Otolaryngology Head and Neck Surgery

Otolaryngology Head and Neck Surgery

Clinical Practice Guideline: Sudden Hearing Loss (Update)

01-08-2019 – Sujana S. Chandrasekhar,Betty S. Tsai Do,Seth R. Schwartz,Laura J. Bontempo,Erynne A. Faucett,Sandra A. Finestone,Deena B. Hollingsworth,David M. Kelley,Steven T. Kmucha,Gul Moonis,Gayla L. Poling,J. Kirk Roberts,Robert J. Stachler,Daniel M. Zeitler,Maureen D. Corrigan,Lorraine C. Nnacheta,Lisa Satterfield

Journal Article

Sudden hearing loss is a frightening symptom that often prompts an urgent or emergent visit to a health care provider. It is frequently but not universally accompanied by tinnitus and/or vertigo. Sudden sensorineural hearing loss affects 5 to 27 per 100,000 people annually, with about 66,000 new cases per year in the United States. This guideline update provides evidence-based recommendations for the diagnosis, management, and follow-up of patients who present with sudden hearing loss. It focuses on sudden sensorineural hearing loss in adult patients aged ≥18 years and primarily on those with idiopathic sudden sensorineural hearing loss. Prompt recognition and management of sudden sensorineural hearing loss may improve hearing recovery and patient quality of life. The guideline update is intended for all clinicians who diagnose or manage adult patients who present with sudden hearing loss. The purpose of this guideline update is to provide clinicians with evidence-based recommendations in evaluating patients with sudden hearing loss and sudden sensorineural hearing loss, with particular emphasis on managing idiopathic sudden sensorineural hearing loss. The guideline update group recognized that patients enter the health care system with sudden hearing loss as a nonspecific primary complaint. Therefore, the initial recommendations of this guideline update address distinguishing sensorineural hearing loss from conductive hearing loss at the time of presentation with hearing loss. They also clarify the need to identify rare, nonidiopathic sudden sensorineural hearing loss to help separate those patients from those with idiopathic sudden sensorineural hearing loss, who are the target population for the therapeutic interventions that make up the bulk of the guideline update. By focusing on opportunities for quality improvement, this guideline should improve diagnostic accuracy, facilitate prompt intervention, decrease variations in management, reduce unnecessary tests and imaging procedures, and improve hearing and rehabilitative outcomes for affected patients. Consistent with the American Academy of Otolaryngology-Head and Neck Surgery Foundation’s “Clinical Practice Guideline Development Manual, Third Edition” (Rosenfeld et al. The guideline update group made Incorporation of new evidence profiles to include quality improvement opportunities, confidence in the evidence, and differences of opinion Included 10 clinical practice guidelines, 29 new systematic reviews, and 36 new randomized controlled trials Highlights the urgency of evaluation and initiation of treatment, if treatment is offered, by emphasizing the time from symptom occurrence Clarification of terminology by changing potentially unclear statements; use of the term

Highlights from the Current Issue: August 2019

01-08-2019 – John H. Krouse

Journal Article

The Fox and the Crow: Predatory Open Access Journals in Otolaryngology

28-05-2019 – Albert Mudry,Robert J. Ruben

Journal Article

Clinical Practice Guideline: Sudden Hearing Loss (Update) Executive Summary

01-08-2019 – Sujana S. Chandrasekhar,Betty S. Tsai Do,Seth R. Schwartz,Laura J. Bontempo,Erynne A. Faucett,Sandra A. Finestone,Deena B. Hollingsworth,David M. Kelley,Steven T. Kmucha,Gul Moonis,Gayla L. Poling,J. Kirk Roberts,Robert J. Stachler,Daniel M. Zeitler,Maureen D. Corrigan,Lorraine C. Nnacheta,Lisa Satterfield,Taskin M. Monjur

Journal Article

Sudden hearing loss is a frightening symptom that often prompts an urgent or emergent visit to a health care provider. It is frequently, but not universally, accompanied by tinnitus and/or vertigo. Sudden sensorineural hearing loss affects 5 to 27 per 100,000 people annually, with about 66,000 new cases per year in the United States. This guideline update provides evidence-based recommendations for the diagnosis, management, and follow-up of patients who present with sudden hearing loss. It focuses on sudden sensorineural hearing loss in adult patients aged 18 and over and primarily on those with idiopathic sudden sensorineural hearing loss. Prompt recognition and management of sudden sensorineural hearing loss may improve hearing recovery and patient quality of life. The guideline update is intended for all clinicians who diagnose or manage adult patients who present with sudden hearing loss. The purpose of this guideline update is to provide clinicians with evidence-based recommendations in evaluating patients with sudden hearing loss and sudden sensorineural hearing loss, with particular emphasis on managing idiopathic sudden sensorineural hearing loss. The guideline update group recognized that patients enter the health care system with sudden hearing loss as a nonspecific primary complaint. Therefore, the initial recommendations of this guideline update address distinguishing sensorineural hearing loss from conductive hearing loss at the time of presentation with hearing loss. They also clarify the need to identify rare, nonidiopathic sudden sensorineural hearing loss to help separate those patients from those with idiopathic sudden sensorineural hearing loss, who are the target population for the therapeutic interventions that make up the bulk of the guideline update. By focusing on opportunities for quality improvement, this guideline should improve diagnostic accuracy, facilitate prompt intervention, decrease variations in management, reduce unnecessary tests and imaging procedures, and improve hearing and rehabilitative outcomes for affected patients. Consistent with the American Academy of Otolaryngology-Head and Neck Surgery Foundation’s The guideline update group made strong recommendations for the following: clinicians should distinguish sensorineural hearing loss from conductive hearing loss when a patient first presents with sudden hearing loss (KAS 1); clinicians should educate patients with sudden sensorineural hearing loss about the natural history of the condition, the benefits and risks of medical interventions, and the limitations of existing evidence regarding efficacy (KAS 7); and clinicians should counsel patients with sudden sensorineural hearing loss who have residual hearing loss and/or tinnitus about the possible benefits of audiological rehabilitation and other supportive measures (KAS 13). These strong recommendations were modified from the initial clinical practice guideline for clarity and timing of intervention. The guideline update group made strong recommendation against the following: clinicians should Incorporation of new evidence profiles to include quality improvement opportunities, confidence in the evidence, and differences of opinion Included 10 clinical practice guidelines, 29 new systematic reviews, and 36 new randomized controlled trials Highlights the urgency of evaluation and initiation of treatment, if treatment is offered, by emphasizing the time from symptom occurrence Clarification of terminology by changing potentially unclear statements; use of the term

Plain Language Summary: Sudden Hearing Loss

01-08-2019 – Sujana S. Chandrasekhar,Deena B. Hollingsworth,Taskin M. Monjur,Lisa Satterfield

Journal Article

This plain language summary explains sudden hearing loss (SHL) to patients and focuses on sudden sensorineural (pronounced sen-suh-ree-noo r-uh l) hearing loss (SSNHL). The summary is for adult patients aged 18 and over and is based on the 2019 “Clinical Practice Guideline: Sudden Hearing Loss (Update).” The guideline uses research to advise doctors and other health care providers on the proper testing and treatment of patients with SSNHL. The guideline includes recommendations that are explained in this summary. Recommendations may not apply to every patient but can be used to help patients ask questions and make decisions in their own care.

Assessment and Treatment of Pain during In-Office Otolaryngology Procedures: A Systematic Review

19-03-2019 – Ethan Frank,Bradley Carlson,Amanda Hu,Derrick R. Randall,Shanalee Tamares,Jared C. Inman,Brianna K. Crawley

Journal Article

To qualitatively assess practices of periprocedural pain assessment and control and to evaluate the effectiveness of interventions for pain during in-office procedures reported in the otolaryngology literature through a systematic review. PubMed, CINAHL, and Web of Science searches from inception to 2018. English-language studies reporting qualitative or quantitative data for periprocedural pain assessment in adult patients undergoing in-office otolaryngology procedures were included. Risk of bias was assessed via the Cochrane Risk of Bias or Cochrane Risk of Bias in Non-Randomized Studies of Interventions tools as appropriate. Two reviewers screened all articles. Bias was assessed by 3 reviewers. Eighty-six studies describing 32 types of procedures met inclusion criteria. Study quality and risk of bias ranged from good to serious but did not affect assessed outcomes. Validated methods of pain assessment were used by only 45% of studies. The most commonly used pain assessment was Many reports of measures and management of pain for in-office procedures exist but few employ validated measures, few are standardized, and current data do not support any specific pain control measures over others. Significant opportunity remains to investigate methods for improving patient pain and tolerance of in-office procedures.

Submandibular Gland Invasion by Oral Cavity Cancers: A Systematic Review

26-03-2019 – Yusuf Dundar,Quinton Mandle,Syed N. Raza,Ho-Sheng Lin,John Cramer,Jeffrey M. Hotaling

Journal Article

The submandibular gland (SMG) is typically included in level I neck dissection specimens despite limited data demonstrating SMG invasion. The main objective of this article is to determine the rate and pathways of SMG invasion by squamous cell carcinoma of the oral cavity and oropharynx. A systematic review of relevant studies was performed, evaluating articles identified via the PubMed, Cochrane, and Medline databases. Descriptive features of primary tumors, primary treatment modalities, the rate and pathway of SMG invasion, and survival outcomes, if present, were reported following the PRISMA guidelines. The initial literature search yielded 273 articles, of which 17 met inclusion criteria. A total of 2306 patients with 2792 SMG resections were analyzed. Fifty-eight resections (2.0%) were revealed to have tumor involvement. Among patients with SMG tumor involvement, the most common invasion pathway was direct SMG invasion by primary tumor (43 of 58, 74.1%). The second-most common mode of SMG invasion was from involved adjacent lymph nodes (10 of 58, 17.2%). Only 3 SMG resections out of 2792 (0.1%) had isolated metastatic parenchyma without evidence of direct tumor invasion or invasion by involved lymph nodes. Given this rarity of SMG involvement, preservation of SMG might be feasible in selected patient population. However, additional studies need to examine the functionality of preserved SMGs among patients who receive postoperative adjuvant radiation therapy.

