Original Research
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Prevalence of Pediatric Dizziness and Imbalance in the United States
Jacob R. Brodsky, MD, Sophie Lipson, Neil Bhattacharyya, MD
First Published 5 Nov 2019.https://doi.org/10.1177/0194599819887375
Abstract
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Objectives
Understand the prevalence of vestibular symptoms in US children.
Study Design
Cross-sectional analysis
Setting
2016 National Health Interview Survey.
Subjects and Methods
Responses from the 2016 National Health Interview Survey for children ages 3 to 17 years were examined to determine the prevalence of vestibular symptoms and provider-assigned diagnoses.
Results
Dizziness or imbalance was reported in 3.5 (95% confidence interval, 3.1-3.9) million patients (5.6%) with a mean age of 11.5 years. Dizziness was reported in 1.2 million patients (2.0%) with a mean age of 12.7 years and balance impairment in 2.3 million patients (3.7%) with a mean age of 10.6 years. Prevalence of dizziness and imbalance did not vary by sex (P = .6, P = .2). Evaluation by a health professional was reported for 42% of patients with dizziness and 43% of patients with imbalance, with diagnoses reported in 45% and 48% of patients with dizziness and imbalance, respectively. The most common diagnoses reported for dizziness were depression or child psychiatric disorder (12%), side effects from medications (11%), head/neck injury or concussion (8.4%), and developmental motor coordination disorder (8.3%). The most common diagnoses reported for imbalance were blurred vision with head motion, “bouncing” or rapid eye movements (9.1%), depression or child psychiatric disorder (6.2%), head/neck injury or concussion (6.1%), and side effects from medications (5.9%).
Conclusion
The national prevalence of childhood vestibular symptoms is more common than previously thought. Reported diagnoses varied greatly from the literature, suggesting a need for increased awareness of causes of vestibular symptoms in children.
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Quality of Life in Children with Sensorineural Hearing Loss
Evette A. Ronner, Liliya Benchetrit, Patricia Levesque, MS, Razan A. Basonbul, MBBS, MPH, Michael S. Cohen, MD
First Published 5 Nov 2019.https://doi.org/10.1177/0194599819886122
Abstract
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Objective
To assess quality of life (QOL) in pediatric patients with sensorineural hearing loss (SNHL) with the Pediatric Quality of Life Inventory 4.0 (PedsQL 4.0) and the Hearing Environments and Reflection on Quality of Life 26 (HEAR-QL-26) and HEAR-QL-28 surveys.
Study Design
Prospective longitudinal study.
Setting
Tertiary care center.
Subjects and Methods
Surveys were administered to patients with SNHL (ages 2-18 years) from July 2016 to December 2018 at a multidisciplinary hearing loss clinic. Patients aged >7 years completed the HEAR-QL-26, HEAR-QL-28, and PedsQL 4.0 self-report tool, while parents completed the PedsQL 4.0 parent proxy report for children aged ≤7 years. Previously published data from children with normal hearing were used for controls. The independent t test was used for analysis.
Results
In our cohort of 100 patients, the mean age was 7.7 years (SD, 4.5): 62 participants had bilateral SNHL; 63 had mild to moderate SNHL; and 37 had severe to profound SNHL. Sixty-eight patients used a hearing device. Mean (SD) total survey scores for the PedsQL 4.0 (ages 2-7 and 8-18 years), HEAR-QL-26 (ages 7-12 years), and HEAR-QL-28 (ages 13-18 years) were 83.9 (14.0), 79.2 (11.1), 81.2 (9.8), and 77.5 (11.3), respectively. Mean QOL scores for patients with SNHL were significantly lower than those for controls on the basis of previously published normative data (P < .0001). There was no significant difference in QOL between children with unilateral and bilateral SNHL or between children with SNHL who did and did not require a hearing device. Low statistical power due to small subgroup sizes limited our analysis.
Conclusion
It is feasible to collect QOL data from children with SNHL in a hearing loss clinic. Children with SNHL had significantly lower scores on validated QOL instruments when compared with peers with normal hearing.
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Short Scientific Communication
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US Medical Trainees’ Knowledge of Human Papilloma Virus and Head and Neck Cancer
Benjamin M. Laitman, MD, PhD, Lukas Ronner, Kristin Oliver, MD, Eric Genden, MD
First Published 29 Oct 2019.https://doi.org/10.1177/0194599819886117
Abstract
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Given the increasing incidence of human papilloma virus (HPV)–positive head and neck cancers (HNCs), discussion of this oncologic outcome should be incorporated into HPV vaccine counseling practices. Yet, preliminary evidence shows that knowledge of the association between HPV and HNC is lacking among most medical trainees. To better characterize this deficit, we nationally assessed knowledge of HPV’s association with HNC among medical students and residents across 4 specialties (pediatrics, obstetrics and gynecology, family medicine, and otolaryngology). A total of 3141 responses from 46 states were obtained (n = 402 pediatric residents, n = 346 obstetrics/gynecology residents, n = 260 family medicine residents, n = 87 otolaryngology residents, and n = 2045 medical students). Only 40.3% of surveyed medical students and 56.1% of surveyed obstetrics/gynecology, pediatrics, and family medicine residents identified associations between persistent HPV infection and HNC. When counseling on the vaccine, nonotolaryngology residents more often discussed cervical cancer (99.8%) as compared with HNC (39.7%), commonly because of less HNC knowledge (61.5%). These results suggest that it is imperative to develop educational interventions targeted at medical students and resident trainees on the front line of HPV vaccine counseling and administration.
