lucency perforating the schneiderian membrane. Seven of the 142 patients enrolled in this study had an odontogenic source based on computed tomography scans. Relative to this reference standard, high-throughput DNA sequencing produced a sensitivity of 85.7% (95% CI, 42.1%-99.6%), a specificity of 81.5% (95% CI, 73.9%-87.6%), a positive predictive value of 19.4% (95% CI, 13.1%-27.7%), and a negative predictive value of 99.1% (95% CI, 94.7%-99.9%). This study supports the use of high-throughput DNA sequencing in supplementing other methods of investigation for identifying an odontogenic etiology of sinusitis.

Association of Midlife Hypertension with Late-Life Hearing Loss

06-08-2019 – Nicholas S. Reed,Matthew G. Huddle,Joshua Betz,Melinda C. Power,James S. Pankow,Rebecca Gottesman,A. Richey Sharrett,Thomas H. Mosley,Frank R. Lin,Jennifer A. Deal

Journal Article

To investigate the association of midlife hypertension with late-life hearing impairment. Data from the Atherosclerosis Risk in Communities study, an ongoing prospective longitudinal population-based study (baseline, 1987-1989). Washington County, Maryland, research field site. Subjects included 248 community-dwelling men and women aged 67 to 89 years in 2013. Systolic blood pressure (SBP) and diastolic blood pressure were measured at each of 5 study visits from 1987-1989 to 2013. Hypertension was defined by elevated systolic or diastolic blood pressure or antihypertensive medication use. A 4-frequency (0.5-4 k
Hz) better-hearing ear pure tone average in decibels hearing loss (d
B HL) was calculated from pure tone audiometry measured in 2013. A cutoff of 40 d
B HL was used to indicate clinically significant moderate to severe hearing impairment. Hearing thresholds at 5 frequencies (0.5-8 k
Hz) were also considered separately. Forty-seven participants (19%) had hypertension at baseline (1987-1989), as opposed to 183 (74%) in 2013. The SBP association with late-life pure tone average differed by the time of measurement, with SBP measured at earlier visits associated with poorer hearing; the difference in pure tone average per 10-mm Hg SBP measured was 1.43 d
B HL (95% CI, 0.32-2.53) at baseline versus -0.43 d
B HL (95% CI, -1.41 to 0.55) in 2013. Baseline hypertension was associated with higher thresholds (poorer hearing) at 4 frequencies (1, 2, 4, 8 k
Hz). Midlife SBP was associated with poorer hearing measured 25 years later. Further analysis into the longitudinal relationship between hypertension and hearing impairment is warranted.

Postoperative Opioid Prescribing and Consumption Patterns after Tonsillectomy

30-07-2019 – Stephanie Choo,Stephen Nogan,Laura Matrka

Journal Article

Despite increased concern with the opioid epidemic, literature remains scant regarding narcotic prescription and use following tonsillectomy. Retrospective cohort study with telephone interview. A chart review from January to August 2018 evaluated the difference between prescribed amounts of narcotic and patient-reported usage following tonsillectomy ( Sixty-four patients were enrolled at a mean 4.47 months after tonsillectomy. The mean ± SD prescribed morphine milligram equivalent (MME) was 456.1 ± 281.7, with only 302.8 ± 206.2 consumed. The mean MME prescribed per day was 74.1 ± 44.8, and average days of narcotic usage postoperatively was 9.6 ± 4.6, correlating with a mean MME per day of 49.2 ± 34.3 if the maximum prescribed dose per day was consumed. Fifty-four (84.4%) patients reported pain as well controlled. Forty-three (67.2%) patients reported residual narcotic medication, with 228.1 ± 208.5 MMEs remaining per patient. Narcotic solutions were more completely consumed than tablet forms, with 23.1% and 44.0% remaining, respectively. Patients cited uncertainty about safe disposal and safeguarding for future use as reasons for keeping residual narcotic. Patient-reported narcotic use is significantly lower than the amount prescribed after tonsillectomy for benign disease. Providers can use these data to adjust narcotic-prescribing patterns while maintaining appropriate pain management for patients undergoing tonsillectomy.

Contributions of Contemporary Human Temporal Bone Histopathology to Clinical Otology

30-07-2019 – Debara L. Tucci,Joni K. Doherty

Journal Article

Contemporary techniques have greatly enhanced the contributions of human temporal bone (HTB) histopathology to our understanding of the mechanisms of human otologic disease and disease treatment. Herein, we review some of the most salient contributions of this research to disease management. The field of HTB histopathology is challenged by limited resources as applies to trained investigators, infrastructure, and well-equipped laboratories. This research provides insights into clinical otology that cannot be obtained by any other means. Measures should be taken to preserve and extend the contributions of HTB research.