Does Clearance of Positive Margins Improve Local Control in Oral Cavity Cancer? A Meta-analysis

26-03-2019 – Mustafa G. Bulbul,Osama Tarabichi,Rosh K. Sethi,Anuraag S. Parikh,Mark A. Varvares

Journal Article

To compare local recurrence-free survival (LRFS) in early oral cavity cancer (OCC) patients with positive/close frozen section (FS) cleared with further resection (R1 to R0) or positive FS not cleared (R1) to those with negative margins on initial FS analysis (R0). PubMed, EMBASE, and Cochrane. We followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) for reporting in our study. Only English-language articles that included patients with OCC and local recurrence (LR) comparisons between R0 and initially R1 to final R0 or final R1 groups were included. We requested the raw data from the corresponding authors of eligible studies and performed an individual participant data (IPD) meta-analysis of LRFS outcomes across groups. Pooled LRFS data from 8 studies showed that patients in the R1 to R0 group had worse LRFS compared to the R0 group (hazard ratio [HR] = 2.897, Margin revision of initially positive margins to “clear” based on FS guidance does not equate to an initially negative margin and does not significantly improve local control. These findings call into question the effectiveness of the current methodology of intraoperative FS in OCC resections and call for a prospective study to determine what system of resected specimen analysis best predicts completeness of resection.

Common Pitfalls of Head and Neck Research Using Cancer Registries

02-04-2019 – Evan A. Jones,Andrew G. Shuman,Brian L. Egleston,Jeffrey C. Liu

Journal Article

To highlight common pitfalls observed in scientific research derived from national cancer registries, predominantly the Survival, Epidemiology, and End Results Program and the National Cancer Database. Literature review and expert opinion. This state-of-the-art review consolidates the literature with editorial experiences describing how and why statistically flawed studies are usually rejected for publication, highlighting common errors in submitted articles employing national cancer registries. Pitfalls were identified in 2 major areas-design and data analysis. Design pitfalls included unbalanced cohorts, uncontrolled covariates, and flawed oncologic variables. Analytical pitfalls included incorrect application of univariate analyses, inclusion of inaccurate data, and inclusion of stage IVc disease in curative survival analysis. Additional limitations of database studies were identified, including absence of patient-related outcomes, hypothesis-generating vs practice-changing implications, and inability to differentiate between overall survival and disease-specific survival. Methodological strategies are suggested to ensure careful analytical design and appropriate interpretation. Although national cancer registries provide a wealth of data, researchers must remain vigilant when designing studies and analyzing these data sets. Inherent design flaws raise considerable problems with interpretation; however, when analyzed judiciously, registries can lead to a better understanding of cancer outcomes.

Parathyroid Computed Tomography Angiography: Early Experience with a Novel Imaging Technique in Primary Hyperparathyroidism

09-04-2019 – Isaac E. Schwartz,Gregory G. Capra,David P. Mullin,Terence E. Johnson,Gilbert E. Boswell

Journal Article

To describe parathyroid computed tomography angiography (PCTA), determine its accuracy, and, as a secondary objective, calculate its mean radiation dosimetry. Retrospective chart review of patients who underwent parathyroidectomy for primary hyperparathyroidism from 2007 to 2015. Single-center tertiary care academic military hospital. PCTA is a 2-phase computed tomography imaging technique that uses individualized timing of contrast infusion and novel patient positioning to accurately identify parathyroid adenomas. Consecutive patients who underwent parathyroidectomy for primary hyperparathyroidism from 2007 to 2015 were reviewed; 55% of patients were women. The mean age was 50.9 years (range, 26-68 years). Sensitivity and specificity were calculated as well as mean radiation dosimetry and timing of contrast. A total of 108 procedures were performed during the study period. Twenty-one patients undergoing 22 PCTAs after prior sestamibi scans were nonlocalizing or equivocal. In this group, there were 15 true-positive, 3 false-positive, 4 true-negative, and 0 false-negative PCTAs. This represents a sensitivity of 100% (95% CI, 74.7%-100%) and a specificity of 57% (95% CI, 20%-88%). The mean calculated radiation dose was 5.15 m
Sv. In the most recent studies, a mean dose of 4.1 m
Sv was calculated. The ideal time of image acquisition contrast administration varied from 20 to 30 seconds after contrast infusion. PCTA is a new technique in anatomic imaging for hyperparathyroidism. In a single-center, single-radiologist retrospective study, it demonstrates excellent accuracy for patients with parathyroid adenomas that are otherwise difficult to localize preoperatively. Preliminary experience suggests that its use may be indicated as a primary imaging modality in the future.

Barriers Pushed Aside: Insights on Career and Family Success from Women Leaders in Academic Otolaryngology

16-04-2019 – Tanya K. Meyer,Regan Bergmark,Marcy Zatz,Maya G. Sardesai,Jamie R. Litvack,Anne Starks Acosta

Journal Article

Although the literature adequately identifies the current gender inequality that exists in academic otolaryngology and describes the barriers to advancement of women in academic medicine, there is little information regarding the daily details of how successful women in academic otolaryngology achieve work-life balance. This study was designed to better understand how women in academic otolaryngology achieve work-life balance while negotiating family and childrearing commitments, clinical workload, and scholarly activity, as well as to highlight coping strategies and behaviors that women have used to achieve these successes. Qualitative research design. Thirteen successful women in academic otolaryngology with children were recruited using a networking/snowball sampling methodology to participate in a semistructured qualitative interview about the daily process of work-life balance in an academic otolaryngology practice. A focus group of 7 additional participants was held to validate critical topics/themes. Four broad categories of findings emerged from the study: (1) participants’ strong commitment to academic medicine, (2) the fluid/elusive nature of work-life balance, (3) specific approaches to successfully managing home life, and (4) insights related to achieving psychoemotional health. The conflicting demands between home and professional life are one of the barriers to recruiting, promoting, and retaining women in academic otolaryngology. Fostering a better environment for work-life balance is critical to promote the advancement of women in otolaryngology and otolaryngology leadership.

Industry Involvement in Otolaryngology: Updates from the 2017 Open Payments Database

26-03-2019 – Elliot Morse,Elisa Berson,Saral Mehra

Journal Article

To characterize drug and device industry payments to otolaryngologists in 2017 and compare them with payments from 2014 to 2016. Retrospective cross-sectional analysis. 2017 Open Payments Database. We identified otolaryngologists in the Open Payments Database receiving nonresearch industry payments in 2017. We determined the total number and value of payments and the mean and median payments per compensated otolaryngologist. We characterized payments by census region, nature of payment, and sponsor subspecialty. A total of 8131 otolaryngologists received 66,414 payments totaling to $11.2 million in industry compensation in 2017. This is decreased from $14.5 million in 2016. The mean and median payment per compensated otolaryngologist was $1383 ($10,459) and $159 ($64-$420), respectively. Of the total compensation, 85% was received by the top 10th percentile of otolaryngologists. Speaking fees accounted for $3.1 million (28% of total payments), and food and beverage was the most common payment type (57,691 payments; 87%). Consulting fees decreased by $1 million from 2016 to 2017, and ownership interests decreased by $1.2 million from 2016 to 2017. The south had the highest total compensation value ($4.2 million), while the west had the highest mean payment value ($1561). Rhinology accounted for the highest proportion of payments of all otolaryngology subspecialties at $3.9 million (34%). Industry payments to otolaryngologists decreased to $11.2 million in 2017 from $14.5 million in 2016. Much of the decrease can be attributed to decreases in consulting fees and ownership payments. It is important that otolaryngologists remain aware of changes in industry funding with each release of the Open Payments Database.

Predictors of High Costs of Care among Otolaryngology Patients

26-03-2019 – Karthik Balakrishnan,James P. Moriarty,Jordan Rosedahl,Colin L. Driscoll,Bijan J. Borah

Journal Article

Identify predictors of high-cost otolaryngology care. Cross-sectional. Tertiary academic multispecialty hospital. All patients undergoing ≥1 otolaryngologic procedures from 2011 to 2015. Encounter costs were standardized using previously described methods approximating Medicare reimbursement. Patients were stratified by adult/pediatric and inpatient/outpatient. “Outliers” were defined as total encounter costs ≥95th percentile. Logistic regression measured predictors of outlier status. In total, 2433 adult inpatient encounters (95th percentile $57,611), 10,031 adult outpatient encounters ($10,772), 346 pediatric inpatient encounters ($84,639), and 3027 pediatric outpatient encounters ($8978) were included. For adult inpatient and outpatient, isolated head and neck oncologic procedures were the reference group. Among adult inpatients, laryngology and facial plastics procedures predicted higher odds of outlier status (odds ratio [OR] = 4.1 and 7.2). Involvement of multiple otolaryngology subspecialties increased the odds (OR = 4.7). Neck dissection and reconstructive procedures were the most common primary operations for adult inpatient outliers. For adult outpatients, several subspecialties had lower odds than head and neck (OR ≤0.44). Increased comorbidities predicted outliers for adult inpatient care (OR = 1.5); sex, age, race, and ethnicity did not. Cochlear implant was the most common primary operation among adult and pediatric outpatient outliers. Greater subspecialty involvement and increasing age predicted pediatric outpatient outliers (OR = 8.0 and 1.1); younger age and female sex predicted pediatric inpatient outliers (OR = 0.8 and 3.5). Airway procedures dominated pediatric inpatient outliers. This is the first large-scale study of high-cost otolaryngology care across multiple subspecialties. Specific procedures and subspecialties and increased comorbidities predicted high-cost care. Contrary to previous studies, patient sex, race, and ethnicity did not.