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Original Research
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Recognizing Persistent Disease in Well-Differentiated Thyroid Cancer and Association with Lymph Node Yield and Ratio
Julia E. Noel, MD, Lisa A. Orloff, MD
First Published 29 Oct 2019.https://doi.org/10.1177/0194599819886123
Abstract
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Objective
To establish the association between lymph node yield and ratio in neck dissection for well-differentiated thyroid cancer and risk for persistent postoperative disease.
Study Design
Retrospective cohort study of patients undergoing lymphadenectomy for thyroid carcinoma.
Setting
Tertiary referral center.
Subjects and Methods
Included patients underwent central and/or lateral neck dissection for papillary thyroid carcinoma at our institution between 1994 and 2015. They were divided into a persistent disease group with biochemical and structural disease (49 patients) and a disease-free group with no disease after a minimum 2 years of follow-up (175 patients). Demographic characteristics, adjuvant therapy, tumor, and lymph node features were compared.
Results
There were no significant differences in demographic characteristics between the groups. The mean nodal yield of patients with central and lateral neck persistence was significantly lower than that of patients remaining disease free (4.8 vs. 11.9: odds ratio [OR] 0.69; 95% CI, 0.59 to 0.8; P < .001; 14.8 vs. 31.0: OR, 0.89; 95% CI, 0.84-0.94; P < .001, respectively). Nodal ratio was higher in patients with persistence in the central and lateral neck (74.2% vs 29.4%: OR, 1.06; 95% CI, 1.04-1.08; P < .001; 54.2% vs 19.8%: OR, 1.08; 95% CI, 1.04-1.12; P < .001, respectively).
Conclusions
Lower lymph node yield and higher node ratio from cervical lymph node dissections are associated with persistent disease and have potential applications in surgical adequacy.
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Commentary
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Female Authorship of Opinion Pieces in Leading Otolaryngology Journals between 2013 and 2018
Ashley L. Miller, MD, Vinay K. Rathi, MD, Stacey T. Gray, MD, Regan W. Bergmark, MD
First Published 29 Oct 2019.https://doi.org/10.1177/0194599819886119
Abstract
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Although women represent an increasing proportion of the physician workforce, barriers to the professional advancement of women persist, particularly within surgical fields such as otolaryngology. Authorship of scientific opinion articles serves as an important opportunity for professional development. We conducted a retrospective cross-sectional study to characterize the authorship patterns of scientific opinion articles by gender in leading otolaryngology journals between 2013 and 2018. Outcome measures were the number and proportion of female physician first authors and female last authors as compared with the proportion of the otolaryngology workforce. Between 2013 and 2018, female authors accounted for 24.1% of first of multiple authors, 30.4% of sole authors, and 25.3% of last authors. Women were equitably represented in comparison with the proportion of practicing female otolaryngologists (17.1% in 2017). The proportion of female first authorship increased from 20.0% in 2013 to 32.0% in 2018. Additional efforts are necessary to support the equitable advancement of women in otolaryngology.
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Patient Safety/Quality Improvement
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Surgical Instrument Optimization to Reduce Instrument Processing and Operating Room Setup Time
Lauren Crosby, MSc, Eric Lortie, MHA, Brian Rotenberg, MD, MPH, FRCSC, Leigh Sowerby, MD, MHM, FRCSC
First Published 22 Oct 2019.https://doi.org/10.1177/0194599819885635
Abstract
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Objective
As health care expenditures rise, novel ways to increase efficiency are sought. The operating room (OR) represents an area where there is opportunity to optimize work flow and supply use. Evidence suggests that instrument redundancy in the OR tends to be high and that direct cost savings can be achieved by “optimizing” surgical trays. The purpose of this study was to quantify the potential time savings associated with surgical tray optimization.
Methods
Instrument utilization was reviewed for 4 procedures: tonsillectomy, sinus surgery, septoplasty, and septorhinoplasty. Instruments used in <20% of cases were excluded. Data on tray assembly time in the central processing department and instrument setup time in the OR were prospectively collected over a 3-month period before and after tray optimization. Student’s t test (α = 0.05) was used to determine whether times were significantly different following optimization.
Results
Tray assembly times were found to be significantly shorter following optimization, with percentage reduction in time ranging from 58% to 66% (P < .05). In the OR, percentage reduction in setup time ranged from 26% to 37% (P < .05). Variability in assembly and setup times was also found to be narrower postoptimization.
Discussion
Tray optimization may reduce stress and adverse events and allow managers to better estimate staffing requirements. Cost-benefits could not be determined given a limited understanding of how departments choose to redistribute time savings.
Implications for Practice
Measurable and significant time savings can be achieved by assessing instrument utilization rates and reducing tray redundancy, leading to lower performance variability and improved efficiency.
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Original Research
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Adverse Events Associated with Balloon Sinuplasty: A MAUDE Database Analysis
Kevin Hur, MD, Marshall Ge, MD, Jeehong Kim, MD, Elisabeth H. Ference, MD, MPH
First Published 22 Oct 2019.https://doi.org/10.1177/0194599819884902
Abstract
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Objective
Balloon sinuplasty utilization has increased significantly since its introduction over a decade ago. However, the most common associated complications are still unknown. The objective of this study was to analyze adverse events related to balloon sinuplasty.
