Journal of Otolaryngology - Head & Neck Surgery最新文献

ImportanceThere are many methods for pediatric voice assessment, but each has its own limitations. Currently, there are few studies that have compared the outcomes of subjective and objective evaluation methods in children with voice disorders.ObjectiveTo apply and compare the pediatric Voice Handicap Index (pVHI) with acoustic analysis in pediatric benign voice disorders.DesignCase-control study.SettingThis study was conducted at a single institution.ParticipantsPediatric participants with and without benign voice disorders were included from August 2021 to April 2023.Intervention or ExposuresThe questionnaire results for the pVHI were obtained, and acoustic analysis was conducted.Main Outcome MeasuresThe main outcomes included the pVHI scores, acoustic parameters, and the Pearson Correlation Coefficient.ResultsOut of the 338 participants, 160 children were diagnosed with voice disorders, whereas 178 did not exhibit such conditions. The total scores and those of each subscale were significantly higher in the patient group than in the control group (P < .05). Significant differences were also observed in the fundamental frequency (228.13 ± 66.78 vs 253.65 ± 47.21), jitter (2.08 ± 2.59 vs 2.42 ± 1.75), shimmer (8.52 ± 5.78 vs 9.44 ± 3.69), harmonic to noise ratio (HNR) (0.50 ± 0.68 vs 0.65 ± 0.19), s/z ratio (1.46 ± 1.89 vs 0.99 ± 0.44), and maximum phonation time (6.08 ± 3.38 vs 7.82 ± 2.50) (P < .05). When comparing the types of diseases, the physical dimension of the pVHI (17.43 ± 7.02 vs 15.29 ± 6.92 vs 13.32±7.71) and the HNR (0.39 ± 0.16 vs 0.41 ± 0.21 vs 0.75 ± 1.24) were most negatively affected in the vocal fold polyps group. Moderate to strong correlations were shown among the pVHI total and each subscale scores (P < .05), while the highest r score was shown between the physical and the total scores of the pVHI (r = 0.882).Conclusions and RelevancePediatric patients with voice disorders exhibit more severe voice handicaps in both pVHI scores and acoustic parameters. The total score of the pVHI is moderately to strongly correlated with each subscale, whereas no strong correlation was presented between different acoustic parameters or between acoustic parameters and pVHI scores. This indicates that the two evaluation methods are not interchangeable; thus, a comprehensive evaluation is essential in clinical practice to prevent bias.

ImportanceBilateral vocal cord paralysis is a challenging problem to manage in adults, and a known complication of thyroid surgery which is more common in resource-limited settings. Posterior graft laryngotracheal reconstruction is a management option that has not been studied in this population or setting.ObjectiveTo report the surgical outcomes of posterior graft laryngotracheal reconstruction for bilateral vocal cord paralysis in a resource-limited setting, and to evaluate the efficacy of a hybrid system for teaching this technique in Kenya.DesignRetrospective cohort study.SettingTertiary public referral hospital, Eldoret, KenyaParticipantsAdults >18 years with tracheostomy dependence secondary to bilateral vocal cord paralysis after thyroid surgery or other iatrogenesis. The hybrid training program included Kenyan surgeons and surgical trainees.Intervention or ExposuresPosterior graft laryngotracheal reconstruction and hybrid training system included didactic lectures, simulation-based training, case discussion and planning, and live cases.Main Outcomes MeasuresOne-year airway outcomes measured by achievement of tracheostomy decannulation, and self-reported surgeon knowledge and skill acquisition.ResultsTen patients met criteria and were included in the analysis, with mean age 42 years (range 30-62 years) and had been tracheostomy dependent for an average of 6 years (range 1-12 years). Seven (70%) had open reconstruction, and 3 (30%) had endoscopic reconstruction. All were decannulated and remained tracheostomy-free at 1 year. Three surgeons and 7 trainees participated in the hybrid teaching methods. All reported increased comfort in laryngotracheal reconstruction, with all 3 surgeons reporting comfort performing the surgeries independently.ConclusionPosterior graft laryngotracheal reconstruction shows promise as a potential method of treating bilateral vocal cord paralysis and achieving decannulation in a resource-limited setting.RelevanceThe methods reported in this study lend themselves to replication and expansion to other similar settings. The authors plan to replicate this work in other centers in East Africa.

