Journal of Otolaryngology - Head & Neck Surgery最新文献

Background: The objective of the following retrospective review was to perform a cost-effectiveness analysis of the use of molecular testing of indeterminate thyroid nodules compared to current management practices in Nova Scotia, Canada.

Methods: All cases of cytologically indeterminate thyroid nodules from January 1st, 2014 to December 31st, 2018 were reviewed. All interventions related to an indeterminate thyroid nodule were recorded. Patients were excluded if less than 18 years old if no further information regarding medical management was electronically available beyond the diagnosis of an indeterminate thyroid nodule, history of radiation, or previous thyroid surgery prior to diagnosis of an indeterminate thyroid nodule in the remaining lobe. Microcosting was performed to determine the cost of all relevant interventions including repeat fine needle aspiration biopsy, ultrasound, thyroid surgery(s), and molecular testing. Institution-specific transition state probabilities were calculated and used to build a cost-effectiveness analysis model. Model output was an incremental cost-effectiveness ratio, defined as the ratio of cost difference to effectiveness difference between routine molecular testing and the current management strategy, yielding cost per surgery avoided.

Results: The mean effectiveness of the current management of indeterminate thyroid nodules in Nova Scotia based on the American Thyroid Association guidelines is 64% at a mean cost of $6431, while the simulated mean effectiveness of routine molecular testing is 89% at a mean cost of $8414. Differences in management strategies generated an incremental cost-effectiveness ratio of $7876 per surgery avoided.

Conclusion: Routine molecular testing is the more effective strategy for the appropriate management of indeterminate thyroid nodules; however, it comes at a higher mean cost compared to the current management strategy. As the cost of molecular testing continues to decrease, and the cost of OR resources continues to rise, molecular testing is likely to become the optimal strategy in Nova Scotia.

Background: The CO₂ laser is frequently used during microlaryngeal surgery (MLS) for a variety of pathology including laryngeal malignancy and stenosis. Learning how to use the laser safely is part of the curriculum for every otolaryngology resident. However, assessment of laryngoscopy technical skills can be challenging for supervisors, making it difficult to adequately provide feedback to trainees.

Objectives: "LAser Surgical skills Evaluation for Residents" (LASER) Scale aims to facilitate the evaluation of residents' performance and promote constructive feedback.

Methods: The initial evaluation grid was based on a literature review of CO₂ laser laryngoscopy (with an emphasis on indications, technique, safety, and efficacy) using Covidence systematic review software (Veritas Health Innovation). The final version was produced after 4 rounds of Delphi surveys.

Results: This study was an international collaboration including 15 otolaryngologists with either laryngology or head and neck surgery subspecialties. Panelists were based in Canada (8), the United States (3), France (1), Spain (1), Belgium (1), and Lebanon (1). The process involved 4 rounds of Delphi surveys. Assessment categories included: anesthesia considerations, pre- and perioperative laser safety measures, and surgical technique. Consensus was reached on final survey completion.

Conclusions: Through a modified Delphi method, a novel scale was developed through an international collaborative effort that evaluates resident skillset in CO₂ laser MLS. Future studies are warranted to validate this assessment tool.

Background: The high incidence of pediatric acute otitis media (AOM) makes the implications of overdiagnosis and overtreatment far-reaching. Quality indicators (QIs) for AOM are limited, drawing from generalized upper respiratory infection QIs, or locally developed benchmarks. Recognizing this, we sought to develop pediatric AOM QIs to build a foundation for future quality improvement efforts.

Methods: Candidate indicators (CIs) were extracted from existing guidelines and position statements. The modified RAND Corporation/University of California, Los Angeles (RAND/UCLA) appropriateness methodology was used to select the final QIs by an 11-member expert panel consisting of otolaryngology-head and neck surgeons, a pediatrician and family physician.

