Factors Associated With Patient Portal Engagement in Otolaryngology Jesse Siegel, MD, Agnes M. Hurtuk, MD, Chloe Verducci, BA
Introduction: Patient portal use has been increasing particularly since the Covid-19 pandemic and provides logistical and financial benefits for both patients and providers, but disparities exist in patient portal usage with respect to age, gender, race, and insurance status. This has not been studied specifically in otolaryngology and not since the onset of the Covid-19 pandemic. In this project we measure patient portal use at a tertiary care medical center and aim to analyze patient-specific factors associated with portal engagement. Methods: We retrospectively analyzed data from all Loyola University outpatient otolaryngology visits over a 4-year period (December 2018 – December 2022). We use univariate analyses to measure how rates of portal use for online clinic scheduling vary across patient demographic groups and provider subspecialty. We also use multivariate analysis to measure the extent to which these factors affect likelihood of portal self-scheduling. Results: From December 2018 through December 2022, 49,462 patients scheduled 221,611 clinic visits, and significantly more online scheduling occurred after the onset of the Covid-19 pandemic (OR 6.0, P < .001). In multivariate analysis, male gender, age < 18 or > 65, primary language other than English, and PCP outside of Loyola were all associated with significantly lower likelihood of online appointment scheduling (P < .001 for each). Patients with Medicare engaged in the portal more than commercially insured patients when controlling for demographic variables (OR 3.8, P = .34). Conclusions: Patient use of MyChart in the Loyola University otolaryngology practice has markedly increased over the past 4 years. We identified several patient factors, including male gender, age less than 18 or over 65, primary language other than English, and PCP outside of Loyola, that are associated with decreased likelihood of engaging with the patient portal. These data provide an opportunity to improve patient portal content and outreach to patients regarding the benefits of portal use and ultimately to make the portal more accessible to diverse patient populations.
Diagnostic and Management Applications of ChatGPT in Otolaryngology Clinical Scenarios Roy Wang Qu, MD, Uneeb A. Qureshi, MD, Garrett Petersen, Steve C. Lee, MD, PhD
Introduction: With public interest at a high, ChatGPT, among other large language models, may become an increasingly utilized tool for both patients and clinicians. Its efficacy in diagnosis and treatment for specialty care, such as otolaryngology, has not been well evaluated. Methods: ChatGPT 4.0 was queried for diagnoses and management plans for 20 physician-written clinical vignettes in otolaryngology. Attending physicians then rated the difficulty of the clinical vignettes and agreement with the differential diagnoses and management plans of ChatGPT responses on a 5-point Likert scale. Summary statistics were calculated. Univariate linear regression was then performed between vignette difficulty and quality of the diagnoses and management plans. Results: Six attending physicians completed the survey (33% response rate). Overall, vignettes were rated as very easy to neutral difficulty (range of median score: 1.00 – 3.50; overall median: 2.00). There was high agreement with the differential diagnosis provided by ChatGPT (range of median score: 3.50 – 5.00; overall median: 5.00). There was also high agreement with treatment plans (range of median score: 3.50 – 5.00; overall median: 5.00). There was no association between vignette difficulty and agreement with differential diagnosis or treatment. There was a significant association between agreement with diagnosis and agreement with treatment (r = 0.33; 95% CI, 0.21 – 0.69; P < .001). Conclusions: Generative artificial intelligence models like ChatGPT are being rapidly adopted in medicine. Performance with curated, easy to moderate difficulty otolaryngology scenarios indicate high agreement with physicians for diagnosis and management. However, a decreased quality in diagnosis is associated with decreased quality in management. Further research is necessary on ChatGPT’s ability to handle unstructured clinical information.
Hearing Loss and HRQoL in Sickle Cell Disease and Traits Titus S. Ibekwe, MD, FWACS, Christine Rogers, PhD, Lebogang Ramma, PhD
Introduction: Sickle cell disease (SCD) and traits (SCT) are genetic disorders with relatively high prevalence among sub-Saharan Africans and African Americans. Hearing loss and overall poor health status have been associated with SCD but no consensus on SCT. Hence, the aim of this study was to assess and characterize the hearing loss and health-related quality of life (HRQoL) in SCD and SCT. Methods: A comparative cross-sectional study was conducted between February 2, 2022, and June 30, 2023, on cohorts and control groups for hearing and assessment of HRQoL in SCD and SCT at University of Abuja Teaching Hospital, Nigeria. The audiometric tests and WHOADS2 questionnaire/instruments assessed for hearing loss and HRQoL, respectively. Statistical analyses were done with SAS 9.4. The study was fully registered and for a PhD thesis by UCT (Capetown) and University of Abuja Nigeria, respectively. Results: A total of 212 participants (cohorts and tests), age range 6 months – 55 years (mean 15.1 ± 9.9 and 15.6 ± 12.9), featured in the research. Prevalence of hearing loss 28% (95% CI, 18.3 – 35.3) (SNHL, mainly moderate to severe) was significant in SCD but not SCT. The occupation/educational levels of the mothers of both SCD and SCT participants (P = .016) and the duration of diagnosis of SCD genotype for (P < .001) were strong demographic factors that influenced the health status. The HRQoL study showed that cognition, mobility, work ability, and social life were significantly impaired among SCD, whereas only work ability and relationship were affected in SCT. Conclusions: Hearing loss is significantly associated with SCD, whereas the health-related qualities of lives are depressed in both SCDs and SCTs and with higher impacts on the SCDS. Awareness and early diagnosis appear to be strong positive predictive factors.
Olfactory-Related Adverse Events: An Analysis of the FDA Reporting System Daniel H. Lofgren, DO, Katrina M. Minutello, DO, Christopher P. Lenkeit, DO, Eriel Emmer, Olga Santiago Rivera, PhD, Asha J. Downs, DO
Introduction: Olfactory dysfunction recently gained considerable interest because of its association with the coronavirus pandemic; however, olfactory-related adverse events (ORAEs) associated with medications are potentially underreported. This study aims to identify and classify medications with patient- and provider-reported ORAEs using the FDA Adverse Event Reporting System (FAERS) database. Additionally, we aim to describe the association of olfactory-associated adverse effects with differences in patient demographics, including gender and country of origin. Methods: This study was a retrospective cross-sectional review of ORAEs reported in the FAERS database from August 2012 to August 2022. Our population of interest included adult cases with olfactory-associated adverse effects (anosmia, parosmia, hyposmia, and olfactory dysfunction) stemming from a single suspected product active ingredient (SPAI), the main determinant variable. We excluded reports with multiple reported SPAIs and olfactory symptoms and incomplete reports. Other variables of interest were patient age, gender, date of report, and country of origin. Data were presented in both frequencies and percentages. Results: There were 10,505 reported cases for the study period, with 1111 remaining after fulfilling inclusion/exclusion criteria. Forty-four SPAIs were identified. Across all categories, the most common SPAIs were monoclonal antibodies (281, 25.29%), intranasal steroids (234, 21.06%), immunomodulators (228, 20.52%), intranasal decongestants (82, 7.38%), antibiotics (41, 3.69%), antidepressants (40, 3.60%), and various homeopathic (40, 3.60%). Conclusions: Using the open-source FAERS database, we found the most common SPAIs to be monoclonal antibodies, intranasal steroids, immunomodulators, intranasal decongestants, antibiotics, antidepressants, and homeopathic medications. Findings from this study may function as an educational resource for both prescribers and patients to help reduce the cost and workup for patients with olfactory dysfunction.
Postoperative Complications in Lingual vs Palatine Tonsillectomy Chloe Cottone, BA, David Riccio, BS, Erin M. Gawel, BS, Michele M. Carr, DDS, MD, PhD
Introduction: Risks of lingual tonsillectomy (LT) have not been described in a large cohort. Our objective was to compare these risks to those of palatine tonsillectomy (PT). Methods: A retrospective cohort study was conducted using data from the US collaborative network within TriNetX, a global EHR database. The LT group was defined using CPT code 42870 and PT group using CPT codes 42820, 42821, 42825, or 42826. Groups were further subdivided into pediatric and adult populations. Postoperative bleeding, dehydration, dysphagia, ER visits, ICU care, and subsequent hospital care occurring within 14 days of procedure were compared between the groups within adult and pediatric populations. Results: Propensity score matching was conducted for age, yielding a mean age of 43 years for the adult population (n = 1357) and 8 for the pediatric population (n = 848). Compared with the adult PT group, dysphagia occurred 2.77 times more frequently (P < .0001), initiation of ICU care occurred 3.87 times more frequently (P < .0001), and subsequent hospital care occurred 2.77 times more frequently (P < .0001) in the LT group. In the pediatric group, subsequent hospital care occurred 6.25 times more frequently (P < .0001) and dysphagia occurred 2.4 times more frequently (P = .02) in the LT group than in the PT group. In the pediatric PT group, however, postoperative bleeding occurred 2.67 times more frequently than in the pediatric LT group, occurring in 3.77% of PTs and 1.41% of LTs (P = .004). There was no statistical difference in bleeding between adult PT and LT groups, occurring at a rate 3.83% and 4.42%, respectively (P = .50). Conclusions: Postoperative complications after lingual tonsillectomy are more common than after palatine tonsillectomy in both adults and children.
Virtual Interviews for Otolaryngology: Applicant Data From the 2022-2023 Cycle Elliot Schiff, BA, Benjamin Wajsberg, MD, John P. Bent, MD, Richard V. Smith, MD
Introduction: Since the onset of the COVID-19 pandemic, residency interviews have utilized the virtual interview format. Previous studies have examined applicants’ perspectives of the preliminary virtual format. Since it now appears the shift to virtual may not be temporary, this study aims to reexamine the perspectives and attitudes of applicants during the 2022 – 2023 application cycle, as programs and applicants wonder if in-person interviews will ever resume. Methods: Applicants to a single otolaryngology residency program were surveyed electronically in February 2023 to assess their attitudes toward virtual interviews. Results: One hundred forty-seven of 405 applicants (36.3%) completed surveys. Seventy respondents (48%) would have preferred in-person interviews. However, only 24 respondents (16.3%) were “dissatisfied” or “strongly dissatisfied” with the virtual interviews. First-time applicants reported a higher mean number of interview offers received than reapplicants (15.8 vs 7.0) and a higher mean number of interviews attended (13.67 vs 6.70) (P < .00001). There was no significant relationship between dedicating a year to research and number of interview offers received (P = .542) or interviews attended (P = .530). Conclusions: The main advantages of virtual interviews remain decreased cost and time spent for each interview. As a result, there is more incentive for applicants to attend all interviews offered. Many respondents supported a limit on the number of interviews an applicant can accept. To address perceived disadvantages of the virtual format such as an inability to satisfactorily communicate with residents or to assess program culture, many applicants advocated for increased “second look” opportunities.
Virtual Interviews in Otolaryngology: Programs’ Perspectives After Three Years Elliot Schiff, BA, Benjamin Wajsberg, MD, John P. Bent, MD, Richard V. Smith, MD
Introduction: Virtual interviews were introduced to the residency application process in 2020 by the AAMC during the COVID-19 pandemic. Yet, while the pandemic wanes, virtual interviews remain a part of the application process. Prior studies described the attitudes of program directors and department chairs in otolaryngology before and immediately following that initial application cycle. This study aims to determine their perspectives on virtual interviews in 2023, as programs prepare for a fourth cycle with virtual interviews. Methods: An online survey was distributed to otolaryngology residency program directors and department chairs during the 2022 – 2023 application cycle. Results: Eighty-five responses were collected from program directors and department chairs of 129 programs (33%). Twenty-four (28.24%) were “satisfied” or “strongly satisfied” with the virtual interview format. When asked to score the likelihood that they would continue virtual interviews in future cycles on a scale of 1 to 100, the mean score was 47.18. Ability to assess applicants’ professionalism, clinical skills and knowledge, and program “fit” achieved scores of 2.92, 2.84, and 2.58 out of a maximum of 5, respectively. Conclusions: When compared to data from the 2020 – 2021 application cycle, overall satisfaction with virtual interviews has decreased from 63.8% to 28.2%. Specific challenges such as the inability to assess program “fit” or to describe the geographic location remain consistent. These findings should spur conversation about how best to adapt the virtual interview if it is to remain a fixture of the application process.
Facial Plastic and Reconstructive Surgery
Appearance Normalization to the Casual Observer Following HNC Surgery Devon Durham, MPH, Julia Toman, MD, MPH
Introduction: Head and neck cancer (HNC) makes up 5% of all cancers, but given the visible nature of the area affected, patients experience a disproportionate disability related to appearance, self-image, and quality of life. Using a novel method of objective eye-tracking technology, we hypothesize that plastic and reconstructive surgery following HNC treatment normalizes casual observer focus. Methods: This is a prospective observational study taking place from September 2022 to April 2023. A total of 16 photographs from 4 patients were placed in random order, a preoperative and postoperative anterior and sideview photograph for each patient. All patients received primary treatment for their HNC followed by a Grecian urn submentoplasty for neck rejuvenation. After proper calibration of the Tobii Pro Nano eye tracker, participants viewed each photograph for 6 seconds in a random order, without prior sensitization to the study objective. The primary outcome measurement was total duration of fixations on the neck before and after submentoplasty, using a paired t test to determine significance. Results: Eighty-three participants were included in the final analysis—27 males and 56 females with an average age of 52 (19 – 88; SD 19.6). The largest difference in mean duration of fixation was observed in sideview photographs of patients 1 – 4: 163 ms, 360 ms, 205 ms, and 160 ms, respectively (P < .05). Anterior views were more variable with a mean difference of 94 ms (95% CI, -29 to 216), 99 ms (95% CI, -32 to 231), 41 ms (95% CI, -91 to 173), and -51 ms (P < .05; 95% CI, -92 to -11), respectively. Conclusions: HNC survival rates have increased recently and demand more focus on quality of life following primary treatment. Rejuvenation surgery to address stigmas of HNC treatment is important in addressing patient concerns with appearance following HNC management. We used a novel method to objectify changes in casual observer focus following rejuvenation treatment, confirming a favorable decrease in onlooker focus on areas of surgery. Greater study is needed to further quantify appearance-related quality of life patient concerns and social stigma.