ObjectiveTo compare hearing preservation outcomes between lateral wall and perimodiolar electrode arrays for cochlear implant patients.Study DesignRetrospective cohort study.SettingA large Western Australian cochlear implant clinicMethodsA total of 311 adult cochlear implant recipients (321 ears) implanted between 2017 and 2022 were included. Of these, 174 presented with postlingual hearing loss and preoperative functional low-frequency hearing. The change in low-frequency pure-tone average was assessed as the difference between preoperative to 3-, 6-, and 12-months postoperative measurements. Data were analyzed through linear mixed-effects modeling and one-way ANOVA.ResultsPreoperative low-frequency, pure-tone average was higher for those implanted with perimodiolar compared with lateral wall electrodes (P < .05). The linear mixed-effects model revealed that change in low-frequency pure-tone average at all postoperative timepoints was similar between lateral wall and perimodiolar electrodes (P > .05).ConclusionThere were similar changes in residual postoperative hearing between all electrode types when controlling for preoperative low-frequency hearing and age implanted. These data suggest that newer, thinner perimodiolar and lateral wall electrodes could be considered for individuals with greater levels of preoperative low-frequency hearing.

Importance: The closure technique for the radial forearm free flap (RFFF), a commonly utilized flap in head and neck reconstruction, remains a debated topic as there are unique advantages and drawbacks to each technique.

Objective: The present study aims to report on the outcomes of the closure of the RFFF with the superficial cephalic vein (CV)-only system in terms of venous compromise and flap survival.

Methods (design, setting, participants, intervention, measures): A retrospective review of patients who underwent head and neck reconstruction with RFFF between January 2015 and May 2021 at the authors' institution was performed. Cases were categorized as superficial, dual, and deep systems. Multiple population and operative variables were collected for the study group.

Results: In total, 221 cases of RFFF were included, of which 169 (76.5%) cases were performed using the CV alone, whereas the remaining 52 (22.5%) cases utilized either the dual or the deep system alone. The operative time in the superficial group was 265 minutes. There were 9 venous complications in the CV group, of which 5 required re-exploration in the operating room and 4 were treated conservatively. All venous-related flap complications were salvaged.

Conclusion and relevance: A majority of the RFFF cases could successfully be completed using the CV as the sole venous drainage, with high rates of flap survival, low complications, and low operative time.

ImportancePost-tonsillectomy complications often present in emergency departments (EDs). Reducing postoperative ED visits is one strategy to relieve the strain on healthcare systems and patients.ObjectiveTo assess the rate and reason for ED visits within 90-days post-discharge from adult tonsillectomy.DesignRetrospective cohort study.SettingNova Scotia, Canada.ParticipantsAll adult patients (≥16 years old) with a Nova Scotia Healthcare card who underwent a tonsillectomy in Nova Scotia, Central Zone from April 1, 2016 to March 31, 2022, and had an ED visit anywhere in Nova Scotia from April 1, 2016 to June 30, 2022, to allow a 90-days post-discharge window.MethodsRetrospective chart review utilizing administrative datasets for province-wide ED visits within 90-days post-discharge from an adult tonsillectomy. The patients' first ED visit postoperation was analyzed.ResultsOverall, 356 adult patients underwent tonsillectomy, of which 129 (36.2%) presented to the ED within 90 days. Of these, 99 were related to the tonsillectomy, resulting in a surgery-specific ED rebound rate of 27.8%. Most surgical ED visits (84/99, 84.8%) occurred within 7 days, most commonly for bleeding (47/99, 47.5%) and pain (36/99, 36.4%). Of the surgical visits, 26/99 (26.3%) were admitted, with 22/26 (84.6%) for bleeding. Of the surgical visits not related to bleeding, 48/52 (92.3%) were discharged home or left without being seen, which suggests 48/99 (48.5%) surgical ED visits may be preventable.ConclusionThe ED rebound rate for visits related to the tonsillectomy was 27.8% in our population. Given the potentially severe consequences of post-tonsillectomy bleeding, a high ED visit rate may be necessary. However, optimization of postoperative pain control along with greater access to urgent outpatient otolaryngology and primary care resources may reduce the burden of ED visits. This data adds to recent literature suggesting a higher rate of healthcare usage post-adult tonsillectomy.

