Original Research
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Psychometric Evaluation of the Nasal Obstruction Symptom Evaluation Scale for Pediatric Patients
Hena Din, MPH, Nour Bundogji, Shelby C. Leuin, MD
First Published 10 Dec 2019.https://doi.org/10.1177/0194599819890835
Abstract
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Objective
To evaluate the psychometric properties of the nasal obstruction symptom scale within a sample of pediatric patients undergoing septoplasty or functional septorhinoplasty.
Study Design
This was a prospective study with nasal obstruction symptom scale evaluations conducted pre- and postoperatively.
Setting
A tertiary care pediatric hospital.
Subjects and Methods
Pediatric patients underwent septoplasty or functional septorhinoplasty (FSR) from January 2013 to January 2017. Reliability of the scale was assessed through measures of internal consistency. In addition, item response models of each item were evaluated to assess how well each item captured individuals with varying levels of nasal obstruction. Study authors assessed face validity, and construct validity was assessed by correlation measures between items and exploratory factor analysis.
Results
A total of 136 patients, ages 8 to 18 years with a mean age of 15.7 ± 2.1 years, completed pre- and postoperative evaluations. Internal consistency of the scale was high (Cronbach’s α = 0.83). Predominantly a unidimensional scale resulted from exploratory factor analyses. Item response models indicate questions capture low to moderate levels of nasal obstruction within this population. Additional analyses show the scale functions similarly between septoplasty and FSR patients.
Conclusion
The Nasal Obstruction Symptom Evaluation scale is a robust tool that may be incorporated as a subjective evaluation of severity of nasal obstruction among pediatric patients undergoing a septoplasty or functional septorhinoplasty.
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Short Scientific Communication
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Evaluation of Tonsillotomy Effects on Pharyngeal Volume and Compliance in Children
Abeer Al Ali, MD, Emilie Bois, MD, Imene Boujemla, MD, Natacha Teissier, MD, PhD, Thierry Van den Abbeele, MD, PhD, Christophe Delclaux, MD, PhD, Plamen Bokov, MD, PhD
First Published 10 Dec 2019.https://doi.org/10.1177/0194599819889912
Abstract
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Our objective was to assess whether adenotonsillotomy improved pharyngeal compliance, which is a risk factor for sleep-disordered breathing. Otherwise healthy children underwent Obstructive Sleep Apnea (OSA)-18 questionnaire and a pre- and postoperative acoustic pharyngometry in both sitting and supine positions, allowing the measurement of the volume of the palatine tonsil region and pharyngeal compliance. Thirty-five children (median age 5.3 years) were enrolled; they were reevaluated at a median of 18 days (25th-75th percentiles, 15-25) after surgery. Participants were compared according to a normal (n = 18) or an increased (n = 17) preoperative pharyngeal compliance. Surgery was associated with a significant decrease in OSA-18 and Brodsky scores, with a median increase in palatine volume of 0.13 cm3 (25th-75th percentiles, 0.00-0.73). A decrease in pharyngeal compliance was observed in children with increased preoperative compliance. The variation of palatine volume after surgery was positively related to the variation of pharyngeal compliance, suggesting that obstruction relief was associated with muscle relaxation in children with normal preoperative compliance.
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Systematic Review/Meta-Analysis
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Adenotonsillectomy for the Treatment of Obstructive Sleep Apnea in Children with Prader-Willi Syndrome: A Meta-analysis
Chia-Hsuan Lee, MD, MPH, Wei-Chung Hsu, MD, PhD, Jenq-Yuh Ko, MD, PhD, Te-Huei Yeh, MD, PhD, Ming-Tzer Lin, MD, Kun-Tai Kang, MD, MPH
First Published 10 Dec 2019.https://doi.org/10.1177/0194599819893115
Abstract
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Objective
Adenotonsillectomy outcomes in obstructive sleep apnea (OSA) treatment among children with Prader-Willi syndrome (PWS) remain unclear. This study aimed to elucidate the effectiveness of adenotonsillectomy in OSA treatment among children with PWS.
Data Source
PubMed, MEDLINE, Embase, and Cochrane Review up to February 2019.
Review Methods
The registry number of the protocol published on PROSPERO was CRD42015027053. Two authors independently searched the relevant database. Polysomnography outcomes in these children were examined, including net postoperative changes in the apnea-hypopnea index (AHI), net postoperative changes in the minimum and mean oxygen saturation, the overall success rate for a postoperative AHI <1, and the overall success rate for a postoperative AHI <5.
Results
Six studies with 41 patients were analyzed (mean age, 5.0 years; 55% boys; mean sample size, 6.8 patients). All children had PWS and received adenotonsillectomy for the treatment of OSA. The AHI was 13.1 events per hour (95% CI, 11.0-15.1) before surgery and 4.6 events per hour (95% CI, 4.1-5.1) after surgery. The mean change in the AHI was a significant reduction of 8.0 events per hour (95% CI, −10.8 to −5.1). The overall success rate was 21% (95% CI, 11%-38%) for a postoperative AHI <1 and 71% (95% CI, 54%-83%) for a postoperative AHI <5. Some patients developed velopharyngeal insufficiency postoperatively.
Conclusion
Adenotonsillectomy was associated with OSA improvement among children with PWS. However, residual OSA was frequently observed postoperatively in these patients.
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Original Research
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Outcomes of Overlapping Surgery in Otolaryngology
Pedrom C. Sioshansi, MD, Robert K. Jackler, MD, Edward J. Damrose, MD
First Published 10 Dec 2019.https://doi.org/10.1177/0194599819889670
Abstract
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Objective
To compare outcomes in otolaryngology between overlapping and nonoverlapping surgeries.
Study Design
Retrospective cohort study.
Setting
Tertiary referral center.
Subjects and Methods
All patients undergoing otolaryngologic procedures at Stanford University Hospital between January 2009 and June 2016 were included (n = 13,479). Cases were divided into 2 cohorts: overlapping (n = 1806, 13.4%) vs nonoverlapping (n = 11,673, 86.6%). Variables reviewed were type of operation performed, multidisciplinary team involvement, complications, reoperations, readmissions, and deaths.
Results
The total complication rate over 7.5 years studied was 3.3% (n = 450). Complication rates were lower for overlapping cases (0.77%) compared to nonoverlapping cases (3.73%) with an odds ratio of 0.2014, which was statistically significant (P < .0001). When examined by subspecialty, the complication rate for rhinology and endoscopic skull base procedures was approximately 10 times lower when overlapping (0.30%) was compared to nonoverlapping (3.15%), with an odds ratio of 0.094 (P = .0001). There was no difference in complication rates for other surgical subspecialties. There were no deaths associated with overlapping surgery. The rate of major complications requiring reoperation was similarly lower for overlapping procedures (0.276%) compared to nonoverlapping procedures (1.35%) with an odds ratio of 0.2023 (P = .0004). Readmission rates were lower for overlapping cases (0.49%) when compared to nonoverlapping cases (1.09%), with an odds ratio of 0.4553 (P = .0229).
Conclusions
Patients undergoing overlapping surgery had lower overall complication rates, lower reoperation rates, lower readmission rates, and no mortalities. The institutional experience presented provides evidence that with appropriate patient and case selection, otolaryngologists may safely perform overlapping surgery without increased risk of adverse patient outcomes.
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History of Otolaryngology
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The First Pull-through Approach to a Tongue Tumor by Giorgio Regnoli in 1838
Riccardo F. Mazzola, MD, Giovanna Cantarella, MD
First Published 10 Dec 2019.https://doi.org/10.1177/0194599819886124
Abstract
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The aim of this article is to describe the first report of a “pull-through” submental approach for excision of a tongue tumor, performed by Giorgio Regnoli in 1838 on a 14-year-old girl affected by a huge swelling of the tongue, which obstructed the upper airway and hindered swallowing and speech. Regnoli made a midline submental incision, divided the mylohyoid muscle and the oral mucosa, and entered the floor of the mouth. The tongue was pulled into the neck through the newly created opening, and the tumor was circumscribed by thread loops to prevent bleeding and was excised. Then the tongue stump was repositioned in the oral cavity. The skin margins were approximated by bandages. Despite limited armamentarium, the operation was successful. The described approach, subsequently named “pull-through,” is still utilized nowadays for selected cases of tongue neoplasms when mandibular splitting is not required.