Pattern of Intraoperative Parathyroid Hormone and Calcium in the Treatment of Tertiary Hyperparathyroidism

30-07-2019 – André Luís Maion Casarim,Fernando Antonio Maria Claret Arcadipane,Antonio Santos Martins,André Del Negro,André Afonso Nimtz Rodrigues,Alfio Jose Tincani,Evaldo Marchi

Journal Article

Tertiary hyperparathyroidism, an autonomous hyperproduction of parathyroid hormone (PTH), has a challenge in its treatment. This study asked whether the intraoperative PTH and calcium drop can confirm the resection of all parathyroid tissues. Case series with planned data collection. Tertiary referral medical center. The study assessed patients with tertiary hyperparathyroidism who were treated at the Hospital of the State University of Campinas from 2007 to 2015. All patients underwent total parathyroidectomy with autotransplantation of parathyroid fragments. PTH and calcium were collected during the preoperative period; at 10, 20, and 240 minutes after resection of the glands; and at 1 year after the procedure. Data were analyzed by analysis of variance and logistic regression analysis with statistical values of Thirty-five patients were assessed: 17 women (48.57%) and 18 men (51.43%). The percentage of PTH drop was statistically significant at all times, unlike the calcium analysis, but only PTH collected at 20 minutes was able to confirm the removal of all parathyroid tissues ( Treatment success can be predicted by analyzing the decrease of intraoperative PTH and not by calcium. The 71.2% PTH drop at 20 minutes after parathyroidectomy had high sensitivity and specificity to predict surgical cure.

Flexible Endoscopic Zenker’s Diverticulotomy with an Articulating Bipolar Energy Sealer

30-07-2019 – Philip A. Weissbrod,Aria Jafari,Shanglei Liu,Santiago Horgan,Robert A. Weisman

Journal Article

The surgical management of Zenker’s diverticula is performed through open or endoscopic approaches. The purpose of this report is to review our early experience with flexible endoscopic diverticulotomy with an articulating bipolar energy sealer for cricopharyngeal and diverticular wall division in a series of 5 patients where transoral rigid access was not possible. In addition to technical details, safety and efficacy data are included. The average diverticulum size was 2.5 cm. All patients reported symptom resolution, and there were no surgical complications. Liquid diet was initiated on postoperative day 1 for all patients and solids on day 11.8 ± 14.4 (mean ± SD) per protocol. Results demonstrate that treatment of Zenker’s diverticula can safely and successfully be performed with flexible endoscopic visualization and utilization of an articulating bipolar energy sealer to perform diverticulotomy in a population of patients where transoral diverticulotomy would not otherwise be feasible due to anatomic constraints. Early results support obtaining further experience to study this technology as an alternative to open surgery, especially when visualization and access are suboptimal with rigid endoscopy.

Clinical Traits Characterizing an Exacerbation-Prone Phenotype in Chronic Rhinosinusitis

30-07-2019 – Katie M. Phillips,Eric Barbarite,Lloyd P. Hoehle,David S. Caradonna,Stacey T. Gray,Ahmad R. Sedaghat

Journal Article

Acute exacerbation of chronic rhinosinusitis (AECRS) is associated with significant quality-of-life decreases. We sought to determine characteristics associated with an exacerbation-prone phenotype in chronic rhinosinusitis (CRS). Cross-sectional. Tertiary care rhinology clinic. Patients with CRS (N = 209). Patient-reported number of sinus infections, CRS-related antibiotics, and CRS-related oral corticosteroids taken in the last 12 months were used as metrics for AECRS frequency. Sinonasal symptom burden was assessed with the 22-item Sinonasal Outcome Test (SNOT-22). Ninety patients reporting 0 for all AECRS metrics were considered to have had no AECRS in the prior 12 months. A total of 119 patients reported >3 on at least 1 AECRS metric and were considered as having an exacerbation-prone phenotype. Characteristics associated with patients with an exacerbation-prone phenotype were identified with exploratory regression analysis. An exacerbation-prone phenotype was positively associated with comorbid asthma (adjusted odds ratio [OR In total, these results point to a CRS exacerbation-prone phenotype characterized by high sinonasal disease burden with comorbid asthma but interestingly without polyps.

