Journal of Otolaryngology - Head & Neck Surgery最新文献

ImportancePostoperative hypocalcemia following total thyroidectomy (TT) can significantly affect patients' quality of life. However, the most effective intraoperative interventions to mitigate this risk remain uncertain.ObjectiveTo assess the efficacy of parathyroid gland autotransplantation (PTA), near-infrared autofluorescence (NIRAF), and indocyanine green angiography (ICGA) in reducing postoperative hypocalcemia risk after TT.DesignMeta-analysis.SettingThis meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, utilizing data from PubMed, Embase, and the Cochrane Library, with searches conducted through February 2024.ParticipantsPatients undergoing TT with or without intraoperative interventions of PTA, NIRAF, ICGA, or a combined approach.InterventionsPTA, NIRAF, ICGA, or a combination of these methods.Main Outcome MeasuresIncidence of postoperative transient and permanent hypocalcemia.ResultsFrom 582 identified records, 32 studies, including 13,299 TT patients (6386 with benign and 6913 with malignant conditions), met the inclusion criteria. PTA was associated with a higher incidence of transient postoperative hypocalcemia (OR = 1.98; 95% CI: 1.42-2.77; I² = 84%). Conversely, NIRAF (OR = 0.45; 95% CI: 0.35-0.57; I² = 0%) and ICGA (OR = 0.22; 95% CI: 0.07-0.69; I² = 0%) showed reduced incidences of transient hypocalcemia. The combined NIRAF and ICGA approach, evaluated in 2 studies, yielded inconclusive results (OR = 0.62; 95% CI: 0.28-1.37).Conclusions and RelevanceIntraoperative use of NIRAF and ICGA significantly decreased the incidence of transient hypocalcemia following TT, whereas PTA did not demonstrate similar efficacy. Minimal effects on permanent hypocalcemia were observed across interventions. Further research is necessary to clarify the effectiveness of the combined NIRAF and ICGA approach.

ImportanceOnabotulinumtoxin A (BTX) is the first-line treatment for laryngeal dystonia (LD). The US FDA designated BTX as a pregnancy category C drug because there are no well-controlled studies in pregnant women.ObjectivesTo describe pregnancy and neonatal outcomes in pregnant LD patients treated with BTX injections and to assess the current practice and comfort level of Canadian laryngologists in treating these patients.DesignCase Series and Survey.SettingAcademic, tertiary care, laryngology center.ParticipantsPregnant women who received BTX for LD from 2010 to 2020.InterventionA retrospective chart review was conducted for eligible patients. An anonymous, online, cross-sectional survey was distributed to Canadian laryngologists, according to Dillman's Total Design method.Main outcome measuresPregnancy and neonatal outcomes.ResultsFour adductor LD patients received BTX during each of their 2 pregnancies; 8 pregnancies were examined. Patients received a median of 4.5 treatments (IQR 3) with a median cumulative dose of 5.12 U (IQR 2.93 U) over the whole pregnancy. One pregnancy was pre-term and the median APGAR score was 9 (IQR 0.5). All mothers breastfed their infants. There were no adverse events (AE) and all children were healthy, with a median age of 7 (IQR 2). Twenty-three Canadian laryngologists responded to the survey, for an 85.2% response rate. Three laryngologists (13.0%) have previously injected BTX in a total of 5 pregnant women. All 5 pregnancies went to term with no AE. The majority (68.4%) of respondents indicated that they would offer BTX injections to pregnant LD patients after obtaining informed consent.ConclusionThis case series was the largest in the literature of pregnant LD patients undergoing BTX treatment. The majority of Canadian laryngologists would offer the procedure to pregnant women with informed consent.RelevanceThis study added to the growing literature on the safety of BTX injections in LD patients during pregnancy.

Importance: Pituitary adenomas (PAs) present a notable economic burden on healthcare systems due to their management's reliance on multimodal, often costly interventions.

Objective: To determine total and relative healthcare costs for PAs at Ontario-based institutions.

Design: A retrospective, propensity-score-matched cohort analysis.

Setting: Ontario, Canada, encompassing public healthcare facilities and covering costs over a 6-year study period.

Participants: Adults diagnosed with PA (n = 1675) between April 1, 2013, and March 31, 2019, compared to a general population cohort and a hospitalized control cohort matched on demographics and health factors.

Intervention/exposures: Analysis of healthcare cost components (inpatient, outpatient, and diagnostic services) and cost trajectories postsurgery for PAs.

Main outcome measures: Primary outcome was total annualized healthcare costs for patients with PA relative to the general and hospitalized cohorts. Relative costs were estimated using a negative binomial regression model.