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Original Research
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Patient and Provider Perspectives Regarding Enrollment in Head and Neck Cancer Research
Andrew G. Shuman, MD, Michele C. Gornick, MA, PhD, Collin Brummel, Madison Kent, Kayte Spector-Bagdady, JD, MBE, Elliot Biddle, Carol R. Bradford, MD, J. Chad Brenner, PhD
First Published 10 Dec 2019.https://doi.org/10.1177/0194599819889976
Abstract
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Objective
The advent of precision oncology complicates how clinicians and participants understand how clinical care and research interface. Here we examine how key stakeholders perceive the utility of, and evaluate the decision to participate in, genomic sequencing head and neck cancer research. The goal of this study was to highlight unique considerations for our community as this type of research proliferates across the country.
Study Design
Prospective multimethod qualitative and quantitative embedded ethics protocol.
Setting
Single-institution National Cancer Institute–designated academic cancer center.
Subjects and Methods
Multimethod study using paired surveys and semistructured interviews among patients and providers involved in a prospective precision head and neck oncology sequencing protocol (116 survey patient-participants, response rate 82%) with 18 interviewees.
Results
Participants were generally enthusiastic about enrollment in research, both to help future patients and as a way of giving back to the community. They described reliance on information from and trust in their cancer doctor regarding the decision to participate in research, but paradoxically there was discordance in how doctors and patients reported their respective influence in the decision-making process. Clinicians also stressed the importance in separating clinical and research-informed consent processes, although patients did not describe this tension.
Conclusion
As we enter an era of increasing personalized medicine and targeted therapies, the relationship between clinicians, scientists, and patients plays a larger role in how we individualize and contextualize cancer research. Our data are another step toward the ultimate goal of respecting and protecting patients as participants in head and neck translational oncology.
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Original Research
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Distance Traveled to Head and Neck Cancer Provider: A Measure of Socioeconomic Status and Access
Sean T. Massa, MD, Adam P. Liebendorfer, MA, Jose P. Zevallos, MD, MPH, Angela L. Mazul, MPH, PhD
First Published 3 Dec 2019.https://doi.org/10.1177/0194599819892015
Abstract
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Objective
Improved head and neck cancer survival has been associated with traveling farther distances for treatment, potentially due to patients seeking higher-quality facilities. This study investigates the role of both facility and confounding patient factors on this relationship.
Study Design
Review of national registry data.
Setting
National Cancer Database.
Subjects and Methods
Adults with head and neck cancer diagnosed from 2004 to 2014 were identified. Overall survival was compared among distance-to-facility quartiles via univariate and multivariate survival models. Then, the analysis was stratified by facility and patient factors, and the association between distance and survival was compared among strata.
Results
Overall survival was worst in the shortest-distance quartile (<5 miles; median survival, 80.7 months; 95% CI, 79.2-82.3), while other distance groups showed similar survival (range, 96.4-104 months). This finding remained in the multivariate model (adjusted hazard ratio vs first distance quartile: 0.88; 95% CI, 0.87-0.89). The association between survival and distance persisted in all subgroups when stratified by facility volume and type (adjusted hazard ratio range, 0.82-0.91), suggesting that facility quality does not fully account for this association. When stratified by income, distance remained statistically associated with survival but with a smaller effect size than that of income.
Conclusion
The association between distance to treating facility and head and neck cancer survival is limited to patients with worse survival outcomes living within 5 miles of the facility and is not fully explained by measures of facility quality.
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Patient Safety/Quality Improvement
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Dysphagia Screening for Pneumonia Prevention in a Cancer Hospital: Results of a Quality/Safety Initiative
Barbara Ebersole, MA, CCC-SLP, Miriam Lango, MD, John Ridge, MD, PhD, Elizabeth Handorf, PhD, Jeffrey Farma, MD, Sarah Clark, MS, CCC-SLP, Nausheen Jamal, MD
First Published 3 Dec 2019.https://doi.org/10.1177/0194599819889893
Abstract
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Objective
Hospital-acquired aspiration pneumonia remains a rare but potentially devastating problem. The best means by which to prevent aspiration in a cancer hospital population has not been evaluated. The aim of this study was to evaluate the impact of dysphagia screening on aspiration pneumonia rates in an acute care oncology hospital.
Methods
A prospective single-institution quality improvement dysphagia screening protocol at a comprehensive cancer center. Effect of dysphagia screening implemented in 2016 on hospital-acquired aspiration pneumonia rates coded “aspiration pneumonitis due to food/vomitus” was compared with rates from 2014 to 2015 prior to implementation. Screening compliance, screening outcomes, patient demographics, and medical data were reviewed as part of a post hoc analysis.
Results
Of 12,392 admissions in 2014 to 2016, 97 patients developed aspiration pneumonia during their hospitalization. No significant change in aspiration pneumonia rate was seen during the dysphagia screening year when compared to prior years (baseline, 7.36; screening year, 8.78 per 1000 discharges; P = .33). Sixty-eight of the cases (66%) were associated with emesis/gastrointestinal obstruction or perioperative aspiration and only 15 (15%) with oropharyngeal dysphagia. Multivariate analysis found that patients admitted to gastrointestinal surgery had an aspiration risk equivalent to patients admitted to head and neck, thoracic, and pulmonary services (odds ratio, 0.65; P = .2).
Discussion
Nursing-initiated dysphagia screening did not decrease aspiration pneumonia rates. The causes of aspiration-associated pneumonia were heterogeneous. Aspiration of intestinal contents is a more common source of hospital-acquired pneumonia than oropharyngeal dysphagia.
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Original Research
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Cytotoxicity of Ear Drop Excipients in Human and Mouse Tympanic Membrane Fibroblasts
Carolyn O. Dirain, PhD, David N. Karnani, Patrick J. Antonelli, MD
First Published 3 Dec 2019.https://doi.org/10.1177/0194599819889701
Abstract
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Objective
Commercial ear drops contain ingredients reported to be inactive. We sought to evaluate such excipients for possible cytotoxicity on human and mouse tympanic membrane (TM) fibroblasts.
Study Design
Prospective, in vitro.
Setting
Tertiary academic center.
Subjects and Methods
Mouse and human TM fibroblasts were treated with 1:10 dilutions of benzalkonium chloride (BKC) 0.0025%, 0.006%, or 0.01%; benzyl alcohol 0.9%; polysorbate 80 (PSB) 2.5%; glycerin 2.4%; povidone 0.2%; or water (control), twice within 24 hours or 4 times within 48 hours, for 2 hours each time. Cells were placed back in growth media after the treatments. Cells were observed with phase-contrast microscopy until the cytotoxicity assay was performed.
Results
Mouse fibroblasts had lower survival in only the PSB-treated cells compared to the control (P < .0001) after 24 hours. After 48 hours, PSB killed nearly all mouse fibroblasts (P < .0001). BKC decreased fibroblast survival in a dose-dependent manner (P < .001). In human TM fibroblasts, all excipients except povidone and benzyl alcohol after 24 hours and povidone after 48 hours reduced cell survival compared to control (P = .012 to P < .0001). The cytotoxicity of BKC in human TM fibroblasts was also dose dependent (<.0001). PSB was less cytotoxic to human fibroblasts. Phase-contrast images mirrored the cytotoxicity findings.
Conclusion
Polysorbate 80 and benzalkonium chloride, at concentrations found in commercial ear drops, may be cytotoxic to human and mouse TM fibroblasts. “Inactive” ingredients may need to be considered when evaluating clinical outcomes with commercial ear drops.
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Originl Research
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Risks of Neoplasia and Malignancy in Surgically Resected Cystic Parotid Lesions
Brian C. Boursiquot, MD, MS, Nancy J. Fischbein, MD, Davud Sirjani, MD, Uchechukwu C. Megwalu, MD, MPH
First Published 3 Dec 2019.https://doi.org/10.1177/0194599819889699
Abstract
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Objectives
To evaluate the risks of neoplasm and malignancy in surgically treated cystic parotid masses compared with solid or mixed lesions and to evaluate the performance of fine-needle aspiration (FNA) in parotid cysts.
Study Design
Retrospective cross-sectional study.
Setting
Single-institution academic tertiary care center.
Subjects and Methods
Patients without a history of human immunodeficiency virus or head and neck cancer who underwent parotidectomy for parotid masses and had preoperative imaging to characterize lesions as cystic, solid, or mixed (ie, partially cystic and partially solid). We assessed the risks of neoplasia and malignancy, adjusting for age, sex, race/ethnicity, facial nerve weakness, and history of malignancy. We also evaluated the sensitivity and specificity of FNA.