Incidence and Significance of Hypermetabolic PET-CT Findings in Unilateral TVF Motion Impairment

23-07-2019 – Luke Stanisce,Timothy Renzi,Nikita Paripati,Nadir Ahmad,Thomas C. Spalla,Howard L. Roth,Yekaterina Koshkareva

Journal Article

To determine the incidence and significance of asymmetric hypermetabolic laryngeal findings on positron emission tomography-computed tomography (PET-CT) in patients with unilateral true vocal fold (TVF) motion abnormalities. Retrospective cohort. Single-center tertiary care institution. The medical records of patients with unilateral TVF motion abnormalities were reviewed. The incidence of normal and asymmetric hypermetabolic laryngeal findings was calculated in patients who underwent PET-CT and laryngeal examination, operative laryngoscopy with biopsy, or injection medialization laryngoplasty. A total of 135 patients with unilateral TVF motion abnormalities underwent PET-CT. After exclusion of patients who completed new or surveillance imaging for a laryngeal neoplasm (n = 27), asymmetric hypermetabolic findings in the larynx were noted in 21 (19%) cases: 13 (12%) on the contralateral side of the impaired TVF, 8 (7%) on the ipsilateral side. Two (25%) patients with ipsilateral hypermetabolism had concerning subsequent fiberoptic laryngeal examinations prompting operative biopsy. There was no evidence of inflammatory or neoplastic disease in all patients with contralateral hypermetabolic findings. Fifteen patients completed PET-CT scans after injection medialization procedures; 6 (40%) displayed avidity ipsilateral to the side of the injection. The median time from injection to scan was 27 days, as opposed to 193 days in the unremarkable scans ( Contralateral hypermetabolism in patients with unilateral TVF motion abnormalities may represent a false-positive finding. Ipsilateral hypermetabolic uptake without recent fold instrumentation warrants prompt diagnostic evaluation.

Does Attending Surgeon Presence at the Preinduction Briefing Improve Operating Room Efficiency?

23-07-2019 – Rajeev C. Saxena,Mark E. Whipple,Moni B. Neradilek,Stuart Solomon,Christine T. Fong,Bala G. Nair,John D. Lang

Journal Article

To examine if attending surgeon presence at the preinduction briefing is associated with a shorter time to incision. Retrospective cohort study and survey. Tertiary academic medical center. A retrospective cohort study was conducted of 22,857 operations by 141 attending surgeons across 12 specialties between August 3, 2016, and June 21, 2018. The independent variable was attending surgeon presence at the preinduction briefing. Linear regression models compared time from room entry to incision overall, by service line, and by surgeon. We hypothesized a shorter time to incision when the attending surgeon was present and a larger effect for cases with complex surgical equipment or positioning. A survey was administered to evaluate attending surgeons’ perceptions of the briefing, with a response rate of 68% (64 of 94 attending surgeons). Cases for which the attending surgeon was present at the preinduction briefing had a statistically significant yet operationally minor reduction in mean time to incision when compared with cases when the attending surgeon was absent. After covariate adjustment, the mean time to incision was associated with an efficiency gain of 1.8 ± 0.5 minutes (mean ± SD; Attending surgeon presence at the preinduction briefing has only a minor effect on efficiency as measured by time to incision.

Predictive Value of First Posttreatment Imaging Using Standardized Reporting in Head and Neck Cancer

23-07-2019 – Derek Hsu,Falgun H. Chokshi,Patricia A. Hudgins,Suprateek Kundu,Jonathan J. Beitler,Mihir R. Patel,Ashley H. Aiken

Journal Article

The Neck Imaging Reporting and Data System (NI-RADS) is a standardized numerical reporting template for surveillance of head and neck squamous cell carcinoma (HNSCC). Our aim was to analyze the accuracy of NI-RADS on the first posttreatment fluorodeoxyglucose positron emission tomography/contrast-enhanced computed tomography (PET/CECT). Retrospective cohort study. Academic tertiary hospital. Patients with HNSCC with a 12-week posttreatment PET/CECT interpreted using the NI-RADS template and 9 months of clinical and radiologic follow-up starting from treatment completion between June 2014 and July 2016 were included. Treatment failure was defined as positive tumor confirmed by biopsy or Response Evaluation Criteria in Solid Tumors criteria. Cox proportional hazards models were performed. This study comprised 199 patients followed for a median of 15.5 months after treatment completion (25% quartile, 11.8 months; 75% quartile, 20.2 months). The rates of treatment failure increased with each incremental increase in NI-RADS category from 1 to 3 (4.3%, 9.1%, and 42.1%, respectively). A Cox proportional hazards model demonstrated a strong association between NI-RADS categories and treatment failure at both primary and neck sites (hazard ratio [HR], 2.60 and 5.22, respectively; Increasing NI-RADS category at the baseline posttreatment PET/CECT is strongly associated with increased risk of treatment failure in patients with HNSCC.