Body Image Disturbance in Surgically Treated Head and Neck Cancer Patients: A Patient-Centered Approach

09-04-2019 – Mark A. Ellis,Katherine R. Sterba,Terry A. Day,Courtney H. Marsh,Stacy Maurer,Elizabeth G. Hill,Evan M. Graboyes

Journal Article

To promote patient-centered oncology care through an in-depth analysis of the patient experience of body image disturbance (BID) following surgery for head and neck cancer (HNC). Qualitative methods approach using semistructured key informant interviews. Academic medical center. Participants with surgically treated HNC underwent semistructured key informant interviews and completed a sociodemographic survey. Recorded interviews were transcribed, coded, and analyzed using template analysis to inform creation of a conceptual model. Twenty-two participants with surgically treated HNC were included, of whom 16 had advanced stage disease and 15 underwent free tissue transfer. Five key themes emerged characterizing the participants’ lived experiences with BID following HNC treatment: personal dissatisfaction with appearance, other-oriented appearance concerns, appearance concealment, distress with functional impairments, and social avoidance. The participant’s perceived BID severity was modified by preoperative patient expectations, social support, and positive rational acceptance. These 5 key themes and 3 experiential modifiers form the basis of a novel, patient-centered conceptual model for understanding BID in HNC survivors. A patient-centered approach to HNC care reveals that dissatisfaction with appearance, other-oriented appearance concerns, appearance concealment, distress with functional impairments, and social avoidance are key conceptual domains characterizing HNC-related BID. Recognition of these psychosocial dimensions of BID in HNC patients can inform development of HNC-specific BID patient-reported outcome measures to facilitate quantitative assessment of BID as well as the development of novel preventative and therapeutic strategies for those at risk for, or suffering from, BID.

Organ Function Preservation Failure after (Chemo)Radiotherapy in Head and Neck Cancer: A Retrospective Cohort Analysis

07-05-2019 – Jolien Heukelom,Arash Navran,Zeno A. R. Gouw,Margot E. Tesselaar,Charlotte L. Zuur,Erik van Werkhoven,Jan-Jakob Sonke,Coen R. N. Rasch,Abrahim Al-Mamgani

Journal Article

The aim of the current study was to determine the incidence of organ function preservation failure (OFPF) in patients with head and neck squamous cell carcinoma (HNSCC) treated by (chemo)radiotherapy and to identify its risk factors. Retrospective cohort analysis. Tertiary cancer care center. A single-center retrospective cohort analysis was done (n = 703) in which OFPF after (chemo)radiotherapy was assessed. OFPF was defined as local failure or pure functional failure in the absence of local failure because of major surgical intervention (total laryngectomy, commando resection, permanent tracheostomy) or feeding tube dependence >2 years. OFPF occurred in 153 patients (21.8%). Reasons for OFPF were local failure in 103 patients (14.6%) and functional failure in 50 patients (7.2%). Evidence of functional failure included need for total laryngectomy (n = 9, 1.3%), commando resection (n = 2, 0.3%), permanent tracheostomy (n = 16, 2.3%), and/or long-term feeding tube for functional reasons (n = 23, 3.3%). In a Cox proportional hazards model, OFPF was worse for patients with T4 tumors (hazard ratio [HR] <0.5 and This work shows a detrimental effect of smoking on functional outcomes after (chemo-)radiotherapy for HNSCC. Moreover, T4 tumor, laryngeal subsite, and pretreatment tracheostomy are strong predictors of OFPF.

Timing of Postoperative Radiotherapy in Surgically Treated HPV-Positive Oropharyngeal Squamous Cell Carcinoma

04-06-2019 – Melanie Townsend,Todd DeWees,Jennifer Gross,Mackenzie Daly,Hiram Gay,Wade Thorstad,Ryan S. Jackson

Journal Article

Optimal timing of postoperative radiotherapy (PORT) remains understudied in human papillomavirus (HPV)-related oropharyngeal squamous cell carcinoma. Objectives are to determine if delays between surgery and radiotherapy, breaks during radiotherapy, disease, or patient factors are associated with recurrence or survival decrements in HPV-related disease. Retrospective review. Academic medical center. A total of 240 cases of HPV-positive oropharyngeal squamous cell carcinoma from 2000 to 2016. Patient and tumor characteristics (American Joint Committee on Cancer, eighth edition), delays to radiation initiation, and breaks during radiation were recorded. Overall survival (OS) and recurrence-free survival (RFS) were analyzed. RFS and OS were not significantly affected by delays to PORT >6 weeks or by treatment intervals >100 days (surgery to PORT completion). Breaks during PORT significantly imparted an OS detriment (hazard ratio [HR], 2.4; 95% CI, 1.2-4.8). Advanced-stage disease was significantly associated with reduced RFS and OS. Subgroup analysis of stage I versus stage II/III disease found that >6 weeks to PORT initiation and treatment intervals >100 days did not significantly decrease RFS or OS in either stage group. Advanced-stage disease was significantly associated with worsened OS (HR, 6.6; 95% CI, 2.3-19.1) and RFS (HR, 5.3; 95% CI, 1.5-18.4). Breaks during PORT significantly reduced RFS (HR, 3.6; 95% CI, 1.2-10.8) and OS (HR, 3.2; 95% CI, 1.2-9.0) in the stage II/III subset. Delays to radiotherapy initiation and prolonged treatment time did not affect recurrence or survival in HPV-related oropharyngeal disease. Locoregionally advanced disease was consistently associated with worse outcomes. Breaks during PORT may affect recurrence and survival, although larger studies are needed to confirm this finding.

Long-term Swallowing Function, Pulmonary Complications, and Quality of Life after Supracricoid Laryngectomy

12-03-2019 – Davide Di Santo,Stefano Bondi,Leone Giordano,Andrea Galli,Michele Tulli,Barbara Ramella,Mario Bussi

Journal Article

Long-term effects of supracricoid laryngectomies are nowadays under discussion. The purpose of this study was to detect the prevalence of chronic aspiration and incidence of pulmonary complications, to investigate possible influencing factors, and to analyze dysphagia-related quality of life in a cohort of patients who recovered swallowing function after undergoing supracricoid laryngectomies. Retrospective observational study. San Raffaele Hospital, Vita-Salute University, Milan, Italy. A cohort of 39 patients who recovered swallowing function free of disease after a minimum 3-year follow-up period was retrospectively investigated between October and December 2017-clinically with the Pearson’s Scale and M. D. Anderson Dysphagia Inventory and instrumentally with fiberoptic endoscopic evaluation of swallowing. Chronic aspiration was demonstrated in a significant portion of patients (clinically in 33.3% and instrumentally in 35.9%). Aspiration was influenced by advanced age at surgery ( Chronic aspiration is frequent and affects patients’ quality of life. However, incidence of pulmonary complications is low; therefore, oral feeding should not be contraindicated for aspirating patients. Preservation of laryngeal sensation and cough reflex is mandatory to prevent pulmonary complications.

Endoscopic Type 1 Tympanoplasty in Chronic Otitis Media: Comparative Study with a Postauricular Microscopic Approach

26-03-2019 – Masafumi Ohki,Shigeru Kikuchi,Sunao Tanaka

Journal Article

To compare surgical outcomes after tympanoplasty without ossiculoplasty for chronic otitis media between transcanal endoscopic ear surgery (TEES) and postauricular microscopic ear surgery (PAMES). Case-control study. Tertiary care university hospital. Consecutive patients ( The surgical success rate for hearing (air-bone gap ≤20 d
B) was 95.7% in the TEES group and 84.0% in the PAMES group. Lower middle ear risk resulted in similar mean (95% CI) closure of air-bone gaps (TEES: 9.6, 6.5-12.6; PAMES: 8.0, 6.4-9.7; Under favorable conditions of the middle ear, TEES and PAMES resulted in similar hearing improvement by tympanoplasty without ossiculoplasty. However, under adverse conditions of the middle ear, TEES was a more beneficial approach for hearing improvement than PAMES.

Associations of Video Head Impulse Test and Caloric Testing among Patients with Vestibular Schwannoma

26-03-2019 – C. Scott Brown,Sarah B. Peskoe,Thomas Risoli,Douglas B. Garrison,David M. Kaylie

Journal Article

To determine relationships between caloric testing (CT) and video head impulse testing (v
HIT) among patients with unilateral vestibular schwannoma (VS). To describe the distribution of CT and v
HIT measurements and assess associations with tumor size and self-perceived handicapping effects. Retrospective review. Tertiary referral hospital. Subjects were adults with presumed unilateral VS between 2014 and 2017. Interventions were CT and v
HIT. Primary outcomes were v
HIT value (abnormal 25%). Secondary outcomes were tumor size and Dizziness Handicap Inventory scores. Fifty-one individuals had complete data for CT and v
HIT. The odds of abnormal gain increases by 2.18 for every 10% increase in unilateral weakness on CT (range, 1.44-3.34; CT and v
HIT both effectively assess vestibular function for patients with VS and correlate to tumor size. These findings are important as v
HIT has a lower overall cost, improved patient tolerance, and demonstrated reliability.