Cost-Effectiveness Analysis of Liquid vs Surgical Rhinoplasty Jason Han Lee, MD, Alia Tayara, James D. Warren, BS, J. Randall Jordan, MD
Introduction: Filler injections for nonsurgical rhinoplasty have increased in popularity over the past decade, particularly among patients seeking to alter their noses’ appearance with reduced risk, upfront cost, and downtime associated with traditional surgery. Methods: A Markov model was used to analyze the cost-effectiveness of permanent surgical vs temporary liquid rhinoplasty lasting 1 year in adult patients, with the test case of a 30-year-old considering both options over 40 years. The cost assumptions were as follows: $15,000 for primary surgical and $2000 for primary liquid rhinoplasty, as well as $10,000 for revision surgery and $1000 for revision liquid rhinoplasty. The primary rhinoplasty revision rate was set as 5%, and revision rates for the other procedures were assumed to be 10%. These figures were derived from literature and expert opinion from the senior author. The primary outcome measures included individual and total costs, quality-adjusted life years (QALYs) using published health utility values, and incremental cost-effectiveness ratios (ICERs). The ICERs were evaluated against a published willingness-to-pay (WTP) threshold of $12,264 per QALY for surgical rhinoplasty. Results: The average cost for liquid rhinoplasty was $68,297, while the average cost of surgical rhinoplasty was $18,260, assuming a onetime revision after 1 year to assess satisfaction. In terms of effectiveness, the average QALY gained for surgical rhinoplasty was 37.34, compared with 10.13 for liquid rhinoplasty. With respect to established literature, the ICER of $1839 was well below the published WTP threshold. Conclusions: To the best of our knowledge, this is the first study to assess QALY and cost-effectiveness of liquid vs surgical rhinoplasty. Our findings suggest that surgical rhinoplasty is both less costly and more effective than liquid rhinoplasty, falling within the acceptable cost-saving range. Further analysis incorporating complication rates and costs, postoperative recovery time, and variations in perioperative and operating room expenses will be conducted.
Ultrasonic Shears Decrease Hematomas in Head and Neck Microvascular Reconstruction Arman Danielian, MD, Keith E. Blackwell, MD, Rhorie P. Kerr, MD, Manwel Labib, MS, Rahul Seth, MD, Vishad Nabili, MD, Ali Razfar, MD
Introduction: This study evaluates postoperative hematoma and takeback rates in a large series of microvascular reconstructions. We sought to determine whether the use of ultrasonic shears reduced these rates. Methods: In total, 2288 patients undergoing free flap reconstruction for head and neck defects between 1995 and 2022 were reviewed. Patients undergoing dissection with and without ultrasonic shears were compared to determine postoperative hematoma and takeback rates. Results: The overall hematoma rate was 1.3% (29/2288) for the entire cohort. The postoperative hematoma rates with and without ultrasonic shears were 0.63% (9/1418) and 2.3% (20/870) (relative risk = 0.28, P = .0015). Of 870 patients undergoing surgery without ultrasonic shears, 14 (1.61%) were taken back to the operating room for control of bleeding compared with 8 of 1418 (0.56%) in the ultrasonic shears cohort. Conclusions: Our large series of patients undergoing microvascular reconstruction shows a decrease in postoperative hematoma rate and takeback for bleeding with the adoption of ultrasonic shears. Ultrasonic shears are an effective tool that can help decrease perioperative morbidity secondary to hematoma after head and neck tumor resection and microvascular reconstruction.
Head and Neck Surgery
Agent Orange and Head and Neck Cancer: A Meta-Analysis Neil Monaghan, BS, Kelsey A. Duckett, BS, Shaun A. Nguyen, MD, Jason G. Newman, MD, Alexandra E. Kejner, MD, William G. Albergotti, MD
Introduction: Our objective was to assess the incidence and mortality of head and neck cancer (HNC) in patients exposed to Agent Orange and related dioxins. Methods: The PubMed, CINAHL, and Scopus databases were searched from inception to May 05, 2023. A meta-analysis of proportions with comparison (Δ) of weighted proportions was conducted. Results: Of 1530 unique abstracts screened, 13 studies were included in the systematic review. Of 8,890,769 patients with reported sex, 92.7% were male. Of 160,449 with reported race, 83% were White, 9.1% were Black. Of the exposed patients with reported subsites, oral cavity (31.2%) and larynx (14%) were the most common. Of the exposed patients with reported deaths and subsites, oropharynx (0.25%) was the most common primary site in patients who died. Of those that were not exposed, oropharynx (0.13%) and larynx (0.16%) were the most common sites. On comparison of proportions between groups, HNC incidence of all subsites was significantly more common in those exposed to Agent Orange than in unexposed controls (Δ 0.06%; 95% CI, 0.04 – 0.08%; P < .0001). We do not, however, appreciate a significant increase in frequency of any site-specific cancer among those exposed. Conclusions: Our findings suggest that HNC overall is more common in those exposed to Agent Orange than those who are not, with most common sites including oral cavity and larynx. Further investigation is warranted to evaluate site-specific outcomes and risk given the limitations of our study design.
Dental Implants in Radiated Fibula Free Flaps: A Systematic Review Veronica Drozdowski, MD, Morgan Sandelski, MD, Amy L. Pittman, MD, Eric J. Thorpe, MD, Danae Alexandrou, BS
Introduction: Dental rehabilitation in irradiated patients with free flap reconstruction is a challenge given concern for osseointegration. Current studies cite success rates from 38% to 90%; however, these percentages are derived from small, largely retrospective chart reviews. Given that the quality of life in these patients is greatly diminished when dental rehabilitation limited, we sought to systematically review the available literature. Methods: The protocol was registered with the systematic review database PROSPERO (CRD42022372499). We included studies that discussed osseointegrated dental implants placed into fibula free flaps in patients with a history of radiation, including adjuvant radiation, primary radiation with surgical salvage, or resultant osteoradionecrosis as the indication for free flap. Results: There were 14 studies that met the criteria for inclusion. On pooled analysis, 415 dental implants were placed in 148 patients. We noted an overall survival (OS), defined as successfully osseointegrated implants, of 74% (308/415). At 6 months postimplant, the OS was 86% (284/330). Five of the 14 studies provided comparative data between RT vs no RT: 2 reported no difference and 3 reported statistically significant worse outcomes in patients with RT; however, no articles provided data to run pooled statistical analysis. Five of 14 studies discussed adjuvant hyperbaric oxygen, with an OS of 69.8% (125/179; P = .075). Thirteen of the 14 studies reported timing of implant placement, either immediate at the time of surgery or delayed after a period of healing. Immediate implants had an OS of 93.9% (62/66) and delayed of 74.5% (182/244). Immediate placement was associated with better OS (P ≤ .001). Conclusions: Despite limitations we were able to conclude that a history of radiation does appear to decrease survival rates for dental implants placed into fibula free flaps. An unexpected finding was that immediate placement appears to improve survival; however, data on timing of radiation are still lacking. Our hope is that our paper serves as a catalyst for larger, perhaps prospective research on this topic.
Endoscopic Surgery vs Conservative Treatment for Nasopharyngeal Necrosis in NPC Chao Lin, PhD, Xiong Zou, MD, PhD, Lan Peng, MD, Qi Yang, PhD, Youping Liu, MD, Wenbin Wu, MD, Ming-Yuan Chen, MD, PhD
Introduction: Nasopharyngeal necrosis is a common sequela of treatment for nasopharyngeal carcinoma, especially in recurrent cases. Nasal endoscopic surgery and conservative therapy are the main treatments for nasopharyngeal necrosis, but there is no study directly comparing their efficacy. This retrospective study aims to compare the effect of endoscopic surgery and conservative therapy on the treatment of nasopharyngeal necrosis and to identify the potential beneficiaries for each treatment. Methods: This study included 517 NPC patients with nasopharyngeal necrosis between 2008 and 2020, of whom 287 received conservative therapy and 230 received nasal endoscopic surgery. The primary end point was overall survival. Propensity score matching and inverse probability of treatment weighting were used to balance confounding factors between both groups. The Cox proportional hazard model was used to identify independent prognostic factors for nasopharyngeal necrosis. Subgroup analysis was performed to determine the effectiveness of endoscopic surgery and conservative therapy in subsets. Results: In the unmatched cohort, the 3-year overall survival was 35.0% (95% CI, 29.3% – 41.8%) in the conservative therapy group vs 70.5% (95% CI, 64.5% – 77.1%) in the endoscopic surgery group. Patients in the surgery group had higher cure rates (73.0%; 95% CI, 67.0% – 78.4%) than those in the conservative therapy group (33.1%; 95% CI, 27.9% – 38.7%). PSM and IPTW analyses yielded similar results. Multivariate analyses in all 3 cohorts showed that nasal endoscopic surgery was an independent protective factor in OS of the nasopharyngeal necrosis patient. The benefit of endoscopic surgery was consistent across all subgroups except for patients with superficial mucosal necrosis. Conclusions: This study shows that treatment with endoscopic surgery yields better efficacy than conservative therapy for NPC patients with nasopharyngeal necrosis. Conservative therapy may be preferred for patients with superficial mucosal necrosis.
Grade III Thyroid Lesion — The Incidence of Histological Malignancy Velauthapillai Nandapalan, FRCS, Cornelia Samian, MD, Meenal Abhyankhar, MD
Introduction: The diagnosis of thyroid cancer is evolving, but detection for malignancy of indeterminate nodules remains below 50% for most centers around the world. In reviewing the literature, local rates for malignancy for the grade III thyroid lesions vary considerably in different centers. A follow-up ultrasound scan in these cases, with repeat fine-needle aspiration (FNA) shows that up to 70% of patients are reclassified at repeat biopsy. Methods: We did a retrospective study with data collection of all patients with thyroid nodule who underwent ultrasound-guided FNA cytology (FNAc) in our trust between 2015 and 2019. The inclusion criteria were cases of thyroid FNA reported according to the Royal College of Pathologists (RCPath) as Thy3a and Thy3f. The aim of the study was to identify the risk of malignancy (ROM) of Thy3a and Thy3f in those that underwent surgery and percentage correlation between the cytology and histology and to estimate the percentage of Thy3a/f with repeat FNA and its results. Results: During a 5-year period, 843 thyroid FNAs were performed. Identified were 94 cases of Thy3a and 89 cases of Thy3f. The total number of cases that underwent surgery during the 5-year period was 126 (68.85%). Thy3a group showed a higher risk of malignancy (ROM) rate compared with RCPath guidelines, equivalent to grade III Bethesda (USA) classification system. Conclusions: The incidence of malignancy within Thy3 thyroid lesions is higher than the RCPath positive predictive value of malignancy. The percentage of Thy3 diagnosis is increasing due to better ultrasound resolution and exclusion of benign nodules from indeterminate or suspicious nodules. The presence of cytology atypia is associated with a higher rate of malignancy.
Ketorolac for Prevention of Microvascular Thrombosis in Free Flaps Carolyn DeBiase, MD, Jeffrey C. Mecham, MD, Nan Zhang, MS, Carrlene Donald, PA-C, Thomas H. Nagel, MD, Richard E. Hayden, MD
Introduction: Prevention of microvascular thrombosis in free tissue transfer for head and neck reconstruction is paramount to maintaining a viable reconstruction. Various antithrombotic agents have been used in the past for this purpose. The aim of this study is to show the noninferiority of ketorolac for prevention of flap failure. Methods: This is a retrospective review of all head and neck free tissue transfers performed at a quaternary care center by the 2 senior authors who routinely use ketorolac for prevention of microvascular thrombosis. Patients who were ineligible to receive ketorolac were included in the study for descriptive purposes. Results: From 2010 to 2020, 322 patients underwent free tissue transfer of the head and neck. Within the cohort, 278 patients were administered ketorolac and 44 were not, most commonly due to kidney dysfunction or cardiac comorbidities requiring aspirin. Within the ketorolac group, the flap failure rate was 2.5% with a venous and arterial thrombosis incidence of 2.2% and 1.4%, respectively. Hematoma incidence was 9.4% in ketorolac group and 6.8% in non-ketorolac group. Rate of acute kidney injury was 3.6% in ketorolac group and 11.4% in non-ketorolac group. Conclusions: This is the largest study of ketorolac usage in head and neck free tissue transfer patients. The flap failure rate of 2.5% is comparable to the literature rate of 5% (P .054). Ketorolac was not associated with increased rate of acute kidney injury when used in patients without kidney dysfunction. The incidence of hematoma is slightly higher than previous studies; however, 23% of hematoma patients received ketorolac and full dose anticoagulation such as a heparin drip. Ketorolac in combination with other full-dose anticoagulants may lead to increased risk of hematoma. This study demonstrates the safety and efficacy of ketorolac for prevention of microvascular thrombosis and free flap failure in head and neck reconstruction patients.
Long-Term Outcomes of Cricothyroidotomy: A Retrospective Comparative Analysis Cohort Study Nir Tsur, MD, Tomer Talmy, MD, Mor Rittblat, MD, Irina Radomislensky, MSc, Ofer Almog, MD, Jonathan Meizoso, MD, Sami Gendler, MD
Introduction: Cricothyroidotomy (CRIC) is a salvage procedure commonly used in failed endotracheal intubation (ETI) or difficult airway cases. However, more data are needed regarding the short- and long-term complications associated with CRIC. This study aimed to evaluate the Israel Defense Forces (IDF) experience with CRIC over the past 2 decades and compare the short-term and long-term sequelae of prehospital CRIC and ETI. Methods: Data on patients undergoing either CRIC or ETI in the prehospital setting between 1997 and 2021 were extracted from the IDF trauma registry. Patient data were then cross-referenced with the Israel national trauma registry, documenting in-hospital care, and the Israel Ministry of Defense rehabilitation department registry, containing long-term disability files of military personnel. Results: Of the 122 patients with short-term follow-up through initial hospitalization, 81% underwent prehospital ETI, while 19% underwent CRIC. There was a higher prevalence of military-related and explosion injuries among the CRIC patients (96% vs 65%, P = .02). Patients who underwent CRIC more frequently exhibited oxygen saturations below 90% (52% vs 29%, P = .002). Injury severity score was comparable between groups. No significant difference was found in ICU length of stay and need for tracheostomy. Regarding long-term complications, with a median follow-up time of 15 years, CRIC patients had more upper airway impairment, with most suffering from hoarseness alone. Conclusions: This retrospective comparative analysis did not reveal significant short- or long-term sequala of prehospital CRIC. The long-term follow-up did not indicate severe aerodigestive impairments, thus suggesting that this technique is safe. Along with the high success rates attributed to this procedure, we recommend that CRIC remains in the armamentarium of trauma care providers.