Image-Guided Mastoidectomy with a Cooperatively Controlled ENT Microsurgery Robot

23-07-2019 – Christopher R. Razavi,Paul R. Wilkening,Rui Yin,Samuel R. Barber,Russell H. Taylor,John P. Carey,Francis X. Creighton

Journal Article

Mastoidectomy is a common surgical procedure within otology. Despite being inherently well suited for implementation of robotic assistance, there are no commercially available robotic systems that have demonstrated utility in aiding with this procedure. This article describes a robotic technique for image-guided mastoidectomy with an experimental cooperatively controlled robotic system developed for use within otolaryngology-head and neck surgery. It has the ability to facilitate enhanced operative precision with dampening of tremor in simulated surgical tasks. Its kinematic design is such that the location of the attached surgical instrument is known with a high degree of fidelity at all times. This facilitates image registration and subsequent definition of virtual fixtures, which demarcate surgical workspace boundaries and prevent motion into undesired areas. In this preliminary feasibility study, we demonstrate the clinical utility of this system to facilitate performance of a cortical mastoidectomy by a novice surgeon in 5 identical temporal bone models with a mean time of 221 ± 35 seconds.

Comparing Hematoma Incidence between Hemostatic Devices in Total Thyroidectomy: A Systematic Review and Meta-analysis

23-07-2019 – Nadia Hua,Alexandra Elizabeth Quimby,Stephanie Johnson-Obaseki

Journal Article

Alternative energy devices have become a popular alternative to conventional hemostasis in thyroid surgery. These devices have been shown to reduce operative time and thermal nerve injury. As hemostasis is paramount in thyroid surgery, we sought to examine the relative efficacy of 2 alternate energy devices compared to conventional hemostasis in preventing postoperative hematoma following total thyroidectomy. Ovid MEDLINE, EMBASE, PubMed, and Cochrane Central Register of Controlled Trials. A systematic literature search was performed for all relevant English-language studies published between 1946 and July 2018. Two authors independently extracted data and analyzed articles for quality using the National Institute of Health Quality Assessment Scale. Our primary outcome of interest was hematoma requiring reoperation. A total of 348 studies were screened, with 23 meeting the inclusion criteria. We found no significant difference in postoperative hematoma rates using alternate energy devices compared to conventional hemostasis ( We found no significant difference in postoperative hematoma rates following total thyroidectomy for any indication with the use of alternate energy devices compared to conventional hemostatic techniques. This suggests that hematoma occurrence does not necessarily need to be considered when choosing between these hemostatic devices. This information may help guide surgeons’ decisions regarding choice of hemostatic technique during thyroid surgery.

A Standardized Care Pathway following Mandibular Distraction in Infants Less Than 3 Months of Age

23-07-2019 – Grace R. Leu,Andrew R. Scott

Journal Article

To assess for differences in postoperative care following mandibular distraction osteogenesis (MDO) in infants before and after implementation of a standardized protocol. Retrospective chart review. Urban tertiary pediatric hospital. The inpatient charts of infants who underwent MDO before 90 days of age were assessed for metrics such as postoperative length of stay (LOS), duration of mechanical ventilation, and the choice and duration of sedating medications. Over a 6-year period, 16 patients met inclusion criteria. The first 4 consecutive patients were managed at the discretion of the critical care staff. The remaining 12 infants were managed with a planned 4- to 6-day period of postoperative intubation, during which a standard protocol determined the choice, dosage, and duration of sedating medications. The mean age was similar between groups (preprotocol: mean, 26.5 days; protocol: mean, 20.3 days; Among infants undergoing MDO, standardizing postoperative airway and sedation practices may offer a more predictable postoperative course as compared with a case-by-case management philosophy.

Analysis of Olfaction after Bilateral Nasoseptal Rescue Flap Transsphenoidal Approach with Olfactory Mucosal Preservation

23-07-2019 – Chester F. Griffiths,Garni Barkhoudarian,Aaron Cutler,Huy T. Duong,Kian Karimi,Olivia Doyle,Ricardo Carrau,Daniel F. Kelly

Journal Article

To ascertain the impact of septal olfactory strip preservation and bilateral rescue flap elevation on the incidence of olfactory dysfunction. Case series with chart review of patients undergoing endoscopic endonasal skull base surgery (2012-2014). Providence Saint John’s Health Center and John Wayne Cancer Institute. The incidences of postoperative epistaxis, hyposmia, and anosmia were analyzed using the Brief Smell Identification Test (B-SIT), which was completed in 110 of the 165 patients. Seventy-eight patients required extended approaches. Bilateral nasoseptal rescue flaps were elevated in 144 patients (87.3%) and pedicled nasoseptal or middle turbinate flaps in 21 patients (12.7%). The neurovascular pedicles were preserved in all patients, and there were no episodes of postoperative arterial epistaxis. Normal olfaction was noted in 95 patients (86%), with new hyposmia noted in 5 patients (5.5%). Within the rescue flap cohort, new hyposmia occurred in 6.3% ( Superior olfactory strip preservation during elevation of reconstructive flaps preserves olfactory function and maintains adequate surgical exposure. In addition, rescue flaps have significantly diminished the rate of arterial postoperative epistaxis while maintaining the ability to harvest nasoseptal flaps for future reconstruction.