Risk Recall of Complications Associated with Vestibular Schwannoma Treatment

19-03-2019 – Khodayar Goshtasbi,Mehdi Abouzari,Omid Moshtaghi,Marlon Maducdoc,Brandon M. Lehrich,Harrison W. Lin,Hamid R. Djalilian

Journal Article

To assess the risk recall of complications among patients who underwent different vestibular schwannoma (VS) treatments. Patients with VS completed a voluntary and anonymous survey. Survey links were distributed via the Acoustic Neuroma Association (ANA) website, Facebook, and email list. Surveys were distributed to ANA members from January to March 2017. Of the 3200 ANA members with a VS diagnosis at the time of survey distribution, 789 (25%) completed the survey. Subjects reported the following incidence of posttreatment complications: imbalance (60%), hearing issues (51%), dry eyes (30%), headache (29%), and facial weakness (27%). Overall, 188 (25%) recalled remembering all the risks associated with their treatment. Among those in the surgical cohort (52%) who experienced balance issues, facial weakness, cerebrospinal fluid leak, meningitis, and stroke, 73%, 91%, 77%, 67%, and 33% claimed recall of these associated risks. Among those in the radiosurgery cohort (28%) who experienced balance issues, facial weakness, and hydrocephalus, 56%, 52%, and 60% recalled discussions of those risks. Patients with higher-level education ( Not all patients with VS who experienced treatment complications recalled remembering those risks being discussed with them. Patients with higher education and those who underwent surgery had a better recall of risks associated with different treatment modalities. The risk recall ratio of patients experiencing complications ranged 33% to 91%, suggesting an opportunity for decision-making and discussion improvement.

Efficacy of HRCT Imaging vs SPECT/CT Scans in the Staging of Malignant External Otitis

16-04-2019 – Ramaswamy Balakrishnan,Pooja Dalakoti,Dipak Ranjan Nayak,Kailesh Pujary,Rohit Singh,Rajesh Kumar

Journal Article

The prognosis of patients with malignant external otitis (MEO) depends on the extent of the inflammatory changes in the temporal bone and skull base. The efficacy of high-resolution computed tomography (HRCT) imaging in accurately assessing the extent of disease is compared with that of single-photon emission computed tomography/computed tomography (SPECT/CT) scan. A clinical chart review was conducted with medical records and radiologic images. Tertiary care medical college hospital. This study involved patients with clinically diagnosed MEO who underwent both modalities of imaging of the skull base. Staging of the disease extent was compared between the imaging systems among patients. Symptom control and survival rates were analyzed with respect to the SPECT/CT staging of MEO. Out of 28 patients included in this study, 72% had SPECT/CT scans showing higher staging than the HRCT imaging. Four patients had mild uptake (stage 1), and 15 had disease confined to the mastoid/temporal bone, not reaching midline (stage 2). All patients in stages 1 and 2 were surviving with good symptom control. Five patients with petrous involvement reaching midline (stage 3) had persistent symptoms, and all 4 cases with SPECT/CT showing sphenoid involvement and crossing midline (stage 4) died within a year of diagnosis. SPECT/CT scan is more sensitive than HRCT imaging in detecting the extent of disease and is a better prognosticator for patients with MEO.

Cost Benefit and Utility Decision Analysis of Turbinoplasty with Adenotonsillectomy for Pediatric Sleep-Disordered Breathing

23-04-2019 – Grace Baik,Scott E. Brietzke

Journal Article

Use decision analysis techniques to assess the potential utility gains/losses and costs of adding bilateral inferior turbinoplasty to tonsillectomy/adenoidectomy (T/A) for the treatment of obstructive sleep-disordered breathing (o
SDB) in children. Use sensitivity analysis to explore the key variables in the scenario. Cost-utility decision analysis model. Hypothetical cohort. Computer software (Tree
Age Software, Williamstown, Massachusetts) was used to construct a decision analysis model. The model included the possibility of postoperative complications and persistent o
SDB after surgery. Baseline clinical and quality-adjusted life year (QALY) parameters were estimated using published data. Cost data were estimated from Centers for Medicare and Medicaid 2018 databases ( www.cms.gov ). Sensitivity analyses were completed to assess for key model parameters. The utility analysis of the baseline model favored the addition of turbinoplasty (0.8890 vs 0.8875 overall utility) assuming turbinate hypertrophy was present. Sensitivity analysis indicated the treatment success increase (%) provided by concurrent turbinoplasty was the key parameter in the model. A treatment success increase of 3% of turbinoplasty was the threshold where concurrent turbinoplasty was favored over T/A alone. The incremental cost-effectiveness ratio (ICER) of $27,333/QALY for the baseline model was favorable to the willingness-to-pay threshold of $50,000 to $100,000/QALY for industrialized nations. The addition of turbinoplasty for children with turbinate hypertrophy to T/A for the treatment of pediatric o
SDB is beneficial from both a utility and cost-benefit analysis standpoint even if the benefits of turbinoplasty are relatively modest.

Surgical Outcomes for the Treatment of Velopharyngeal Insufficiency in 22q11.2 Deletion Syndrome

02-04-2019 – Lauren A. Bohm,Jessa E. Miller,Noëlle Morrell,James D. Sidman,Brianne B. Roby

Journal Article

This study aimed to compare outcomes of concomitant palatoplasty and sphincter pharyngoplasty with pharyngeal flap and sphincter pharyngoplasty alone for the treatment of velopharyngeal insufficiency in patients with 22q11.2 deletion syndrome. Thirty-one cases were identified for inclusion in the study. Patients were separated into 3 surgical groups: combined palatoplasty and sphincter pharyngoplasty (n = 11), pharyngeal flap (n = 7), and sphincter pharyngoplasty (n = 13). Outcome measures included perceptual speech analyses, surgical complications, and revision rates. There were no differences in preoperative speech analysis scores (

Nasopharyngeal Angiofibroma Staging with a Novel Nominal Basis: An 18-Year Study in a Tertiary Center

23-04-2019 – Mohamed Abdelwahab,Jonathan B. Overdevest,Ali Elmokadem,Hossam El-sisi,Noha Ahmed El-Kholy,Hesham Zaki,Elsharawy Kamal,Yasser Khafagy,Ali Tawfik,Hany Eldawoody,Peter Hwang,Abdelwahab Rakha

Journal Article

To develop a systematic method for anatomic mapping of juvenile nasopharyngeal angiofibroma (JNA) tumors to standardize communication, facilitate surgical planning, and convey prognosis. Retrospective cohort. Tertiary referral center. Following Institutional Review Board approval, we performed a retrospective review of radiologic and angiographic data of patients with JNA presenting to the Department of Otolaryngology-Head and Neck Surgery, Mansoura University, from 2001 to 2017. All patients underwent angiography with embolization and had >1-year follow-up. Based on frequently involved anatomic sites and factors predictive of prognosis, the NSF-COR staging system (nose/nasopharynx, sinus, fossa-cranium, orbit, residual internal carotid artery supply) was developed to explicitly convey anatomic site of involvement and presence of residual vascularity. We validated the NSF-COR staging system against other systems with Pearson chi-square test based on risk factors and clinical outcomes of blood transfusion volume, recurrence, and JNA resectability. Fifty-four patients met inclusion criteria, where all primary cases (100%) demonstrated nose/nasopharynx involvement, followed by sinus (85.2%), natural fossae (85.2%), intracranial (26%), and orbital involvement (16.7%). These sites, with assessment of residual internal carotid artery vascular supply, were used to develop the NSF-COR anatomically based staging system. The components COR showed significant association with clinical outcomes of blood transfusion and recurrence. Contingency coefficients between the NSF-COR staging system and available staging systems showed significant correlations ( The NSF-COR staging system conveys a communicable anatomic map of JNA tumors that integrates residual vascularity of the tumor and demonstrates strong concordance with current staging systems to assess clinical outcomes.

Impact of Distraction Osteogenesis Maxillary Expansion on the Internal Nasal Valve in Obstructive Sleep Apnea

14-05-2019 – Mohamed Abdelwahab,Audrey Yoon,Tyler Okland,Sasikarn Poomkonsarn,Chris Gouveia,Stanley Yung-Chuan Liu

Journal Article

To assess the effect of distraction osteogenesis maxillary expansion (DOME) on objective parameters of the internal nasal valve and correlate findings with subjective outcomes. Retrospective cohort study. Tertiary referral center. After Institutional Review Board approval, included subjects were those with obstructive sleep apnea, had undergone DOME from September 2014 to April 2018, and had cone beam computed tomography scans available before and after expansion. Measurement of the internal nasal valve parameters was performed with Invivo6 Software (version 6.0.3). Interrater reliability of all pre- and postexpansion parameters was measured. Patient-reported outcome measures included the Nasal Obstruction and Septoplasty Effectiveness Scale (NOSE) and Epworth Sleepiness Scale scores, and correlation between objective and subjective outcomes were evaluated by Spearman correlation analysis. Thirty-two subjects met inclusion criteria. All showed significant improvement in their subjective outcomes as well as an increase in their internal valve parameters. Significant correlation was observed between increased angles and improvement in postexpansion NOSE score (right angle, DOME widens the internal nasal valve objectively (dimensions), which correlates significantly with subjective improvement (NOSE scores).

Closure of Tracheoesophageal Puncture after Total Laryngectomy

16-04-2019 – Giuseppe Riva,Federico Dagna,Eugenia Ricci,Andrea Luigi Cavalot

Journal Article

Tracheoesophageal puncture with voice prosthesis placement is used to restore vocal function after total laryngectomy. However, closure of the fistula is sometimes needed. At our department, a simple and effective technique for closure was developed. It does not require interposed tissues or materials. Moreover, our procedure allows for a short rehabilitation time for swallowing and a short hospitalization. We describe advantages, pitfalls, and errors to avoid. This technique should not be performed for patients who are irradiated and those with large fistulas.