Study Design
Retrospective cross-sectional analysis.
Setting
Food and Drug Administration’s MAUDE database (Manufacturer and User Facility Device Experience; 2008-2018).
Subjects and Methods
The MAUDE database was searched for all reports on adverse events involving balloon sinuplasty devices from the 3 leading manufacturers: Acclarent, Entellus, and Medtronic. Reported events were reviewed and categorized.
Results
During the study period, there were 211 adverse events from 208 reports divided into the following categories: patient related (n = 102, 48.3%), device related (n = 101, 47.9%), and packaging related (n = 8, 3.8%). Four periprocedural deaths were reported but were not clearly associated with technical complications. The most common device-related complications were guide catheter malfunction (39.6%), balloon malfunction (38.6%), and imprecise navigation (17.8%). The most common patient-related complications were cerebrospinal fluid leak (36.3%), eye swelling (29.4%), and epistaxis (11.8%). A lateral canthotomy was performed in 30.0% of eye-swelling complications. Sixty percent of eye complications occurred during balloon dilation of the maxillary sinus. The years 2014 (n = 48) and 2012 (n = 32) had the highest number of adverse events reported as compared with all other years.
Conclusion
The most common adverse events associated with balloon sinuplasty include balloon malfunction, guide catheter malfunction, cerebrospinal fluid leak, and significant eye swelling. Health care providers should discuss these possible complications when consenting patients for balloon sinuplasty.
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Five-Year Objective and Subjective Outcomes of Velopharyngeal Surgery for Patients with Obstructive Sleep Apnea
Guoping Yin, MD, Mu He, MD, Xin Cao, MD, Jinkun Xu, MD, Yuhuan Zhang, MM, Dan Kang, MM, Jingying Ye, MD, PhD
First Published 22 Oct 2019.https://doi.org/10.1177/0194599819884889
Abstract
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Objective
To assess the long-term effects of velopharyngeal surgery on objective and subjective symptoms in patients with obstructive sleep apnea (OSA).
Study Design
Prospective cohort study.
Setting
University medical center.
Subjects and Methods
Eighty-six patients with OSA underwent velopharyngeal surgery, which consisted of revised uvulopalatopharyngoplasty with uvula preservation, with or without concomitant transpalatal advancement pharyngoplasty. The results from polysomnography and the Epworth Sleep Scale after 6 months and 5 years were compared with baseline. Baseline variables were compared between responders and nonresponders.
Results
Sixty-three patients were successfully followed up at the end of study. The surgical success rate after 6 months and 5 years was 66.67% (42 of 63) and 60.32% (38 of 63), respectively, with no significant difference (P = .459). The apnea-hypopnea index and Epworth Sleep Scale dramatically decreased from baseline after 6 months and 5 years in responders and nonresponders (P < .001 for all). As compared with nonresponders, the responders exhibited larger tonsil size, higher nocturnal lowest oxygen desaturation, lower CT90 (percentage of time with oxygen saturation <90%), and shorter MH (vertical distance between the lower edge of the mandible and hyoid in the midsagittal plane of computed tomography). Tonsil size and CT90 showed significant predictive value for surgery success (P < .001 for both).
Conclusion
Velopharyngeal surgery was effective in improving nocturnal respiration and excessive daytime sleepiness in patients with OSA at 6-month and 5-year follow-up. Tonsil size and CT90 could be predictors for surgery responders.
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Original Research
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Impact of Neck Disability on Health-Related Quality of Life among Head and Neck Cancer Survivors
Marci L. Nilsen, PhD, RN, Lingyun Lyu, MS, Michael A. Belsky, Leila J. Mady, MD, PhD, MPH, Dan P. Zandberg, MD, David A. Clump, II, MD, PhD, Heath D. Skinner, MD, PhD, Shyamal Das Peddada, PhD, Susan George, DPT, PT, Jonas T. Johnson, MD
First Published 15 Oct 2019.https://doi.org/10.1177/0194599819883295
Abstract
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Objective
Although neck impairment has been described following surgical resection, limited studies have investigated its prevalence in nonsurgical treatment. The purpose of this study is to determine the prevalence and predictors of neck disability following head and neck cancer (HNC) treatment and to explore its association with quality of life (QOL).
Study Design
Cross-sectional study.
Setting
HNC survivorship clinic.
Subjects and Methods
We identified 214 survivors who completed treatment ≥1 year prior to evaluation in the clinic. Self-reported neck impairment was measured using the Neck Disability Index. QOL was measured using the University of Washington QOL Questionnaire, with physical and social subscale scores calculated. Regression analysis and trend tests were employed to explore associations.
Results
Over half of survivors (54.2%) reported neck disability. The odds of neck disability in survivors who received nonsurgical treatment and those who received surgery plus adjuvant treatment were 3.46 and 4.98 times higher compared to surgery alone (P = .008, P = .004). Survivors who underwent surgery only had higher physical and social QOL than those who received nonsurgical treatment (physical QOL: P < .001, social QOL: P = .023) and those who received surgery plus adjuvant treatment (physical QOL: P < .001, social QOL: P = .039).
Conclusion
This study revealed a high prevalence of neck disability following nonsurgical treatment. While neck disability is an established sequela of surgical resection, the impact of nonsurgical treatment has gone unrecognized. Early identification and intervention to prevent progression of neck disability are crucial to optimize QOL.