Risk Factors and Incidence of Postoperative Delirium in Patients Undergoing Laryngectomy

23-07-2019 – Yiru Wang,Huiqian Yu,Hui Qiao,Chan Li,Kaizheng Chen,Xia Shen

Journal Article

To explore the risk factors and incidence of postoperative delirium (POD) in patients undergoing laryngectomy for laryngeal cancer. Prospective cohort study. Shanghai Eye, Ear, Nose, and Throat Hospital, Fudan University. A total of 323 patients underwent laryngectomy from April 4, 2018, to December 28, 2018. Perioperative data were collected. The primary outcome was the presence of POD as defined by the Confusion Assessment Method diagnostic algorithm. Univariate and multivariable logistic regression analyses were used to identify risk factors associated with POD. Of the patients who underwent laryngectomy during the study period, 99.1% were male, with a mean age of 60.0 years. Of these patients, 28 developed POD, with most episodes (88.1%) occurring during the first 3 postoperative days. The type of POD was hyperactive in 7 cases and hypoactive in 21 cases. The mean duration of POD was 1 day. The mean Delirium Rating Scale-Revised-98 score (a measure of POD severity) was 11.5. For the multivariable analysis, risk factors associated with POD included advanced cancer stage, lower educational level, higher American Society of Anesthesiologists classification, and intraoperative hypotension lasting at least 30 minutes. Intraoperative dexmedetomidine use was protective against POD. This study identified risk factors associated with POD, providing a target population for quality improvement initiatives. Furthermore, intraoperative dexmedetomidine use can reduce POD.

Long-term Effects of Conservative Management of Vestibular Schwannoma on Dizziness, Balance, and Caloric Function

16-07-2019 – Kathrin Skorpa Nilsen,Morten Lund-Johansen,Stein Helge Glad Nordahl,Monica Finnkirk,Frederik Kragerud Goplen

Journal Article

To study the development of dizziness, caloric function, and postural sway during long-term observation of untreated vestibular schwannoma patients. Retrospective review of a prospectively maintained longitudinal cohort. Tertiary referral hospital. Patients with vestibular schwannoma undergoing wait-and-scan management were included-specifically, those who did not require treatment during a minimum radiologic follow-up of 1 year. Baseline data and follow-up included magnetic resonance imaging, posturography, bithermal caloric tests, and a dizziness questionnaire. Main outcomes were prevalence of moderate to severe dizziness, canal paresis, and postural instability at baseline and follow-up, as compared with Mc
Nemar’s test. Out of 433 consecutive patients with vestibular schwannoma, 114 did not require treatment during follow-up and were included. Median radiologic follow-up was 10.2 years (interquartile range, 4.5 years). Age ranged from 31 to 78 years (mean, 59 years; SD, 10 years; 62% women). Median tumor volume at baseline was 139 mm There was no significant change in the prevalence of dizziness, postural sway, or canal paresis during conservative management of vestibular schwannoma, while tumor volume remained unchanged. This indicates a favorable prognosis in these patients with regard to vestibular symptoms.

Facial Nerve Duplication and First Branchial Cleft Cysts: An Association in an Uncommon Pathology

02-07-2019 – Jacob Eide,André Isaac,John Maddalozzo

Journal Article

A Critical Analysis of Medicare Claims for Otolaryngology Procedures

25-06-2019 – Stephanie J. Youssef,Krishna S. Vyas

Journal Article

This study was performed to outline and analyze the overall Medicare landscape with respect to otolaryngologists and beneficiaries, services, and reimbursements. This is a retrospective analysis of publicly available Medicare utilization and payment data for all otolaryngologists in facility and nonfacility practice settings who provided services to Medicare beneficiaries between January 1, 2012, and December 31, 2016. In 2016, a total of $701,195,375 was distributed to 8572 otolaryngology physician providers for 815 unique Healthcare Common Procedure Coding System codes for 13,942,536 procedure claims. Of specialty care, otolaryngology ranks 20th among 54 subspecialties for total Medicare payments. The average number of services coded per provider was 1627. The average otolaryngologist was paid $81,800.67. Thirty-two percent of otolaryngologists did not receive reimbursement for services from Medicare in 2016. In 2016, the most significant contributors to Medicare payments to otolaryngologists were large-scale, low-cost events that are relatively short procedures done in clinic. Utilization of nasal endoscopy was up trending from 2012 to 2016. Some of the It is increasingly valuable for physicians to know factors that affect reimbursement for procedures and operations in different settings and to be aware of the trends in variation in their specialty. Otolaryngologists should communicate with policy makers in efforts toward sustainable reimbursement models.