Confounding Factors on the Prediction of Opioid Usage after Thyroidectomy and Parathyroidectomy Surgery

01-08-2019 – Feel G. Kang

Journal Article

Response to Confounding Factors on the Prediction of Opioid Usage after Thyroidectomy and Parathyroidectomy Surgery

01-08-2019 – Theresa Tharakan,Sydney Jiang,Judd Fastenberg,Thomas J. Ow,Bradley Schiff,Richard V. Smith,Vikas Mehta

Journal Article

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.

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 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.

Relationship between Drug-Induced Sleep Endoscopy Findings, Tonsil Size, and Polysomnographic Outcomes of Adenotonsillectomy in Children

23-07-2019 – Derek J. Lam,Natalie A. Krane,Ron B. Mitchell

Journal Article

(1) Determine the correlation of awake tonsil scores and preadenotonsillectomy (pre-AT) sleep endoscopy findings. (2) Assess the relationship between polysomnographic AT outcomes with awake tonsil scores and sleep endoscopy ratings of tonsil and adenoid obstruction. Retrospective case series with chart review. Tertiary care children’s hospital. Children aged 1 to 18 years who underwent sleep endoscopy and AT from January 1, 2013, to August 30, 2016, were included. Pre-AT sleep endoscopy findings were scored with the Sleep Endoscopy Rating Scale. Awake tonsil scores and sleep endoscopy ratings were compared with Spearman correlation. Associations between changes in pre- and post-AT polysomnography parameters and (1) awake tonsil scoring and (2) sleep endoscopy scoring were assessed with 1-way analysis of variance and linear regression. Participants included 36 children (mean ± SD age, 6.8 ± 4.3 years; 68% male, 44% obese). Awake tonsil scores and sleep endoscopy ratings were strongly correlated ( In children at risk for AT failure, assessment of dynamic collapse with sleep endoscopy may better predict the outcome of AT than awake tonsil size assessment, thus helping to inform surgical expectations.

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.

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.

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.

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.

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.

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.

Long-term Efficacy of Uvulopalatopharyngoplasty among Adult Patients with Obstructive Sleep Apnea: A Systematic Review and Meta-analysis

11-06-2019 – Mu He,Guoping Yin,Siyan Zhan,Jinkun Xu,Xin Cao,Jingjing Li,Jingying Ye

Journal Article

To evaluate the long-term efficacy and potential predictors of uvulopalatopharyngoplasty (UPPP) among adult patients with obstructive sleep apnea (OSA). A systematic search was conducted through PubMed/Medline, Embase, Web of Science, and the Cochrane Library until December 2018. Full-text articles were selected that studied adult patients who underwent single-level UPPP or its modification for OSA and had a long-term follow-up (at least 34 months) with objective sleep study results. Studies that had no objective outcomes or performed other surgical procedures for OSA were excluded. Of 2600 studies, 11 were included. Meta-analysis comparing long-term post- and preoperative outcomes showed significant improvements, with an 15.4 event/h (46.1%) decrease of apnea-hypopnea index. Compared with the short-term outcomes (3-12 months), the long-term outcomes were less effective, with apnea-hypopnea index increasing 12.3 events/h (63.8%) and the surgical response decreasing from 67.3% to 44.35%. Subanalysis of individual patient data showed significant correlations of baseline body mass index, lowest arterial oxygen saturation, and proportion of sleep time with oxygen saturation <90% with long-term surgical response. Despite the surgical efficacy decreasing over time, UPPP and its modification are an effective surgical method for adult OSA in both the short term and the long term after the surgery. Baseline body mass index, lowest arterial oxygen saturation, and proportion of sleep time with oxygen saturation <90% were potentially predictive for long-term surgical response. Case-control studies of the long-term surgical effect of OSA are needed.

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.

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.

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 ( P = .002) and was associated with a significant 4.3 ± 7.5 semitone decrease in the maximum fundamental frequency ( P < .001) and a 5.3 ± 8.2 d
B reduction in maximum intensity. Further, it was associated with a 4.5 ± 11.2 second reduction in MPT ( P = .001) and an increase of 0.40 ± 1.19 in grade, 0.42 ± 1.41 in roughness, and 0.36 ± 1.11 in breathiness. Signs of postoperative RLN/EBSLN paresis correlated with an 11.0-point ( P = .02) poorer improvement in goiter symptoms at both 3 weeks and 6 months after surgery. 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.

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, P = .04). Other demographic and clinical data, including subglottic stenosis (SGS) grades, were similar. For patients with SGS, 53.8% and 46.2% in the study group had a grade 1-2 and 3-4 SGS, respectively, as compared with 46.2% and 53.8% in the control group ( P = .65). Manifestations of petiole prolapse included failure of decannulation (8.6%), exercise intolerance (16.0%), and obstructive sleep apnea (11.1%). After 4 years of follow-up, 4.5% of the study group versus 27.1% of the control group had prolapse of the petiole ( P = .04). Petiole prolapsed affected >50% of patients with no PPS after 10 years of follow-up. Patients with petiole prolapse at the first surveillance microlaryngoscopy and bronchoscopy after stent removal had an odds ratio of 10.2 (95% CI, 1.1-94.8; P = .04) of becoming symptomatic. 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.

Evidence-Based Medicine in Otolaryngology Part 10: Cost-Effectiveness Analyses in Otolaryngology

11-06-2019 – Lisa Caulley,Danielle Rodin,Shaun Kilty,Gregory Randolph,Myriam G. Hunink,Jennifer J. Shin

Journal Article

Clinicians seek to pursue the most clinically effective treatment strategies, but costs have also become a key determinant in contemporary health care. Economic analyses have thus emerged as a valuable resource to both quantify and qualify the value of existing and emerging interventions and programs. Cost-effectiveness analyses estimate the benefits gained per monetary unit, providing insights to guide resource allocation. Herein, we delineate the related concepts and considerations to facilitate understanding and appraisal of these analyses, so as to better inform the stakeholders in our otolaryngology community.

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]; P < .001). There were 23 (4.4%) readmissions within 30 days in the balloon cohort versus 474 (3.5%) in the ESS cohort. The median cost of balloon maxillary antrostomy (US $6560 [$5420-$8250]) was higher than that of traditional maxillary antrostomy (US $5630 [$4130-$7700], P < .001). Physicians who performed BS had a larger volume of ESS procedures when compared with those who did not perform BS. 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.

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 ( P = .0001), anxiety ( P < .0001), and pain ( P = .0004) than the control group. 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.

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.

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.

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.

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, P < .001; T4a: OR = 2.89, P < .001), adenoid cystic carcinoma histology (OR = 1.54, P = .020), and those treated at nonacademic facilities (OR = 1.41, P = .008). Patients who underwent a preoperative diagnostic biopsy had decreased odds of positive margins (OR = 0.72, P = .014). Positive margins were associated with reduced overall survival (58% vs 69% 5-year overall survival, P < .001; hazard ratio = 1.49, P = .001) when controlling for patient, tumor, and management factors. 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.

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.

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 ( P < .001), but the older group showed a greater reduction (7.6 ± 6.9 vs 11.9 ± 13.4, P = .01). The Epworth Sleepiness Scale score decreased from 12.3 ± 5.4 to 7.1 ± 4.8 ( P < .001) among younger adults and from 10.7 ± 5.7 to 6.3 ± 4.4 ( P < .001) among older adults. Usage was slightly higher among older adults (6.0 ± 2.0 vs 5.4 ± 2.1 hours/night, P = .02). Surgical time was similar between younger patients (2.4 ± 0.7 hours) and older patients (2.3 ± 0.7 hours, P = .40), with comparably low complications. 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.

Longus Capitis Reconstruction of the Soft Palate

14-05-2019 – Jennifer H. Gross,Joseph Zenga,Jeffrey D. Sharon,Ryan S. Jackson,Patrik Pipkorn

Journal Article

Soft palate (SP) reconstruction remains a challenge for the head and neck reconstructive surgeon. One favorable local flap option is the longus capitis muscle (LCM), a deep neck flexor with redundant muscle function, appropriate bulk, and a relatively straightforward surgical harvest. A retrospective review of 3 patients with T2 to T4 tonsil squamous cell carcinoma requiring SP resection and LCM reconstruction at a single institution was performed. Three patients underwent primary transoral resection, all resulting in at least 50% full-thickness SP defects. Reconstruction comprised a superiorly based LCM local flap. Patients underwent adjuvant (chemo)radiation therapy as indicated. Within 3 to 8 months, each patient was tolerating a full oral diet with no dysphagia, nasal regurgitation, or velopharyngeal insufficiency. For select patients with SP defects, a superiorly based LCM flap may provide a functionally acceptable reconstruction with minimal donor site morbidity.

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

14-05-2019 – François Thibouw,Mireille Folia

Journal Article

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.

Salivary Gland Cancers of the Nasopharynx: A Population-Based Analysis of 383 Cases

14-05-2019 – J. Renee Booth,Aykut A. Unsal,Sandra Tadros,J. Kenneth Byrd,Stilianos E. Kountakis

Journal Article

Salivary gland nasopharynx cancers (SGNPCs) are rare malignancies with few cases discussed in the literature. This study represents the largest cohort of SGNPC to date. Retrospective population-based analysis. The Surveillance, Epidemiology, and End Results registry from 1973 to 2015 was utilized to extract 383 cases of SGNPC. Data were analyzed for demographic characteristics, incidence, clinicopathologic traits, and outcome prognosticators. White female patients aged >40 years were most commonly affected. The incidence was measured as 0.019 per 100,000 people. The majority of tumors presented at advanced stages (stage III/IV, 60.8%). Adenoid cystic carcinoma, adenocarcinoma, and mucoepidermoid carcinoma were the most commonly encountered histologies (43.1%, 31.6%, 13.3%, respectively). Cervical node involvement and distant metastasis were measured at 23% and 11.9%, respectively. Mucoepidermoid carcinomas presented with the best disease-specific survival at 5 and 10 years. Asian ethnicity, age <80 years, and earlier American Joint Committee on Cancer stages were positive prognostic factors. The inclusion of surgical therapy improved 5-year outcomes among the most common histologies, except for mucoepidermoid carcinoma. Salivary gland nasopharyngeal cancer represents a group of rare histologies with similar outcomes as squamous cell carcinomas. However, prognosis is primarily dependent on histologic subtype, race, age, and American Joint Committee on Cancer stage.