Occult Neck Metastasis in Salvage Laryngectomy Ahmed Sobhy Youssef, MD, PhD, FRCS, Greg A. Krempl, MD, Rusha J. Patel, MD, Rachad Mhawej, MD
Introduction: For patients presented with locally recurrent/residual squamous cell carcinoma of the larynx, there is debate over the role of elective neck dissection (END) for clinically and radiologically negative nodal metastasis defined as N0 neck. Some surgeons do believe that neck dissection is a must, considering it as standard care for those patients; others do not favor it with respect to potential morbidity in irradiated neck. None of these helped to answer another important question regarding contralateral neck or possible value of super selective neck dissection in those patients. Methods: This is a retrospective study, over a time frame of 6 years (2016 – 2022), for patients who underwent bilateral neck dissection and salvage laryngectomy for recurrent or persistent disease without prior clinical or radiological evidence of positive cervical lymph nodes, classified as N0 neck. Our primary objective was to study the incidence of contralateral neck disease in these patients. Our secondary objective was to calculate incidence of ipsilateral neck disease with respect to lymph node levels to check feasibility of super-selective neck dissection in salvage laryngectomy. Results: Seventy-four patients underwent salvage laryngectomy and bilateral neck dissection over the period 2016 – 2022. Incidence of ipsilateral neck disease was calculated as 8.11%. Incidence of contralateral neck nodal metastasis was 0%. Regarding ipsilateral nodal level distribution, level II was the highest calculated as 6.76, followed by level III calculated as 5.41%. Level IV showed 0% metastasis as well as level IIb. Conclusions: In patients undergoing salvage laryngectomy with preoperative N0 neck, ipsilateral super selective neck dissection could be considered to maximize chances of cure with less operative time and less morbidity related to unnecessary dissection of level IIB, level IV, and contralateral neck.
The Occult Nodal Metastasis Rate of Early Tongue Cancer (T1-T2) Dong Jin Lee, MD, Sun Choi, MD
Introduction: In this study, a meta-analysis was conducted to evaluate the occult lymph node metastasis rate in patients with early stage (T1 – T2) oral tongue squamous cell carcinoma. Also, the correlation between occult lymph node metastasis rate and T2 ratio among T1 – T2 or the reported year of each study was analyzed to adjust other confound variables. Methods: A systematic computerized search of electronic databases was carried out for articles published between January 1, 1980, and December 31, 2021, that reported occult nodal metastasis rate in T1 and T2 (separately) tongue cancer patients. Statistical analysis was performed using Comprehensive Meta-Analysis version 3.3.070. Publication bias was assessed by the Egger test and Begg funnel plot method. The correlation between occult nodal metastasis rate and T2 ratio or reported year, respectively, was assessed by meta-regression analysis. Results: From 19 studies, 1567 cases were included in the meta-analysis. By random effects model, the mean occult cervical lymph node metastasis was 24.4% (95% CI, 0.205 – 0.248). The meta-regression revealed that the T2 ratio and the reported year of the studies did not have a significant effect on the occult metastasis rate (correlation coefficient = 0.531 and 0.002, respectively; P = .426 and P = .921, respectively). Conclusions: The meta-analysis revealed that the early-stage oral tongue squamous cell carcinoma had a rate of 24.4% for occult nodal metastasis. The occult nodal metastasis rate was not significantly affected by T2 ratio among T1 – T2 or reported year of the studies.
Parotid Nodal Metastases From HPV-Mediated Oropharyngeal Squamous Cell Carcinoma Nicholas B. Drury, MD, George M. Davies, MD, Nicholas Sorensen, Eric Pan, Daniel D. Sharbel, MD, J. Kenneth Byrd, MD
Introduction: We encountered 3 cases of human papilloma virus (HPV)-mediated oropharyngeal squamous cell carcinoma (OPSCC) with parotid nodal metastasis, which has yet to be described in the literature. Methods: Patients were identified retrospectively based on unanticipated spread to the parotid lymph nodes. A thorough review of articles referencing atypical metastases in OPSCC was conducted in PubMed. Results: The first case involved an 82-year-old female with an invasive right parotid mass. Following parotidectomy and neck dissection, immunohistochemistry demonstrated p16 and HPV positivity. Postoperative positron emission tomography (PET) scan identified primary disease of the base of tongue. In the second case, a 65-year-old male with known history of HPV+ OPSCC treated with chemoradiation presented with new onset cervical lymphadenopathy. PET scan and pathology following salvage neck dissection revealed recurrent, metastatic HPV-mediated disease to the parotid lymph nodes. Lastly, a 47-year-old male with a history of HPV+ OPSCC of the left tonsil treated with radical tonsillectomy and neck dissection presented with a new submandibular mass. Subsequent biopsy and imaging confirmed recurrent disease with metastasis to the parotid gland. All 3 patients developed distant metastatic disease. Two patients are alive with disease on immunotherapy, and 1 patient died of his disease. Conclusions: Although rare, atypical spread to the parotid nodes can occur in HPV-mediated OPSCC, which may be a predictor of aggressive disease.
Preoperative Serum Albumin as a Predictor of Outcomes After Thyroidectomy Bao Y. Sciscent, BS, Hanel Eberly, BS, F. Jeffrey Lorenz, MD, Nguyen Minh Truong, BS, Neerav Goyal, MD, MPH
Introduction: Albumin is considered a surrogate marker for inflammation and nutritional status. Levels usually decrease after surgery, but little is known about the predictive value of preoperative albumin levels in patients undergoing thyroidectomy. This study aimed to investigate the 30-day incidence of postoperative outcomes in thyroidectomy patients with and without preoperative hypoalbuminemia (HA). Methods: TriNetX, a federated de-identified database, was retrospectively queried to identify patients who underwent thyroidectomy. Postoperative outcomes within 30 days of thyroidectomy, based on ICD-10 and CPT codes, in patients with preoperative HA (< 3.4g/dL) (cohort 1) were analyzed and compared with patients without HA (cohort 2). Results: After propensity score matching, 2113 patients were identified in each cohort. HA patients were more likely to have postoperative pneumonia (OR 2.866; 95% CI, 1.643 – 5.00), acute renal failure (OR 2.485; 95% CI, 1.617 – 3.817), pulmonary embolism/venous thromboembolism (OR 1.614; 95% CI, 1.019-2.557), and sepsis (OR 2.327; 95% CI, 1.21 – 4.473). The prevalence of mortality, surgical site infection, use of tracheostomy, and respiratory dependence were comparable between cohorts. Conclusions: Patients undergoing thyroidectomy with preoperative HA have a higher incidence of postoperative complications compared with patients without preoperative HA. While not routinely assessed, preoperative evaluation of serum albumin levels may help guide expectations and optimal management of thyroidectomy patients.
Quality of Life Outcomes for Surgically Treated Parotid Cancer Patients Anthony Tang, Alexandra Florescu Eubank, Jinhong Li, MS, Nicole Scheff, PhD, Jonas T. Johnson, MD, Marci Lee Nilsen, PhD, RN, CHPN
Introduction: Surgical treatment of parotid gland cancer (PGC) can cause a variety of complications impacting patient quality of life (QOL). The aim of this study is to describe the QOL impact of surgical treatment and to find associations related to QOL outcomes. Methods: This is a retrospective study of 57 PGC patients seen in a multidisciplinary survivorship clinic between 2017 and 2023. QOL was assessed using the University of Washington Quality of Life (UW-QOL) questionnaire, the Eating Assessment Tool-10, the Patient Health Questionnaire-8 for depression, the Generalized Anxiety Disorder-7 survey, and the Neck Disability Index. Secondary aims include the impact of adjuvant treatment and cancer perineural invasion on patient QOL. Results: Eleven patients (19.3%) were treated with surgery alone, 10 (17.5%) were treated with both surgery and adjuvant chemoradiation therapy (CRT), and 36 (63.2%) were treated with surgery and adjuvant radiation. Twenty-nine patients (50.9%) had perineural invasion. The most frequently selected important posttreatment issues for PGC survivors were salivation (38.6%), persistent pain (29.8%), and the ability to maintain daily activities (28.1%). Twenty-nine survivors (50.9%) reported 3 or more important issues that impact their daily lives. PGC survivors treated with surgery and CRT were associated with lower physical and social QOL, increased swallowing difficulty, depression, and increased neck pain during daily activities (P < .001, P = .012, P = .002, P = .051, P = .031, respectively). Survivors with perineural invasion were associated with decreased physical QOL (P = .045). Conclusions: Our study showed that salivation and persistent pain had the greatest impact on the QOL of patients with surgically treated parotid gland cancer after finishing treatment. Secondary analyses suggest that surgery with CRT and perineural invasion were both associated with worse QOL outcomes. Understanding the most important issues PGC survivors face posttreatment can direct personalized patient care and improve patient survivorship.
Racial Disparities in Outcomes After Major Head and Neck Surgery Ryan M. Kong, BS, Natalie Cipriano, BS, Jennifer J. Liang, MD, Katie Cinyee Kong, Lori Hoepner, DrPH, MPH, Nira A. Goldstein, MD, MPH, Natalya Chernichenko, MD
Introduction: Understanding racial disparities in postoperative outcomes after major head and neck cancer surgery (MHNCS) is crucial in improving overall cancer survival; however, evidence of the independent impact of race on outcomes is lacking. This study aims to investigate the effect of race/ethnicity on surgical outcomes after major head and neck surgery using a large national database. Methods: A retrospective cohort study was done querying the ACS-NSQIP database between 2014 and 2021. Patients undergoing MHNCS were divided into 5 groups: White, Black, Hispanic, Asian, and Unknown/Not Reported. Multivariable regression was used to analyze adverse outcomes between the groups after adjustment for age, sex, BMI, smoking status, ASA score, preoperative estimation of morbidity, and comorbidities. Results: For 8372 patients, group distributions were as follows: White, 5702 (68.1%); Black, 507 (6.1%); Hispanic, 407 (4.9%); Asian, 336 (4.0%); Unknown/Not Reported, 1420 (17.0%). Multivariable regression showed Black patients when compared with White patients had significantly increased odds ratios of overall (1.42 [1.12 – 1.81]; P = .004), severe (1.69 [1.37 – 2.09]; P < .001), sepsis-related (1.96 [1.19 – 3.25]; P = .009), and thromboembolic complications (2.32 [1.22 – 4.42]; P = .010), as well as readmission (1.34 [1.00 – 1.79]; P = .048). Hispanic patients, however, had decreased odds of pulmonary (0.26 [0.10 – 0.72]; P = .009) and severe complications (0.50 [0.35 – 0.72]; P < .001), as well as reoperation (0.50 [0.30 – 0.83]; P = .007); Asian patients had decreased odds of severe complications (0.66 [0.46 – 0.94]; P = .020) and reoperation (0.39 [0.21 – 0.72]; P = .003). Conclusions: Significant racial disparities exist in complications following MHNCS, with a higher odds ratio of complications in Black patients. However, minority populations are often underrepresented in the reporting of ACS-NSQIP data. Additional research is needed to identify those factors causing health care outcome disparities, which would help in enabling effective interventions and increased reporting of health care data from minority populations.
Telemedicine-Enabled Biofeedback Electropalatography Rehabilitation (TEBER): A Pilot Study Justine Philteos, MD, Carly Barbon, PhD, Alex Esemezie, BSc, John R. De Almeida, MD, MSc, David P. Goldstein, MD, FRCSC, MSc, Jonathan C. Irish, MD, MSc, FRCSC, Douglas B. Chepeha, MD, MScPH
Introduction: Oral cavity cancer survivors may develop significant social and functional barriers after treatment that adversely impacts quality of life related to speaking and swallowing. To address the barriers to speech and swallowing rehabilitation, we conducted a pilot trial using an electropalatography device paired with telemedicine. Methods: A prospective 8-week telemedicine-enabled biofeedback electropalatography rehabilitation (TEBER) program following 8 weeks of standard of care (SOC) rehabilitation conducted through a tertiary care center. Twenty-seven patients who underwent primary surgery with or without adjuvant radiation for oral cavity carcinoma were consented. Outcome measures (tongue mobility, speech intelligibility, and diet outcomes) were collected at baseline, midterm (after SOC rehabilitation, prior to TEBER), and final (postrehabilitation). Results: Eleven patients adhered to the rehabilitation protocol to completion. All outcome measures except speaking in public improved across the 16-week program. When examining the benefit of TEBER independent of standard of care, range of liquids improved by + 0.36 (95% CI, 0.025 – 0.70; P < .05) and range of solids improved by + 0.73 (95% CI, 0.12 – 1.34; P < .05). There was a positive trend toward improved oral cavity obliteration, as residual volume decreased by 1.2 (95% CI, –2.45 to 0.53; P = .06). Qualitative comments from patients who completed the protocol indicated that 7/10 patients were satisfied with using the electropalatography device. Conclusions: This pilot suggests that TEBER has potential to improve oral rehabilitation beyond 8-week SOC rehabilitation. TEBER is a complex intervention requiring further refinements in patient selection, device design, and program design to improve compliance. However, TEBER provides a potential framework for decreasing barriers to care and implementing personalized rehabilitation programs for patients following surgery for oral cavity cancer.