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Systematic Review
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Effectiveness of Canal Occlusion for Intractable Posterior Canal Benign Paroxysmal Positional Vertigo: A Systematic Review
Britta D. P. J. Maas, MD, Hester J. van der Zaag-Loonen, MD, PhD, Peter Paul G. van Benthem, MD, PhD, Tjasse D. Bruintjes, MD, PhD
First Published 15 Oct 2019.https://doi.org/10.1177/0194599819881437
Abstract
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Objectives
A last resort for therapy for intractable benign paroxysmal positional vertigo (BPPV) is mechanical occlusion of the posterior semicircular canal. The aim of this review was to assess the effect of posterior canal occlusion for intractable posterior canal BPPV on vertigo and to determine the risk of loss of auditory or vestibular function.
Data Sources
A systematic literature search according to the PRISMA statement was performed on PubMed, the Cochrane Library, Embase, Web of Science, and CINAHL. The last search was conducted in June 2018.
Review Methods
Cohort studies with original data and case reports describing >5 cases were included if they analyzed the effect of posterior semicircular canal obliteration in adults with intractable posterior BPPV on vertigo. Two authors screened titles and abstracts for eligibility. The first author screened full texts and analyzed the data.
Results
Eight retrospective studies met the eligibility criteria. The quality of all individual studies was rated fair. Canal occlusion was performed on 196 patients. All studies reported complete resolution of BPPV in all patients (100%). Among postoperatively tested patients, total loss of auditory function and vestibular function was reported in 2 of 190 (1%) and 9 of 68 (13%), respectively.
Conclusion
Posterior semicircular canal plugging resulted in 100% resolution of BPPV in patients with intractable BPPV in all studies. However, the strength of evidence was weak. Potential serious complications, such as deafness and loss of vestibular function, should be taken into account.
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Original Research
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Should You Follow the Better-Hearing Ear for Congenital Cytomegalovirus Infection and Isolated Sensorineural Hearing Loss?
Vanessa Torrecillas, MD, Chelsea M. Allen, PhD, Tom Greene, PhD, Albert Park, MD, Winnie Chung, AUD, Tatiana M. Lanzieri, MD, MPH, Gail Demmler-Harrison, MD
First Published 8 Oct 2019.https://doi.org/10.1177/0194599819880348
Abstract
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Objective
To describe the progression of sensorineural hearing loss (SNHL) in the better- and poorer-hearing ears in children with asymptomatic congenital cytomegalovirus (CMV) infection with isolated SNHL.
Study Design
Longitudinal prospective cohort study.
Setting
Tertiary medical center.
Subjects and Methods
We analyzed hearing thresholds of the better- and poorer-hearing ears of 16 CMV-infected patients with isolated congenital/early-onset or delayed-onset SNHL identified through hospital-based CMV screening of >30,000 newborns from 1982 to 1992.
Results
By 12 months of age, 4 of 7 patients with congenital/early-onset SNHL developed worsening thresholds in the poorer-hearing ear, and 1 had an improvement in the better-hearing ear. By 18 years of age, all 7 patients had worsening thresholds in the poorer-hearing ear and 3 patients had worsening thresholds in the better-hearing ear. Hearing loss first worsened at a mean age of 2 and 6 years in the poorer- and better-hearing ears, respectively. Nine patients were diagnosed with delayed-onset SNHL (mean age of 9 years vs 12 years for the poorer- and better-hearing ears), 6 of whom had worsening thresholds in the poorer-hearing ear and 1 in both ears.
Conclusion
In most children with congenital CMV infection and isolated SNHL, the poorer-hearing ear worsened earlier and more precipitously than the better-hearing ear. This study suggests that monitoring individual hearing thresholds in both ears is important for appropriate interventions and future evaluation of efficacy of antiviral treatment.
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Original Research
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Surgical Explantation of Bone-Anchored Hearing Devices: A 10-year Single Institution Review
Christian G. Fritz, Dennis I. Bojrab, II, MD, Kenny F. Lin, MD, Christopher A. Schutt, MD, Seilesh C. Babu, MD, Robert S. Hong, MD, PhD
First Published 1 Oct 2019.https://doi.org/10.1177/0194599819879653
Abstract
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Objective
To identify clinical variables associated with the decision to surgically discontinue bone-anchored hearing device function.
Study Design
Retrospective chart review.
Setting
Tertiary neurotology referral center.
Subjects and Methods
This study examines surgical interventions performed on existing bone-anchored hearing devices at a single institution from 2008 to 2018. Patient characteristics, indications for implantation, and complications prompting surgical intervention were assessed.
Results
Seventy-seven cases were included in this study. Among patients in the younger cohort (<37 years old), 100% (13 of 13) of those discontinuing their device had a contralateral normal-hearing ear. Conversely, 0% (0 of 14) of the younger patients with bilateral hearing loss surgically discontinued their devices. Within the older cohort (≥37 years old), female patients (P = .002) and those with an increased body mass index (P = .035) were more likely to surgically discontinue their devices. Multivariate analysis revealed that a contralateral normal-hearing ear (P = .001) and infection without soft tissue overgrowth of the abutment (P = .026) were the strongest predictors of device discontinuation, after adjusting for potential confounders.
Conclusion
Surgical discontinuation is associated with several clinical variables. Targeted interventions that are viable alternatives to removal, such as device relocation, should be presented to younger patients with a contralateral normal-hearing ear who experience persistent complications. Patients with persistent infection in the absence of soft tissue overgrowth would especially benefit from enhanced counseling on proper hygiene.