Analysis of Process-Related Quality Metrics and Survival of Patients with Oral Cavity Squamous Cell Carcinoma

07-05-2019 – Swathi Appachi,Janki Shah,Chandana Reddy,Andrew Bowen,Shlomo Koyfman,Eric Lamarre

Journal Article

To analyze the association of prior reported key quality metrics-neck dissection ≥18 nodes, radiation oncology referral for stage III/IV disease, unplanned surgery ≤14 days, and unplanned readmission ≤30 days-with disease-free survival (DFS) and overall survival (OS) in oral cavity cancer (OCC). A retrospective chart review. A tertiary care center from 1995 to 2016. Data from patients with OCC who underwent primary surgery were studied. The association of quality metrics and pathology with DFS/OS was determined by Cox proportional hazards regression analysis. A total of 514 patients were included, and 398 (77.4%) underwent elective neck dissection. Key metrics were not associated with DFS on analysis, but higher pathologic stage and extracapsular extension (ECE) were. When stratified by stage, unplanned readmission within 30 days was associated with decreased survival on multivariate analysis (HR = 0.40; 95% CI, 0.20-0.85; P = .02) for patients with clinical stage III or IV disease. ECE was associated with decreased survival among these patients as well. Neck dissection with ≤18 nodes (HR = 0.62; 95% CI, 0.44-0.86; P = .004) and unplanned surgery within 14 days (HR = 0.56; 95% CI, 0.32-0.96; P = .03) were associated with decreased survival on univariate analysis but not on multivariate analysis. ECE and higher-stage disease were associated with decreased OS on multivariate analysis. In this study, aggressive pathology, rather than adherence to key quality metrics, was associated with lower DFS and OS among patients with OCC. More studies are needed to elucidate the association of quality metrics with survival.

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 t test, P > .05). The mean insertion loss (REOG-REUG) at all frequencies also did not differ significantly between the two earmolds (paired t test, P > .05). 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.

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.

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.

Middle Turbinate Friendly Technique for Cribriform Cerebrospinal Fluid Leak Repair

30-04-2019 – Lauren J. Luk,Allison Ikeda,Sarah K. Wise,John M. DelGaudio

Journal Article

To compare surgical outcomes between 2 techniques for cribriform cerebrospinal fluid leak (CSF) repair with middle turbinate preservation (MTP) vs middle turbinate resection (MTR). A secondary outcome is to examine the effectiveness of collagen dura matrix (CDM) as a grafting material for repair of isolated cribriform skull base defects. A retrospective chart review was performed of consecutive patients who underwent cribriform CSF repair at Emory University over the past 15 years. Tertiary care rhinology practice. Adult patients with cribriform defects limited to the cribriform plate that did not extend lateral to the middle turbinate (MT) and were reconstructed with a free graft (mucosal or synthetic). Patients were stratified into 2 primary groups by surgical technique: MTP vs MTR. A subset of patients underwent repair with CDM alone and was analyzed separately for CSF repair failure rate. Of 68 patients identified with cribriform defects, 42 underwent repair with MTP and 26 underwent repair with MTR. Average follow-up time was 495 days. Patients with idiopathic intracranial hypertension were also equally distributed ( P = .20). Primary CSF leak repair success was 95.6%, with 100% of leaks ultimately repaired. A subset of 39 patients underwent repair with CDM alone, with a primary repair success rate of 94.9%. We present an effective method for repair of cribriform CSF leaks while preserving the MT. CDM can be successfully used as a free graft alone for repair of isolated cribriform CSF leaks.

Utility of Magnetic Resonance Imaging in Differentiating Cerebrospinal Fluid Leak from Middle Ear Effusion

30-04-2019 – Joseph T. Breen,Colin R. Edwards,Rebecca S. Cornelius,J. Michael Hazenfield,Gavriel D. Kohlberg,Ravi N. Samy,Myles L. Pensak

Journal Article

To demonstrate the clinical utility, sensitivity, and specificity of standard magnetic resonance imaging (MRI) sequences in differentiating temporal bone cerebrospinal fluid leaks from all other middle ear effusions. Retrospective imaging review. Academic medical center. Patients with cerebrospinal fluid leaks or other middle ear effusions who also underwent MRI. Patients were assigned to cerebrospinal fluid leak and other effusion cohorts based on clinical course, findings at surgery/myringotomy, and beta-2 transferrin fluid analysis. Reviewers blinded to the clinical outcome examined T1-weighted, T2-weighted, diffusion-weighted, fluid-attenuated inversion recovery (FLAIR), and 3-dimensional (3D) acquired T2-weighted MRI sequences. For each sequence, fluid imaged in the temporal bone was graded as either similar or dissimilar in signal intensity to cerebrospinal fluid in the adjacent subarachnoid space. Signal similarity was interpreted as being diagnostic of a leak. Test characteristics in predicting the presence of a leak were calculated for each series. Eighty patients met criteria (41 leaks, 39 other effusions). The 3D T2 series was 76% sensitive and 100% specific in diagnosing a leak, and FLAIR was 44% sensitive and 100% specific. The T1-weighted (73% sensitive, 69% specific), T2-weighted (98% sensitive, 5.1% specific), and diffusion-weighted (63% sensitive, 66% specific) series were less useful. MRI, with attention to 3D T2 and FLAIR series, is a noninvasive and highly specific test for diagnosing cerebrospinal fluid leak in the setting of an indeterminate middle ear effusion.

Intraoperative Imaging with Second Window Indocyanine Green for Head and Neck Lesions and Regional Metastasis

30-04-2019 – Vanessa C. Stubbs,Samantha Jaffe,Karthik Rajasekaran,Steven B. Cannady,Rabie M. Shanti,John Y. K. Lee,Jason G. Newman

Journal Article

While optical imaging with near-infrared (NIR) fluorescent dye has been used in oncologic surgery, its use in the head and neck has not been established. We aimed to evaluate the feasibility of using NIR to visualize primary tumor and regional metastasis in head and neck malignancy. Patients undergoing resection of primary head and neck tumors were included in this pilot study. Each patient was injected with indocyanine green dye (ICG) the day prior to surgery. The Vision
Sense Iridium camera system was used to visualize the primary lesion, its margins, and neck dissection specimen intraoperatively. Fourteen patients were enrolled. Eighty-six percent of primary tumors showed fluorescence as compared with surrounding tissues. ICG positivity showed 100% sensitivity for pathologic nodes in 7 neck dissection specimens; however, for 3 patients, nonpathologic nodes also showed ICG positivity. NIR imaging with ICG dye can be considered for intraoperative imaging of head and neck lesions.

Air Pollution and Angioedema

30-04-2019 – Suraj Kedarisetty,Evan Jones,Derrick Tint,Ahmed M. S. Soliman

Journal Article

To identify environmental factors that may precipitate angioedema. Case series with chart review. An urban tertiary care medical center. After institutional review board approval was obtained, a chart review of all patients who presented to Temple University Hospital with angioedema from January 2012 to December 2014 was performed. Patient demographics and hospital course were gathered. Environmental data on the dates of presentation, including precipitation, humidity, and air pollution, were obtained from regional Environmental Protection Agency online data banks and used for statistical analysis. In total, 408 patients, representing 450 episodes of angioedema, met the inclusion criteria for the study. Most patients were female (58%), African American (74%), and on an angiotensin-converting enzyme inhibitor (ACE-I) upon presentation (61%). Days with unhealthy levels of air pollution were associated with an increased likelihood of angioedema presentation (odds ratio [OR], 1.82; confidence interval [CI], 1.01-3.30; P = .046). Subgroup analysis revealed that elevated ground-level ozone was the primary air pollutant significantly associated with angioedema presentations (OR, 4.95; CI 1.92-12.76; P = .0009). Higher ground-level ozone was also associated with ACE-I angioedema presentations ( P = .017) but not with non-ACE-I angioedema presentations ( P = .86). Air quality was not predictive of angioedema severity or need for intubation. Angioedema is a complex, multifactorial disease resulting in potentially life-threatening complications. This is the first study to demonstrate that higher levels of air pollution, specifically ground-level ozone, are associated with significantly increased rates of angioedema episodes, although not severity.