Tracheotomy Outcomes in Super-Super Obese Patients: Are They Worse? Sherrie L. Wang, BS, Logan Napoli, BS, Traeden Wilson, MD, Luke Thomas Stanisce, MD, Yekaterina A. Koshkareva, MD
Introduction: The purpose of this study is to explore the presence of trends in postoperative complications and/or mortality between super-super obese patients, BMI > 60; super obese patients, BMI 50 – 59.99; and obese patients, BMI 30 – 49.99. Methods: This is a retrospective review of patients treated at a single tertiary care center who underwent tracheotomy from January 1, 2010, through January 1, 2023. Inclusion criteria for patients included age > 18 years and BMI > 30 at time of tracheotomy. Medical records were reviewed and patient characteristics (BMI, race/ethnicity, sex, age, comorbidities), history of previous tracheotomy, length of time for ventilator dependence, postoperative complications (pneumothorax, bleeding, fistula formation), and 30-day mortality rates were extracted. Results: The 3 groups consisted of (1) BMI > 60, (2) BMI 50 – 59.99, and (3) BMI 30 – 49.99. Primary outcomes consisted of presence of postoperative complications—including pneumothorax, bleeding, development of tracheal vascular fistulas (P > .99)—and 30-day mortality (P = .50), which were both calculated among the 3 groups using chi-square analysis. Secondary outcomes included length of hospital stay (P = .33) and amount of perioperative blood loss (P = .82), which were both calculated among the 3 groups using ANOVA analysis. Conclusions: No increased risk for postoperative complications were observed in super-super obese patients when compared with super obese patients and obese patients. Therefore, no evidence from this study can be used to support special considerations for management for this upper threshold subset of the obese population.
Adult Laryngomalacia: A Systematic Scoping Review With Meta-Analysis John F. Mills, Neil Monaghan, BS, Shaun A. Nguyen, MD, Ashli K. O’Rourke, MD, Lucinda A. Halstead, MD, Ted A. Meyer, MD, PhD
Introduction: This review sought to determine the characteristics of adults diagnosed with new onset laryngomalacia including airway symptoms, laryngoscopic findings, treatments, and outcomes. Moreover, we wanted to highlight suspected limitations in the literature. Methods: The search was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist by 2 independent investigators. Studies were identified through CINAHL, Cochrane Review, PubMed, and Scopus for articles published from inception through May 2023. Our goal was to identify broad information on patient characteristics, as well as the suspected etiology including neurologic, traumatic, iatrogenic, and idiopathic causes. A meta-analysis of continuous measures and proportions was performed. Results: Of the 1121 abstracts identified, 33 articles pertaining to laryngomalacia in the adult population were included. The most common presenting symptoms were stridor at rest (78.3%, 65.1 to 88.3) and dyspnea with exertion (83.8%, 64.8 to 96.3). The most suspected etiology was exercise induced (86.0%, 69.4 to 95.5), and the most common description of laryngomalacia on visualization was collapse of supraglottic structures during exercise (93.3%, 79.0 to 99.1). Nonsurgical options were attempted in 87.0% (54.0 to 99.1), which included oral appliances, respiratory retraining, breathing techniques, and working with a speech pathologist. Surgical options were ultimately performed in 84.2% (75.0 to 91.0). Complete resolution of symptoms following therapy was seen in 61.9% (48.0 to 74.6). Conclusions: Adult onset laryngomalacia is difficult to characterize. It typically presents in patients during exercise, with neurological injury, or idiopathically. Surgical management can lead to improvement or complete resolution of symptoms. The need for a universal nomenclature is highlighted in this review, as it is inconsistently classified.
Are We Missing Sleep Apnea in Patients With Subglottic Stenosis? Taylor Gilliland Lackey, MD, Avery Allen, Nevan McCabe, Matthew S. Clary, MD, Katherine K. Green, MD, MS, Daniel S. Fink, MD
Introduction: Subglottic stenosis (SGS) is a narrowing of the subglottic airway with an impact on daytime dyspnea and reduced peak expiratory flow (PEF). The aim of this study is to characterize the prevalence of obstructive sleep apnea (OSA). We hypothesize a reduced airflow at night with a greater predisposition to OSA and hypoxemia in this population. Methods: A prospective cohort study was conducted on adult subjects at a tertiary academic medical center from 2022 to 2023. Subjects with a recent airway dilation (< 3 months), tracheostomy, prior diagnosis of OSA, posterior glottic stenosis, and/or vocal fold paralysis were excluded from enrollment. Demographic data were collected. All subjects completed a PEF measurement and single night home sleep test (HST). HSTs were scored by a board-certified sleep medicine physician and total recording time (TRT), obstructive apnea-hypopnea index (OAHI), central apnea index (CAI), oxygen (O2) nadir, and time O2 < 89% were collected. OSA severity was categorized into none (OAHI < 5), mild (OAHI ≥ 5 and < 15), moderate (OAHI ≥ 15 and < 30), and severe (OAHI ≥30). Descriptive statistics with 25% and 75% quartiles and correlation between AHI and PEF controlling for BMI were performed. Results: Twenty subjects participated in the study; all were White females with a median age of 49 (41, 55) years and a BMI of 24.6 (21.8, 26.6). The majority (n = 18, 80%) presented with idiopathic SGS and a median PEF of 290 (236, 346). All studies had more than 6 hours of recording time with OSA present in 43% of subjects. Severity in subjects with OSA was categorized into 67% mild, 33% severe, and none with severe OSA. Central apneas were minimal with a median CAI of 0.05 (0, 0.3). Median O2 nadir was 84.5% (80, 87) with median hypoxemia (time O2 < 89%) of 2% (0, 13). PEF did not correlate to AHI, adjusting for BMI (P > .05). Conclusions: Reduced nighttime airflow is present within a small cohort of patients with SGS demonstrating an elevated prevalence of OSA. Further study of airway dilation’s impact on airflow and associated threshold to prevent OSA is necessary to prevent the long-term consequences of untreated OSA.
In-Office Balloon Dilation: A Novel Protocol for Idiopathic Subglottic Stenosis Catherine F. Roy, MD, Antonia Lagos-Villasceca, MD, Jennifer Silver, MD, Eli Layous, MD, Jonathan Young, MD, FRCS, Anne V. Gonzales, MD, MSc, Karen M. Kost, MD, FRCS
Introduction: Idiopathic subglottic stenosis is a debilitating condition, which often recurs and may require frequent interventions. Endoscopic balloon dilation is a well-recognized, minimally invasive treatment to alleviate symptoms and is typically performed in the operating room. We herein describe in-office balloon dilation in the awake patient as a novel approach, allowing safe, effective, and timely treatment while mitigating the need for general anesthesia. Methods: Adult patients with Cotton-Myer grade I-II idiopathic subglottic stenosis undergoing in-office balloon dilation at the Voice Laboratory of the Royal Victoria Hospital between June 1, 2022, and July 1, 2023, were prospectively recruited. All patients completed pre- and postprocedure questionnaires including patient-reported outcomes and validated dyspnea and voice scales. Patient- and physician-reported adverse events were thoroughly documented. Pre- and postprocedure nasolaryngotracheoscopy recordings and spirometry were reviewed as objective measures of airflow obstruction. Results: Eleven patients underwent in-office balloon dilation during the study period (F:M 10:1, mean age 56 (SD 12.3) years. The median (IQR: 25th – 75th percentile) dyspnea index and voice handicap index both showed a statistically significant decrease following the procedure: from 31 (26.5 – 32) to 6 (4 – 13) (P = .003) and from 13 (6.5 – 23) to 5 (1.5 – 9.5) (P = .02), respectively. In-office balloon dilation improved airway patency, with an estimated median (IQR) of 40% (30% – 55%) to 10% (5% – 17.5%) stenosis (P = .004). The normalized peak expiratory flow percentage of predicted values significantly increased from a median (IQR) of 62% (55% – 98%) to 99% (88.5% – 109.5%) (P = .004). Conclusions: In-office balloon dilation is a safe and viable option for the management of mild-moderate idiopathic subglottic stenosis, with demonstrated improvement in both objective and patient-reported outcomes.
Menopausal Status Influences Time to Recurrence in Idiopathic Subglottic Stenosis Andrew S. Awadallah, BS, Andrew J. Bowen, MD, Aisha Aiden, BS, Semirra L. Bayan, MD, Eric S. Edell, MD, Matthew J. Koster, MD, Dale C. Ekbom, MD
Introduction: Idiopathic subglottic stenosis occurs almost exclusively in females, which suggests a hormonal link. Our study evaluates disease characteristics in pre- and postmenopausal women who have high and low estrogen, respectively. Methods: Our study controlled for prior airway surgery by only enrolling patients with idiopathic subglottic stenosis (iSGS) who underwent their first laser wedge excision (LWE) between 2002 and 2021. In this retrospective chart review, data pertaining to patient menopausal status, median time to first recurrence, and disease clinical features were collected and analyzed. Results: One hundred female patients with an age range of 19 – 70 years were identified. The proportion of patients identified as pre-, peri-, and postmenopausal (and their average age) were n = 20 (37 years), n = 8 (43 years), n = 72 (55 years), respectively. All groups had a median full-term pregnancy of 2. There was no difference in the percentage of patients who received a tracheostomy or had an open surgery. Notably, the median time to recurrence (MTR) for the first recurrence was 24, 27.5, and 36 months for the pre-, peri-, and postmenopausal groups, respectively. Conclusions: Our data suggest that menopause leads to a longer time to first recurrence (36 months vs 24 months) in a large cohort of iSGS patients after controlling for prior airway surgery. This study provides evidence of the role of menopause in disease progression and the role of estrogen in iSGS’s disproportionate impact on females. Additional analyses are underway to evaluate recurrence rates and control for other variables such as triple therapy compliance and estrogen replacement therapy.
Subjective and Objective Outcomes in Management of Idiopathic Subglottic Stenosis Hyun Seo Jung, MD, MS, James J. Daniero, MD, MS
Introduction: The purpose of this study is to compare the subjective and objective outcome measures in patients with idiopathic subglottic stenosis (iSGS) by utilizing pulmonary function tests and patient-reported outcome measures (PROM). Ultimately, we aim to identify patient characteristics that contribute to any correlation or discrepancy between subjective and objective outcomes in iSGS patients. Methods: This is a retrospective case series of 50 patients with iSGS in a single tertiary academic center managed between 2015 and 2022. Each patient underwent multiple pulmonary function testing as well as survey questionnaires (VHI-10 and CDQ). Subsequently, 4 spirometry measures—FEV1, PEFR, EDI, and TPFR—were correlated with PROM scores. Multiple linear regression was performed. Secondary analysis was performed after stratifying population with comorbid anxiety, depression, BMI, length of iSGS diagnosis, types of intervention, and frequency of intervention. Multivariate analyses were performed. Results: A total of 130 total observations were used in our analysis. Multiple linear regression models showed no significant correlation between PFT parameters and PROM scores with the exception of TPFR vs VHI-10 scores. Stratified multivariate analyses looking into comorbid factors showed association with anxiety, BMI, and length of diagnosis, although these findings were not statistically significant (P < .05). Conclusions: The results of the study demonstrate no significant correlation between spirometry measures and PROM scores as measured with VHI-10 and CDQ. However, the presence of association, despite lack of statistical significance, with comorbid anxiety, BMI, and length of diagnosis shows that there are factors that potentially affect the correlation between the objective and subjective outcome measures. These findings suggest that patient perception of disease severity may change over time and that certain patients have a more sensitive perception of disease progression. Further studies are needed elucidate these factors and potentially affect the shared decision-making process in treating iSGS.
BPPV Information on Google vs AI (ChatGPT) Jeffrey R. Bellinger, BS, Julian S. De La Chapa, MD, Minhie W. Kwak, BA, Gabriel A. Ramos, BA, Daniel R. Morrison, MD, Bradley W. Kesser, MD
Introduction: This study aims to quantitatively compare online patient education materials found using traditional search engines (Google) vs conversational AI models (ChatGPT) for benign paroxysmal positional vertigo (BPPV). Methods: The top 30 Google search results for “benign paroxysmal positional vertigo” were compared with responses of the OpenAI conversational AI language model, ChatGPT, for 5 common patient questions posed about BPPV in February 2023. Metrics included readability, quality, understandability, and actionability. Questions asked to ChatGPT were scored individually and then also as a combined response to simulate the questions being asked sequentially. Outcome measures included the scores of validated online information metrics including Flesch-Kincaid grade level (FKGL), Flesch reading ease (FRE), DISCERN instrument score, and Patient Education Materials Assessment Tool for printed materials (PEMAT-P). These metrics were scored by 2 reviewers. Additionally, to evaluate for inaccurate or outdated information, 2 experts in the field, an attending otolaryngologist with subspecialty certification in neurotology and a second-year fellow in otology/neurotology, reviewed the ChatGPT responses for accuracy and currency and scored responses using a 5-point Likert scale. Results: Mean readability scores, FKGL, and FRE, for the Google web pages were 10.7 ± 2.6 and 46.5 ± 14.3, respectively. ChatGPT responses had a higher FKGL score of 13.9 ± 2.5 (P < .001) and lower FRE score of 34.9 ± 11.2 (P = .005), both corresponding to lower readability. The Google web pages had a DISCERN part 2 score of 25.4 ± 7.5 compared with the individual ChatGPT responses with a score of 17.5 ± 3.9 (P = .001) and the combined ChatGPT responses with a score of 25.0 ± 0.9 (P = .928). The average scores of the reviewers for all ChatGPT responses for accuracy was 4.19 ± 0.82 and 4.31 ± 0.67 for currency. Conclusions: The results of this study suggest that the information on ChatGPT for BPPV is more difficult to read, of lower quality, and more difficult to comprehend compared with information on Google searches.