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Prevalence of Pediatric Dizziness and Imbalance in the United States
Jacob R. Brodsky, MD, Sophie Lipson, Neil Bhattacharyya, MD
First Published 5 Nov 2019.https://doi.org/10.1177/0194599819887375
Abstract
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Objectives
Understand the prevalence of vestibular symptoms in US children.
Study Design
Cross-sectional analysis
Setting
2016 National Health Interview Survey.
Subjects and Methods
Responses from the 2016 National Health Interview Survey for children ages 3 to 17 years were examined to determine the prevalence of vestibular symptoms and provider-assigned diagnoses.
Results
Dizziness or imbalance was reported in 3.5 (95% confidence interval, 3.1-3.9) million patients (5.6%) with a mean age of 11.5 years. Dizziness was reported in 1.2 million patients (2.0%) with a mean age of 12.7 years and balance impairment in 2.3 million patients (3.7%) with a mean age of 10.6 years. Prevalence of dizziness and imbalance did not vary by sex (P = .6, P = .2). Evaluation by a health professional was reported for 42% of patients with dizziness and 43% of patients with imbalance, with diagnoses reported in 45% and 48% of patients with dizziness and imbalance, respectively. The most common diagnoses reported for dizziness were depression or child psychiatric disorder (12%), side effects from medications (11%), head/neck injury or concussion (8.4%), and developmental motor coordination disorder (8.3%). The most common diagnoses reported for imbalance were blurred vision with head motion, “bouncing” or rapid eye movements (9.1%), depression or child psychiatric disorder (6.2%), head/neck injury or concussion (6.1%), and side effects from medications (5.9%).
Conclusion
The national prevalence of childhood vestibular symptoms is more common than previously thought. Reported diagnoses varied greatly from the literature, suggesting a need for increased awareness of causes of vestibular symptoms in children.
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Original Research
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Quality of Life in Children with Sensorineural Hearing Loss
Evette A. Ronner, Liliya Benchetrit, Patricia Levesque, MS, Razan A. Basonbul, MBBS, MPH, Michael S. Cohen, MD
First Published 5 Nov 2019.https://doi.org/10.1177/0194599819886122
Abstract
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Objective
To assess quality of life (QOL) in pediatric patients with sensorineural hearing loss (SNHL) with the Pediatric Quality of Life Inventory 4.0 (PedsQL 4.0) and the Hearing Environments and Reflection on Quality of Life 26 (HEAR-QL-26) and HEAR-QL-28 surveys.
Study Design
Prospective longitudinal study.
Setting
Tertiary care center.
Subjects and Methods
Surveys were administered to patients with SNHL (ages 2-18 years) from July 2016 to December 2018 at a multidisciplinary hearing loss clinic. Patients aged >7 years completed the HEAR-QL-26, HEAR-QL-28, and PedsQL 4.0 self-report tool, while parents completed the PedsQL 4.0 parent proxy report for children aged ≤7 years. Previously published data from children with normal hearing were used for controls. The independent t test was used for analysis.
Results
In our cohort of 100 patients, the mean age was 7.7 years (SD, 4.5): 62 participants had bilateral SNHL; 63 had mild to moderate SNHL; and 37 had severe to profound SNHL. Sixty-eight patients used a hearing device. Mean (SD) total survey scores for the PedsQL 4.0 (ages 2-7 and 8-18 years), HEAR-QL-26 (ages 7-12 years), and HEAR-QL-28 (ages 13-18 years) were 83.9 (14.0), 79.2 (11.1), 81.2 (9.8), and 77.5 (11.3), respectively. Mean QOL scores for patients with SNHL were significantly lower than those for controls on the basis of previously published normative data (P < .0001). There was no significant difference in QOL between children with unilateral and bilateral SNHL or between children with SNHL who did and did not require a hearing device. Low statistical power due to small subgroup sizes limited our analysis.
Conclusion
It is feasible to collect QOL data from children with SNHL in a hearing loss clinic. Children with SNHL had significantly lower scores on validated QOL instruments when compared with peers with normal hearing.
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Short Scientific Communication
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US Medical Trainees’ Knowledge of Human Papilloma Virus and Head and Neck Cancer
Benjamin M. Laitman, MD, PhD, Lukas Ronner, Kristin Oliver, MD, Eric Genden, MD
First Published 29 Oct 2019.https://doi.org/10.1177/0194599819886117
Abstract
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Given the increasing incidence of human papilloma virus (HPV)–positive head and neck cancers (HNCs), discussion of this oncologic outcome should be incorporated into HPV vaccine counseling practices. Yet, preliminary evidence shows that knowledge of the association between HPV and HNC is lacking among most medical trainees. To better characterize this deficit, we nationally assessed knowledge of HPV’s association with HNC among medical students and residents across 4 specialties (pediatrics, obstetrics and gynecology, family medicine, and otolaryngology). A total of 3141 responses from 46 states were obtained (n = 402 pediatric residents, n = 346 obstetrics/gynecology residents, n = 260 family medicine residents, n = 87 otolaryngology residents, and n = 2045 medical students). Only 40.3% of surveyed medical students and 56.1% of surveyed obstetrics/gynecology, pediatrics, and family medicine residents identified associations between persistent HPV infection and HNC. When counseling on the vaccine, nonotolaryngology residents more often discussed cervical cancer (99.8%) as compared with HNC (39.7%), commonly because of less HNC knowledge (61.5%). These results suggest that it is imperative to develop educational interventions targeted at medical students and resident trainees on the front line of HPV vaccine counseling and administration.
