Ethical Considerations in the Advent of Artificial Intelligence in Otolaryngology
Alexandra M. Arambula, MD1, Andrés M. Bur, MD1
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, MPH1, Paul J. Rowan, PhD, MPH2
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, MD1, Yanru Li, MD2, Yue Qu, MD3, Junbo Zhang, MD4, Xin Cao, MM3, Jingying Ye, MD3
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, MD1, Marco Mascarella, MD12, Maida J. Sewitch, PhD2, François Cloutier, MD, FRCSC3, Tamara Mijovic, MD, FRCSC1
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, MPH12, Almut G. Winterstein, PhD134, Xi Wang, MPH1, Kiyon Rhew, PharmD15, Patrick J. Antonelli, MD46
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, MBBS1, Zhi Min Ng, MBBS, MRCPH2, Yu Xian Pang, MBBS3, Annette H. C. Ang, MBBS, MRCS, MMed4, Cristelle C. T. Chow, MBBS, MRCPH, MMed2, Oon Hoe Teoh, MBBS, MMed, MRCPCH2, Jan Hau Lee, MBBS, MRCPCH, MCI56
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, MD1, Xiaoxia Han, PhD2, Donald H. Penning, MD3, John R. Craig, MD4
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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PHQ-9 and SNOT-22: Elucidating the Prevalence of Depression in Chronic Rhinosinusitis
Laura J. Vandelaar, MD1, Zi Yang Jiang, MD1, Alok Saini, MD2, William C. Yao, MD1, Amber U. Luong, MD, PhD1, Martin J. Citardi, MD1
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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Prevalence of Pediatric Dizziness and Imbalance in the United States
Jacob R. Brodsky, MD12, Sophie Lipson1, Neil Bhattacharyya, MD23
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. Ronner1, Liliya Benchetrit2, Patricia Levesque, MS1, Razan A. Basonbul, MBBS, MPH13, Michael S. Cohen, MD14
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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Commentary–Reflections
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Reflections: Starting an Otolaryngology Medical Student Interest Group
Amanda Hu, MD, FRCSC12
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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Short Scientific Communication
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US Medical Trainees’ Knowledge of Human Papilloma Virus and Head and Neck Cancer
Benjamin M. Laitman, MD, PhD1, Lukas Ronner2, Kristin Oliver, MD3, Eric Genden, MD1
First Published 29 Oct 2019.https://doi.org/10.1177/0194599819886117
Abstract
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Recognizing Persistent Disease in Well-Differentiated Thyroid Cancer and Association with Lymph Node Yield and Ratio
Julia E. Noel, MD1, Lisa A. Orloff, MD1
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, MD12, Vinay K. Rathi, MD123, Stacey T. Gray, MD12, Regan W. Bergmark, MD245
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, MSc1, Eric Lortie, MHA2, Brian Rotenberg, MD, MPH, FRCSC3, Leigh Sowerby, MD, MHM, FRCSC3
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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Adverse Events Associated with Balloon Sinuplasty: A MAUDE Database Analysis
Kevin Hur, MD12, Marshall Ge, MD1, Jeehong Kim, MD1, Elisabeth H. Ference, MD, MPH1
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, MD1, Mu He, MD1, Xin Cao, MD1, Jinkun Xu, MD1, Yuhuan Zhang, MM1, Dan Kang, MM2, Jingying Ye, MD, PhD1
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, RN12, Lingyun Lyu, MS3, Michael A. Belsky2, Leila J. Mady, MD, PhD, MPH2, Dan P. Zandberg, MD4, David A. Clump, II, MD, PhD5, Heath D. Skinner, MD, PhD5, Shyamal Das Peddada, PhD3, Susan George, DPT, PT6, Jonas T. Johnson, MD2
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, MD1, Hester J. van der Zaag-Loonen, MD, PhD1, Peter Paul G. van Benthem, MD, PhD2, Tjasse D. Bruintjes, MD, PhD1
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, MD1, Chelsea M. Allen, PhD2, Tom Greene, PhD2, Albert Park, MD1, Winnie Chung, AUD3, Tatiana M. Lanzieri, MD, MPH4, Gail Demmler-Harrison, MD5
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. Fritz1, Dennis I. Bojrab, II, MD2, Kenny F. Lin, MD2, Christopher A. Schutt, MD234, Seilesh C. Babu, MD2345, Robert S. Hong, MD, PhD2345
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.