Microvascular Decompression vs Less Invasive Interventions for Primary Trigeminal Neuralgia William Alexander Meadows, BS, Mary Prickett, BS, Shaun A. Nguyen, MD, Robert F. Labadie, MD, PhD
Introduction: The widely accepted treatment of primary trigeminal neuralgia (PTN) is microvascular decompression (MVD) of the trigeminal nerve root, although other less-invasive interventions are available. We aim to comprehensively analyze the efficacy of MVD as well as the proportions of procedure failure, reoperation, and complications compared with less-invasive procedures. Methods: A literature search was conducted from February to May 2023 in accordance with PRISMA recommendations using PubMed, MEDLINE, and Scopus to identify studies comparing MVD to other interventions for PTN. Interventions included for meta-analysis were percutaneous balloon microcompression (PBC), radiofrequency rhizotomy (RFR), and stereotactic radiosurgery (SRS). All subjects were diagnosed with primary trigeminal neuralgia and were surgically naive. The Barrow Neurological Institute pain intensity score was used to determine procedure success or failure. Demographic information, reported complications, and reoperation were also recorded. Outcomes were reported as single means and proportions that were meta-analyzed and compared at a 95% CI. Results: Seventeen studies were included for analysis with a total of 2756 patients. Pain relief was greater in MVD (88.37%) compared with RFR (57.35%) and SRS (73.75%) (P < .0001) but not significantly different between MVD and PBC (P = .7533). The proportion of patients requiring reoperation was less in MVD (9.57%) compared with RFR (54.03%) and SRS (18.11%) (P < .0001 and P = .0005, respectively). The proportion of postoperative complications was greater following MVD (13.50%) compared with both RFR (8.39%) and SRS (2.34%) (P = .0288 and P < .0001, respectively). Conclusions: The authors conclude that patients undergoing MVD were more likely to experience a successful outcome than patients undergoing RFR or SRS. This supports the literature proposing neurovascular compression as the etiology of primary trigeminal neuralgia. However, the invasiveness of MVD leads to a higher proportion of patients experiencing postoperative complications.
Neuromodulation for Treatment of Tinnitus: A Systematic Review and Meta-Analysis Luke D. Heiland, BS, Johnny M. Owen, BS, Shaun A. Nguyen, MD, Robert F. Labadie, MD, PhD, Paul R. Lambert, MD, Ted A. Meyer, MD, PhD
Introduction: This study aims to evaluate the treatment efficacy of electric neuromodulation vs placebo for the treatment of tinnitus. Methods: The Cochrane Library, CINAHL, PubMed, and Scopus were searched from inception through June 2023 for English-language articles documenting “neuromodulation” and “tinnitus” stratified by placebo-controlled randomized control trials with 40 or more patients. Data collected included Beck Depression Inventory (BDI), Tinnitus Handicap Inventory (THI), Visual Analogue Scale (VAS), and tinnitus questionnaire (TQ). A meta-analysis of continuous measures (mean), mean difference (Δ), and proportions (%) were conducted. Results: A total of 15 randomized control trials (n = 1001) were included. The mean age was 48.4 years (range: 19 – 74 years), mean duration of tinnitus was 34.1 months ([17.2 to 50.9], P < .0001), 58.6% were males ([47.7 to 69.1], P < .0001), and 68.4% ([45.4 to 87.5], P < .0001) had unilateral tinnitus. The effect of neuromodulation vs placebo on THI score is -8.8 ([-14.5 to -3.1], P = .002) at 1 week, -6.0 ([-8.9 to -3.1], P < .0001) at 1 month, and -6.3 ([-15.4 to 2.7], P = .17) at 6 months. Conclusions: Our findings suggest that the effect of neuromodulation compared to placebo reaches significant benefit both in the short and long term, as measured by the THI.
Outcomes of Endoscopic Congenital Cholesteatoma Removal in South Korea Jeonggum Lee, MD, Mincheol Jung, MD, Ji Eun Choi, MD, In Seok Moon, MD
Introduction: Transcanal endoscopic ear surgery (TEES) provides minimally invasive transcanal access to the middle ear and improves middle ear visibility during cholesteatoma resection. However, the literature on outcomes following TEES alone for the removal of congenital cholesteatoma (CC) is lacking and limited to small series. Methods: This study aims to assess outcomes of TEES for CC limited to the middle ear and/or mastoid antrum and to explore the risk factors associated with recidivism (ie, recurrent and/or residual cholesteatoma). This cohort study evaluated retrospective, multicenter data for 271 children with CC who underwent TEES at 9 tertiary referral hospitals in South Korea between January 1, 2013, and December 31, 2021, and had a follow-up of at least 6 months after surgery. Outcomes included the incidence of residual cholesteatoma and audiometric data after TEES. A multivariable analysis using Cox proportional hazards regression models was used to assess associations between cholesteatoma characteristics and recidivism, with hazard ratios (HRs) and 95% CIs reported. Results: Of the 271 patients (mean [SD] age, 3.5 [2.9] years; 194 [71.6%] boys, 77 [28.4%] girls), 190 had Potsic stage I CC (70.1%), 21 (7.7%) had stage II, 57 (21.0%) had stage III, and 3 (1.1%) had stage IV. Thirty-six patients (13.3%) with residual cholesteatoma were found, including 15 (7.9%) with Potsic stage I, 3 (14.3%) with stage II, and 18 (31.6%) with stage III. In the multivariable analysis, invasion of the malleus (HR, 2.257; 95% CI, 1.074 – 4.743) and posterosuperior quadrant location (HR, 3.078; 95% CI, 1.540 – 6.151) were associated with the incidence of recidivism. Overall, hearing loss (> 25 dB on auditory behavioral test or > 30 dB of auditory evoked responses) decreased from 24.4% to 17.7% after TEES. Conclusions: This cohort study involved the largest known population to date of CC removed by TEES. The findings suggest that TEES may be feasible and effective for the removal of CC limited to the middle ear and/or mastoid antrum in children.
Temporal Trends in Ménière Disease Diagnosis and Treatment Tyler J. Gallagher, BS, BA, Meredith E. Adams, MD, MS, Janet S. Choi, MD, MPH
Introduction: Management approaches for Meniere disease (MD) have changed significantly over time. This study investigated management practices of MD and its temporal trends from 2008 to 2022 based on the TriNetX network. Methods: Study cohort included patients (≥18 years) with MD diagnosis between 2008 and 2022 from TriNetX, a multinational network of EMR data primarily from the US (> 87% annually). ICD-10, CPT, and RXNorm codes were used to create an MD cohort and quantify rates of treatments per new (within 12 months) and any diagnosis of MD. Temporal trends were analyzed via joinpoint regression. Results: Our cohort included 71,465 adults with MD diagnosis (age, mean [SD]: 64). During 2020 – 2022, 164.8/10,000 MD diagnosis received intratympanic injection (steroid and gentamicin), 61.9/10,000 received endolymphatic sac surgery, and 20.8/10,000 received labyrinthectomy. When examining temporal trends, there was significant increase in rates of medications prescribed within 12 months of MD diagnosis after 2020. Annual percent change (APC) for diuretics increased from 5.8 (95% CI, 2.7 – 9.0) 2013 – 2020 to 41.5 (25.6 – 59.4) 2020 – 2022; antihistamines increased from 4.4 (2.5 – 6.3) 2008 – 2020 to 35.6 (16.0 – 58.4) 2020-2022; and benzodiazepine increased from 3.1 (1.0 – 5.2) 2008 – 2020 to 44.5 (22.0 – 71.2) 2020 – 2022. The APC of intratympanic injection within 12 months of MD diagnosis increased from 8.9 (1.4 – 17.1) 2008 – 2020 to 104.5 (37.6 – 203.9) 2020 – 2022. Rate of endolymphatic sac surgery and labyrinthectomy for any patients with MD diagnosis gradually decreased from 2008 to 2022 (APC -9.5 [-12.9 to -5.9] and APC -10.2 [-13.8 to -6.5], respectively) without significant joinpoints. Conclusions: In this cohort, use of medical management and intratympanic injection has significantly increased since 2020 and use of surgical treatments has decreased over recent years. Data limitations include potential unpublished variation in cohort composition over time. While heterogeneity in management of MD continues, our findings demonstrate a potential impact of the COVID pandemic and new clinical guidelines.
Testing a Novel Piezoelectric Middle-Ear Microphone in Sheep Nicholas A. Waring, BS, Chaoqun Zhou, MS, Emma Wawrzynek, BS, Brandon J. Vilarello, BA, Jeffrey Lang, PhD, Elizabeth Olson, PhD, Hideko Heidi Nakajima, MD, PhD
Introduction: We have designed a novel middle-ear implantable microphone for fully implantable cochlear implants, which has performed well in cadaveric human temporal bones. In this study we tested the middle-ear microphone in sheep temporal bones in preparation for future live-sheep trials. Methods: Temporal bones from 3 cadaveric fresh but previously frozen Hampshire sheep heads were surgically prepared with an extended facial recess approach preserving the facial nerve. The piezoelectric middle-ear microphone was secured in a micromanipulator with the sensing region interfacing the convex portion of the manubrium close to the umbo within the middle-ear cavity. Open-field single-tone stimuli from 1 – 20 kHz at 60 – 90 dB SPL were presented and measured with a reference microphone at the ear canal. Simultaneously, we measured the middle-ear microphone’s output in volts via a custom-made amplifier and manubrium velocity via a laser Doppler vibrometer through the ear canal. Results: Measured middle-ear microphone output that sensed the manubrium motion was more than 30 dB above the noise level at 60 dB SPL stimulus across all frequencies. The measured output behaved linearly across the tested range of stimulus sound pressure. Conclusions: The middle-ear microphone can be inserted with preservation of the facial nerve in Hampshire sheep. The middle-ear microphone has good signal-to-noise ratio and behaves linearly across a dynamic range of input sound pressure levels for all frequencies. These results suggest that Hampshire sheep will be suitable for future in vivo large-animal trials of our middle-ear microphone and potentially other types of middle-ear implants.
Trends in Procedural Management of Ménière Disease Nihar Rama, BS, Samuel R. Auger, MD, Terence E. Imbery, MD
Introduction: In recent years, many within the otolaryngology community have discussed the implications of reframing Ménière disease (MD) as a migraine-variant disorder. Little is known regarding how such shifts in perspective have affected the national landscape of MD management, particularly with regard to procedural management as more nondestructive migraine therapies are presumably being implemented. In this study, we utilized a billing database to investigate patterns in procedural management of MD to provide context about the reframing of MD as a migraine-variant disorder on otolaryngologists’ practice patterns. Methods: Medical claims between January 2003 and December 2021 from the MarketScan Commercial Claims and Encounters and Medicare supplemental databases were queried for MD ICD codes. A subset of claims was isolated via a query for CPT codes corresponding to procedures used for MD management. Descriptive statistics were performed to summarize total record counts and records per person per year. Results: In total, 1.75 million claims with MD diagnostic codes were identified (MD claims). The number of MD claims peaked in 2012 with a 65% decrease in the number of MD claims from 2013 to 2021. A total of 44,831 MD claims contained procedural CPT codes of interest (procedural MD claims). The number of procedural MD claims peaked in 2012 and had a 50% decrease from 2013 to 2021, with the most commonly utilized procedures for MD management being intratympanic injections and endolymphatic sac surgery. From 2003 to 2021, the proportion of MD claims with procedural CPT codes increased from 1.4% in 2003 to 3.9% in 2021. Conclusions: While the total number of procedures being used to manage MD has decreased over the last decade, the proportion of MD patients being managed with procedural therapy, most commonly intratympanic injections, nearly tripled from 2003 to 2021. The use of endolymphatic sac surgery has decreased over the past decade. Further study is warranted to investigate factors contributing to the observed billing trends in MD management patterns, including the use of migraine-related therapies for MD management.
Worldwide Differences in Surgeon Intraoperative Practices for Cochlear Implantation Nicole T. Jiam, MD, Archana Podury, BA, Alicia M. Quesnel, MD, Ophir Handzel, MD
Introduction: Cochlear implant performance is dependent on precise intracochlear positioning. Despite published evidence demonstrating that intraoperative functional or radiologic tools can be helpful for hearing preservation and determining final electrode position, there is considerable practice heterogeneity among surgeons. This study aims to characterize surgical practice patterns for using intraoperative imaging or functional confirmation of cochlear implant location worldwide. Methods: A cross-sectional survey of otolaryngologists actively performing cochlear implantation was conducted between March 1, 2023, and May 6, 2023. Participants were recruited across the world using otologic society membership email lists and at professional meetings. Seventy-five of 125 invited participants (60%) completed the survey. Participants were categorized by continent: Africa (n = 1), Asia (n = 22), Europe (n = 24), North America (n = 24), Oceania (n = 3), South America (n = 1). Results: North American surgeons use intraoperative x-rays more frequently than surgeons in Europe and Asia (P < .001). Otolaryngologists in Europe and Asia more frequently use no intraoperative imaging (P = .02). There is no significant regional difference between the intraoperative use of electrophysiologic instruments. European and Asian surgeons implant MED-EL devices (P = .012) more frequently than North American surgeons who more frequently use Cochlear Corporation devices (P = .003). MED-EL use is related to less frequent intraoperative x-ray use (P = .02). Advanced Bionics use is related to more frequent intraoperative CT use (P = .03). There was no statistically significant association between the years of practice, the number of cochlear implantation surgeries performed yearly, and the use of intraoperative tools. Conclusions: Intraoperative use of radiologic and functional adjuncts for verifying cochlear implant positioning varies worldwide. Practice guidelines may help establish a standard of care for surgeons performing cochlear implantation.