Results
We included 308 patients, 27 of whom had cystic parotid masses (5 simple and 22 complex). Cystic masses were less likely to be neoplastic compared to solid or mixed masses (44% vs 97%; odds ratio [OR], 0.03; 95% confidence interval [CI], 0.01-0.07); however, there was no difference in the risk of malignancy (22% vs 26%; OR, 0.81; 95% CI, 0.32-2.10). Cystic masses were more likely to yield nondiagnostic FNA cytology results, but for diagnostic samples, FNA was 86% sensitive and 33% specific for diagnosing neoplasia and 75% sensitive and 83% specific for diagnosing malignancy.
Conclusion
In our population, cystic masses undergoing surgery were less likely to be neoplastic but had a similar risk of malignancy as solid masses. The risk of malignancy should be considered in the management of cystic parotid masses.
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Short Scientific Communication
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Preoperative Stellate Ganglion Block for Perioperative Pain in Lateralized Head and Neck Cancer: Preliminary Results
Daniel Sharbel, MD, Paramvir Singh, MBBS, Daniel Blumenthal, James Sullivan, Anterpreet Dua, MBBS, W. Greer Albergotti, MD, Michael Groves, MD, J. Kenneth Byrd, MD
First Published 3 Dec 2019.https://doi.org/10.1177/0194599819889688
Abstract
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Patients with head and neck cancer represent a vulnerable population at particular risk of opioid dependence due to frequent histories of substance abuse, requirement of extensive surgery, and the synergistic toxicity of multimodal therapy. Regional anesthetic techniques have been used by other surgical disciplines to facilitate early recovery after surgery and decrease postoperative patient narcotic requirements. This pilot study investigates the efficacy of a preoperative regional analgesia using stellate ganglion block in lateralized head and neck cancer surgery. From our early results, stellate ganglion blockade may hold promise as an effective preoperative intervention for controlling early postoperative pain, lessening narcotic requirements, and improving quality of life.
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Commentary
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Ethical Considerations in the Advent of Artificial Intelligence in Otolaryngology
Alexandra M. Arambula, MD, Andrés M. Bur, MD
First Published 26 Nov 2019.https://doi.org/10.1177/0194599819889686
Abstract
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Artificial intelligence (AI) is quickly expanding within the sphere of health care, offering the potential to enhance the efficiency of care delivery, diminish costs, and reduce diagnostic and therapeutic errors. As the field of otolaryngology also explores use of AI technology in patient care, a number of ethical questions warrant attention prior to widespread implementation of AI. This commentary poses many of these ethical questions for consideration by the otolaryngologist specifically, using the 4 pillars of medical ethics—autonomy, beneficence, nonmaleficence, and justice—as a framework and advocating both for the assistive role of AI in health care and for the shared decision-making, empathic approach to patient care.
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Systematic Review/Meta-analysis
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Laryngotracheal Stenosis in Early vs Late Tracheostomy: A Systematic Review
Steven D. Curry, MD, MPH, Paul J. Rowan, PhD, MPH
First Published 26 Nov 2019.https://doi.org/10.1177/0194599819889690
Abstract
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Objective
For critically ill patients undergoing long-term mechanical ventilation, to determine whether early conversion from endotracheal intubation to tracheostomy reduces the incidence of laryngotracheal stenosis.
Data Sources
MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, and the Cumulative Index to Nursing and Allied Health Literature.
Review Methods
A systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and an assessment of bias were performed. Included studies reported outcomes of patients who were converted from endotracheal intubation to tracheostomy, compared early vs late tracheostomy, and reported the incidence of laryngotracheal stenosis and details of postoperative surveillance. Data were also collected for intensive care setting, method of tracheostomy, and timing of tracheostomy.
Results
Seven articles met inclusion criteria: 2 randomized trials, 2 quasi-randomized trials, 1 prospective cohort, and 2 retrospective cohorts. A total of 966 patients were included in this analysis (496 in the early tracheostomy group and 470 in the late tracheostomy group). The mean incidence of laryngotracheal stenosis was 8.9% (range, 0%-20.8%), with a mean incidence of 8.1% in early tracheostomy groups and 10.9% in late tracheostomy groups. In studies with the least risk of bias, there were no differences in the incidence of laryngotracheal stenosis in patients who underwent early vs late tracheostomy.
Conclusion
In critically ill patients undergoing long-term mechanical ventilation, early conversion to tracheostomy within 7 days of intubation does not significantly decrease the risk of laryngotracheal stenosis compared to later conversion as defined by the included studies.
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Original Research
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The Role of Genioglossus Activity in Predicting Uvulopalatopharyngoplasty Outcomes
Di Zhao, MD, Yanru Li, MD, Yue Qu, MD, Junbo Zhang, MD, Xin Cao, MM, Jingying Ye, MD
First Published 26 Nov 2019.https://doi.org/10.1177/0194599819889346
Abstract
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Objective
The aim of this study was to evaluate the association between genioglossus activity during sleep onset and the outcome of uvulopalatopharyngoplasty (UPPP) in patients with obstructive sleep apnea.
Study Design
Case series with planned data collection.
Setting
Sleep medical center.
Subjects and Methods
Forty-four patients with obstructive sleep apnea underwent overnight polysomnography with synchronous genioglossus electromyography (GGEMG) with intraoral electrodes. In addition, all patients underwent revised UPPP with uvula preservation and were followed up with polysomnography at least 3 months after surgery.
Results
Twenty-five patients (56.8%) were responders. Multiple regression analysis revealed that increasing tonsil size (odds ratio [OR], 0.086; P = .038) and higher sleep-onset GGEMG (OR, 0.664; P = .04) were significant predictors for surgical success. The area under the receiver operating characteristic curve was 0.942 (OR, 0.040; P < .001) for those predictors, 0.884 for GGEMG, and 0.848 for tonsil size. Moreover, all patients were divided into 4 groups according to tonsil size and sleep-onset GGEMG. The success rate of patients with tonsil size III or IV and sleep-onset GGEMG >11.20% (maximal GGEMG) was optimal (92.9%, 13 of 14), while the success rate of patients with tonsil size I or II and sleep-onset GGEMG ≤11.20% was 0% (0 of 10).
Conclusions
Sleep-onset GGEMG and tonsil size are both important in deciding outcomes of UPPP. Patients with tonsil size III or IV and higher sleep onset may be more suitable candidates for UPPP because of the higher probability of surgical success.
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Original Research
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Association between Smoking and 30-Day Outcomes in Otologic Surgery
Emily Kay-Rivest, MD, Marco Mascarella, MD, Maida J. Sewitch, PhD, François Cloutier, MD, FRCSC, Tamara Mijovic, MD, FRCSC
First Published 19 Nov 2019.https://doi.org/10.1177/0194599819889622
Abstract
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Objective
To determine the effect of current smoking status on 30-day postoperative adverse events in patients undergoing otologic surgery.
Study Design
Retrospective cohort study.
Setting
Database of the American College of Surgeons National Surgical Quality Improvement Program from 2006 to 2016.
Subjects and Methods
Adult patients undergoing middle ear and mastoid surgery were included. Preoperative smoking status was determined, and adverse events within 30 days of surgery were recorded. Descriptive statistics were used to characterize the study sample. Multivariable logistic regression was performed to identify the association between sociodemographic and clinical variables and postoperative adverse events. Population-attributable fractions were then calculated.
Results
A total of 10,684 patients who underwent otologic surgery were included, of whom 2036 (19.1%) were smokers. The most commonly performed surgery was tympanoplasty with and without ossicular chain reconstruction, followed by canal wall up tympanomastoidectomy. Adverse events occurred in 221 (2.1%) patients; the most common was superficial wound infections (n = 99, 0.9%). In smokers, the odds ratio for any adverse event was 1.97 (95% CI, 1.42-2.71). The odds ratios (95% CIs) for superficial wound infections, wound dehiscence, and 30-day readmission among smokers were 1.89 (1.32-2.86), 3.92 (1.26-11.60), and 1.84 (1.15-2.87), respectively. The population-attributable fraction for any adverse event in smokers was 15.5%.
Conclusions
In patients undergoing otologic surgery, smokers are more likely than nonsmokers to have postoperative adverse events—in particular, wound infections, wound dehiscence, and readmission to hospital.
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Appropriateness of Otic Quinolone Use among Privately Insured US Patients
Phuong T. Tran, MPH, Almut G. Winterstein, PhD, Xi Wang, MPH, Kiyon Rhew, PharmD, Patrick J. Antonelli, MD
First Published 19 Nov 2019.https://doi.org/10.1177/0194599819889607
Abstract
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Objective
Considering emerging safety concerns involving otic quinolones, we assessed the extent of otic quinolone use for questionable indications.