Results: Twenty-seven CIs were identified after literature review, with an additional CI developed by the expert panel. After the first round of evaluations, the panel agreed on 4 CIs as appropriate QIs. After an expert panel meeting and subsequent second round of evaluations, the panel agreed on 8 final QIs as appropriate measures of high-quality care. The 8 final QIs focus on topics of antimicrobial management, specialty referral, and tympanostomy tube counseling.

Conclusions: Evidence of variable and substandard care persists in the diagnosis and management of pediatric AOM despite the existence of high-quality guidelines. This study proposes 8 QIs which compliment guideline recommendations and are meant to facilitate future quality improvement initiatives that can improve patient outcomes.

Importance: The management of hypopharyngeal squamous cell carcinoma (HPSCC) continues to be one of the most formidable challenges in the realm of head and neck oncology.

Objectives: The aim of this meta-analysis was to evaluate the disparity in survival outcomes between upfront surgery and upfront concurrent chemoradiotherapy as the primary treatment modality in patients with HPSCC.

Design: Systemic review with meta-analysis.

Setting: The meta-analysis was conducted in strict accordance with the PRISMA guideline. A literature search through PubMed, EMBASE, and the Cochrane Library were conducted until January 2023. The adjusted hazard ratio (aHR) with 95% confidence intervals (CIs) of different survival outcomes were extracted and pooled.

Participants: Studies that incorporated HPSCC patients without receiving induction chemotherapy.

Interventions: Upfront surgery versus upfront concurrent chemoradiotherapy.

Main outcome measures: Overall survival (OS) and disease-free survival (DFS).

Results: Eight studies published between 2015 and 2023, with a pooled patient population of 1619, were included in this meta-analysis. The outcomes reveal that upfront surgery was notably linked with improved OS (aHR 0.66, 95% CI 0.57-0.78) and DFS (aHR 0.75, 95% CI 0.63-0.90). Subgroup analyses were conducted to investigate the impact of the overall stage of the tumor and the extent of surgery on OS. In patients with advanced HPSCC (stages III and IV), upfront surgery remained associated with better OS (aHR 0.65, 95% CI 0.56-0.77). Concerning the extent of surgery, both subgroups exhibited a superior OS outcome associated with upfront surgery (exclusive total laryngopharyngectomy group: aHR 0.54, 95% CI 0.39-0.75; total/partial laryngopharyngectomy group: aHR 0.71, 95% CI 0.59-0.84).

Conclusions and relevance: The results demonstrated that upfront surgery showed better OS and DFS than concurrent chemoradiation and remind the clinicians of the potential reduction in survival outcomes when choosing concurrent chemoradiotherapy as primary treatment.

Importance: Stapedectomy is an effective treatment option for patients with symptomatic otosclerosis. A common surgical technique today is laser stapedotomy, although the equipment required adds a significant cost to the procedure and may not be available in certain, particularly remote, centers. This study aimed to evaluate cold steel stapedectomy in a modern otology practice as a cost-effective and versatile alternative.

Objective: The primary objective was to evaluate the efficacy and safety of cold steel stapedectomy. The secondary objectives included characterizing the prevalence of relevant computed tomography (CT) findings and evaluating other factors such as piston size.

Design: A retrospective case series from April 2006 to November 2021.

Setting: A single tertiary care hospital in Montreal, QC, Canada.

Participants: Patients with suspected otosclerosis and no prior stapes surgery.

Intervention: Cold steel primary stapedectomy.

Main outcome measures: In primary analysis, change in pure tone thresholds, pure tone average (PTA), and complication rates were obtained. Secondary analysis measures included rates of relevant CT findings and change in PTA with piston size.

Results: A total of 302 cases were included in the analysis. The average change in air conduction PTA was a decrease of 27 dB, with 91% (276/302) having over 10 dB of improvement. The air-bone gap was closed to within 10 dB in 82% (248/302) of cases and within 20 dB in 96% (290/302) of cases. Overclosure occurred in 19% of cases, while only 4% resulted in worsened PTA bone conduction thresholds. In secondary analysis, 74% of CT scans demonstrated radiologic otosclerosis. Other findings included suspected superior semicircular canal dehiscence in 1.8%.