Outcomes of Vocal Fold Motion Impairment and Dysphagia after Pediatric Cardiothoracic Surgery: A Systematic Review

25-06-2019 – Susannah Orzell,Rahul Joseph,Julina Ongkasuwan,Joshua Bedwell,Jennifer Shin,Nikhila Raol

Journal Article

The objective of this study was to systematically review the literature regarding vocal fold motion impairment (VFMI), respiratory outcomes, and swallowing outcomes in children following congenital heart surgery (CHS). PubMed, Embase, Medline, and CINAHL databases. Data sources were searched from inception to November 30, 2018. Studies that described recovery of VFMI and swallowing function following CHS were included, and a qualitative analysis was performed. A total of 1371 studies were identified, of which 8 met inclusion criteria for VFMI and 5 met inclusion criteria for swallowing outcomes. Studies including patients who underwent isolate patent ductus arteriosus ligation were excluded. VFMI was present in 8% to 59% of subjects, and rates of recovery ranged from 9% to 96% at 6 months to 6 years of follow-up. Inability to maintain an oral diet occurred in 14% to 100% of subjects with VFMI and 11% to 61% without VFMI following surgery. Tolerance of an oral diet without tube feeding was present in 66% to 75% of subjects with VFMI and 88% to 100% without VFMI at 24 days to 3.2 years of follow-up. Limited data suggest that time to extubation is longer in VFMI subjects, but overall hospital length of stay and mortality may not be affected by VFMI status. Data evaluating dysphagia and VFMI after CHS are limited. Most studies suggest significant improvement in swallowing function, while rate of recovery of VFMI is variable. Future prospective studies with standardized screening and follow-up are needed to better elucidate outcomes to help develop algorithms for identification and management of VFMI after CHS.

Previous Surgery and Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea

25-06-2019 – Eric J. Kezirian,Clemens Heiser,Armin Steffen,Maurits Boon,Benedikt Hofauer,Karl Doghramji,Joachim T. Maurer,J. Ulrich Sommer,Ryan J. Soose,Richard Schwab,Erica Thaler,Kirk Withrow,Alan Kominsky,Christopher G. Larsen,Jennifer Hsia,Reena Mehra,Tina Waters,Kingman Strohl

Journal Article

To examine whether previous palate or hypopharyngeal surgery was associated with efficacy of treatment of obstructive sleep apnea with hypoglossal nerve stimulation. Cohort (retrospective and prospective). Eleven academic medical centers. Adults treated with hypoglossal nerve stimulation were enrolled in the ADHERE Registry. Outcomes were defined by the apnea-hypopnea index (AHI), in 3 ways: change in the AHI and 2 definitions of therapy response requiring ≥50% reduction in the AHI to a level <20 events/h (Response20) or 15 events/h (Response15). Previous palate and hypopharyngeal (tongue, epiglottis, or maxillofacial) procedures were documented. Linear and logistic regression examined the association between previous palate or hypopharyngeal surgery and outcomes, with adjustment for age, sex, and body mass index. The majority (73%, 217 of 299) had no previous palate or hypopharyngeal surgery, while 25% and 9% had previous palate or hypopharyngeal surgery, respectively, including 6% with previous palate and hypopharyngeal surgery. Baseline AHI (36.0 ± 15.6 events/h) decreased to 12.0 ± 13.3 at therapy titration ( Previous upper airway surgery was not clearly associated with efficacy of hypoglossal nerve stimulation.

Variations in Stapes Surgery Cost within a Multihospital Network

11-06-2019 – Geoffrey C. Casazza,Andrew J. Thomas,Jesse Dewey,Richard K. Gurgel,Clough Shelton,Jeremy D. Meier