Study Design
Descriptive cross-sectional study of a national sample of privately insured patients.
Setting
Outpatient encounters in the United States.
Subjects and Methods
Children and adults with outpatient pharmacy-dispensing claims for new prescriptions of otic or ophthalmic quinolones in 2017 were identified within the IBM MarketScan Commercial Claims & Encounters and the Medicare Supplemental Database. Each dispensing ≥30 days apart constituted a unique episode. Only claims with supporting ear-related diagnoses on outpatient encounters ±3 days of dispensing were considered. Ophthalmic drops were excluded if eye-related diagnoses were found ±30 days. Prescribing was classified as appropriate, questionable, or undetermined.
Results
We found 214,897 episodes in 200,270 patients. Adults were twice as likely as children to have otic treatment with questionable indications (6.2% vs 3.0%). Sensitivity analyses with broader time windows to ascertain diagnoses showed similar proportions of questionable use. Otalgia and cerumen impaction constituted 90% of questionable indications. Family physicians (6.8%) and internists (8.0%) had higher percentages of questionable use than other specialties.
Conclusion
Based on the demonstrated risks of quinolone ear drops, opportunities exist to decrease otic quinolone use, especially in adults.
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Epidemiology of Pediatric Tracheostomy and Risk Factors for Poor Outcomes: An 11-Year Single-Center Experience
Aletheia Z. H. Chia, MBBS, Zhi Min Ng, MBBS, MRCPH, Yu Xian Pang, MBBS, Annette H. C. Ang, MBBS, MRCS, MMed, Cristelle C. T. Chow, MBBS, MRCPH, MMed, Oon Hoe Teoh, MBBS, MMed, MRCPCH, Jan Hau Lee, MBBS, MRCPCH, MCI
First Published 19 Nov 2019.https://doi.org/10.1177/0194599819887096
Abstract
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Objective
Children with long-term tracheostomies are at higher risk of complications. This study aims to describe the epidemiology, outcomes, and factors associated with successful decannulation in children undergoing tracheostomy.
Study Design
Case series with chart review.
Setting
Tertiary hospital.
Subjects and Methods
A retrospective analysis was conducted on pediatric tracheostomies performed from 2006 to 2016. Demographics, preexisting comorbidities, indications for tracheostomy, and pretracheostomy ventilatory requirements were collected. A multivariate regression model with covariates of age, failure to thrive (FTT), and comorbidities was used to identify factors associated with successful decannulation. Secondary outcomes were ventilation and oxygen requirements at hospital discharge, hospital and intensive care unit length of stay, and complications.
Results
In total, 105 patients received a tracheostomy at a median age of 8.0 months (interquartile range, 2.0-45.0). The most common indication was anatomic airway obstruction (55 of 105, 52.5%). Forty-four (41.9%) patients had preexisting FTT. In-hospital mortality was 14 of 105 (13.3%). None were directly related to tracheostomy. At discharge, 40 of 91 (44.0%) and 12 of 91 (13.2%) required home mechanical ventilation and supplemental oxygen, respectively. Forty-one (39%) patients underwent successful decannulation at a median 408 days (interquartile range, 170-1153) posttracheostomy. On adjusted analysis, unsuccessful decannulation was more common in patients with FTT and neurologic comorbidities. Postoperative complications were more common in younger patients and those with a longer time to decannulation.
Conclusion
Neurologic comorbidities and FTT were risk factors for unsuccessful decannulation after pediatric tracheostomy. Nutritional interventions may have a role in improving long-term outcomes following pediatric tracheostomies and should be investigated in future studies.
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Approximate Weight of 1:1000 Topical Epinephrine on Wrung-Out Epinephrine-Soaked Pledgets
Hannah N. Kuhar, MD, Xiaoxia Han, PhD, Donald H. Penning, MD, John R. Craig, MD
First Published 19 Nov 2019.https://doi.org/10.1177/0194599819888651
Abstract
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Objective
Topical 1:1000 epinephrine solution is commonly applied intranasally with cottonoid pledgets in endoscopic sinonasal surgery for local vasoconstriction and hemostasis. Pledgets are typically submerged in epinephrine solution and applied without measurement. Hemodynamic complications have been reported when pledgets have been saturated and not wrung out. The amount of epinephrine absorbed per pledget has not been studied methodically. The purpose of this study was to determine the amount of topical 1:1000 epinephrine remaining on a cottonoid pledget after wringing out the pledget, to simulate intraoperative application.
Study Design
Cohort study.
Setting
Tertiary care center.
Subjects and Methods
Sixty 0.5-in × 3-in cottonoid pledgets were submerged in canisters filled with 1:1000 epinephrine solution (1 mg/mL). Weights of the epinephrine-filled canisters were measured before submerging the pledgets and then after removing and wringing out the pledgets. Measurements were recorded for each pledget after being submerged for 0, 1, and 5 minutes and then wrung out. Mean weights were calculated and compared between the submersion durations.
Results
The mean overall weight of epinephrine on a wrung-out pledget was 0.931 mg. Mean weights of epinephrine absorbed onto wrung-out pledgets after submersion for 0, 1, and 5 minutes were 0.914, 0.913, and 0.967 mg, respectively. There were no significant differences in weights based on submersion duration (P = .296).
Conclusion
Approximately 1 mg of epinephrine was absorbed onto 0.5-in × 3-in cottonoid pledgets when pledgets were wrung out after being submerged in 1:1000 epinephrine, whether being removed from solution immediately or after up to 5 minutes.
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Original Research
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PHQ-9 and SNOT-22: Elucidating the Prevalence of Depression in Chronic Rhinosinusitis
Laura J. Vandelaar, MD, Zi Yang Jiang, MD, Alok Saini, MD, William C. Yao, MD, Amber U. Luong, MD, PhD, Martin J. Citardi, MD
First Published 12 Nov 2019.https://doi.org/10.1177/0194599819886852
Abstract
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Objective
Chronic rhinosinusitis (CRS) has been associated with comorbid depression, yet the prevalence of depression among all patients with CRS is not well described. The Patient Health Questionnaire–9 (PHQ-9), a validated instrument for diagnosing depression, has been used to assess depression in a variety of clinical settings. PHQ-9 scores ≥10 are the threshold for a depression diagnosis. The purpose of this study was to assess the prevalence of depression in a rhinology practice and compare the PHQ-9 with the 22-item Sinonasal Outcome Test (SNOT-22).
Study Design
Retrospective chart review.
Setting
Tertiary rhinology practice.
Subjects and Methods
During the 2-month period ending April 30, 2018, all rhinology patients were asked to complete the PHQ-9 and SNOT-22.
Results
Among 216 patients, 46 (21.3%) had a self-reported history of depression, and 39 (18.1%) had a PHQ-9 score ≥10. Of the 39 patients screening positive for depression, 18 (41.9%) had no history of depression. Comparison of PHQ-9 with overall SNOT-22 score had a Pearson’s coefficient of 0.632 (P < .005). Logistic regression showed that the highest 2 quintiles of SNOT-22 scores had an odds ratio of 60.6 (95% CI, 9.7-378.3) for a positive depression screen (PHQ-9 score ≥10).
Conclusion
Depression rates (estimated by PHQ-9 responses) among rhinology patients are similar to chronic disease populations; depression may be underdiagnosed in rhinology patients. Higher SNOT-22 scores were associated with higher PHQ-9 scores. Further studies are warranted to understand the impact of comorbid conditions of depression and CRS in patient quality of life.
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Commentary–Reflections
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Reflections: Starting an Otolaryngology Medical Student Interest Group
Amanda Hu, MD, FRCSC
First Published 5 Nov 2019.https://doi.org/10.1177/0194599819886121
Abstract
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A decline in applicants for otolaryngology residency spots has been reported. Several possible factors include the lack of exposure to otolaryngology, the lack of role models, work-life balance, and the competitiveness of otolaryngology as a deterrent. Our institution started a medical student interest group to address several of these factors. Key stakeholders who were engaged in this process included medical students, otolaryngology residents, and faculty members. Sustainability of the interest group was investigated with funding and succession planning. Early exposure to otolaryngology through shadowing in the operating room and research projects were initiated with a database on a website. Logistics of starting a club and organizing a clinical skills session were discussed. Awareness of our specialty and branding of the interest group as otolaryngology versus ear, nose, and throat were debated. Starting a medical student interest group in otolaryngology may be an excellent way to foster interest in our specialty.