Mice Lacking Brain-Derived Serotonin Have Altered Swallowing Function

30-04-2019 – Megan M. Haney,Joseph Sinnott,Kate L. Osman,Ian Deninger,Ellyn Andel,Victoria Caywood,Alexis Mok,Brayton Ballenger,Kevin Cummings,Lori Thombs,Teresa E. Lever

Journal Article

The intricate sensorimotor neural circuits that control swallowing are heavily reliant on serotonin (5-hydroxytryptamine [5-HT]); however, the impact of 5-HT deficiency on swallow function remains largely unexplored. We investigated this using mice deficient in tryptophan-hydroxylase-2 (TPH2), the enzyme catalyzing the rate-limiting step in 5-HT synthesis. Videofluoroscopy was utilized to characterize the swallowing function of TPH2 knockout ( TPH2

Pediatric Obstructive Sleep-Disordered Breathing: Updated Polysomnography Practice Patterns

30-04-2019 – Norman R. Friedman,Amanda G. Ruiz,Dexiang Gao,Alexandria Jensen,Ron B. Mitchell

Journal Article

To assess the current practice patterns of pediatric otolaryngologists in managing obstructive sleep-disordered breathing 6 years following the 2011 publication of the clinical practice guideline “Polysomnography for Sleep-Disordered Breathing prior to Tonsillectomy in Children.” Cross-sectional survey. American Society of Pediatric Otolaryngology (ASPO) members. An electronic survey to assess ASPO members’ adherence to polysomnography guidelines prior to tonsillectomy. Forty percent (170 of 427) of ASPO members completed the survey, with 73% in academic practice and 27% in private practice. Snoring represented, on average, 48% of the respondents’ practices. The percentage of respondents who requested a polysomnogram prior to tonsillectomy ≥90% of the time was 55% (n = 94) for Down syndrome, 41% (n = 69) for a child <2 years old, and 29% (n = 49) for obese children. A total of 109 (73%) and 112 (75%) respondents admit at least 90% of the time for a child with Down syndrome and for a child <3 years of age, respectively, but only 52 (35%) have a similar practice for an obese child. Only 37% adhere to the inpatient admission recommendation for children with documented obstructive sleep apnea on polysomnogram. The current polysomnogram practice patterns for responding pediatric otolaryngologists are not aligned with the clinical practice guideline of the American Academy of Otolaryngology-Head and Neck Surgery Foundation. The threshold for overnight observation when a preoperative polysomnogram has not been performed may be too low. A campaign is necessary to educate clinicians who take care of children with obstructive sleep-disordered breathing and to obtain more evidence to further define best practice.

Factors Influencing Poor Outcomes in Synthetic Tissue-Engineered Tracheal Replacement

30-04-2019 – Victoria Pepper,Cameron A. Best,Kaila Buckley,Cynthia Schwartz,Ekene Onwuka,Nakesha King,Audrey White,Sayali Dharmadhikari,Susan D. Reynolds,Jed Johnson,Jonathan Grischkan,Christopher K. Breuer,Tendy Chiang

Journal Article

Humans receiving tissue-engineered tracheal grafts have experienced poor outcomes ultimately resulting in death or the need for graft explantation. We assessed the performance of the synthetic scaffolds used in humans with an ovine model of orthotopic tracheal replacement, applying standard postsurgical surveillance and interventions to define the factors that contributed to the complications seen at the bedside. Large animal model. Pediatric academic research institute. Human scaffolds were manufactured with an electrospun blend of polyethylene terephthalate and polyurethane reinforced with polycarbonate rings. They were seeded with autologous bone marrow-derived mononuclear cells and implanted in sheep. Animals were evaluated with routine bronchoscopy and fluoroscopy. Endoscopic dilation and stenting were performed to manage graft stenosis for up to a 4-month time point. Grafts and adjacent native airway were sectioned and evaluated with histology and immunohistochemistry. All animals had signs of graft stenosis. Three of 5 animals (60%) designated for long-term surveillance survived until the 4-month time point. Graft dilation and stent placement resolved respiratory symptoms and prolonged survival. Necropsy demonstrated evidence of infection and graft encapsulation. Granulation tissue with signs of neovascularization was seen at the anastomoses, but epithelialization was never observed. Acute and chronic inflammation of the native airway epithelium was observed at all time points. Architectural changes of the scaffold included posterior wall infolding and scaffold delamination. In our ovine model, clinically applied synthetic tissue-engineered tracheas demonstrated infectious, inflammatory, and mechanical failures with a lack of epithelialization and neovascularization.


25-04-2019 –

Journal Article, Published Erratum

End-of-Life Costs and Hospice Utilization in Patients with Head and Neck Cancer

23-04-2019 – Michelle M. Chen,Eben L. Rosenthal,Vasu Divi

Journal Article

The Quality Oncology Practice Initiative has several metrics related to end-of life (EOL) care, including hospice enrollment ≤3 days, with lower scores signaling better performance. Of privately insured patients with head and neck cancer, 3.5% were enrolled in hospice prior to death and 21.3% spent ≤3 days in hospice, indicating aggressive EOL care. Patients with late hospice enrollment had higher spending in the last 30 days of life (DOL). Patients in hospice ≤3 days spent $37,426, while those in hospice >3 days spent $24,418 ( P = .002). The largest portion of this difference was attributable to inpatient services. Patients in hospice ≤3 days spent $22,089 on inpatient services in the last 30 DOL, while those in hospice >3 days spent $8361 ( P < .001). Further research is needed to determine if more high-value care can be provided with earlier hospice enrollment and to ensure that goal concordance is included in defining high-value care.

Computed Tomography Data to Generate a Reproducible, Anatomically Accurate Hemilaryngeal Model

23-04-2019 – Justin M. Hintze,Cheryl E. Myers,Michael J. McPhail,Yourka D. Tchoukalova,David G. Lott

Journal Article

The study aims to demonstrate the reproducibility and feasibility of creating a hemilaryngeal model with a medialized vocal fold (VF) using 3-dimensional (3D) modeling techniques in both healthy larynges and those affected by cancer. Three-dimensional modeling of human larynges. Tertiary academic referral center and regenerative medicine laboratory. Computed tomography (CT) scans from 10 healthy control and 10 patients with laryngeal cancer were segmented and imported into 3D modeling software. The larynx was cut sagittally to create a hemilaryngeal model and the vocal fold medialized. Measurements were taken from the CT and 3D model data and compared. All control modeling data closely matched the CT data and were not statistically different from each other. There was a significant correlation between subglottic anteroposterior diameter and VF length ( r CT scan-based 3D modeling of the larynx and VF is possible and reproducible. The results closely match those previously reported in the literature and can also be replicated in cases with laryngeal cancer. This study paves the way for future de novo fabricated laryngeal scaffolds that can be synthesized using 3D printers and tailored to meet surgical demands.

Feasibility of Intensive Ecological Sampling of Tinnitus in Intervention Research

23-04-2019 – Katherine M. Gerull,Dorina Kallogjeri,Marilyn L. Piccirillo,Thomas L. Rodebaugh,Eric J. Lenze,Jay F. Piccirillo

Journal Article

To assess whether adults with bothersome tinnitus will complete multiple ecological momentary assessments (EMAs) per day, including those during a therapeutic intervention trial. EMA is defined as repeated sampling of subjects’ current behaviors and experiences in real time. Twelve-week longitudinal cohort study conducted from August 28, 2017, to December 14, 2017. Online only. Thirty adults with self-reported bothersome nonpulsatile tinnitus of >6 months’ duration. Participants completed 2 weeks of EMA text surveys 7 times per day (preintervention), followed by 8 weeks of EMA questions 4 times per day (during intervention), concluding with 2 weeks of EMA questions 7 times per day (postintervention) for a total of 420 surveys over 12 weeks. During the 8-week intervention period, participants used a commercially available auditory-intensive online cognitive brain training program for 20 minutes per day, 5 times per week (total, 800 minutes). The primary outcome measures were compliance with EMA surveys, as measured by survey response rates, and participant-reported effects of EMA on their tinnitus bother. Of the 30 participants in this study (20 women and 10 men; median age, 54 years [range, 47-64 years]), 25 participants completed the study protocol (83%). Participants completed a median 87% of EMA surveys (range, 67%-99%). Qualitative analysis of free-text responses found that participants did not report negative side effects of the EMA. Excellent participant compliance can be achieved with multiweek temporally rigorous EMA sampling. EMA sampling can successfully be conducted during an intervention. EMA is a promising sampling methodology in tinnitus research.

Hearing as an Independent Predictor of Postural Balance in 1075 Patients Evaluated for Dizziness

23-04-2019 – Jan Erik Berge,Stein Helge Glad Nordahl,Hans Jørgen Aarstad,Frederik Kragerud Goplen

Journal Article

To evaluate the association between hearing and postural balance. Retrospective cross-sectional study. Tertiary care otolaryngology clinic. Patients examined for suspected vestibular disorder were included in this study. The outcome variable was postural sway measured by static posturography during quiet standing with eyes closed. The predictor variable was pure-tone average hearing threshold on the best hearing ear at 0.5, 1, 2, and 3 k
Hz. Covariates were age, sex, and vestibular disease or vestibular asymmetry assessed by bithermal caloric irrigation. In total, 1075 patients were included. Increased hearing threshold was a strong predictor of increased postural sway (path length) after correcting for age and sex. A 10-d
B increase in hearing loss on the best hearing ear predicted a mean 6.0% increase in path length (confidence interval, 2.9%-9.3%, P < .001). Of the covariates, increasing age ( P < .001) and male sex ( P = .009) were significant predictors of increased postural sway. The effect of increased hearing threshold was also significant after adjusting for vestibular disease. Increased hearing threshold was an independent predictor of increased postural instability, and this effect was strongest for the best hearing ear. Unilateral vestibular disease did not seem to explain this association between hearing and postural balance. Reduced hearing is associated with impaired balance, and interventions to prevent falls should be considered for patients at risk.

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.