Patient Safety and Quality Improvement
Cost and Carbon Footprint of Tonsillectomies at High-Income Tertiary Center Gaelen B. Stanford-Moore, MD, Gabrielle Cahill, MD, Omeed Miraftab-Salo, BS, Allison C. Rollins, MD
Introduction: Climate change directly impacts health and safety. Health care services are responsible for 8% of greenhouse gas emissions in the US, with operating rooms contributing up to 70% of all hospital waste. This is the first study to explore the cost and carbon footprint of all opened, used, and unused supplies during a standard tonsillectomy in a high-income tertiary care center. Methods: This was a prospective audit of all waste generated during a standard tonsillectomy between January 2023 and June 2023. Pediatric tonsillectomy with monopolar cautery or cold steel technique were included. A member of the team was present in the operating room to document supplies. All waste was weighed by type: landfill, recycling, biohazard. Kilograms of carbon dioxide equivalent were calculated using an estimate developed by the Yale Center for Climate Change based on hospital-provided costs of individual supplies. Results: Nineteen tonsillectomies met criteria for inclusion, 9 cold steel and 10 monopolar cautery. No differences were found in average length of surgery, type, and weight of waste generated, cost nor carbon dioxide equivalent between the 2 techniques. Overall, 47% of supplies opened were not used. The overall cost of surgical supplies averaged $320, while unused supplies averaged $39. The most commonly opened but unused supplies were sterile blue towels, tonsil sponges, and x-ray opaque sponges (74%, 63%, and 79% unused, respectively). The overall kilogram of carbon dioxide equivalents was 78, with a 12.9% contribution from unused supplies and equipment. Of all supplies opened, 80% were single-use disposable items, primarily made of plastic. Conclusions: There was no significant difference in cost and carbon footprint between monopolar cautery and cold steel techniques; however, a significant portion of supplies opened were left unused and discarded. Surgeons should be aware of waste generated by their procedures. Updating preference cards is a simple step to decrease wasted supplies. Further research should characterize how operating room waste differs in the same procedure in different settings.
High-Value Otolaryngologist Scorecard: Barriers and Lessons Learned in Multi-Hospital System J.B. Eyring, Brandon Hemeyer, Wesley Allen, Jeremy D. Meier, MD
Introduction: Delivering value in health systems has become paramount as payer contracts move away from fee-for-service payment models; accurately measuring value (ie, quality over cost) is key to this transition. This study describes the Otolaryngology High-Value Surgeon Scorecard, surgeon adherence, and barriers to implementation in a multi-facility health system. Methods: We developed and implemented the Otolaryngology High-Value Surgeon Scorecard, within a multi-hospital nonprofit health system. The scorecard is an internal auditing and feedback mechanism for employed and affiliated otolaryngologists to see their performance across quality metrics. A point system is derived from benchmark values in each category, resulting in a total “value” score for each surgeon. Scorecard categories were defined based on 5 clinical pathways measuring preoperative, intraoperative, and postoperative metrics. These include preoperative patient screening and optimization, appropriate perioperative antibiotic stewardship, appropriateness for surgery, on-time starts, opioid prescribing patterns, and unanticipated postoperative return rates. Surgeons are given a quarterly report and offered mentoring and continuing education resources to improve. Results: At the time of implementation (Q1 2021), 23 of 105 otolaryngologists (21.9%) met the high-value criteria, which increased to 63.5% in the most recent iteration (Q2 2023). Since implementation, antibiotic and opioid prescription rates have decreased by 52.8% and 32.2%, respectively. Barriers persist in getting reliable, accurate, and timely data, particularly when measuring meaningful quality outcomes. Conclusions: Since implementing the Otolaryngology High-Value Surgeon Scorecard, surgeons meeting the criteria for high value has significantly increased. This has been associated with a significant decrease in inappropriate perioperative antibiotic administration and opioid prescribing patterns. Future research is needed to determine the most meaningful metrics for ascertaining value in care delivered by otolaryngologists.
Impact of Surgical Experience on Revision Sinus Surgery Rate Chun-Kang Liao, MD, Chia-Hsuan Lee, MD, Wei-Chung Hsu, MD, PhD, Kun-Tai Kang, MD, MPH, Te-Huei Yeh, MD
Introduction: The implications of cumulative surgical experience on endoscopic sinus surgery (ESS) revision rates remain unclear. This study aims to elucidate the correlation between a surgeon’s cumulative surgical volume and the rates of ESS revisions in Taiwan. Methods: A nationwide population-based retrospective study was conducted, collating data from adult inpatients (age > 18 years) who underwent ESS between the years 2000 and 2008. Data were acquired from the Taiwan National Health Insurance Research Database (NHIRD), with patients being followed up until 2018. Cumulative surgical volume was divided into 4 quartiles: very low volume (quartile 1, cumulative volume: 1 – 137 cases), low volume (quartile 2, cumulative volume: 138 – 328 cases), high volume (quartile 3, cumulative volume: 329 – 643 cases), and very high volume (quartile 4, cumulative volume > 644 cases). Results: The study included 68,282 adults (mean age, 45.6 years; 62% men). The initial revision rate stood at 14.6% (9951/68,282), and the secondary revision rate at 2.9% (1989/68,282). There was a significant association between lower surgical volume and an increased first revision rate (very low volume: 14.9%; low volume: 15%; high volume: 14.3%; very high volume: 14.0%; P for trend = .006). However, there was no significant correlation with the second revision rate (P for trend = .11). A subgroup analysis highlighted the effect of cumulative surgical volume on revision ESS as being more pronounced in hospitals with low surgical volume compared with high surgical volume hospitals (P for interaction = 0.049). Restricted cubic spline modeling revealed a linear, inverse correlation between cumulative surgical volume and revision ESS (P for linearity < .001). Conclusions: The data suggest that lower cumulative surgical volume is associated with a higher propensity for a first ESS revision in adult patients. The correlation between low cumulative surgical volume and increased revision ESS is particularly noticeable in lower volume hospitals.
Vascular Events in Head and Neck Cancer Patients: A Meta-Analysis Neil Monaghan, BS, Kelsey A. Duckett, BS, Shaun A. Nguyen, MD, Jason G. Newman, MD, William G. Albergotti, MD, Alexandra E. Kejner, MD
Introduction: Our objective was to assess the frequency of vascular events in patients with head and neck cancer (HNC). Methods: The PubMed, CINAHL, and Scopus databases were searched from inception to June 25, 2023. A Meta-analysis of proportions with comparison (Δ) of weighted proportions was conducted. Results: Of 6716 unique abstracts screened, 146 studies were included. Of 683,515 patients with reported sex, 72.2% were male. Of 160,449 with reported race, 77.3% were White, and 7.8% were Black. Of the patients with reported subsites, oral cavity (31.2%) and larynx (14%) were the most common. Of those with reported stage, 5% were stage I, 13.6% were stage II, 20.6% were stage III, and 54.8% were stage IV. Of 1,184,160 patients, 4.3% experienced a vascular event of any kind. The most frequent events were hemorrhage (3.2%), TIA (2.9%), CVA (2.7%), and MI (2%). Significant differences (*P < .0001) were noted in rates of PE in those with chemoprophylaxis when compared with the overall group (Δ 0.5%*). Patients primarily treated with radiation therapy (RT) had the highest frequency of overall events and CVA when compared with surgery (Δ 5.8%* and Δ 5.6%*) and chemotherapy (Δ 3.3%* and Δ 1.4%*). Additionally, patients treated primarily with RT had higher rates of hemorrhage (4.7%) than those with primary surgery (Δ 2.4%*) and chemotherapy (Δ 2.0%, P = .01). Patients with chemotherapy had higher rates of overall events and CVA than patients with surgery (Δ 2.5%* and Δ 4.2%*). Conclusions: Vascular events occur in 4% – 5% of patients with HNC. Our data do not support the use of anticoagulation in these patients as we do not appreciate a significant reduction in DVT or PE in those receiving chemoprophylaxis. Additionally, we find that RT had the highest frequency of vascular events, especially CVA, followed by chemotherapy at intermediate frequency and surgery at lowest frequency of events.
Acute Otitis Media in Children With Obstructive Sleep Apnea Chloe Cottone, BA, Eunice Im, BS, Michele M. Carr, DDS, MD, PhD
Introduction: There is suspicion that children with obstructive sleep apnea (OSA) experience acute otitis media (AOM) at higher rates than the general pediatric population. Our goal was to investigate the verity of this claim using a large-scale global network database. Methods: A retrospective cohort study was conducted using TriNetX, a global EHR database. A search for patients 18 and younger within the US Collaborative Network identified 15,648,542 subjects. Within this group, ICD-10 code G47.33 was used to define the OSA group and yielded 218,666 patients. Prevalence of AOM (ICD-10 codes H65.0, H65.1, and H66.0), ventilation tube insertion (CPT codes 69433 and 69436), adenoidectomy (CPT codes 42830 and 42831), adenotonsillectomy (CPT codes 42820 and 42821), and allergic rhinitis (ICD-10 J30.9) were compared in this cohort. Results: The non-OSA group’s mean age was 10 years and contained 8,207,512 males (52.4%). Mean age of the OSA group was 11 years, with 126,826 males (58%). AOM occurred in 35,203 (16.1%) of OSA cases and 1,039,304 (6.7%) of non-OSA cases (P < .0001). Ventilation tubes were placed in 192,637 (11.9%) of children with OSA and in 15,317,995 (1.4%) of patients without OSA (P < .0001). In total, 47,256 (21.6%) of children with OSA and 688,862 (4.4%) of non-OSA children were diagnosed with allergic rhinitis (P < .0001). Adenoidectomy and adenotonsillectomy occurred in 11,013 (5.0%) and 76,459 (35.0%) of OSA children compared with 66,588 (0.4%) and 172,722 (1.1%) of non-OSA children (P < .0001). Conclusions: Children with OSA appear to experience AOM and require related surgical intervention more than children without OSA. Since allergic rhinitis and adenoid hypertrophy are contributors to both OSA and AOM, their increased prevalence in children with OSA may explain their increased frequency of AOM.
Examining Magnetic Resonance Imaging Use in Infants With Pharyngeal Dysphagia Napiera Shareef, BS, Swapna Koppera, Patrick Kennedy, Ashley Heilingoetter, MD, Prasanth Pattisapu, MD, MPH
Introduction: Magnetic resonance imaging (MRI) is often used to evaluate neuroanatomical abnormalities in infants with pharyngeal dysphagia. However, its role in otherwise healthy infants is uncertain. The purpose of this study is to evaluate the findings of MRI in infants with pharyngeal dysphagia. Methods: We conducted an IRB-approved (STUDY00001937) retrospective chart review of all infants under 1 year of age who underwent a videofluoroscopic swallow study (VFSS) between January 2019 and December 2021 at a tertiary referral children’s hospital. Exclusion criteria were normal VFSS, significantly premature birth (< 35 weeks gestation), or a history of major genetic, neurologic, or anatomic comorbidities. We assessed patients for the following: degree of aspiration (Rosenbek Penetration-Aspiration Scale [PAS]), age at the time of VFSS and MRI, indications for MRI, abnormalities seen in MRI, resolution of dysphagia, and normalization of VFSS. Data were analyzed using descriptive statistics. Results: Of 108 eligible patients, 64.8% were male and 20 (18.5%) received an MRI. The median age was 5 months (range: 1 – 12) at VFSS and 5 months (range: 1 – 11) at MRI. Besides dysphagia and aspiration, indications for MRI included hypotonia (n = 2), hypertonia (n = 1), and macrocephaly (n = 3). Of patients who received an MRI, 14 (65%) had at least 1 abnormality. However, noted abnormalities included mild ventriculomegaly (n = 2), nonspecific white matter changes (n = 3), and abnormalities of limited clinical significance (n = 12). One patient had a cerebellar abnormality. Of eligible patients, 22 (20.4%) had a PAS > 3. Of patients who had an abnormal MRI, 12 (85.7%) had resolution of their dysphagia. Conclusions: In the otherwise healthy patient with pharyngeal dysphagia, MRI appears to have limited utility. Future research is needed to determine decision thresholds for MRI in infants with pharyngeal dysphagia.
Hearing Screening Disparities in Minnesota Schools Autefeh S. Sajjadi, MD, Soorya Todatry, Nicholas Hable, Asitha D.L. Jayawardena, MD, MPH
Introduction: Standardization of newborn hearing screening improved equity in access to hearing health care at the newborn level. Unfortunately, the lack of standardization at the school screening level has exacerbated inequities in access to hearing screening as care is currently distributed based on the local resources of the school. Of 9-year-olds with educationally significant hearing loss, 50% passed their newborn hearing screen and approximately 14% of school-aged children have permanent and/or transient hearing loss in 1 or both ears. Methods: Prospective surveys of current hearing screening practices were conducted March-June 2023 of all elementary schools in the 2 most populous counties in Minnesota (Hennepin and Ramsey Counties). Standardized hearing screen was defined as hearing screens being performed on all students in a grade. Schools that performed hearing screens on students in only special education and individualized education program (IEP) or per parent/teacher requests were not considered standardized. Results: In total, 315 schools met inclusion criteria (81.9% response rate [RR]); 151 were public schools (100% RR), 72 charter schools (60% RR), and 92 private schools (70% RR). Of the 258 schools that responded, 154 had a standardized hearing screen, 103 did not. Only 12 schools (4.7%) screened all students, and 15 schools (5.8%) had no screenings. One hundred seventy-one (54%) were in zip codes with median household income below the county average; 47% of these schools had standardized hearing screen compared with 51% of schools in zip codes greater than the county average. Ultimately, 89% of all schools that responded expressed interest in a pilot program providing free hearing screens to students in grades 1, 3, and 5. Conclusions: The lack of hearing screening standardization further exacerbates inequities in hearing health care at the elementary school level. Access to school hearing screenings should not be dependent on the school type or school zip code. Our preliminary data results demonstrate a need for standardized hearing screens with 89% of schools expressing interest in participating in additional hearing screening.