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Psychometric Evaluation of the Nasal Obstruction Symptom Evaluation Scale for Pediatric Patients
Hena Din, MPH, Nour Bundogji, Shelby C. Leuin, MD
First Published 10 Dec 2019.https://doi.org/10.1177/0194599819890835
Abstract
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Objective
To evaluate the psychometric properties of the nasal obstruction symptom scale within a sample of pediatric patients undergoing septoplasty or functional septorhinoplasty.
Study Design
This was a prospective study with nasal obstruction symptom scale evaluations conducted pre- and postoperatively.
Setting
A tertiary care pediatric hospital.
Subjects and Methods
Pediatric patients underwent septoplasty or functional septorhinoplasty (FSR) from January 2013 to January 2017. Reliability of the scale was assessed through measures of internal consistency. In addition, item response models of each item were evaluated to assess how well each item captured individuals with varying levels of nasal obstruction. Study authors assessed face validity, and construct validity was assessed by correlation measures between items and exploratory factor analysis.
Results
A total of 136 patients, ages 8 to 18 years with a mean age of 15.7 ± 2.1 years, completed pre- and postoperative evaluations. Internal consistency of the scale was high (Cronbach’s α = 0.83). Predominantly a unidimensional scale resulted from exploratory factor analyses. Item response models indicate questions capture low to moderate levels of nasal obstruction within this population. Additional analyses show the scale functions similarly between septoplasty and FSR patients.
Conclusion
The Nasal Obstruction Symptom Evaluation scale is a robust tool that may be incorporated as a subjective evaluation of severity of nasal obstruction among pediatric patients undergoing a septoplasty or functional septorhinoplasty.
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Short Scientific Communication
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Evaluation of Tonsillotomy Effects on Pharyngeal Volume and Compliance in Children
Abeer Al Ali, MD, Emilie Bois, MD, Imene Boujemla, MD, Natacha Teissier, MD, PhD, Thierry Van den Abbeele, MD, PhD, Christophe Delclaux, MD, PhD, Plamen Bokov, MD, PhD
First Published 10 Dec 2019.https://doi.org/10.1177/0194599819889912
Abstract
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Our objective was to assess whether adenotonsillotomy improved pharyngeal compliance, which is a risk factor for sleep-disordered breathing. Otherwise healthy children underwent Obstructive Sleep Apnea (OSA)-18 questionnaire and a pre- and postoperative acoustic pharyngometry in both sitting and supine positions, allowing the measurement of the volume of the palatine tonsil region and pharyngeal compliance. Thirty-five children (median age 5.3 years) were enrolled; they were reevaluated at a median of 18 days (25th-75th percentiles, 15-25) after surgery. Participants were compared according to a normal (n = 18) or an increased (n = 17) preoperative pharyngeal compliance. Surgery was associated with a significant decrease in OSA-18 and Brodsky scores, with a median increase in palatine volume of 0.13 cm3 (25th-75th percentiles, 0.00-0.73). A decrease in pharyngeal compliance was observed in children with increased preoperative compliance. The variation of palatine volume after surgery was positively related to the variation of pharyngeal compliance, suggesting that obstruction relief was associated with muscle relaxation in children with normal preoperative compliance.
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Systematic Review/Meta-Analysis
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Adenotonsillectomy for the Treatment of Obstructive Sleep Apnea in Children with Prader-Willi Syndrome: A Meta-analysis
Chia-Hsuan Lee, MD, MPH, Wei-Chung Hsu, MD, PhD, Jenq-Yuh Ko, MD, PhD, Te-Huei Yeh, MD, PhD, Ming-Tzer Lin, MD, Kun-Tai Kang, MD, MPH
First Published 10 Dec 2019.https://doi.org/10.1177/0194599819893115
Abstract
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Objective
Adenotonsillectomy outcomes in obstructive sleep apnea (OSA) treatment among children with Prader-Willi syndrome (PWS) remain unclear. This study aimed to elucidate the effectiveness of adenotonsillectomy in OSA treatment among children with PWS.
Data Source
PubMed, MEDLINE, Embase, and Cochrane Review up to February 2019.
Review Methods
The registry number of the protocol published on PROSPERO was CRD42015027053. Two authors independently searched the relevant database. Polysomnography outcomes in these children were examined, including net postoperative changes in the apnea-hypopnea index (AHI), net postoperative changes in the minimum and mean oxygen saturation, the overall success rate for a postoperative AHI <1, and the overall success rate for a postoperative AHI <5.
Results
Six studies with 41 patients were analyzed (mean age, 5.0 years; 55% boys; mean sample size, 6.8 patients). All children had PWS and received adenotonsillectomy for the treatment of OSA. The AHI was 13.1 events per hour (95% CI, 11.0-15.1) before surgery and 4.6 events per hour (95% CI, 4.1-5.1) after surgery. The mean change in the AHI was a significant reduction of 8.0 events per hour (95% CI, −10.8 to −5.1). The overall success rate was 21% (95% CI, 11%-38%) for a postoperative AHI <1 and 71% (95% CI, 54%-83%) for a postoperative AHI <5. Some patients developed velopharyngeal insufficiency postoperatively.
Conclusion
Adenotonsillectomy was associated with OSA improvement among children with PWS. However, residual OSA was frequently observed postoperatively in these patients.
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Outcomes of Overlapping Surgery in Otolaryngology
Pedrom C. Sioshansi, MD, Robert K. Jackler, MD, Edward J. Damrose, MD
First Published 10 Dec 2019.https://doi.org/10.1177/0194599819889670
Abstract
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Objective
To compare outcomes in otolaryngology between overlapping and nonoverlapping surgeries.
Study Design
Retrospective cohort study.
Setting
Tertiary referral center.
Subjects and Methods
All patients undergoing otolaryngologic procedures at Stanford University Hospital between January 2009 and June 2016 were included (n = 13,479). Cases were divided into 2 cohorts: overlapping (n = 1806, 13.4%) vs nonoverlapping (n = 11,673, 86.6%). Variables reviewed were type of operation performed, multidisciplinary team involvement, complications, reoperations, readmissions, and deaths.
Results
The total complication rate over 7.5 years studied was 3.3% (n = 450). Complication rates were lower for overlapping cases (0.77%) compared to nonoverlapping cases (3.73%) with an odds ratio of 0.2014, which was statistically significant (P < .0001). When examined by subspecialty, the complication rate for rhinology and endoscopic skull base procedures was approximately 10 times lower when overlapping (0.30%) was compared to nonoverlapping (3.15%), with an odds ratio of 0.094 (P = .0001). There was no difference in complication rates for other surgical subspecialties. There were no deaths associated with overlapping surgery. The rate of major complications requiring reoperation was similarly lower for overlapping procedures (0.276%) compared to nonoverlapping procedures (1.35%) with an odds ratio of 0.2023 (P = .0004). Readmission rates were lower for overlapping cases (0.49%) when compared to nonoverlapping cases (1.09%), with an odds ratio of 0.4553 (P = .0229).
Conclusions
Patients undergoing overlapping surgery had lower overall complication rates, lower reoperation rates, lower readmission rates, and no mortalities. The institutional experience presented provides evidence that with appropriate patient and case selection, otolaryngologists may safely perform overlapping surgery without increased risk of adverse patient outcomes.
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History of Otolaryngology
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The First Pull-through Approach to a Tongue Tumor by Giorgio Regnoli in 1838
Riccardo F. Mazzola, MD, Giovanna Cantarella, MD
First Published 10 Dec 2019.https://doi.org/10.1177/0194599819886124
Abstract
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The aim of this article is to describe the first report of a “pull-through” submental approach for excision of a tongue tumor, performed by Giorgio Regnoli in 1838 on a 14-year-old girl affected by a huge swelling of the tongue, which obstructed the upper airway and hindered swallowing and speech. Regnoli made a midline submental incision, divided the mylohyoid muscle and the oral mucosa, and entered the floor of the mouth. The tongue was pulled into the neck through the newly created opening, and the tumor was circumscribed by thread loops to prevent bleeding and was excised. Then the tongue stump was repositioned in the oral cavity. The skin margins were approximated by bandages. Despite limited armamentarium, the operation was successful. The described approach, subsequently named “pull-through,” is still utilized nowadays for selected cases of tongue neoplasms when mandibular splitting is not required.