ImportanceReparative granuloma (RG) is a rare but severe complication of otosclerosis surgery, presenting with vertigo, tinnitus, and hearing loss. Surgical intervention may offer effective symptom relief.ObjectiveTo evaluate the effectiveness of surgical management for RG following otosclerosis surgery in alleviating vestibular symptoms and preserving hearing.DesignRetrospective cohort study (STROBE guidelines).SettingTertiary referral center.ParticipantsNineteen adult patients with histologically confirmed RG and persistent symptoms (vertigo and/or hearing loss) within 3 months of primary stapes surgery.InterventionRevision surgery included granuloma resection, prosthesis replacement, and corticosteroid-soaked graft placement as needed.Main Outcome MeasuresPostoperative relief of vestibular symptoms, hearing thresholds [pure-tone average (PTA)], and length of hospital stay.ResultsSymptoms developed on average 3.6 ± 3.9 days postoperatively. Revision surgery resolved vertigo in 18 of 19 patients (95%) by discharge (mean 4.8 ± 1.9 days). Audiometric improvement was limited, with 11 patients retaining serviceable hearing. Preoperative versus postoperative bone conduction PTA showed no significant change (P = .58).ConclusionsSurgical management effectively alleviates vestibular symptoms associated with RG but has minimal impact on hearing restoration.RelevanceThis study highlights the efficacy of revision surgery for RG in addressing vestibular symptoms. Further multicenter studies are warranted to better understand reparative granuloma and improve treatment strategies.

Importance: Preoperative risk factors can guide appropriate postoperative disposition location to a ward bed, intermediate care, or intensive care unit after pediatric microlaryngoscopy and bronchoscopy (MLB), resulting in optimization of resource use and costs.

Objective: Identify risk factors associated with postoperative respiratory events requiring escalation of care after MLB to identify a subpopulation of high-risk patients.

Design: Retrospective cohort study.

Setting: Tertiary pediatric center.

Participants: Patients undergoing MLB alone or with intervention from 2017 to 2023.

Intervention: MLB alone or with intervention.

Main outcome measures: Primary outcome was postoperative respiratory events requiring escalation of nursing care: escalation of oxygen supplementation for >2 hours, laryngospasm, bronchospasm, unplanned escalation of care to ICU, O₂ desaturation <80% and Pediatric Early Warning Score (PEW score) >5. Multivariate logistic regression was performed to identify risk factors for postoperative respiratory events.

Results: 420 patients were included. The mean age was 39.4 months and 41% were female. Overall, 229 patients (54.5%) had events that required escalation of care. Five patients (1.2%) had laryngospasm, 5 (1.2%) desaturated below 80%, and 15 (3.6%) required an unplanned escalation of care to the ICU. 157 (37.4%) required escalation of care based on a PEW score >5, and 148 (35.2%) required supplemental O2 for >2 hours. Multivariate analysis identified independent risk factors for postoperative respiratory events including age 1 to 2 years (OR 2.47, P = .037), cardiovascular disease (OR 2.96, P = .0066), GERD (OR 1.89, P = .042), ASA IV (OR 5.76, P = .0032), MLB with supraglottoplasty (OR 4.34, P = .0081), inpatient surgery (OR 4.68, P < .0001), and operative time ≥180 minutes (OR 2.16, P = .05).

Conclusion: Risk factors for postoperative respiratory events after MLB include age 1 to 2 years, CVD, GERD, ASA 4, MLB with supraglottoplasty, inpatient emergency, OR time >180 minutes. Tailoring postoperative disposition based on these preoperative risk factors may result in a reduction in ICU utilization while ensuring patients are safely monitored in an appropriate setting.

Level of evidence: Level 3.

ImportanceSurgical difficulty quantification is crucial to develop educational curricula for progressive training. This need remains unmet in endoscopic endonasal surgery (EES).ObjectiveThe objective was to classify the basic skills and procedures of EES according to the perceived difficulty by experts to build a progressive curriculum.DesignThree-round modified Delphi study.SettingE-survey with an international panel of EES experts.ParticipantsFifty-nine international experts were selected on their publications in the field of EES and medical education and invited to participate. Fifteen experts from 5 countries completed the survey.InterventionA 3-round modified Delphi study was conducted.Main Outcome MeasuresIn round#1, basic skills and EES procedures were identified and the basic skills required for these procedures were listed. In round#2, the expert panel ranked the difficulty of basic skills, and in round#3, the difficulty of the EES procedures. The basic skills were grouped into 3 categories of increasing difficulty, and the subsequently-calculated difficulty of each EES procedure was compared with the experts' score. Consensus was defined at ≥80% agreement.ResultsTwenty-three basic skills and 26 EES procedures were identified. Basic skills were ranked in 3 groups of increasing difficulty, from easiest (navigation with a 0° telescope) to most difficult (suturing in the nasal cavity), with ≥80% agreement. The least difficult procedure ranked was polypectomy, whereas the most difficult was Vidian neurectomy. The correlation between the expert score and the calculated score reached an R² of .75, reflecting the cumulative effect of these required competencies on procedure difficulty.ConclusionsConsensus was achieved to rank basic skills and EES procedure according to the perceived difficulty by experts.RelevanceThis study provides a basis for quantifying surgical difficulty in EES and pave the way for developing a progressive educational curriculum.