Inclusive Soundscapes: Investigating Access to Pediatric Cochlear Implantation in Memphis Sofia Torres-Small, Christina N. Ward, MD, MS, Ana Tomescu, Sarah Warren, AuD, PhD, Charles B. MacDonald, MD, Robert J. Yawn, MD, MBA, Celine C. Richard, MD, PhD
Introduction: The presence of health-promoting options in our homes, neighborhoods, and schools significantly impacts our well-being, health care access, and health care management choices. This study aimed to assess how race, social vulnerability index (SVI), and maternal age at birth influence pediatric cochlear implant (CI) access, and we hypothesized that patients of color with higher SVI and younger mothers would face an increased risk of delays in diagnosis and CI acquisition, as well as lower daily CI usage. Methods: This study was a retrospective cohort analysis of individuals aged 0 to 18 who received a CI at our center between the years 2000 and 2022. SVI data from 2020 were obtained from the Centers for Disease Control and Prevention. One-way analysis of variance was used to determine the association between our variables of interest. Our independent variables included race, SVI, and maternal age, and our dependent variables were age at hearing loss diagnosis (AHL), time from diagnosis to CI acquisition (TDI), and average daily CI use (ADU). Results: A total of 303 patients were included in our study, of which 43% were Black and 50% were White. Patients from the highest to lowest SVI quintiles comprised 31%, 25%, 18%, 10%, and 14% of our sample, respectively. Race was significantly correlated with SVI (P < .001), with a mean SVI of 0.70 (± 0.26) and 0.49 (± 0.27) for Black and White patients, respectively. SVI was significantly associated with AHL (P = .0162) and TDI (P = .036). Sex was also significantly associated with TDI (P < .001). Conclusions: Over 50% of the pediatric patients who receive a CI at our center live in areas with an SVI greater than 0.6, and the average SVI for Black patients is significantly higher than for White patients. SVI was found to be associated with AHL and TDI, with those in the most vulnerable category presenting with the longest diagnostic and acquisition delays. Interestingly, sex was also significantly associated with TDI, with males receiving a CI faster on average than females. We are currently conducting in-depth analyses to support the development of intervention programs for those in need in our community.
Maxillary Frenotomy Relapse Rate Is High Alexandra F. Corbin, BS, Lauren A. DiNardo, BS, Alison C. Ma, BS, MS, Francesca C. Viola, MD, Michele M. Carr, DDS, MD, PhD
Introduction: The frequency of pediatric maxillary frenotomy has significantly increased in the past decade. Our purpose was to determine whether maxillary frenotomy results in a sustained change in the depth of insertion of the frenulum. Methods: All children who visited a pediatric otolaryngology clinic between July 1, 2022, and December 1, 2022, had their maxillary frenulum scored using the Kotlow classification system. History of maxillary frenotomy, age, gender, and race were recorded. Results: A total of 570 children were included, out of which 23 had undergone maxillary frenotomy. There was no significant difference in the Kotlow score between children who had undergone maxillary frenotomy and those who had not undergone the surgery (P = .81). Among unoperated children, 21 (4%) had a class 1 frenum, 127 (23%) had a class 2 frenum, 262 (48%) had class 3, and 137 (25%) had class 4. Of the children who had undergone frenotomy, 3 (13%) had a class 1 frenum, 4 (17%) had a class 2 frenum, 10 (44%) had a class 3 frenum, and 6 (26%) had a class 4 frenum. Kotlow scores tended to decrease as the child’s age increased. The mean age of children with a class 1 frenum was 8.7 years, compared with 1.3 years for a class 4 frenum (P < .001). Among the 513 unoperated children whose race was identified by their parents, class 1 frenum occurred in 12 (27%) children who identified as Black/African American and 7 (1.5%) children who identified as White (P < .001). Of the 23 children who had undergone maxillary frenotomy, 20 (87%) were White and 3 (13%) were Hispanic. Conclusions: At least a quarter of children who undergo maxillary frenotomy still have a low-lying frenulum later in childhood. The results suggest a significant relapse rate with this procedure.
MRI as Hearing Loss Predictor in Children Receiving Chemotherapy Hengameh K. Behzadpour, MSHS, Sam D. Schild, MD, Dixon Johns, MD, Esin Namoglu, Kathleen Webber, Matthew T. Whitehead, MD, Brian K. Reilly, MD
Introduction: Platinum-based therapies are commonly utilized as first-line treatments despite associations with permanent, dose-dependent ototoxic effects, including hearing loss, for pediatric brain tumors. Magnetic resonance imaging (MRI) can detect hearing loss due to cochlear signal changes and improve clinical decisions, such as therapeutic regimen and audiometric monitoring. This study presents the first longitudinal investigation of MRI signal changes and hearing outcomes in pediatric patients undergoing chemotherapy for intracranial neoplasm. Methods: A comprehensive chart review of patients receiving treatment for intracranial neoplasms at Children’s National Hospital between 2000 and 2019 was conducted. Data abstracted included demographics, clinical characteristics, evaluations, treatment course, and imaging. Patients with intracranial neoplasms who underwent serial MRI and audiologic examinations were included. The timeline of initial cochlear signal abnormality (T2 FLAIR hyperintensity) and audiometric 4-tone pure tone average were assessed. Data were further analyzed to evaluate the temporal relationship between cochlear changes on MRI and onset of hearing loss. MRI changes were defined in 2 groups: mild vs moderate/severe. Results: Of the 29 patients, 25 had medulloblastoma (86.2%) and 24 (82.8%) had localized disease. Median age at diagnosis was 8 years. Of the 29, all underwent radiation and 27 (93.1%) received cisplatin. Hearing loss was diagnosed in 26 (89.7%) of the patients, with 19 (73.1%) being noted on MRI imaging changes prior to diagnosis. Median time to developing hearing loss from initial MRI change was 20 weeks, although degree of MRI change did not differ significantly. Conclusions: Tumor evolution often involves ototoxic therapeutic interventions and can prove detrimental in children. Detection of biomarker alterations, such as hearing loss, can improve treatment timelines and outcomes.
Pediatric Otolaryngology Procedure Volume Before, During, and After COVID-19 Wesley P. Allen, BS, J.B. Eyring, Brandon Hemeyer, Alexander Ramirez, Jeremy D. Meier, MD
Introduction: Pediatric otolaryngology case volumes fell precipitously during the COVID-19 pandemic, as care was delayed or avoided altogether. This study examined pre-, mid-, and post-pandemic case volumes for common operations and the potential subsequent increase in patient age. Methods: Pediatric tympanostomy tube placement (TT) and adenoidectomy/tonsillectomy (T&A) performed in a 31-hospital health system from January 2018 to June 2023 were queried. ANOVA, t tests, and linear regression were used to determine differences in case volumes and patient age across time periods and patient race/ethnicity. Pre-pandemic baselines were established for year-over-year percentage change analysis. Results: Baseline case volumes for TT and T&A cases were 3334 and 5168 per year, respectively. Both TT and T&A cases dropped drastically in the last 3 quarters of 2020, dropping to 37% and 58% of baseline. This trend continued throughout the first 6 months of 2021, dropping as low as 27% and 52% of baseline. Volumes began to recover starting the last 6 months of 2021 and rose to 102% and 110% of baseline between July 2022 and June 2023. Isolating 2023 data alone (January – June), TT volume has maintained 95% of baseline while T&A cases have risen to 125% of baseline. For both TT and T&A, median patient age differed across years (P < .0001), increasing during the pandemic to 2.0 (± 3.5) vs 1.9 (± 3.1) and 7.1 (± 4.9) vs 6.5 (± 4.2) pre-pandemic, respectively. However, while median TT age has become increasingly elevated in 2023 (2.4 ± 2.8), median T&A age has essentially returned to normal (6.5 ± 3.8). Race/ethnicity was not associated with patient ages or case volumes. Conclusions: The COVID-19 pandemic significantly decreased pediatric otolaryngology case volume for common procedures early in the pandemic but has rebounded to baseline for TT and has increased for T&A. Future research should elucidate the effects of delayed pediatric otolaryngology care and understanding factors that drive surgical volume.
Professional and Personal Development
The Current State of Women in Otolaryngology-Head and Neck Surgery Nicole G. DeSisto, BA, Lexi Goehring, BA, Shiayin F. Yang, MD
Introduction: Women represent 36% of otolaryngology-head and neck surgery (OHNS) residents and faculty. Although much of recent research has focused on the advancement of women in otolaryngology, no studies have systematically investigated the current published literature on the state of women in OHNS. We aim to understand the progress that has been made and to identify current disparities and experiences affecting women in OHNS. Methods: PubMed, Scopus, and Embase online databases were systematically searched in May 2023. Articles were included if they answered 1 of the following questions: (1) How has gender diversity of OHNS residency programs changed over the past 4 decades? (2) How has diversity of OHNS leadership positions changed? (3) How has the gender diversity of academic OHNS changed? (4) What factors and experiences have the most impact on women in OHNS? Non-English language articles, commentary, and editorial articles were excluded. Results: Four hundred and seven unique articles were identified with 70 articles meeting inclusion criteria. The percentage of female OHNS residents has increased from 32.7% in 2010 to 38% in 2022. The percentage of female program directors has increased from 12.7% in 2012 to 26.5% in 2019 with the percentage of female chairs increasing from 3.6% to 5.1%. Overall, women in leadership had lower academic ranks, fewer years of practice, and lower H indices. Conclusions: A discrepancy in gender diversity at the highest levels of OHNS leadership remains. By reflecting on our progress, shortcomings, and factors impacting women in OHNS, we may better provide future mentorship and sponsorship.
The Current Trend of Women Surgeon Speakers at AAO-HNS Amanda Joy Bastien, MD, Priya D. Krishna, MD, MS, Anca M. Barbu, MD
Introduction: The importance of gender diversity is well recognized in medicine among other fields, but little is known about the gender diversity of the annual speakers at the American Academy of Otolaryngology-Head and Neck Surgery Foundation Annual Meeting (AAO-HNS), the largest otolaryngology-head and neck surgery meeting in the United States. Our objective was to investigate the current trend at AAO-HNS. Methods: The Academy publishes all oral presentations delivered at the Annual Meeting as a supplement in the journal Otolaryngology–Head and Neck Surgery. The year 2008 was chosen as this was 2 years prior to the founding of the Women in Otolaryngology (WIO) Section, and 2022 was the most recent AAO-HNS. The presenting speakers’ genders were identified using publicly available author pronouns. Statistical analysis was performed in R language for statistical computing, version 4.1.1. Categorical variables were evaluated using the chi-square test. Results: Overall, 41.67% of oral presentations were given by female speakers at the 2022 Annual Meeting. This is a striking increase from 19.74% in 2008 (P < .001). At the 2022 meeting, facial plastics and reconstruction surgery and head and neck cancer sections had the highest female speaker representations at 55.18% and 54.31%, respectively. Business of medicine and professional development are newer additions to the meeting and include notable oral presentations delivered by female speakers (41.67% and 72.7%). Compared with 2008 rhinology and sleep presentations have made insignificant gains in female representation. In 2022 female presenters accounted for only 27.23% (rhinology) and 23.81% (sleep) oral presentations. This is not a significant changed since 2008 (P = .1, P = .33) but is trending upward. Conclusions: The WIO Section was founded in 2010 at the Academy. There has been meaningful work over the years focused on improving gender-based achievement. In recent years there has been increased implicit bias training, emphasis on mentorship and sponsorship, and newly implemented work-life integration policies. Over the study period, our field has expanded to include business and professional development, as well as the addition of WIO Section.
DEI Journal Club Benefits in Era of Banned “Compelled Speech” Christine E. DeMason, MD, Doris Lin, MD, Amelia F. Drake, MD
Introduction: In February 2023 the University of North Carolina Board of Governors prohibited compelled speech in hiring, admission, or promotion and stated that no representative can “solicit or require an applicant or faculty member to attest to beliefs about political debate or social action.” Since then, faculty have been trying to meet these new requirements, while balancing the importance of diversity, equity, and inclusion (DEI) to our learners, patients, and research, including fulfilling DEI requirements for NIH grant funding. We started a faculty-led DEI health care journal club to discuss these important topics. Our study’s objective was to evaluate the journal club participants’ awareness of DEI issues and whether attending club meetings affected their daily interactions. Since DEI is not a factor in promotion, involvement is purely voluntary. Methods: An internet-based survey was sent anonymously to participants after attending the journal club. Results: Seventeen of 25 attendees responded to the survey. Most were faculty, with 4 residents and 2 fellows also responding. Ten males and 7 females responded, with 7 identifying as a member of an underrepresented group in medicine. The majority (94%) felt that the journal club increased their awareness of DEI issues in the workplace, and 88% felt that attending changed the way they think about these issues in the workplace. Of respondents, 71% felt that the journal club led to projects that increased DEI in the workplace, with 70% indicating that it changed the way they interacted with coworkers. Only 66% felt that it changed the way they take care of patients. Conclusions: It is our opinion that the understanding of DEI in health care is pivotal to the success of otolaryngology. While there are several limitations to this study, including a small sample size and a potential selection bias of those who responded, we found that a DEI journal club increased awareness of DEI topics and led to an increase in DEI projects as well as better workplace interactions. This type of interaction, involving journal articles and other publications on DEI issues, may be needed to confront what has become a banned topic of overt discussion.
From Bystanders to Upstanders: A Multi-Institutional Implicit Bias Workshop Series Tracy Cheung, Elliot Schiff, BA, Shravani Pathak, MD, Alice Lee, MD, Ronda E. Alexander, MD, Christina J. Yang, MD
Introduction: Implicit bias influences clinical decision-making in health care delivery. Managing bias is an important aspect of professional development and impacts patient care. This study aims to describe the impact of a novel, interactive, multi-institutional educational workshop defining implicit bias and introducing strategies to combat bias. Methods: A simulation-enhanced, scenario-based educational workshop was implemented at 5 otolaryngology residency programs in 2023. A 19-question electronic survey was administered before and after the workshop. Demographic data, familiarity with implicit bias, and preparedness in responding to it were collected using a 5-point Likert scale. Pre- and post-survey data were analyzed using Wilcoxon signed rank tests. Results: Seventy-four participants (54% female) from 5 institutions participated in this experience. Results revealed a self-assessed increase in overall familiarity with implicit bias across gender and residency program, with median ratings increasing from 4 to 4.5 (P < .001) except among attendings (baseline median rating of 5/5). Participants reported an enhanced sense of preparedness to address implicit bias across all stratifications by gender, training level, and residency program, with an overall median increase from 3 to 4 (P < .001). Conclusions: Participants in this implicit bias workshop demonstrated increased familiarity with implicit bias and improved readiness to respond to it. The workshop facilitated important discussions and shed light on uncomfortable situations, emphasizing the value of ongoing work to target implicit bias in health care.