Alexandra M. Arambula, MD1, Andrés M. Bur, MD1
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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Laryngotracheal Stenosis in Early vs Late Tracheostomy: A Systematic Review
Steven D. Curry, MD, MPH1, Paul J. Rowan, PhD, MPH2
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, MD1, Yanru Li, MD2, Yue Qu, MD3, Junbo Zhang, MD4, Xin Cao, MM3, Jingying Ye, MD3
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, MD1, Marco Mascarella, MD12, Maida J. Sewitch, PhD2, François Cloutier, MD, FRCSC3, Tamara Mijovic, MD, FRCSC1
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, MPH12, Almut G. Winterstein, PhD134, Xi Wang, MPH1, Kiyon Rhew, PharmD15, Patrick J. Antonelli, MD46
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, MBBS1, Zhi Min Ng, MBBS, MRCPH2, Yu Xian Pang, MBBS3, Annette H. C. Ang, MBBS, MRCS, MMed4, Cristelle C. T. Chow, MBBS, MRCPH, MMed2, Oon Hoe Teoh, MBBS, MMed, MRCPCH2, Jan Hau Lee, MBBS, MRCPCH, MCI56
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, MD1, Xiaoxia Han, PhD2, Donald H. Penning, MD3, John R. Craig, MD4
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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PHQ-9 and SNOT-22: Elucidating the Prevalence of Depression in Chronic Rhinosinusitis
Laura J. Vandelaar, MD1, Zi Yang Jiang, MD1, Alok Saini, MD2, William C. Yao, MD1, Amber U. Luong, MD, PhD1, Martin J. Citardi, MD1
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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Prevalence of Pediatric Dizziness and Imbalance in the United States
Jacob R. Brodsky, MD12, Sophie Lipson1, Neil Bhattacharyya, MD23
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. Ronner1, Liliya Benchetrit2, Patricia Levesque, MS1, Razan A. Basonbul, MBBS, MPH13, Michael S. Cohen, MD14
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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Commentary–Reflections
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Reflections: Starting an Otolaryngology Medical Student Interest Group
Amanda Hu, MD, FRCSC12
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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Short Scientific Communication
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US Medical Trainees’ Knowledge of Human Papilloma Virus and Head and Neck Cancer
Benjamin M. Laitman, MD, PhD1, Lukas Ronner2, Kristin Oliver, MD3, Eric Genden, MD1
First Published 29 Oct 2019.https://doi.org/10.1177/0194599819886117
Abstract
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Recognizing Persistent Disease in Well-Differentiated Thyroid Cancer and Association with Lymph Node Yield and Ratio
Julia E. Noel, MD1, Lisa A. Orloff, MD1
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, MD12, Vinay K. Rathi, MD123, Stacey T. Gray, MD12, Regan W. Bergmark, MD245
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, MSc1, Eric Lortie, MHA2, Brian Rotenberg, MD, MPH, FRCSC3, Leigh Sowerby, MD, MHM, FRCSC3
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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Adverse Events Associated with Balloon Sinuplasty: A MAUDE Database Analysis
Kevin Hur, MD12, Marshall Ge, MD1, Jeehong Kim, MD1, Elisabeth H. Ference, MD, MPH1
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, MD1, Mu He, MD1, Xin Cao, MD1, Jinkun Xu, MD1, Yuhuan Zhang, MM1, Dan Kang, MM2, Jingying Ye, MD, PhD1
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, RN12, Lingyun Lyu, MS3, Michael A. Belsky2, Leila J. Mady, MD, PhD, MPH2, Dan P. Zandberg, MD4, David A. Clump, II, MD, PhD5, Heath D. Skinner, MD, PhD5, Shyamal Das Peddada, PhD3, Susan George, DPT, PT6, Jonas T. Johnson, MD2
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, MD1, Hester J. van der Zaag-Loonen, MD, PhD1, Peter Paul G. van Benthem, MD, PhD2, Tjasse D. Bruintjes, MD, PhD1
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, MD1, Chelsea M. Allen, PhD2, Tom Greene, PhD2, Albert Park, MD1, Winnie Chung, AUD3, Tatiana M. Lanzieri, MD, MPH4, Gail Demmler-Harrison, MD5
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. Fritz1, Dennis I. Bojrab, II, MD2, Kenny F. Lin, MD2, Christopher A. Schutt, MD234, Seilesh C. Babu, MD2345, Robert S. Hong, MD, PhD2345
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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