ImportanceVertigo accounts for one of the most frequent presenting symptoms in primary care. However, complexities in differential diagnoses and reliance on clinical history contribute to frequent specialist referrals and diagnostic delays. Large language models (LLMs), like LLaMA-3.1-8B, offer new potential for assisting in clinical decision-making.ObjectiveTo assess the utility of a small-scale, open-source LLM in diagnosing peripheral vestibular disorders (PVDs), and evaluate the impact of synthetic data augmentation on diagnostic accuracy.DesignRetrospective chart review.Setting/ParticipantsA retrospective analysis included adult patients presenting with dizziness to a neuro-otologist at St. Joseph's Healthcare Hamilton between 2018 and 2023. The dataset comprised 100 clinical cases, supplemented with 40 synthetic cases generated using GPT-4. The LLaMA-3.1-8B model was evaluated on the clinical, synthetic, and combined datasets. Diagnostic reasoning approaches, including chain-of-thought reasoning and multi-shot prompting, were employed to optimize model performance.Main Outcome MeasuresMetrics for evaluation included top 1 and top 3 diagnostic accuracy, Cohen's kappa for inter-rater agreement, and accuracy in predicting symptom laterality.ResultsThe LLaMA-3.1-8B model achieved a top 1 diagnostic accuracy of 60.7% and a top 3 accuracy of 71.4% in the combined dataset. The most frequent diagnosis was Meniere's disease (55.7%), followed by vestibular migraines (9.3%) and labyrinthitis (9.3%). Diagnostic accuracy was highest for benign paroxysmal positional vertigo (90%), followed by Meniere's disease (80.8%). Less common conditions, such as superior canal dehiscence syndrome and vestibular paroxysmia, exhibited lower diagnostic accuracies. Cohen's kappa indicated substantial agreement for symptom side prediction (κ = 0.96) and moderate agreement for diagnosis (κ = 0.41) in the combined dataset.Conclusions and RelevanceThe LLaMA-3.1-8B model demonstrated promising accuracy in diagnosing PVDs. The model's performance highlights its potential to serve as a high-yield screening tool for primary care physicians and general otolaryngologists.

ImportanceModified Blair and Facelift incisions are conventional approaches to parotid pathologies. However, they frequently result in prominent scars in cosmetically sensitive regions. A newer alternative, U-shaped incision offers a minimally visible scar along the contour of the pinna while enabling management of parotid pathologies.ObjectiveThis study aimed to compare the cosmetic and surgical outcomes between U-shaped incision and conventional incisions including Modified Blair and Facelift incisions.Design/Setting/Participants/Intervention or ExposuresThis is a multicenter case-control study on 16 patients who underwent parotidectomy using U-shaped incisions for parotid tumors between 2019 and 2022. Seventeen disease characteristics-matched controls underwent conventional approach were included, amounting to a total of 33 patients.Main Outcome MeasuresThe surgical outcomes including perioperative events, postoperative complications, and cosmetic outcomes using the Visual Analog Scale (VAS) score of scar satisfaction and the Patient Scar Assessment Scale (PSAS) were analyzed.ResultsThere were no significant differences in the age (P = .817), tumor diameter (P = .398), and pathologies (P = .300) among the 2 groups. No significant differences in length of stays (P = .087) and resection margin (P = .117) were found. U-shaped incision group had a significantly less mean operating time (145 minutes, P < .001) and mean blood loss (10.45 ml, P = .043), compared to the conventional group which had 243 minutes and 43 ml, respectively. A significantly higher overall scar satisfaction based on VAS score in U-shaped incision group (P = .009) was noted. No significant differences between the 2 groups were found in the overall PSAS score and all the subscores. There were no significant differences in postoperative complications including facial nerve dysfunction (P = .520) between the 2 groups except the presence of a significantly higher sialocele in U-shaped incision group (P = .011).ConclusionThe present study indicated that U-shaped incision is a safe alternative with better cosmetic outcomes over conventional incisions and comparable surgical outcomes.RelevanceSurgeons are encouraged to adopt the U-shaped incision to achieve better cosmetic results while ensuring oncological safety.