Results: Of 1675 patients with PA, total annualized costs were $49,992. Highest total costs were associated with inpatient hospitalization ($24,796) and physician services/diagnostic evaluations ($20,075). After propensity score matching, patients with PA had 12.7 times higher costs [95% confidence interval (CI) (10.9, 14.8), P < .0001] during the preadmission/admission period, which remained elevated postoperatively (P < .05). Total costs did not differ between patients with PA and the hospitalized cohort [RR 0.97, 95% CI (0.92, 1.03); P = .3271] in the preadmission/admission period; however, follow-up costs were 37% lower for patients with PA in the 1st follow-up year [RR 0.63, 95% CI (0.51, 0.77); P < .0001], and up to 50% lower by the 5th year [RR 0.50, 95% CI (0.36, 0.68); P < .0001].

Conclusions: This study provided a comprehensive assessment of the economic burden of PAs on the publicly-funded healthcare system. Patients with PA had higher annualized total costs across all observed time periods compared to the general population and lower annualized total costs compared to patients admitted to a surgical ward.

Relevance: This study highlights the financial impact of PA management on healthcare resources and provides a basis for future research aimed at cost-efficiency improvements in long-term PA care.

Importance: The objective response (ORR) rate in patients with locally advanced hypopharyngeal squamous cell-carcinoma (LA-HPSCC) following neoadjuvant chemotherapy (NACT) of albumin-bound paclitaxel plus carboplatin is low. At present, it is unclear whether the addition of pembrolizumab could increase the ORR or not.

Objective: To investigate whether the addition of pembrolizumab could increase the ORR, and to develop a nomogram to predict the response of pembrolizumab addition.

Design: Retrospective cohort study.

Setting: This study was conducted at a single institution.

Participants: This study included 129 patients who conformed to the inclusion criteria.

Intervention or exposures: NACT with or without pembrolizumab for patients with LA-HPSCC.

Main outcome measures: The ORR was analyzed according to the RECIST 1.1 criteria and a nomogram was developed based on least absolute shrinkage and selection operator and multivariable Cox regression analysis. Predictive accuracy and discriminative ability of the nomogram were evaluated by receiver operating characteristics, precision recall, calibration curves, and decision curve analysis.

Results: Eighty-two patients received NACT and 47 also received pembrolizumab. ORR was higher in patients receiving additional pembrolizumab (66.0% vs 47.6%, χ² = 4.074, P = .044). The nomogram identified pretreatment levels of lymphocytes and red blood cells as independent predictors of a high ORR, while basophil levels were an independent predictor of a low ORR. Calibration curve showed that the nomogram-based predictions corresponded well with actual observations. C-index of the nomogram was 0.925 (0.848-1.002) and the area under curve was 0.925. Decision curve analysis affirmed that the nomogram had important clinical value.

Conclusions and relevance: Pembrolizumab could improve the ORR in LA-HPSCC patients treated with NACT. Furthermore, a risk-prediction nomogram incorporating readily assessable routine pretreatment blood parameters can accurately estimate the response to NACT with pembrolizumab, leading to precise treatment and minimizing the waste of medical resources.

Objective: Impacted esophageal foreign bodies (EFBs) are a common but preventable presentation in children, requiring prompt removal in the operating room by esophagoscopy. Our objective was to describe the overall cost of impacted pediatric EFBs and determine factors that increase resource burden.

Methods: A cost analysis of pediatric patients undergoing esophagoscopy for EFB removal from 2010 to 2021 was performed. Characteristics of each EFB, patient transfer, and hospital course were collected. Direct and indirect healthcare costs were calculated using hospital-specific costs and provincial fees. Amounts were calculated in Canadian dollars.

Results: Six hundred and eighty patients were included. The total amount spent on pediatric EFBs from 2010 to 2021 was $2,673,288. The mean total cost per child with an EFB was $3469. An extra hour of delay before Otolaryngology-Head and Neck Surgery (OHNS) consultation at a tertiary hospital corresponded to an $816 cost [95% confidence interval (CI; 244.7-1287.4)]. On average, children requiring transfer to a tertiary care center cost $1965 more than those initially presenting to a tertiary care center (P = .001). Higher-risk EFBs (n = 165, 24%) were associated with a longer hospital stay and greater complication rate and resulted in a $4095 increase in overall cost compared to lower-risk EFBs [$6829 (standard deviation (SD) $11,347) vs $2734 (SD $10,451), P = .02]. Button battery ingestions cost 8.8 times more than non-dangerous EFBs, such as coins. Longer distance for transfer was associated with a higher likelihood of having complications [odds ratios (OR) 1.5, 95% CI (1.1-1.8)].