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Original Research
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Recognizing Persistent Disease in Well-Differentiated Thyroid Cancer and Association with Lymph Node Yield and Ratio
Julia E. Noel, MD, Lisa A. Orloff, MD
First Published 29 Oct 2019.https://doi.org/10.1177/0194599819886123
Abstract
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Objective
To establish the association between lymph node yield and ratio in neck dissection for well-differentiated thyroid cancer and risk for persistent postoperative disease.
Study Design
Retrospective cohort study of patients undergoing lymphadenectomy for thyroid carcinoma.
Setting
Tertiary referral center.
Subjects and Methods
Included patients underwent central and/or lateral neck dissection for papillary thyroid carcinoma at our institution between 1994 and 2015. They were divided into a persistent disease group with biochemical and structural disease (49 patients) and a disease-free group with no disease after a minimum 2 years of follow-up (175 patients). Demographic characteristics, adjuvant therapy, tumor, and lymph node features were compared.
Results
There were no significant differences in demographic characteristics between the groups. The mean nodal yield of patients with central and lateral neck persistence was significantly lower than that of patients remaining disease free (4.8 vs. 11.9: odds ratio [OR] 0.69; 95% CI, 0.59 to 0.8; P < .001; 14.8 vs. 31.0: OR, 0.89; 95% CI, 0.84-0.94; P < .001, respectively). Nodal ratio was higher in patients with persistence in the central and lateral neck (74.2% vs 29.4%: OR, 1.06; 95% CI, 1.04-1.08; P < .001; 54.2% vs 19.8%: OR, 1.08; 95% CI, 1.04-1.12; P < .001, respectively).
Conclusions
Lower lymph node yield and higher node ratio from cervical lymph node dissections are associated with persistent disease and have potential applications in surgical adequacy.
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Commentary
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Female Authorship of Opinion Pieces in Leading Otolaryngology Journals between 2013 and 2018
Ashley L. Miller, MD, Vinay K. Rathi, MD, Stacey T. Gray, MD, Regan W. Bergmark, MD
First Published 29 Oct 2019.https://doi.org/10.1177/0194599819886119
Abstract
Hide Preview
Although women represent an increasing proportion of the physician workforce, barriers to the professional advancement of women persist, particularly within surgical fields such as otolaryngology. Authorship of scientific opinion articles serves as an important opportunity for professional development. We conducted a retrospective cross-sectional study to characterize the authorship patterns of scientific opinion articles by gender in leading otolaryngology journals between 2013 and 2018. Outcome measures were the number and proportion of female physician first authors and female last authors as compared with the proportion of the otolaryngology workforce. Between 2013 and 2018, female authors accounted for 24.1% of first of multiple authors, 30.4% of sole authors, and 25.3% of last authors. Women were equitably represented in comparison with the proportion of practicing female otolaryngologists (17.1% in 2017). The proportion of female first authorship increased from 20.0% in 2013 to 32.0% in 2018. Additional efforts are necessary to support the equitable advancement of women in otolaryngology.
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Patient Safety/Quality Improvement
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Surgical Instrument Optimization to Reduce Instrument Processing and Operating Room Setup Time
Lauren Crosby, MSc, Eric Lortie, MHA, Brian Rotenberg, MD, MPH, FRCSC, Leigh Sowerby, MD, MHM, FRCSC
First Published 22 Oct 2019.https://doi.org/10.1177/0194599819885635
Abstract
Hide Preview
Objective
As health care expenditures rise, novel ways to increase efficiency are sought. The operating room (OR) represents an area where there is opportunity to optimize work flow and supply use. Evidence suggests that instrument redundancy in the OR tends to be high and that direct cost savings can be achieved by “optimizing” surgical trays. The purpose of this study was to quantify the potential time savings associated with surgical tray optimization.
Methods
Instrument utilization was reviewed for 4 procedures: tonsillectomy, sinus surgery, septoplasty, and septorhinoplasty. Instruments used in <20% of cases were excluded. Data on tray assembly time in the central processing department and instrument setup time in the OR were prospectively collected over a 3-month period before and after tray optimization. Student’s t test (α = 0.05) was used to determine whether times were significantly different following optimization.
Results
Tray assembly times were found to be significantly shorter following optimization, with percentage reduction in time ranging from 58% to 66% (P < .05). In the OR, percentage reduction in setup time ranged from 26% to 37% (P < .05). Variability in assembly and setup times was also found to be narrower postoptimization.
Discussion
Tray optimization may reduce stress and adverse events and allow managers to better estimate staffing requirements. Cost-benefits could not be determined given a limited understanding of how departments choose to redistribute time savings.
Implications for Practice
Measurable and significant time savings can be achieved by assessing instrument utilization rates and reducing tray redundancy, leading to lower performance variability and improved efficiency.
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Adverse Events Associated with Balloon Sinuplasty: A MAUDE Database Analysis
Kevin Hur, MD, Marshall Ge, MD, Jeehong Kim, MD, Elisabeth H. Ference, MD, MPH
First Published 22 Oct 2019.https://doi.org/10.1177/0194599819884902
Abstract
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Objective
Balloon sinuplasty utilization has increased significantly since its introduction over a decade ago. However, the most common associated complications are still unknown. The objective of this study was to analyze adverse events related to balloon sinuplasty.