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Patient and Provider Perspectives Regarding Enrollment in Head and Neck Cancer Research
Andrew G. Shuman, MD, Michele C. Gornick, MA, PhD, Collin Brummel, Madison Kent, Kayte Spector-Bagdady, JD, MBE, Elliot Biddle, Carol R. Bradford, MD, J. Chad Brenner, PhD
First Published 10 Dec 2019.https://doi.org/10.1177/0194599819889976
Abstract
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Objective
The advent of precision oncology complicates how clinicians and participants understand how clinical care and research interface. Here we examine how key stakeholders perceive the utility of, and evaluate the decision to participate in, genomic sequencing head and neck cancer research. The goal of this study was to highlight unique considerations for our community as this type of research proliferates across the country.
Study Design
Prospective multimethod qualitative and quantitative embedded ethics protocol.
Setting
Single-institution National Cancer Institute–designated academic cancer center.
Subjects and Methods
Multimethod study using paired surveys and semistructured interviews among patients and providers involved in a prospective precision head and neck oncology sequencing protocol (116 survey patient-participants, response rate 82%) with 18 interviewees.
Results
Participants were generally enthusiastic about enrollment in research, both to help future patients and as a way of giving back to the community. They described reliance on information from and trust in their cancer doctor regarding the decision to participate in research, but paradoxically there was discordance in how doctors and patients reported their respective influence in the decision-making process. Clinicians also stressed the importance in separating clinical and research-informed consent processes, although patients did not describe this tension.
Conclusion
As we enter an era of increasing personalized medicine and targeted therapies, the relationship between clinicians, scientists, and patients plays a larger role in how we individualize and contextualize cancer research. Our data are another step toward the ultimate goal of respecting and protecting patients as participants in head and neck translational oncology.
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Distance Traveled to Head and Neck Cancer Provider: A Measure of Socioeconomic Status and Access
Sean T. Massa, MD, Adam P. Liebendorfer, MA, Jose P. Zevallos, MD, MPH, Angela L. Mazul, MPH, PhD
First Published 3 Dec 2019.https://doi.org/10.1177/0194599819892015
Abstract
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Objective
Improved head and neck cancer survival has been associated with traveling farther distances for treatment, potentially due to patients seeking higher-quality facilities. This study investigates the role of both facility and confounding patient factors on this relationship.
Study Design
Review of national registry data.
Setting
National Cancer Database.
Subjects and Methods
Adults with head and neck cancer diagnosed from 2004 to 2014 were identified. Overall survival was compared among distance-to-facility quartiles via univariate and multivariate survival models. Then, the analysis was stratified by facility and patient factors, and the association between distance and survival was compared among strata.
Results
Overall survival was worst in the shortest-distance quartile (<5 miles; median survival, 80.7 months; 95% CI, 79.2-82.3), while other distance groups showed similar survival (range, 96.4-104 months). This finding remained in the multivariate model (adjusted hazard ratio vs first distance quartile: 0.88; 95% CI, 0.87-0.89). The association between survival and distance persisted in all subgroups when stratified by facility volume and type (adjusted hazard ratio range, 0.82-0.91), suggesting that facility quality does not fully account for this association. When stratified by income, distance remained statistically associated with survival but with a smaller effect size than that of income.
Conclusion
The association between distance to treating facility and head and neck cancer survival is limited to patients with worse survival outcomes living within 5 miles of the facility and is not fully explained by measures of facility quality.
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Patient Safety/Quality Improvement
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Dysphagia Screening for Pneumonia Prevention in a Cancer Hospital: Results of a Quality/Safety Initiative
Barbara Ebersole, MA, CCC-SLP, Miriam Lango, MD, John Ridge, MD, PhD, Elizabeth Handorf, PhD, Jeffrey Farma, MD, Sarah Clark, MS, CCC-SLP, Nausheen Jamal, MD
First Published 3 Dec 2019.https://doi.org/10.1177/0194599819889893
Abstract
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Objective
Hospital-acquired aspiration pneumonia remains a rare but potentially devastating problem. The best means by which to prevent aspiration in a cancer hospital population has not been evaluated. The aim of this study was to evaluate the impact of dysphagia screening on aspiration pneumonia rates in an acute care oncology hospital.
Methods
A prospective single-institution quality improvement dysphagia screening protocol at a comprehensive cancer center. Effect of dysphagia screening implemented in 2016 on hospital-acquired aspiration pneumonia rates coded “aspiration pneumonitis due to food/vomitus” was compared with rates from 2014 to 2015 prior to implementation. Screening compliance, screening outcomes, patient demographics, and medical data were reviewed as part of a post hoc analysis.
Results
Of 12,392 admissions in 2014 to 2016, 97 patients developed aspiration pneumonia during their hospitalization. No significant change in aspiration pneumonia rate was seen during the dysphagia screening year when compared to prior years (baseline, 7.36; screening year, 8.78 per 1000 discharges; P = .33). Sixty-eight of the cases (66%) were associated with emesis/gastrointestinal obstruction or perioperative aspiration and only 15 (15%) with oropharyngeal dysphagia. Multivariate analysis found that patients admitted to gastrointestinal surgery had an aspiration risk equivalent to patients admitted to head and neck, thoracic, and pulmonary services (odds ratio, 0.65; P = .2).
Discussion
Nursing-initiated dysphagia screening did not decrease aspiration pneumonia rates. The causes of aspiration-associated pneumonia were heterogeneous. Aspiration of intestinal contents is a more common source of hospital-acquired pneumonia than oropharyngeal dysphagia.
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Cytotoxicity of Ear Drop Excipients in Human and Mouse Tympanic Membrane Fibroblasts
Carolyn O. Dirain, PhD, David N. Karnani, Patrick J. Antonelli, MD
First Published 3 Dec 2019.https://doi.org/10.1177/0194599819889701
Abstract
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Objective
Commercial ear drops contain ingredients reported to be inactive. We sought to evaluate such excipients for possible cytotoxicity on human and mouse tympanic membrane (TM) fibroblasts.
Study Design
Prospective, in vitro.
Setting
Tertiary academic center.
Subjects and Methods
Mouse and human TM fibroblasts were treated with 1:10 dilutions of benzalkonium chloride (BKC) 0.0025%, 0.006%, or 0.01%; benzyl alcohol 0.9%; polysorbate 80 (PSB) 2.5%; glycerin 2.4%; povidone 0.2%; or water (control), twice within 24 hours or 4 times within 48 hours, for 2 hours each time. Cells were placed back in growth media after the treatments. Cells were observed with phase-contrast microscopy until the cytotoxicity assay was performed.
Results
Mouse fibroblasts had lower survival in only the PSB-treated cells compared to the control (P < .0001) after 24 hours. After 48 hours, PSB killed nearly all mouse fibroblasts (P < .0001). BKC decreased fibroblast survival in a dose-dependent manner (P < .001). In human TM fibroblasts, all excipients except povidone and benzyl alcohol after 24 hours and povidone after 48 hours reduced cell survival compared to control (P = .012 to P < .0001). The cytotoxicity of BKC in human TM fibroblasts was also dose dependent (<.0001). PSB was less cytotoxic to human fibroblasts. Phase-contrast images mirrored the cytotoxicity findings.
Conclusion
Polysorbate 80 and benzalkonium chloride, at concentrations found in commercial ear drops, may be cytotoxic to human and mouse TM fibroblasts. “Inactive” ingredients may need to be considered when evaluating clinical outcomes with commercial ear drops.
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Originl Research
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Risks of Neoplasia and Malignancy in Surgically Resected Cystic Parotid Lesions
Brian C. Boursiquot, MD, MS, Nancy J. Fischbein, MD, Davud Sirjani, MD, Uchechukwu C. Megwalu, MD, MPH
First Published 3 Dec 2019.https://doi.org/10.1177/0194599819889699
Abstract
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Objectives
To evaluate the risks of neoplasm and malignancy in surgically treated cystic parotid masses compared with solid or mixed lesions and to evaluate the performance of fine-needle aspiration (FNA) in parotid cysts.
Study Design
Retrospective cross-sectional study.
Setting
Single-institution academic tertiary care center.
Subjects and Methods
Patients without a history of human immunodeficiency virus or head and neck cancer who underwent parotidectomy for parotid masses and had preoperative imaging to characterize lesions as cystic, solid, or mixed (ie, partially cystic and partially solid). We assessed the risks of neoplasia and malignancy, adjusting for age, sex, race/ethnicity, facial nerve weakness, and history of malignancy. We also evaluated the sensitivity and specificity of FNA.