Journal Article

To identify costs and operative times for stapedotomy and evaluate factors influencing cost variation. Case series with cost analysis. Multihospital network. A multihospital network’s standardized activity-based accounting system was used to determine costs and operative times of all patients undergoing stapedotomy from 2013 to 2017. Subjects with additional procedures were excluded. Correlations between variable factors and cost were calculated by Spearman correlation coefficients. Audiometric and cost data were compared with a Mann-Whitney U test. The study cohort included 176 stapedotomies performed by 23 surgeons at 10 hospitals. Mean ± SD patient age was 44.3 ± 17.4 years. Mean cut-to-close time was 61.1 ± 23.55 minutes. Mean total encounter cost was $3542.14 ± $1258.78 (US dollars). Significant factors correlating with increased total encounter cost were surgical supply cost ( r = 0.74, P < .0001) and cut-to-close time ( r = 0.66, P < .0001). Laser utilization ($563.37 ± $407.41) was the highest-cost surgical supply, with the carbon dioxide laser being significantly more costly than the potassium titanyl phosphate (KTP; $852.60 vs $230.55, P < .001). Additionally, the carbon dioxide laser was associated with a significantly higher mean total encounter cost than the KTP laser ($4645.43 vs $2903.00, P < .001) and cases where no laser was used ($4645.43 vs $2932.47, P < .001). There was no difference in mean total encounter cost between the KTP laser and cases of no laser use ($2903.00 vs $2932.47, P = .75). Significant cost variation exists in stapes surgery. Surgical supply cost, specifically laser use, may be associated with significantly increased costs. Reducing variation in costs while maintaining outcomes may improve health care value.

Influence of Socioeconomic Status on Stage at Presentation of Laryngeal Cancer in the United States

11-06-2019 – Nicole L. Lebo,Diana Khalil,Adele Balram,Margaret Holland,Martin Corsten,James Ted McDonald,Stephanie Johnson-Obaseki

Journal Article

Identify socioeconomic predictors of stage at diagnosis of laryngeal cancer in the United States. Retrospective analysis of the North American Association of Central Cancer Registries’ Incidence Data-Cancers in North America Deluxe Analytic File for expanded races. All centers reporting to the US Centers for Disease Control and Prevention’s National Program of Cancer Registries. All cases of laryngeal cancer in adult patients from 2005 to 2013 were reviewed. Ordinal logistic regression models were used to evaluate odd ratios (ORs) for socioeconomic indicators potentially predictive of advancing American Joint Committee on Cancer stage at diagnosis. A total of 72,472 patients were identified and included. Analysis revealed significant correlation between advanced stage at diagnosis and: Medicaid insurance, lack of insurance, female sex, older age, black race, and certain states of residence. The strongest predictor of advanced stage was lack of insurance (OR, 2.212; P < .001; 95% CI, 2.035-2.406). The strongest protective factor was residing in the state of Utah (OR, 0.571; P < .001; 95% CI, 0.536-0.609). Once adjusted for regional price and wage disparities, relative income was not a significant predictor of stage at presentation across multiple analyses. Multiple socioeconomic factors were predictive of severity of disease at presentation of laryngeal cancer in the United States. This study demonstrated that insurance type was strongly predictive, whereas relative income had surprisingly little influence.

Unilateral vs Bilateral Supraglottoplasty: A Meta-analysis of Rates of Return to Surgery and Supraglottic Stenosis

11-06-2019 – Michael P. Avillion,Cindy Lee P. Neighbors,Andrew Biello,Lauren C. Anderson,Bryan J. Liming,Macario Camacho

Journal Article

To perform a systematic review with meta-analysis of data to determine the rates of repeat surgery and supraglottic stenosis in unilateral versus bilateral supraglottoplasty for laryngomalacia. PubMed/Medline, Cochrane Central, Scopus, Google Scholar, Web of Science, and Embase. Databases were searched through January 30, 2018. Studies with unilateral or bilateral supraglottoplasty techniques for laryngomalacia were included. The need for repeat (revision or completion) surgery and rates of supraglottic stenosis were primary outcomes. Data were substratified and a meta-analysis performed. A total of 251 articles were reviewed, and 20 articles met inclusion criteria (1186 patients: 663 bilateral, 523 unilateral). Regarding the need to return to surgery, the rate of revision for bilateral surgery was 4.1%, compared to the revision and combined revision/completion rates for unilateral surgery which respectively were 1.1% (odds ratio [OR] 0.27; 95% CI 0.11-0.67; P = .002) and 18.0% (OR 5.16; 95% CI 3.31-8.06; P < .0001). The unilateral versus bilateral supraglottic stenosis rates were 0% versus 1.2% ( P = .011). Unilateral supraglottoplasty has a significantly higher rate of repeat surgery, mainly attributed to contralateral surgery, when compared with bilateral supraglottoplasty. There is a small but statistically significant risk of supraglottic stenosis in bilateral procedures. The benefit of a unilateral procedure should be weighed against the cost of subjecting patients to a 4-fold increased risk of repeat surgery.

