JAMA otolaryngology-- head & neck surgery最新文献

Importance: Neural recordings from cochlear implant users provide a valuable, noninvasive measure of auditory nerve function. However, inconsistent methods for acquiring and analyzing these recordings limit their clinical application.

Objective: To develop and validate an automated method for standardizing the analysis of electrically evoked compound action potentials in cochlear implant users, and to characterize longitudinal changes in auditory nerve function across the largest cohort studied to date.

Design, settings, and participants: This multicenter cohort study used nonlinear curve-fitting models to analyze electrically evoked compound action potentials acquired during clinical programming and follow-up at multiple US centers from July 28, 2002, to August 13, 2017. Data were analyzed from October 8, 2024 to May 6, 2025.

Main outcomes and measures: Model fit success rates; variation in auditory nerve response parameters with age, sex, electrode location, and duration of implant use; and identification of age-related periods of peripheral neural plasticity.

Results: The analysis included 1 145 323 electrically evoked compound action potential recordings comprising 169 159 growth functions from 10 111 cochlear implants in 7416 patients (3560 [48%] female and 3856 [52%] male individuals). Both models successfully fit approximately 80% of auditory-nerve growth functions. Thresholds increased from apex to base along the cochlear array, paralleled by a decline in response slope and plateau. Latencies remained stable across electrode locations. Age at implantation significantly predicted nerve response slope, with younger recipients showing steeper slopes that declined with increasing age, particularly after adolescence. In infants and toddlers, slopes continued to increase over 5 years of implant use, suggesting peripheral neural plasticity early in life. Older recipients showed minimal slope change over time. Although thresholds rose modestly with prolonged device use, slope and plateau stabilized after age 30 years, indicating that age at implantation, rather than stimulation duration, was the primary determinant of auditory nerve responsiveness.

Conclusions and relevance: This cohort study introduces a robust and scalable framework for in vivo assessment of auditory nerve function and monitoring of peripheral plasticity across the lifespan. The findings highlight the critical importance of early cochlear implantation for preserving neural health and optimizing long-term outcomes.

Importance: Excessive bleeding during endoscopic sinus surgery (ESS) impairs visualization and increases complications. Controlled hypotension is widely used; however, comparative effectiveness of available pharmacological agents remains uncertain.

Objective: To compare the effectiveness and safety of hypotensive drugs for reduced bleeding in ESS.

Data sources: PubMed, Scopus, Web of Science, and Cochrane databases were searched from inception to December 2024, and updated to include studies up to May 2025.

Study selection: Randomized clinical trials of patients undergoing ESS and receiving dexmedetomidine, clonidine, esmolol, labetalol, bisoprolol, metoprolol, diltiazem, nifedipine, or verapamil vs placebo. A total of 1258 records were screened.

Data extraction and synthesis: Data were extracted and assessed using the Cochrane risk of bias tool. Certainty was rated using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) framework. A random-effects meta-analysis was conducted in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement guidelines.

Main outcomes and measures: Surgical bleeding score, intraoperative mean arterial pressure (MAP), and mean intraoperative heart rate. Secondary outcomes included blood loss, surgery duration, and emergence time.

Results: The analysis included 52 randomized clinical trials involving 3526 participants; of these, 43 studies contributed to the network analysis. Several agents were associated with reduced bleeding vs placebo: diltiazem (mean difference [MD], -1.25; 95% CI, -2.13 to -0.37), esmolol (MD, -1.16; 95% CI, -1.80 to -0.51), dexmedetomidine (MD, -1.09; 95% CI, -1.48 to -0.70), labetalol (MD, -1.00; 95% CI, -1.58 to -0.42), and clonidine (MD, -0.69; 95% CI, -1.23 to -0.16). Dexmedetomidine was associated with the most reduced MAP (MD, -30.30 mm Hg; 95% CI, -47.91 to -12.69), followed by clonidine (MD, -28.61; 95% CI, -53.11 to -4.11), esmolol (MD, -27.62; 95% CI, -49.73 to -5.51), and labetalol (MD, -26.54; 95% CI, -47.20 to -5.87). At 60 minutes, bisoprolol (MD, -58.30; 95% CI, -67.50 to -49.10 beats per minute [bpm]), verapamil (MD, -49.90; 95% CI, -58.98 to -40.82 bpm), and labetalol (MD, -43.89; 95% CI, -54.59 to -33.18 bpm) produced the largest heart rate reductions. Esmolol (MD, -3.67; 95% CI, -4.21 to -3.13 minutes) and labetalol (MD, -3.64; 95% CI, -4.79 to -2.49 minutes) shortened emergence time.

Conclusions and relevance: In this systematic review and network meta-analysis, controlled hypotension improved surgical field quality in ESS with comparable safety. Diltiazem, esmolol, dexmedetomidine, labetalol, and clonidine were effective; dexmedetomidine was associated with reduced MAP the most, and esmolol favored recovery.

Importance: Merkel cell carcinoma (MCC) is a rare neuroendocrine malignant neoplasm often affecting the head and neck. Sentinel lymph node biopsy (SLNB) is routinely performed; however, the accuracy and reliability of SLNB for head and neck MCC remains unknown.

Objective: To determine the accuracy of SLNB in head and neck MCC and inform pre- and post-SLNB risk stratification.

Design, setting, and participants: This was a single-center cohort study of patients with clinically node-negative head and neck MCC who underwent SLNB from January 2006 to January 2025; median (IQR) follow-up was 1.9 (0.8-4.6) years. Data analysis was conducted from April to November 2025.

Interventions: SLNB outcome and nodal disease status.

Main outcomes and measures: SLNB accuracy measured by sensitivity, negative predictive value (NPV), and false negative (FN) rate. FN SLNB was defined as regional nodal recurrence at the first site of recurrence after a negative SLNB without concurrent local or in-transit recurrence. Factors associated with failed SLNB (defined as nonvisualization on lymphoscintigraphy, inability to identify the sentinel lymph node intraoperatively, or absence of nodal tissue in the pathology specimen) were evaluated using effect-size measures. Cox proportional hazards model identified factors associated with nodal disease, comparing patients who developed nodal disease (identified by SLNB or subsequent clinical and/or imaging evaluation) with those who did not develop nodal disease during follow-up.

Results: Of 86 participants (mean [SD] age, 75.6 [9.6] years; 36 female [41.9%] and 50 male [58.1%] individuals) with clinically node-negative head and neck MCC, 69 (80.2%) underwent SLNB. Occult nodal disease was identified in 19 participants (27.5%). SLNB sensitivity was 52.6% (10 of 19 patients), NPV was 88.6% (31 of 35 patients), and FN rate was 26.7% (4 of 15 patients). SLNB failed in 29.0% (20 of 69 patients), with tumor location, female sex, and older age having medium to large effect on SLNB failure. Lymphovascular invasion, infiltrative growth pattern, and tumor size had the largest effect size on nodal disease with Cox analysis.

Conclusions and relevance: In this large single-site cohort study, SLNB remained a useful tool in head and neck MCC, identifying more than half of occult nodal disease. Given reduced performance in this region, patients with failed SLNB or negative SLNB plus high-risk features may benefit from tailored management, including intensified therapy and surveillance.