Results
We included 308 patients, 27 of whom had cystic parotid masses (5 simple and 22 complex). Cystic masses were less likely to be neoplastic compared to solid or mixed masses (44% vs 97%; odds ratio [OR], 0.03; 95% confidence interval [CI], 0.01-0.07); however, there was no difference in the risk of malignancy (22% vs 26%; OR, 0.81; 95% CI, 0.32-2.10). Cystic masses were more likely to yield nondiagnostic FNA cytology results, but for diagnostic samples, FNA was 86% sensitive and 33% specific for diagnosing neoplasia and 75% sensitive and 83% specific for diagnosing malignancy.
Conclusion
In our population, cystic masses undergoing surgery were less likely to be neoplastic but had a similar risk of malignancy as solid masses. The risk of malignancy should be considered in the management of cystic parotid masses.
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Short Scientific Communication
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Preoperative Stellate Ganglion Block for Perioperative Pain in Lateralized Head and Neck Cancer: Preliminary Results
Daniel Sharbel, MD, Paramvir Singh, MBBS, Daniel Blumenthal, James Sullivan, Anterpreet Dua, MBBS, W. Greer Albergotti, MD, Michael Groves, MD, J. Kenneth Byrd, MD
First Published 3 Dec 2019.https://doi.org/10.1177/0194599819889688
Abstract
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Patients with head and neck cancer represent a vulnerable population at particular risk of opioid dependence due to frequent histories of substance abuse, requirement of extensive surgery, and the synergistic toxicity of multimodal therapy. Regional anesthetic techniques have been used by other surgical disciplines to facilitate early recovery after surgery and decrease postoperative patient narcotic requirements. This pilot study investigates the efficacy of a preoperative regional analgesia using stellate ganglion block in lateralized head and neck cancer surgery. From our early results, stellate ganglion blockade may hold promise as an effective preoperative intervention for controlling early postoperative pain, lessening narcotic requirements, and improving quality of life.
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Commentary
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Ethical Considerations in the Advent of Artificial Intelligence in Otolaryngology
Alexandra M. Arambula, MD, Andrés M. Bur, MD
First Published 26 Nov 2019.https://doi.org/10.1177/0194599819889686
Abstract
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Artificial intelligence (AI) is quickly expanding within the sphere of health care, offering the potential to enhance the efficiency of care delivery, diminish costs, and reduce diagnostic and therapeutic errors. As the field of otolaryngology also explores use of AI technology in patient care, a number of ethical questions warrant attention prior to widespread implementation of AI. This commentary poses many of these ethical questions for consideration by the otolaryngologist specifically, using the 4 pillars of medical ethics—autonomy, beneficence, nonmaleficence, and justice—as a framework and advocating both for the assistive role of AI in health care and for the shared decision-making, empathic approach to patient care.
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Systematic Review/Meta-analysis
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Laryngotracheal Stenosis in Early vs Late Tracheostomy: A Systematic Review
Steven D. Curry, MD, MPH, Paul J. Rowan, PhD, MPH
First Published 26 Nov 2019.https://doi.org/10.1177/0194599819889690
Abstract
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Objective
For critically ill patients undergoing long-term mechanical ventilation, to determine whether early conversion from endotracheal intubation to tracheostomy reduces the incidence of laryngotracheal stenosis.
Data Sources
MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, and the Cumulative Index to Nursing and Allied Health Literature.
Review Methods
A systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and an assessment of bias were performed. Included studies reported outcomes of patients who were converted from endotracheal intubation to tracheostomy, compared early vs late tracheostomy, and reported the incidence of laryngotracheal stenosis and details of postoperative surveillance. Data were also collected for intensive care setting, method of tracheostomy, and timing of tracheostomy.
Results
Seven articles met inclusion criteria: 2 randomized trials, 2 quasi-randomized trials, 1 prospective cohort, and 2 retrospective cohorts. A total of 966 patients were included in this analysis (496 in the early tracheostomy group and 470 in the late tracheostomy group). The mean incidence of laryngotracheal stenosis was 8.9% (range, 0%-20.8%), with a mean incidence of 8.1% in early tracheostomy groups and 10.9% in late tracheostomy groups. In studies with the least risk of bias, there were no differences in the incidence of laryngotracheal stenosis in patients who underwent early vs late tracheostomy.
Conclusion
In critically ill patients undergoing long-term mechanical ventilation, early conversion to tracheostomy within 7 days of intubation does not significantly decrease the risk of laryngotracheal stenosis compared to later conversion as defined by the included studies.
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The Role of Genioglossus Activity in Predicting Uvulopalatopharyngoplasty Outcomes
Di Zhao, MD, Yanru Li, MD, Yue Qu, MD, Junbo Zhang, MD, Xin Cao, MM, Jingying Ye, MD
First Published 26 Nov 2019.https://doi.org/10.1177/0194599819889346
Abstract
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Objective
The aim of this study was to evaluate the association between genioglossus activity during sleep onset and the outcome of uvulopalatopharyngoplasty (UPPP) in patients with obstructive sleep apnea.
Study Design
Case series with planned data collection.
Setting
Sleep medical center.
Subjects and Methods
Forty-four patients with obstructive sleep apnea underwent overnight polysomnography with synchronous genioglossus electromyography (GGEMG) with intraoral electrodes. In addition, all patients underwent revised UPPP with uvula preservation and were followed up with polysomnography at least 3 months after surgery.
Results
Twenty-five patients (56.8%) were responders. Multiple regression analysis revealed that increasing tonsil size (odds ratio [OR], 0.086; P = .038) and higher sleep-onset GGEMG (OR, 0.664; P = .04) were significant predictors for surgical success. The area under the receiver operating characteristic curve was 0.942 (OR, 0.040; P < .001) for those predictors, 0.884 for GGEMG, and 0.848 for tonsil size. Moreover, all patients were divided into 4 groups according to tonsil size and sleep-onset GGEMG. The success rate of patients with tonsil size III or IV and sleep-onset GGEMG >11.20% (maximal GGEMG) was optimal (92.9%, 13 of 14), while the success rate of patients with tonsil size I or II and sleep-onset GGEMG ≤11.20% was 0% (0 of 10).
Conclusions
Sleep-onset GGEMG and tonsil size are both important in deciding outcomes of UPPP. Patients with tonsil size III or IV and higher sleep onset may be more suitable candidates for UPPP because of the higher probability of surgical success.
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Association between Smoking and 30-Day Outcomes in Otologic Surgery
Emily Kay-Rivest, MD, Marco Mascarella, MD, Maida J. Sewitch, PhD, François Cloutier, MD, FRCSC, Tamara Mijovic, MD, FRCSC
First Published 19 Nov 2019.https://doi.org/10.1177/0194599819889622
Abstract
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Objective
To determine the effect of current smoking status on 30-day postoperative adverse events in patients undergoing otologic surgery.
Study Design
Retrospective cohort study.
Setting
Database of the American College of Surgeons National Surgical Quality Improvement Program from 2006 to 2016.
Subjects and Methods
Adult patients undergoing middle ear and mastoid surgery were included. Preoperative smoking status was determined, and adverse events within 30 days of surgery were recorded. Descriptive statistics were used to characterize the study sample. Multivariable logistic regression was performed to identify the association between sociodemographic and clinical variables and postoperative adverse events. Population-attributable fractions were then calculated.
Results
A total of 10,684 patients who underwent otologic surgery were included, of whom 2036 (19.1%) were smokers. The most commonly performed surgery was tympanoplasty with and without ossicular chain reconstruction, followed by canal wall up tympanomastoidectomy. Adverse events occurred in 221 (2.1%) patients; the most common was superficial wound infections (n = 99, 0.9%). In smokers, the odds ratio for any adverse event was 1.97 (95% CI, 1.42-2.71). The odds ratios (95% CIs) for superficial wound infections, wound dehiscence, and 30-day readmission among smokers were 1.89 (1.32-2.86), 3.92 (1.26-11.60), and 1.84 (1.15-2.87), respectively. The population-attributable fraction for any adverse event in smokers was 15.5%.
Conclusions
In patients undergoing otologic surgery, smokers are more likely than nonsmokers to have postoperative adverse events—in particular, wound infections, wound dehiscence, and readmission to hospital.
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Appropriateness of Otic Quinolone Use among Privately Insured US Patients
Phuong T. Tran, MPH, Almut G. Winterstein, PhD, Xi Wang, MPH, Kiyon Rhew, PharmD, Patrick J. Antonelli, MD
First Published 19 Nov 2019.https://doi.org/10.1177/0194599819889607
Abstract
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Objective
Considering emerging safety concerns involving otic quinolones, we assessed the extent of otic quinolone use for questionable indications.