Study Design
Retrospective cross-sectional analysis.
Setting
Food and Drug Administration’s MAUDE database (Manufacturer and User Facility Device Experience; 2008-2018).
Subjects and Methods
The MAUDE database was searched for all reports on adverse events involving balloon sinuplasty devices from the 3 leading manufacturers: Acclarent, Entellus, and Medtronic. Reported events were reviewed and categorized.
Results
During the study period, there were 211 adverse events from 208 reports divided into the following categories: patient related (n = 102, 48.3%), device related (n = 101, 47.9%), and packaging related (n = 8, 3.8%). Four periprocedural deaths were reported but were not clearly associated with technical complications. The most common device-related complications were guide catheter malfunction (39.6%), balloon malfunction (38.6%), and imprecise navigation (17.8%). The most common patient-related complications were cerebrospinal fluid leak (36.3%), eye swelling (29.4%), and epistaxis (11.8%). A lateral canthotomy was performed in 30.0% of eye-swelling complications. Sixty percent of eye complications occurred during balloon dilation of the maxillary sinus. The years 2014 (n = 48) and 2012 (n = 32) had the highest number of adverse events reported as compared with all other years.
Conclusion
The most common adverse events associated with balloon sinuplasty include balloon malfunction, guide catheter malfunction, cerebrospinal fluid leak, and significant eye swelling. Health care providers should discuss these possible complications when consenting patients for balloon sinuplasty.
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Five-Year Objective and Subjective Outcomes of Velopharyngeal Surgery for Patients with Obstructive Sleep Apnea
Guoping Yin, MD, Mu He, MD, Xin Cao, MD, Jinkun Xu, MD, Yuhuan Zhang, MM, Dan Kang, MM, Jingying Ye, MD, PhD
First Published 22 Oct 2019.https://doi.org/10.1177/0194599819884889
Abstract
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Objective
To assess the long-term effects of velopharyngeal surgery on objective and subjective symptoms in patients with obstructive sleep apnea (OSA).
Study Design
Prospective cohort study.
Setting
University medical center.
Subjects and Methods
Eighty-six patients with OSA underwent velopharyngeal surgery, which consisted of revised uvulopalatopharyngoplasty with uvula preservation, with or without concomitant transpalatal advancement pharyngoplasty. The results from polysomnography and the Epworth Sleep Scale after 6 months and 5 years were compared with baseline. Baseline variables were compared between responders and nonresponders.
Results
Sixty-three patients were successfully followed up at the end of study. The surgical success rate after 6 months and 5 years was 66.67% (42 of 63) and 60.32% (38 of 63), respectively, with no significant difference (P = .459). The apnea-hypopnea index and Epworth Sleep Scale dramatically decreased from baseline after 6 months and 5 years in responders and nonresponders (P < .001 for all). As compared with nonresponders, the responders exhibited larger tonsil size, higher nocturnal lowest oxygen desaturation, lower CT90 (percentage of time with oxygen saturation <90%), and shorter MH (vertical distance between the lower edge of the mandible and hyoid in the midsagittal plane of computed tomography). Tonsil size and CT90 showed significant predictive value for surgery success (P < .001 for both).
Conclusion
Velopharyngeal surgery was effective in improving nocturnal respiration and excessive daytime sleepiness in patients with OSA at 6-month and 5-year follow-up. Tonsil size and CT90 could be predictors for surgery responders.
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Impact of Neck Disability on Health-Related Quality of Life among Head and Neck Cancer Survivors
Marci L. Nilsen, PhD, RN, Lingyun Lyu, MS, Michael A. Belsky, Leila J. Mady, MD, PhD, MPH, Dan P. Zandberg, MD, David A. Clump, II, MD, PhD, Heath D. Skinner, MD, PhD, Shyamal Das Peddada, PhD, Susan George, DPT, PT, Jonas T. Johnson, MD
First Published 15 Oct 2019.https://doi.org/10.1177/0194599819883295
Abstract
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Objective
Although neck impairment has been described following surgical resection, limited studies have investigated its prevalence in nonsurgical treatment. The purpose of this study is to determine the prevalence and predictors of neck disability following head and neck cancer (HNC) treatment and to explore its association with quality of life (QOL).
Study Design
Cross-sectional study.
Setting
HNC survivorship clinic.
Subjects and Methods
We identified 214 survivors who completed treatment ≥1 year prior to evaluation in the clinic. Self-reported neck impairment was measured using the Neck Disability Index. QOL was measured using the University of Washington QOL Questionnaire, with physical and social subscale scores calculated. Regression analysis and trend tests were employed to explore associations.
Results
Over half of survivors (54.2%) reported neck disability. The odds of neck disability in survivors who received nonsurgical treatment and those who received surgery plus adjuvant treatment were 3.46 and 4.98 times higher compared to surgery alone (P = .008, P = .004). Survivors who underwent surgery only had higher physical and social QOL than those who received nonsurgical treatment (physical QOL: P < .001, social QOL: P = .023) and those who received surgery plus adjuvant treatment (physical QOL: P < .001, social QOL: P = .039).
Conclusion
This study revealed a high prevalence of neck disability following nonsurgical treatment. While neck disability is an established sequela of surgical resection, the impact of nonsurgical treatment has gone unrecognized. Early identification and intervention to prevent progression of neck disability are crucial to optimize QOL.