Conclusion: Cold steel stapedectomy was demonstrated to be a safe and effective technique, with audiometric results comparable to laser and drill studies in recent literature. It should be considered as a cost-effective and global health accessible alternative. Additionally, CT scans can provide valuable information in the pre-operative workup.

Objective: The surgical strategy of cholesteatomas is still controversial. This study aimed to compare the hearing improvement and determine the prognostic factors between endoscopic and microscopic ear surgery for attic cholesteatoma via a multicenter retrospective study.

Methods: This retrospective study included 169 patients with attic cholesteatoma who received endoscopic ear surgery (EES) or microscopic ear surgery (MES) from 12 otorhinolaryngology centers. Hearing improvement between EES and MES was evaluated, including the postoperative pure tone average (PTA) and air-bone gap (A-B Gap), as well as the hearing threshold across the low-, mid-, and high-frequency. The success rate of grafts was collected. Linear regression was performed to access the prognostic value of preoperative PTA and A-B Gap. Patients were followed up for at least 3 years.

Results: The graft success rate of EES was 89.66% (78/87) versus 80.49% (66/82) for MES. The postoperative PTA and A-B Gap demonstrated significant improvement in EES compared to MES (Post-PTA: t = 3.281, P = .001; Post-A-B Gap: t = 2.197, P = .029). In the EES group, there were 59 ears (67.82%) with a postoperative A-B Gap ≤20 dB HL, which revealed a higher rate of successful hearing outcomes in EES as opposed to MES (χ² = 9.904, P = .019). There were significantly better hearing improvement, shorter surgical times, and lower hospital stays in EES for epitympanic cholesteatoma without stapes superstructure involvement. The preoperative AC ≤79 dB and/or preoperative A-B Gap ≤52 dB was associated with a better prognosis in EES for epitympanic cholesteatoma with stapes superstructure involvement.

Conclusions: EES showed higher graft success rate, better hearing improvement, shorter surgical times and hospital stays for attic cholesteatoma, particularly without stapes superstructure involvement. The range of preoperative PTA and A-B Gap have shown the prognostic value, which maybe a favorable surgical indication for EES or MES.

Background: Conductive or mixed hearing loss with an intact tympanic membrane is a group of diseases characterized by similar clinical symptoms. Definitive diagnosis depends on the findings of exploratory tympanic surgery. Cone-beam computed tomography (CBCT) has great potential for middle ear imaging. This study evaluated the diagnostic value of CBCT for conductive or mixed hearing loss with an intact tympanic membrane.

Methods: CBCT and high-resolution computed tomography (HRCT) imaging data were collected from patients with an intact eardrum who received medical treatment in our hospital for conductive or mixed hearing loss from October 2020 to May 2023. The imaging characteristics and diagnostic values of CBCT and HRCT were analyzed.

Results: A total of 137 patients who met the inclusion criteria and underwent CBCT were enrolled, including 89 with otosclerosis, 41 with ossicular chain interruption, and 7 with tympanosclerosis. CBCT clearly displayed a middle ear focus, such as low-density lesions located in the fissula ante fenestram, ossicular chain malformation or dislocation, and tympanic calcification foci. The area under the curve values for otosclerosis, ossicular chain interruption, and tympanic sclerosis were 0.934, 0.967, and 0.850, respectively. CBCT was more effective than HRCT for visualizing the lenticular process, incudostapedial joint, and stapes footplate.

Conclusions: CBCT of the middle ear demonstrated higher-quality imaging to improve the diagnosis of conductive or mixed hearing loss with an intact tympanic membrane. Therefore, CBCT is recommended for further investigation of noninflammatory diseases of the middle ear with no special findings on HRCT.

Background: Injury to the recurrent laryngeal nerve (RLN) and parathyroid glands (PGs) are the most common and serious complications during the transoral endoscopic thyroidectomy vestibular approach (TOETVA), and their exposure and protection are the most important factors affecting the operation time. Here, we report a novel anatomical landmark and surgical method to shorten the operative time and reduce the chance of injury to the RLN and PGs.