Study Design
Descriptive cross-sectional study of a national sample of privately insured patients.
Setting
Outpatient encounters in the United States.
Subjects and Methods
Children and adults with outpatient pharmacy-dispensing claims for new prescriptions of otic or ophthalmic quinolones in 2017 were identified within the IBM MarketScan Commercial Claims & Encounters and the Medicare Supplemental Database. Each dispensing ≥30 days apart constituted a unique episode. Only claims with supporting ear-related diagnoses on outpatient encounters ±3 days of dispensing were considered. Ophthalmic drops were excluded if eye-related diagnoses were found ±30 days. Prescribing was classified as appropriate, questionable, or undetermined.
Results
We found 214,897 episodes in 200,270 patients. Adults were twice as likely as children to have otic treatment with questionable indications (6.2% vs 3.0%). Sensitivity analyses with broader time windows to ascertain diagnoses showed similar proportions of questionable use. Otalgia and cerumen impaction constituted 90% of questionable indications. Family physicians (6.8%) and internists (8.0%) had higher percentages of questionable use than other specialties.
Conclusion
Based on the demonstrated risks of quinolone ear drops, opportunities exist to decrease otic quinolone use, especially in adults.
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Epidemiology of Pediatric Tracheostomy and Risk Factors for Poor Outcomes: An 11-Year Single-Center Experience
Aletheia Z. H. Chia, MBBS, Zhi Min Ng, MBBS, MRCPH, Yu Xian Pang, MBBS, Annette H. C. Ang, MBBS, MRCS, MMed, Cristelle C. T. Chow, MBBS, MRCPH, MMed, Oon Hoe Teoh, MBBS, MMed, MRCPCH, Jan Hau Lee, MBBS, MRCPCH, MCI
First Published 19 Nov 2019.https://doi.org/10.1177/0194599819887096
Abstract
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Objective
Children with long-term tracheostomies are at higher risk of complications. This study aims to describe the epidemiology, outcomes, and factors associated with successful decannulation in children undergoing tracheostomy.
Study Design
Case series with chart review.
Setting
Tertiary hospital.
Subjects and Methods
A retrospective analysis was conducted on pediatric tracheostomies performed from 2006 to 2016. Demographics, preexisting comorbidities, indications for tracheostomy, and pretracheostomy ventilatory requirements were collected. A multivariate regression model with covariates of age, failure to thrive (FTT), and comorbidities was used to identify factors associated with successful decannulation. Secondary outcomes were ventilation and oxygen requirements at hospital discharge, hospital and intensive care unit length of stay, and complications.
Results
In total, 105 patients received a tracheostomy at a median age of 8.0 months (interquartile range, 2.0-45.0). The most common indication was anatomic airway obstruction (55 of 105, 52.5%). Forty-four (41.9%) patients had preexisting FTT. In-hospital mortality was 14 of 105 (13.3%). None were directly related to tracheostomy. At discharge, 40 of 91 (44.0%) and 12 of 91 (13.2%) required home mechanical ventilation and supplemental oxygen, respectively. Forty-one (39%) patients underwent successful decannulation at a median 408 days (interquartile range, 170-1153) posttracheostomy. On adjusted analysis, unsuccessful decannulation was more common in patients with FTT and neurologic comorbidities. Postoperative complications were more common in younger patients and those with a longer time to decannulation.
Conclusion
Neurologic comorbidities and FTT were risk factors for unsuccessful decannulation after pediatric tracheostomy. Nutritional interventions may have a role in improving long-term outcomes following pediatric tracheostomies and should be investigated in future studies.
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Original Research
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Approximate Weight of 1:1000 Topical Epinephrine on Wrung-Out Epinephrine-Soaked Pledgets
Hannah N. Kuhar, MD, Xiaoxia Han, PhD, Donald H. Penning, MD, John R. Craig, MD
First Published 19 Nov 2019.https://doi.org/10.1177/0194599819888651
Abstract
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Objective
Topical 1:1000 epinephrine solution is commonly applied intranasally with cottonoid pledgets in endoscopic sinonasal surgery for local vasoconstriction and hemostasis. Pledgets are typically submerged in epinephrine solution and applied without measurement. Hemodynamic complications have been reported when pledgets have been saturated and not wrung out. The amount of epinephrine absorbed per pledget has not been studied methodically. The purpose of this study was to determine the amount of topical 1:1000 epinephrine remaining on a cottonoid pledget after wringing out the pledget, to simulate intraoperative application.
Study Design
Cohort study.
Setting
Tertiary care center.
Subjects and Methods
Sixty 0.5-in × 3-in cottonoid pledgets were submerged in canisters filled with 1:1000 epinephrine solution (1 mg/mL). Weights of the epinephrine-filled canisters were measured before submerging the pledgets and then after removing and wringing out the pledgets. Measurements were recorded for each pledget after being submerged for 0, 1, and 5 minutes and then wrung out. Mean weights were calculated and compared between the submersion durations.
Results
The mean overall weight of epinephrine on a wrung-out pledget was 0.931 mg. Mean weights of epinephrine absorbed onto wrung-out pledgets after submersion for 0, 1, and 5 minutes were 0.914, 0.913, and 0.967 mg, respectively. There were no significant differences in weights based on submersion duration (P = .296).
Conclusion
Approximately 1 mg of epinephrine was absorbed onto 0.5-in × 3-in cottonoid pledgets when pledgets were wrung out after being submerged in 1:1000 epinephrine, whether being removed from solution immediately or after up to 5 minutes.
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Original Research
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PHQ-9 and SNOT-22: Elucidating the Prevalence of Depression in Chronic Rhinosinusitis
Laura J. Vandelaar, MD, Zi Yang Jiang, MD, Alok Saini, MD, William C. Yao, MD, Amber U. Luong, MD, PhD, Martin J. Citardi, MD
First Published 12 Nov 2019.https://doi.org/10.1177/0194599819886852
Abstract
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Objective
Chronic rhinosinusitis (CRS) has been associated with comorbid depression, yet the prevalence of depression among all patients with CRS is not well described. The Patient Health Questionnaire–9 (PHQ-9), a validated instrument for diagnosing depression, has been used to assess depression in a variety of clinical settings. PHQ-9 scores ≥10 are the threshold for a depression diagnosis. The purpose of this study was to assess the prevalence of depression in a rhinology practice and compare the PHQ-9 with the 22-item Sinonasal Outcome Test (SNOT-22).
Study Design
Retrospective chart review.
Setting
Tertiary rhinology practice.
Subjects and Methods
During the 2-month period ending April 30, 2018, all rhinology patients were asked to complete the PHQ-9 and SNOT-22.
Results
Among 216 patients, 46 (21.3%) had a self-reported history of depression, and 39 (18.1%) had a PHQ-9 score ≥10. Of the 39 patients screening positive for depression, 18 (41.9%) had no history of depression. Comparison of PHQ-9 with overall SNOT-22 score had a Pearson’s coefficient of 0.632 (P < .005). Logistic regression showed that the highest 2 quintiles of SNOT-22 scores had an odds ratio of 60.6 (95% CI, 9.7-378.3) for a positive depression screen (PHQ-9 score ≥10).
Conclusion
Depression rates (estimated by PHQ-9 responses) among rhinology patients are similar to chronic disease populations; depression may be underdiagnosed in rhinology patients. Higher SNOT-22 scores were associated with higher PHQ-9 scores. Further studies are warranted to understand the impact of comorbid conditions of depression and CRS in patient quality of life.
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Commentary–Reflections
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Reflections: Starting an Otolaryngology Medical Student Interest Group
Amanda Hu, MD, FRCSC
First Published 5 Nov 2019.https://doi.org/10.1177/0194599819886121
Abstract
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A decline in applicants for otolaryngology residency spots has been reported. Several possible factors include the lack of exposure to otolaryngology, the lack of role models, work-life balance, and the competitiveness of otolaryngology as a deterrent. Our institution started a medical student interest group to address several of these factors. Key stakeholders who were engaged in this process included medical students, otolaryngology residents, and faculty members. Sustainability of the interest group was investigated with funding and succession planning. Early exposure to otolaryngology through shadowing in the operating room and research projects were initiated with a database on a website. Logistics of starting a club and organizing a clinical skills session were discussed. Awareness of our specialty and branding of the interest group as otolaryngology versus ear, nose, and throat were debated. Starting a medical student interest group in otolaryngology may be an excellent way to foster interest in our specialty.
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