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Effectiveness of Canal Occlusion for Intractable Posterior Canal Benign Paroxysmal Positional Vertigo: A Systematic Review
Britta D. P. J. Maas, MD, Hester J. van der Zaag-Loonen, MD, PhD, Peter Paul G. van Benthem, MD, PhD, Tjasse D. Bruintjes, MD, PhD
First Published 15 Oct 2019.https://doi.org/10.1177/0194599819881437
Abstract
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Objectives
A last resort for therapy for intractable benign paroxysmal positional vertigo (BPPV) is mechanical occlusion of the posterior semicircular canal. The aim of this review was to assess the effect of posterior canal occlusion for intractable posterior canal BPPV on vertigo and to determine the risk of loss of auditory or vestibular function.
Data Sources
A systematic literature search according to the PRISMA statement was performed on PubMed, the Cochrane Library, Embase, Web of Science, and CINAHL. The last search was conducted in June 2018.
Review Methods
Cohort studies with original data and case reports describing >5 cases were included if they analyzed the effect of posterior semicircular canal obliteration in adults with intractable posterior BPPV on vertigo. Two authors screened titles and abstracts for eligibility. The first author screened full texts and analyzed the data.
Results
Eight retrospective studies met the eligibility criteria. The quality of all individual studies was rated fair. Canal occlusion was performed on 196 patients. All studies reported complete resolution of BPPV in all patients (100%). Among postoperatively tested patients, total loss of auditory function and vestibular function was reported in 2 of 190 (1%) and 9 of 68 (13%), respectively.
Conclusion
Posterior semicircular canal plugging resulted in 100% resolution of BPPV in patients with intractable BPPV in all studies. However, the strength of evidence was weak. Potential serious complications, such as deafness and loss of vestibular function, should be taken into account.
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Should You Follow the Better-Hearing Ear for Congenital Cytomegalovirus Infection and Isolated Sensorineural Hearing Loss?
Vanessa Torrecillas, MD, Chelsea M. Allen, PhD, Tom Greene, PhD, Albert Park, MD, Winnie Chung, AUD, Tatiana M. Lanzieri, MD, MPH, Gail Demmler-Harrison, MD
First Published 8 Oct 2019.https://doi.org/10.1177/0194599819880348
Abstract
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Objective
To describe the progression of sensorineural hearing loss (SNHL) in the better- and poorer-hearing ears in children with asymptomatic congenital cytomegalovirus (CMV) infection with isolated SNHL.
Study Design
Longitudinal prospective cohort study.
Setting
Tertiary medical center.
Subjects and Methods
We analyzed hearing thresholds of the better- and poorer-hearing ears of 16 CMV-infected patients with isolated congenital/early-onset or delayed-onset SNHL identified through hospital-based CMV screening of >30,000 newborns from 1982 to 1992.
Results
By 12 months of age, 4 of 7 patients with congenital/early-onset SNHL developed worsening thresholds in the poorer-hearing ear, and 1 had an improvement in the better-hearing ear. By 18 years of age, all 7 patients had worsening thresholds in the poorer-hearing ear and 3 patients had worsening thresholds in the better-hearing ear. Hearing loss first worsened at a mean age of 2 and 6 years in the poorer- and better-hearing ears, respectively. Nine patients were diagnosed with delayed-onset SNHL (mean age of 9 years vs 12 years for the poorer- and better-hearing ears), 6 of whom had worsening thresholds in the poorer-hearing ear and 1 in both ears.
Conclusion
In most children with congenital CMV infection and isolated SNHL, the poorer-hearing ear worsened earlier and more precipitously than the better-hearing ear. This study suggests that monitoring individual hearing thresholds in both ears is important for appropriate interventions and future evaluation of efficacy of antiviral treatment.
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Surgical Explantation of Bone-Anchored Hearing Devices: A 10-year Single Institution Review
Christian G. Fritz, Dennis I. Bojrab, II, MD, Kenny F. Lin, MD, Christopher A. Schutt, MD, Seilesh C. Babu, MD, Robert S. Hong, MD, PhD
First Published 1 Oct 2019.https://doi.org/10.1177/0194599819879653
Abstract
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Objective
To identify clinical variables associated with the decision to surgically discontinue bone-anchored hearing device function.
Study Design
Retrospective chart review.
Setting
Tertiary neurotology referral center.
Subjects and Methods
This study examines surgical interventions performed on existing bone-anchored hearing devices at a single institution from 2008 to 2018. Patient characteristics, indications for implantation, and complications prompting surgical intervention were assessed.
Results
Seventy-seven cases were included in this study. Among patients in the younger cohort (<37 years old), 100% (13 of 13) of those discontinuing their device had a contralateral normal-hearing ear. Conversely, 0% (0 of 14) of the younger patients with bilateral hearing loss surgically discontinued their devices. Within the older cohort (≥37 years old), female patients (P = .002) and those with an increased body mass index (P = .035) were more likely to surgically discontinue their devices. Multivariate analysis revealed that a contralateral normal-hearing ear (P = .001) and infection without soft tissue overgrowth of the abutment (P = .026) were the strongest predictors of device discontinuation, after adjusting for potential confounders.
Conclusion
Surgical discontinuation is associated with several clinical variables. Targeted interventions that are viable alternatives to removal, such as device relocation, should be presented to younger patients with a contralateral normal-hearing ear who experience persistent complications. Patients with persistent infection in the absence of soft tissue overgrowth would especially benefit from enhanced counseling on proper hygiene.
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