Methods: According to the different exposure methods of the RLN, patients were divided into the experimental group (from top to bottom, E-group) and the comparison group (from outside to inside, C-group), and 1:1 propensity score-matching (PSM) was performed. The demographics, operative data, postoperative data, and postoperative complications were analyzed by comparing the 2 groups.

Results: After PSM, a total of 206 patients were included. Except for tumor size, there were no significant differences between the 2 groups in terms of sex, age, body mass index, presence of Hashimoto's thyroiditis, or extent of surgery. Compared with the C-group, the operative time, in minutes, of the E-group was significantly shorter (hemithyroidectomy with central neck dissection (CND), C = 111.81 ± 25.83 vs E = 100.52 ± 16.47, P = .002 and bilateral thyroidectomy with CND, C = 177.87 ± 36.61 vs E = 156.05 ± 25.60, P = .004), the exposure time, in minutes, of the RLN was reduced (hemithyroidectomy with CND, C = 23.31 ± 7.07 vs E = 11.41 ± 2.75, P < .001 and bilateral thyroidectomy with CND, C = 45.64 ± 14.84 vs E = 21.76 ± 5.57, P < .001). The rate of postoperative temporary PGs and RLN injuries were also reduced (transient hypoparathyroidism, C = 13% vs E = 4%, P = .023 and transient RLN palsy, C = 10% vs E = 2%, P = .017). In addition, the remaining parameters such as the amount of bleeding, number of lymph node metastases, postoperative hospital stay, visual analog scale pain score, recurrence rate, and other complication rates were not significantly different between the 2 groups.

Conclusion: It is safe and feasible to construct Thyroid-RLN Entry Triangle (Peng's Triangle) for PGs and RLN protection in TOETVA. It is beneficial to shorten the operation time and reduce postoperative complications, both worthy of clinical promotion.

Trial registration: This study was registered at the Chinese Clinical Trial Registry (UIN: ChiCTR2300067673, https://www.chictr.org.cn) in accordance with the World Medical Association's Declaration of Helsinki, 2013.

Background: Pediatric laryngotracheal stenosis often requires open airway reconstruction. While these surgeries establish an airway for adequate ventilation, many patients develop subsequent dysphonia. Numerous studies have reported outcomes related to voice.

Objective: This study aims to evaluate dysphonia in pediatric patients following open airway reconstruction, focusing on acoustic parameters, perceptual voice quality, and voice-related quality of life.

Methods: A comprehensive search using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines across 6 databases identified articles involving pediatric patients who underwent open airway reconstruction and reported postoperative vocal acoustic parameters, perceptual voice quality, voice-related quality of life, or vocal mechanics. Articles were assessed for bias risk, and common outcomes were synthesized qualitatively and quantitatively using meta-analyses.

Results: Among 4089 articles, 21 were included, involving 497 pediatric patients. Laryngotracheoplasty was the most common procedure followed by cricotracheal resection. The Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) scale was frequently used to assess voice quality, with a mean score of 55.6 [95% confidence intervals (CIs): 47.9-63.3]. Voice-related quality of life was measured using the pediatric Voice Handicap Index (pVHI) and Pediatric Voice-Related Quality of Life Survey, with mean scores of 35.6 (95% CI: 21.4-49.7) and 83.7 (95% CI: 74.1-93.2), respectively. The fundamental frequency was 210.5 (95% CI: 174.6-246.3). Other common findings included supraglottic phonation, anterior commissure blunting, posterior glottic diastasis, and abnormal vocal cord mobility.

Conclusion: Pediatric patients experiencing dysphonia after open airway reconstruction exhibited moderately decreased voice quality and reduced voice-related quality of life. However, there was inconsistency in study protocols and outcome measures used. Preserving voice quality during airway reconstruction is crucial to avoid negative impacts on quality of life.