Rethinking Malignancy Risk in Indeterminate Thyroid Nodules with Positive Molecular Studies: Southern California Permanente Experience

23-04-2019 – David S. Cohen,Jane E. Tongson-Ignacio,Christopher M. Lolachi,Vanessa S. Ghaderi,Babak Jahan-Parwar,Lester D. R. Thompson

Journal Article

To recognize that thyroid nodules with atypia of undetermined significance/follicular lesion of undetermined significance (AUS/FLUS; Bethesda III) have different risks of malignancy based on genetic mutation and to consider molecular testing of nodules with AUS/FLUS to help avoid unnecessary morbidity or cost. Retrospective cohort study. Multiple locations within Southern California Permanente Medical Group. Patients included those with indeterminate thyroid nodules and AUS/FLUS on 2 separate fine-needle aspirations with positive Thy
X testing from 2014 to 2017 who underwent thyroid surgery. Patients were classified as having benign or malignant disease. Noninvasive follicular thyroid neoplasm with papillary-like nuclear features was considered benign. A total of 231 patients had repeat AUS/FLUS with positive molecular testing and surgery. The most frequent type of malignancy was papillary carcinoma, followed by follicular carcinoma. The overall prevalence of malignancy in nodules with mutations was 74.0%, although there was considerable variation: BRAF = 100%, RET = 100%, PAX8-PPARγ = 84.6%, HRAS = 70.7%, NRAS = 63.4%, and KRAS = 33%-a statistically significant finding ( P < .001). Not all molecular mutations in thyroid nodules with AUS/FLUS have a high risk of malignancy. Of note, patients with BRAF and RET mutations in our population had a 100% risk of malignancy. Patients with PAX, HRAS, or NRAS mutations had a high risk of malignancy, while patients with KRAS mutations had a lower risk of malignancy. Further studies are needed to determine if the presence of certain molecular mutations can help personalize care and aid in the decision for thyroid surgery.

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 ( P = .003). Respiratory disturbance index was reduced from 27.3 events/h before supraglottoplasty to 7.8 events/h after surgery ( P = .003). The percentage of REM sleep decreased from 30.1% ± 2.4 to 24.8% ± 1.3 ( P = .04). Sleep efficiency was improved ( P = .05). 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.

Adverse Events after Rigid and Flexible Endoscopic Repair of Zenker’s Diverticula: A Systematic Review and Meta-analysis

23-04-2019 – Brianna Crawley,Salem Dehom,Shanalee Tamares,Abdullah Marghalani,Julina Ongkasuwan,Lindsay Reder,Chandra Ivey,Milan Amin,Mark Fritz,Michael Pitman,Ozlem Tulunay-Ugur,Philip Weissbrod

Journal Article

To determine adverse events after endoscopic flexible vs endoscopic rigid cricopharyngeal myotomy for treatment of Zenker’s diverticulum (ZD). Systematic review of MEDLINE, Web of Science, CINAHL, Clinicaltrials.gov, and Cochrane Central Register of Controlled Trials for all years according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Additional studies were identified from review citations and a by hand search of manuscripts referencing ZD. A structured literature search was conducted to identify studies for this systematic review. Methodological Index for Non-randomized Studies (MINORS) criteria were applied to assess study quality. For inclusion, each study had to provide data for at least 10 adult patients who had undergone endoscopic ZD repair reporting clear association with the postprocedure course in each case. Data extracted included all reported adverse events, recurrences, follow-up, and operative times. In total, 115 studies were included. All but 8 were retrospective case series. Sixty-one reported series of patients after rigid endoscopic stapler repair, 31 after rigid laser repair, and 13 with other rigid endoscopic instruments. Twenty-nine flexible endoscopic studies were included. Mortality, infection, and perforation were not significantly more likely in either the rigid or the flexible group, but bleeding and recurrence were more likely after flexible endoscopic techniques (20% vs <10% and 4% vs 0%, respectively). Dental injury and vocal fold palsy were reported rarely in the rigid endoscopic groups. Adverse events are rare after endoscopic Zenker's repair. The flexible approach minimizes exposure limitations and can be completed in some patients without general anesthesia. Transoral rigid approaches result in fewer revision surgeries compared with flexible diverticulotomy.

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, P < .001) and were less likely to include obstructive sleep-disordered breathing (48% vs 77%, P < .001). 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.

Effect of Water Precautions on Otorrhea Incidence after Pediatric Tympanostomy Tube: Randomized Controlled Trial Evidence

16-04-2019 – Joao Subtil,Ana Jardim,João Araujo,Carla Moreira,Tiago Eµa,Merlin McMillan,Sara Simoes Dias,Paulo Vera Cruz,Richard Voegels,Joao Paço,Richard Rosenfeld

Journal Article

Tympanostomy with ventilation tube insertion is the most common otologic surgery. Many surgeons recommend water precautions, although its utility is questioned. We aimed to investigate if water precautions reduce the rate of otorrhea after transtympanic tube insertion. Multicenter randomized controlled trial. A total of 244 children aged 2 to 10 years undergoing their first set of Shepard tubes for otitis media with effusion and concomitant adenoidectomy were randomized to 2 groups: 1 with ear protection during water exposure (ear plugs and headbands, n = 130) and 1 without (n = 114). Bathing or swimming with unprotected ears was considered the exposure event and incidence of otorrhea, the primary outcome. Outcomes were assessed during the 6-month follow-up period. In the water precaution group, 32% had at least 1 episode of otorrhea as compared with 22% in the unprotected group, which was not statistically significant ( P = .09). Only 37% of the episodes of otorrhea in the protected group and 36% in the unprotected group had a temporal relation to water exposure (no difference, P = .81). Respectively, 56% and 52% of the episodes of otorrhea were in the context of upper respiratory tract infection. Global quality of life improved significantly, irrespective of whether water protection was prescribed. The incidence of otorrhea was not different with or without prescription of ear protection during water exposure among children with tympanostomy tubes, which supports current guideline recommendations that routine water precautions are unnecessary in this population.

Pediatric Tracheostomy Decannulation: 11-Year Experience

16-04-2019 – Kristen L. Seligman,Bryan J. Liming,Richard J. H. Smith

Journal Article

To determine the successful decannulation rate with a published pediatric tracheostomy decannulation protocol. Case series with chart review. A single tertiary care institution. A chart review was performed for patients aged ≤5 years who underwent tracheostomy. Extracted data included demographic data, indication for tracheostomy, age at tracheostomy and decannulation, comorbidities, and surgical complications. Records were searched for documentation of early decannulation failure (within 1 month of decannulation) or late failure (within 1 year). Forty patients with a tracheostomy aged ≤5 years underwent attempted decannulation during the 11-year study period. Seventeen patients were excluded from the study for documentation of nonprotocol decannulation. The final study population of 23 patients underwent a total of 27 decannulations, 26 of which were performed by protocol. Of the 26 protocol decannulations, 22 were successful, for a failure rate of 15%. Twenty-six protocol decannulations were attempted among 23 patients, 4 of which were unsuccessful for an overall failure rate of 15%. This result is consistent with rates reported in other published decannulation protocols. We believe that our protocol minimizes resource utilization in its use of pulse oximetry over polysomnography, while maximizing patient safety and success through the use of capping trials for very young and very small pediatric patients.

Multimodal Analgesia Protocol after Head and Neck Surgery: Effect on Opioid Use and Pain Control

09-04-2019 – Eugenie Du,Zainab Farzal,Elizabeth Stephenson,April Tanner,Katherine Adams,Douglas Farquhar,Mark Weissler,Samip Patel,Jeffrey Blumberg,Maryam Jowza,Trevor Hackman,Adam Zanation

Journal Article

To assess the effect that implementation of a multimodal analgesic plan has on opioid requirements and pain control in head and neck (H&N) surgery patients. Prospective cohort. Tertiary academic hospital. An institutional review board (IRB)-approved quality improvement initiative was undertaken to implement a multimodal analgesic protocol for all admitted H&N surgery patients starting November 2017. Postprotocol data from January to May 2018 were compared to preprotocol data from May to October 2017. Data were obtained from the electronic health records as well as through preoperative and postoperative surveys. Average pain scores and opioid use in morphine milligram equivalents (MMEs) before and after protocol implementation were compared. In total, 139 postprotocol patients were compared to 89 preprotocol patients. The adjusted MMEs in the first 24 hours after surgery decreased significantly from 93.7 mg to 58.6 mg ( P = .026) with protocol implementation. When averaged over the length of stay (MME/hospital day), the change was no longer statistically significant (57.9 vs 46.8 mg, P = .211). The average pain score immediately after surgery and on day of discharge did not change with protocol implementation. Implementation of a multimodal analgesia plan reduced opioid use immediately after surgery but not over the course of hospitalization without any change in reported pain scores. This study shows that multimodal opioid-sparing analgesia after H&N surgery is feasible. Future studies are needed further refine the optimal analgesic strategy for H&N patients and assess the long-term efficacy, safety, and cost of such regimens.

Intranasal Azelastine and Fluticasone as Combination Therapy for Allergic Rhinitis: Systematic Review and Meta-Analysis

09-04-2019 – Peter M. Debbaneh,Anna K. Bareiss,Sarah K. Wise,Edward D. McCoul

Journal Article

Combination therapy with intranasal azelastine and fluticasone propionate is an option for treatment of allergic rhinitis. This systematic review and meta-analysis examines existing literature to determine efficacy in treating allergic rhinitis compared to monotherapy. The PubMed, EMBASE, Cochrane, and MEDLINE databases were systematically searched for randomized controlled trials using Aze
Flu nasal spray. Randomized, controlled trials that reported symptom relief of allergic rhinitis in males and females of all ages were included. Results were reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standard. Systematic review identified 8 articles suitable for review. The risk of bias was generally low. All studies exhibited a greater decrease in patient-reported symptom scores in patients treated with combination therapy compared to monotherapy or placebo. Meta-analysis revealed superiority of combination therapy in reducing Total Nasal Symptom Score compared to placebo (mean change from baseline: -2.41; 95% confidence interval [CI], -2.82 to -1.99; P < .001; I Current evidence supports both efficacy and superiority of combination intranasal azelastine and fluticasone in reducing patient-reported symptom scores in patients with allergic rhinitis. Combination nasal spray should be considered as second-line therapy in patients with allergic rhinitis that is not controlled with monotherapy.

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.