Impact of the COVID-19 Pandemic on Retirement in Female Otolaryngologists Arunima Vijay, BA, Nick Sahlollbey, BHSc, Michele M. Carr, DDS, MD, PhD
Introduction: During the COVID-19 pandemic, female physicians were at higher risk of burnout compared with male counterparts. Female otolaryngologists were also among those with the highest risk for exposure to SARS-CoV-2. This study aimed to describe the impact of the pandemic on retirement plans among female otolaryngologists. Methods: A cross-sectional survey assessing retirement plans was distributed to physicians in the Canadian Society of Otolaryngology from May to June 2023. Respondents shared demographic information and rated 4 pandemic-related factors and 14 independent factors on a 5-point scale from least important to most important for retirement plans. A Mann-Whitney U analysis was employed to evaluate the statistical significance of gender-based differences in the scores. Results: Eighty-two members responded, of which 20 (24.4%) were females. All female participants were 65 or younger, whereas 25 (40.3%) males were 65 or older. A greater proportion of female otolaryngologists worked full-time and in nonacademic practice settings. Eight (40%) females reported an earlier date of retirement compared with 12 (19.3%) of men. Female otolaryngologists reported several factors as significantly more important to retirement than their male counterparts. These included burnout (3.89 vs 2.87), increased workload (3.9 vs 3.04), pandemic-related financial concerns (1.78 vs 1.48), desire to improve quality of life (4.28 vs 3.44), health concerns of a loved one (2.56 vs 1.46), and personal health concerns (3.44 vs 2.09) (P < .05). Conclusions: Pandemic-related financial factors disproportionately affected retirement plans among female otolaryngologists. More females reported earlier retirement dates after the pandemic, which may further exacerbate preexisting gender inequalities in the otolaryngology workforce.
Epidemiology of Chronic Sinusitis in Patients With Inflammatory Bowel Disease Ravi Dhamija, BA, Peng Ding, MD, PhD, MPAS, David C. Kaelber, MD, PhD, MPH
Introduction: Chronic sinusitis (CS) is a prolonged inflammation of the sinus or nasal passages, with potential risk association to inflammatory bowel disease (IBD). This study aimed to investigate CS prevalence in IBD patients, compare ulcerative colitis (UC) and Crohn disease (CD), and explore the impact of nasal polyps on the IBD-CS association. Methods: A retrospective cohort study was conducted using a comprehensive data set from the TriNetX analytics network, encompassing 94,940,088 patients across 57 health care organizations in the United States. The study included 6 patient groups: adults with IBD, adults without IBD, adults with UC, adults without UC, adults with CD, and adults without CD. The diagnosis of IBD, UC, and CD was based on encounter diagnosis. The prevalence of CS and its different forms were determined using ICD-10 criteria. Relative risks (RR) with 95% CIs were calculated to assess the association between IBD and CS, as well as the differences between UC and CD. Results: Of the 79,222,976 patients included in the study, 478,879 had a diagnosis of IBD, resulting in a prevalence of 0.60%. Patients with IBD were 2.99 times more likely to have a diagnosis of CS (95% CI, 2.92 – 3.06). When comparing UC and CD patients separately to those without IBD, UC patients had a higher RR for CS (RR: 3.31; 95% CI, 3.20 – 3.42) compared with CD patients (RR: 2.83; 95% CI, 2.75 – 2.91). Compared with IBD patients, UC patients were slightly more likely to have a CS diagnosis with nasal polyps (RR: 1.10; 95% CI, 1.03 – 1.19) and less likely to have a diagnosis of CS without nasal polyps (RR: 0.994; 95% CI, 0.990 – 0.999). CD patients were slightly less likely to have CS with polyps (RR: 0.90; 95% CI, 0.83 – 0.97) and more likely to have CS without polyps (RR: 1.01; 95% CI, 1.002 – 1.001). Conclusions: We found a significant association between IBD and CS. Patients with IBD were more likely to have a diagnosis of CS compared to those without IBD. Additionally, patients with UC had a higher risk of CS with nasal polyps, while patients with CD had a higher risk of CS without nasal polyps.
Impact of Selective Immunoglobulin Deficiency on Chronic Rhinosinusitis Mohamed Aboueisha, MD, Kevin Tie, MD, Christopher D. Brook, MD
Introduction: The incidence of chronic rhinosinusitis and its exacerbation has been associated with primary immunodeficiency. This study focuses on investigating the influence of selective immunoglobulin deficiency (IgG or IgA) on the rate and exacerbation of chronic rhinosinusitis. Methods: This retrospective study examines patients at Beth Israel Deaconess Medical Center who were tested for selective immunoglobulin deficiency, categorizing them into 2 groups: group A (normal Ig levels) and group B (low Ig with selective IgA or IgG deficiency). The study compares rates of chronic rhinosinusitis (CRS), acute rhinosinusitis (ARS), and surgical interventions between the 2 groups. Results: A total of 385 patients with IgG or IgA deficiency and 11,133 patients with normal IgA and IgG were included in the study. The rate of CRS was significantly higher in the Ig deficiency group (50, 12.99%) compared with the normal Ig group (529, 4.25%) (P < .05). When examining the CRS patients in both groups, there was no statistically significant difference in the number of patients with recurrent ARS (42% vs 33%, P = .2), nor in the average number of ARS attacks (2.28 ± 0.56 vs 1.41 ± 0.17, P = .10). Additionally, there was no difference in the rate of functional endoscopic sinus surgery (14, 28% vs 125, 24%, P = .5). Conclusions: Individuals with selective IgA or IgG show a higher prevalence of chronic rhinosinusitis. Although surgical interventions and exacerbation rates do not significantly differ, an observable upward trend exists. Identifying underlying factors is crucial for effective treatment, warranting further research with larger patient cohorts to explore the underlying mechanism and appropriate treatment.
Neuromodulators for Treatment of Post-Viral Parosmia Kasia Resler, MD, Bruna Castro Silva, MD, Zara M. Patel, MD
Introduction: The recent coronavirus (COVID-19) pandemic has drawn attention to post-viral smell distortion, or parosmia. Parosmia has been poorly studied to date, but neuromodulators have been suggested as a potential treatment option. The aim of this study was to evaluate neuromodulator treatment in patients with post-viral parosmia. Methods: In this retrospective analysis, patients presenting to a tertiary care academic smell center with post-viral parosmia that had been treated with a neuromodulating agent (PwN) between June 2015 and December 2022 were compared with a cohort of patients with post-viral parosmia who had not been treated with a neuromodulating agent (PsN). Duration of parosmia prior to presentation, demographics, medical comorbidities, UPSIT, and SNOT-22 were recorded at presentation. Follow-up was at least 6 months for all patients, and a visual analog scale (VAS) was utilized to assess for subjective score and change over time of smell distortion. Results: Of 21 patients identified in the PwN group, 18 completed follow-up VAS; 18 patients in a controlled, matched cohort of PsN also then completed VAS. Follow-up was at least 6 months with a range of 6 – 24 months. VAS started at an average of 7.61 in both the PwN group and the PsN (range 3 – 10). VAS on follow-up was an average of 5.55 in the PwN group and 4.89 in the PsN group, (range 0 – 9). Seven patients of the PwN group and 6 patients of the PsN group had a > 5-point improvement in the VAS. There was no significant difference between VAS scores between the 2 groups (P = .51) or in duration of parosmia prior to presentation, time to follow-up, comorbidities, or demographic data. Conclusions: Direct retrospective comparison of post-viral parosmia treated with and without neuromodulators did not show a significant effect on the outcome of smell distortion. Limitations of this study are its small number and retrospective nature, and the question will have to be answered in a larger scale randomized controlled trial. Until then, there does not appear to be good evidence supporting use of neuromodulators such as gabapentin, pregabalin, or amitriptyline to treat post-viral parosmia.
Novel Predictor for Sleep Surgery Outcome: Posterior Pillar Hypertrophy Yeonsu Jeong, MD, Chang-Hoon Kim, MD, PhD, Hyung-Ju Cho, MD
Introduction: Since sleep apnea surgery is only effective for certain patients, finding a surgical responder is very important. This study aims to present a new anatomical index that can select patients with favorable surgical outcomes. Methods: This study is a retrospective review for analyzing the treatment effects of patients who were diagnosed with obstructive sleep apnea and underwent multilevel surgery by a single surgeon at the tertiary medical institution from 2012 to 2021. Patient anatomical parameters, endoscopic images, and preoperative/postoperative polysomnography reports were used for analysis. In some patients, the palatopharyngeal muscle, which forms the posterior pillar, is thicker than normal. These patients were assessed as having posterior pillar hypertrophy and described along with other anatomical indices. To evaluate only the effects of posterior pillar hypertrophy, patients who met the conditions were randomly selected and propensity matching was performed. Results: Logistic regression analysis was performed to find anatomical indicators that determine the success of the surgery. As a result of the analysis, Tonsil grade, BMI, and posterior pillar thickness were identified as statistically significant indicators to evaluate the success of the surgery. There was a difference in the success rate of surgery in the 2 groups (after propensity matching, posterior pillar hypertrophy group [PPH+] and normal control group [PPH-] were made). The percentage of patients with surgical success in the PPH- group was 40.7%, which was higher at 51.9% in the PPH+ group. Furthermore, the improvement in AHI and ODI after surgery was statistically significantly higher in the PPH+ group. Conclusions: The presence or absence of posterior pillar hypertrophy is an indicator that can be used to predict the effectiveness of surgical treatment in patients with obstructive sleep apnea and can be used as a basis for selection of patients and surgical methods.
Physiological Changes in a Mouse Model of Obstructive Sleep Apnea Aynur Aliyeva, MD, Laetitia Gaspar, PhD, Shweta Bhadri, MS, Josette Smith, Bala S.C. Koritala, PhD, David F. Smith, MD, PhD
Introduction: Obstructive sleep apnea (OSA) is a condition characterized by recurrent episodes of upper airway obstruction during sleep, leading to intermittent hypoxia (IH) and sleep fragmentation. While the pathophysiological mechanisms underlying OSA remain unclear, it is important to investigate the changes in physiological parameters that occur following short exposures to IH to gain a better understanding of the condition. In this study, we aimed to examine the effects of IH on blood pressure (BP), heart rate (HR), core body temperature (CBT), and activity in a mouse model. Methods: To simulate OSA, we employed a mouse model of IH. Male C57BL/6J mice were acquired from Jackson Laboratory and housed in our animal facility with a 12-hour light/12-hour dark cycle. To assess physiological changes, DSI HD-X10 telemetry probes were surgically implanted into the carotid artery of mice aged 8 to 10 weeks. Following a 2-week surgical recovery, the mice were divided into 2 groups: an experimental group exposed to 4 weeks of IH during their active phase and a control group exposed to normal oxygen levels (normoxia). IH was induced by manipulating the fractional inhaled oxygen concentration between 21% and 8%, resulting in approximately 50 hypoxic events per hour. Subsequently, we utilized the DSI telemetry system to measure the impact of IH on various physiological parameters. Results: Exposure to 4 weeks of IH significantly increased CBT, suggesting a disruption in thermoregulation, but did not exhibit significant effects on BP, HR, and activity levels. These findings may indicate that disrupted thermoregulation is influenced by IH, a characteristic feature of OSA. Conclusions: Gaining insights into the initial physiological changes associated with OSA is crucial for early detection and the development of intervention strategies. The mouse model used in this study provides valuable information about the physiological consequences of IH, particularly with regard to alterations in BP, HR, CBT, and activity levels. These findings contribute to a better understanding of the physiological implications of OSA.
UAS as a Salvage Procedure for Persistent OSA After ESP Chihun J. Han, MD, Praneet Kaki, Thomas M. Kaffenberger, MD, Sophia Shah, Maurits S. Boon, MD, Colin T. Huntley, MD
Introduction: The efficacy of an upper airway stimulation (UAS) for persistent obstructive sleep apnea (OSA) in patients who have undergone expansion sphincter pharyngoplasty (ESP) is unclear. Additionally, the evidence for ESP as a rescue procedure in UAS nonresponse is limited. In this study, we investigated if there is a difference in the outcome of patients who underwent UAS followed by ESP with those who underwent ESP followed by UAS. Methods: This study is a retrospective, single-institution review of patients who underwent both ESP and UAS. Patients were grouped into ESP-first or UAS-first groups. Sleep study data prior to and after the first and second surgeries were collected. Surgical success was defined as a decrease in postoperative apnea-hypopnea index (AHI) ≤ 50% and ≤ 20 events/hour. Pre- and postoperative drug-induced sleep endoscopies (DISE) were compared when available. All statistical analysis was performed in R Studio using an alpha level of 0.05. Results: We identified 20 ESP-first patients and 8 UAS-first patients. No significant differences in gender, age, or preoperative BMI were found between groups. Pre- and postoperative AHI after their first surgery was 39.85 ± 17.72 and 29.72 ± 15.94 in the ESP-first group and 36.29 ± 13.69 and 37.85 ± 23.45 in the UAS-first group. The final AHI and treatment success after UAS in the ESP-first group was 19.65 ± 17.59 and 47%, compared with 36.6 ± 27.66 and 20% in the UAS-first group after ESP. Changes in DISE in the ESP-first group were notable for improved lateral oropharyngeal wall collapse (P = .005) and conversion of complete concentric to anteroposterior velum collapse (P = .003). Conclusions: Our data suggest that ESP may be limited as a rescue procedure after UAS nonresponse. ESP followed by UAS could be an effective staged approach for well-selected patients.
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