Postoperative Bleeding Associated with Ibuprofen Use after Tonsillectomy: A Meta-analysis

04-06-2019 – William Stokes,Robert T. Swanson,Jane Schubart,Michele M. Carr

Journal Article

To better quantify the risk of ibuprofen-associated posttonsillectomy hemorrhage (PTH). PUBMED/MEDLINE, Web of Science, and Cochrane Clinical Trials Database. Literature searches were performed for English-language publications containing the terms tonsillectomy, ibuprofen, and tonsillectomy from database inception to May 2017. Human clinical trials, prospective cohort studies, and retrospective cohort studies related to tonsillectomy, ibuprofen use, and posttonsillectomy hemorrhage among pediatric patients were selected. Electronic searches revealed 151 studies, of which 12 were deemed eligible for analysis. Studies were weighted according to level of evidence and risk of bias. Pooling of results across all studies showed a statistically significant increase in PTH among the patients taking ibuprofen (odds ratio, 1.38; 95% confidence interval, 1.11-1.72). The I Our meta-analysis of available cohort studies and randomized controlled trials (RCTs) shows possible increased tendency to PTH with the use of ibuprofen. This has not been demonstrated in other studies and systematic reviews because their analyses were limited by use of multiple nonsteroidal anti-inflammatory drugs and inclusion of studies limited to the perioperative period and low sample size. However, the current analysis is limited due to inclusion of many retrospective cohort studies with unclear follow-up and no blinding. Further RCTs will be required to investigate this trend toward increased PTH.

High-Frequency Ultrasound: A Novel Diagnostic Tool to Measure Pediatric Tonsils in 3 Dimensions

14-05-2019 – Emily Kay-Rivest,Christine Saint-Martin,Sam J. Daniel

Journal Article

A wide variety of pathologies can affect the palatine tonsils. Ultrasound is a commonly used modality for assessing head and neck masses in children; however, its use in tonsillar evaluation has not been widely explored. The objective of this study was to measure 3-dimensional tonsillar size with ultrasound, in centimeters, and correlate these measurements with actual ex vivo dimensions on pathology specimens. We performed a prospective cohort study. The study was set in a tertiary care children’s hospital. Children undergoing tonsillectomy were included in the study. Transcervical high-frequency ultrasonography (HFU) was performed prior to surgery to obtain 3-dimensional measurements of the right and left palatine tonsils. Mean sizes were compared to ex vivo tonsil measurements and correlations were obtained. Seventy-five consecutive children underwent a transcervical HFU, with a total of 150 tonsils analyzed. The mean differences between HFU and pathology measurements were -0.08 cm and -0.24 cm for the right and left craniocaudal axes, -0.19 cm and -0.18 cm for the right and left mediolateral axes, and 0.05 cm and 0.03 cm for the right and left anteroposterior axes. Correlation coefficients between ultrasound and pathology measurements were all above 0.5. HFU can accurately measure the size of pediatric tonsils in 3 dimensions.

Risk Factors for Blood Transfusion with Neck Dissection

02-04-2019 – Monica C. Azmy,Juanita Pinto,Nirali M. Patel,Aparna Govindan,Evelyne Kalyoussef

Journal Article

To identify risk factors of perioperative blood transfusions (PBTs) for neck dissection and identify the association of PBTs with other postoperative outcomes. This is a retrospective study of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. The database was queried for neck dissection procedures performed by otolaryngologists from 2006 to 2014. Multivariable logistic regression was used to determine associations between demographic and preoperative factors, mortality, unplanned reoperation, and unplanned readmission with PBTs. Of the 3090 patients included in our study, 346 (11.2%) received a PBT, 249 patients (72.0%) received blood intraoperatively or on postoperative day (POD) 0, and 97 patients (28.0%) received blood within 5 PODs. American Society of Anesthesiologists (ASA) class ≥3 (odds ratio [OR], 2.1; 95% confidence interval [CI], 1.4-3.2), preoperative weight loss (OR, 2.2; 95% CI, 1.5-3.2), and anemia (OR, 5.5; 95% CI, 4.1-7.6) were independently associated with PBTs. Free flaps were also significantly associated with PBTs. PBTs were significantly associated with unplanned return to the operating room within 30 days (OR, 4.31; 95% CI, 3.01-6.18) but not with 30-day unplanned readmission or 30-day mortality. Eleven percent of patients undergoing neck dissection receive a PBT. Identifying associated risk factors may reduce PBT among patients with cancer. Comorbid data, such as weight loss, anemia, and ASA class, may be useful in determining risk for transfusion during these procedures. Awareness of preoperative risk factors for PBT may lead surgeons to reduce the risk of PBT, anticipate the need for transfusion, and manage these patients carefully to prevent unplanned reoperation.