Conclusion: EFBs pose a significant economic burden to the healthcare system, driven by transfer to a tertiary care center, delays in transfer to the operating room, and high-risk EFBs. It is critical to identify areas for improved efficiency such as increased parental education for primary prevention, early involvement of the OHNS team and improving the capacity of community hospitals to manage EFB to limit transfers when possible.

ImportanceQuality indicators are used to evaluate the quality of healthcare delivery and as a speciality, otolaryngology-head and neck surgery (OHNS) is beginning to transition toward this empirical understanding of healthcare quality and delivery.ObjectiveTo describe the number and quality of studies that have developed novel quality indicators for any subdiscipline in OHNS.DesignWe performed a database search of MEDLINE (Ovid), EMBASE (Ovid), Web of Science, and Cochrane Database of Systematic Reviews. We did not employ language or study-type restrictions and included studies published from database inception to October 2024.Study SelectionFollowing abstract screening, 184 articles underwent full-text screen. Eligible studies developed quality indicators in any subdiscipline within OHNS. Article screening and full-text review was performed in duplicate.Data Extraction and SynthesisWe extracted study-specific and methodological data in duplicate. Quality appraisal was assessed using the Appraisal of Indicators through Research and Evaluation instrument.ResultsWe identified 10,592 studies, of which 25 studies developed new quality indicators. Quality indicator development studies primarily focused on otology/neurotology, pediatric OHNS, and head and neck surgery. Few studies investigated facial plastics, rhinology and skull base surgery, and laryngology. Most studies employed Delphi consensus methods and patient engagement was rare. Consensus methodology reporting was poor and indicators were often not validated. Outcome indicators were often measured with fewer studies investigation structure or process indicators.ConclusionsQuality indicators may help standardize and improve patient care in OHNS. Future research should focus on structure and process indicators, while improving reporting, optimizing panel composition, and validating quality indicators.

ImportanceLingual thyroglossal duct cysts (LTGDCs) are rare congenital anomalies that necessitate proactive surgical intervention due to their potential for life-threatening airway obstruction. The challenging anatomical location of LTGDCs complicates their surgical management, and there are currently no standardized surgical modalities in place.ObjectiveTo analyze the clinical features of LTGDCs and evaluate the feasibility, safety, and efficacy of coblation-assisted transoral endoscopic excision of LTGDCs.DesignRetrospective case series (2009-2022) analyzing preoperative, intraoperative, and postoperative data.SettingTertiary academic center.ParticipantsTwenty-nine patients (20 males, 9 females; ages 3-70, with a median age of 34 years) were diagnosed with LTGDCs, including 7 (24.1%) with recurrent LTGDCs following prior surgeries at other institutions.InterventionCoblation-assisted transoral endoscopic excision of LTGDC using FK retractors and a 30° Hopkins telescope for optimal visualization and manipulation.Main Outcome MeasuresComplete cyst excision, postoperative recovery, recurrence rates, complications, and surgical feasibility.ResultsAll LTGDCs were completely excised. During the procedure, it was found that the LTGDCs abutted but did not adhere to the hyoid bone, which allowed for their dissection from the periosteum of the hyoid bone using coblation. Postoperative recovery was uneventful, with an average postoperative stay of 3.1 days (range 1-5 days). No complications, such as bleeding, infection, or airway obstruction, occurred. The mean follow-up period was 5.3 years (range 6 months to 12.4 years), with no recurrences observed during this time.ConclusionsCoblation-assisted transoral endoscopic excision is a reliable, effective, and minimally invasive approach for managing LTGDCs. It ensures complete removal with low recurrence and complication rates, aided by superior visualization and manipulation space provided by FK retractors and a 30° Hopkins telescope.RelevanceThis technique offers a safe alternative to traditional surgeries, reducing trauma and enhancing recovery. Future studies should explore comparisons with other surgical modalities to validate their broader applicability.

ImportanceThe retrograde cricopharyngeus dysfunction (R-CPD) is an emerging topic in otolaryngology, gastroenterology, and primary care.ObjectiveTo review the current literature about the etiology, clinical presentation, and management of retrograde cricopharyngeus dysfunction (R-CPD).DesignSystematic review.SettingThree investigators conducted the PubMED, Scopus, and Cochrane Library review of the literature related to the etiologies and management of patients with R-CPD through the PRISMA statements.ParticipantsStudies that incorporated R-CPD patients.InterventionsIn-office, or operating room botulinum toxin injection, or no treatment.Main outcome measuresEtiology, clinical presentation, and therapeutic outcomes.ResultsSeventeen studies met the inclusion criteria (826 patients). A family history was reported in 28.0% of cases with most patients developing R-CDP symptoms in childhood (55.5%). In addition to the cardinal symptom of the inability to belch, associated complaints of bloating and chest pain, gurgling noises, and excessive flatulence were found in 95.7%, 86%, and 80.2% of cases, respectively.The diagnosis was recognized by patients themselves in 78.9% of cases. The immediate success rate of botulinum toxin injection into the cricopharyngeal sphincter in facilitating burping was 92.5%. Recurrence occurred in the first month of follow-up in 9.5% of cases, whereas 12.6% and 27.9% of patients had recurrence during the 1-5 months and more than 6 months posttreatment, respectively. Transient dysphagia is the most prevalent complication after botulinum toxin injection (31.1%). The heterogeneity was high across studies, limiting the establishment of further combined analyses.Conclusion and relevanceR-CPD is a recently-recognized and likely-underdiagnosed condition associated with severe symptoms affecting the quality of life of patients. Future studies are needed to elucidate the etiology of this condition, develop adequate patient-reported outcome questionnaires for the baseline and follow-up evaluations of symptoms, and propose therapeutic consensus.

ImportanceNeck dissection is a common surgical treatment for patients with oral squamous cell carcinoma (OSCC). Due to the low incidence of level IIb metastases and the risk of injury to the spinal accessory nerve during level IIb dissection, the need for preventive neck dissection of this area has been discussed.ObjectiveThis study aimed to verify the incidence of level IIb metastases in patients with cN0 OSCC and to discuss the need for excision.DesignRetrospective cohort study.SettingThis study was conducted at 3 centers: the Department of Oral and Maxillofacial Surgical Oncology at the Institute of Science Tokyo Hospital, the Department of Oral and Maxillofacial Surgery at Kobe University Graduate School of Medicine, and the Department of Clinical Oral Oncology, Hokkaido Cancer Center.ParticipantsIn total, 222 patients with cN0 OSCC underwent supraomohyoid neck dissection (SOHND) between 2013 and 2021.Main Outcome MeasuresIncidence of level IIb metastases in patients with cN0 OSCC.ResultsLymph node metastasis was confirmed in 57 patients (25.7%). Two patients (0.9%) had level IIb metastasis. The primary site in these cases was the tongue in 1 case and the lower gingiva in the other, both with advanced cT4 primary tumors. Isolated level IIb metastasis was observed in tongue OSCC samples. Both patients with level IIb metastases experienced primary recurrence. The 5 year overall survival rates for pN(-) and pN(+) patients were 80.6% and 74.3%, respectively (P = .229). The 5 year disease-specific survival rates for the pN(-) and pN(+) patients were 89.6% and 77.2%, respectively (P = .057).Conclusions and RelevanceLevel IIb lymph node involvement in clinical N0 neck cancers is rare. Thus, SOHND may be adequate for most patients with OSCC. Therefore, level IIb dissection may be omitted in patients with cN0 in early-stage OSCC.

ImportanceNontechnical skills are crucial in delivering critical and urgent patient care. Through our simulation module, we gear residents and interprofessional personnel with the knowledge and skills necessary to tackle complex airway emergencies and limit human error.ObjectiveDevelop, implement, adapt, and evaluate a novel interdisciplinary and interprofessional crisis resource management (CRM) simulation module for the management of complex airways.DesignSimulation-Based Quality Improvement Project.SettingMcGill University's Arnold and Blema Steinberg Medical Simulation Center and a variety of hospital environments at the McGill University Health Centre in Montreal, Quebec, Canada.Participants138 residents (otolaryngology, anesthesia, pediatric emergency medicine) and allied healthcare professionals (nurses and respiratory therapists) participated in 20 unique scenarios.Intervention or ExposuresFrom 2012 to 2022, modules occurred from 4 to 6 half days per year, structured as 3 to 4 simulation scenarios, each followed by debriefing sessions.Main Outcome MeasuresParticipants completed self-assessment forms evaluating module satisfaction, CRM skill development, and narrative commentary. Quantitative and qualitative data were obtained and analyzed.ResultsParticipants reported a significant perceived increase (P < .05) in all nontechnical CRM skills. Participants without previous CRM training reached comparable levels in CRM skills to those with such training. Increasing involvement of allied healthcare professionals, formal debriefing focused on role clarity, and increasing complexity of scenarios are identified as key elements for stressing CRM skills and consolidating lessons learned.ConclusionsThis module is among the first of its kind in otolaryngology given its interprofessional, longitudinal, and evolving nature, while providing an opportunity for residents to develop nontechnical skills through simulation. Its interdisciplinary and interprofessional nature is a key element to its success.RelevanceThis module aims to translate into positive results in patient safety and patient outcomes in challenging airway management scenarios. Implementing modules as continued medical education may help maintain proficiency overtime.