Journal of Otolaryngology - Head & Neck Surgery最新文献

ImportanceEffective anesthesia with minimal side effects is essential for pediatric patients undergoing adenoidectomy.MethodsA single-center, prospective, randomized controlled trial was conducted at Gaoming District People's Hospital (China, January 2022-October 2023). Two-hundred fifty-six children (ASA I-II, age 3-12 years) scheduled for elective plasma radiofrequency adenoidectomy were randomized to 4 groups (n = 64 each). Group A received 0.9% normal saline; groups B, C, and D received continuous infusions of benzenesulfonate remimazolam at 0.4, 0.6, and 0.8 mg/kg/h, respectively, combined with 6% sevoflurane for induction and 2% to 3% for maintenance. Primary outcomes were emergence time and postanesthesia care unit (PACU) stay. Secondary outcomes included incidence of adverse events, peak Pediatric Anesthesia Emergence Delirium (PAED) scores, and parental satisfaction.ResultsMedian awakening time was longer in groups B, C, and D than in group A (P < .001). PACU stay was shorter in groups C and D versus group A (P < .05). Postoperative pain scores (Face, Legs, Activity, Cry, and Consolability) were lower in groups C and D than in groups A and B (P < .05). Peak PAED scores were lower in groups B, C, and D than in group A (P < .05); negative behavioral changes on postoperative day 3 were also reduced (P < .05). Parental satisfaction was higher in groups B, C, and D than in group A (P < .001). No serious adverse events occurred.Conclusion and RelevanceBenzenesulfonate remimazolam (0.6 mg/kg/h) combined with sevoflurane provides effective, safe anesthesia for pediatric plasma radiofrequency adenoidectomy, balancing induction efficacy, sedation depth, and safety. This regimen reduces emergence delirium, postoperative pain, and negative behavioral changes while enhancing parental satisfaction, supporting its use in pediatric adenoidectomy and warranting further investigation in other pediatric procedures.

ImportanceOnline patient education materials (PEMs) and large language model (LLM) outputs can provide critical health information for patients, yet their readability, quality, and reliability remain unclear for Meniere's disease.ObjectiveTo assess the readability, quality, and reliability of online PEMs and LLM-generated outputs on Meniere's disease.DesignCross-sectional study.SettingPEMs were identified from the first 40 Google Search results based on inclusion criteria. LLM outputs were extracted from unique interactions with ChatGPT and Google Gemini.ParticipantsThirty-one PEMs met inclusion criteria. LLM outputs were obtained from 3 unique interactions each with ChatGPT and Google Gemini.InterventionReadability was assessed using 5 validated formulas [Flesch Reading Ease (FRE), Flesch Kincaid Grade Level (FKGL), Gunning-Fog Index, Coleman-Liau Index, and Simple Measure of Gobbledygook Index]. Quality and reliability were assessed by 2 independent raters using the DISCERN tool.Main Outcome MeasuresReadability was assessed for adherence to the American Medical Association's (AMA) sixth-grade reading level guideline. Source reliability, as well as the completeness, accuracy, and clarity of treatment-related information, was evaluated using the DISCERN tool.ResultsThe most common PEM source type was academic institutions (32.2%), while the majority of PEMs (61.3%) originated from the United States. The mean FRE score for PEMs corresponded to a 10th- to 12th-grade reading level, whereas ChatGPT and Google Gemini outputs were classified at post-graduate and college reading levels, respectively. Only 16.1% of PEMs met the AMA's sixth-grade readability recommendation using the FKGL readability index, and no LLM outputs achieved this standard. Overall DISCERN scores categorized PEMs and ChatGPT outputs as "poor quality," while Google Gemini outputs were rated "fair quality." No significant differences were found in readability or DISCERN scores across PEM source types. Additionally, no significant correlation was identified between PEM readability, quality, and reliability scores.ConclusionsOnline PEMs and LLM-generated outputs on Meniere's disease do not meet AMA readability standards and are generally of poor quality and reliability.RelevanceFuture PEMs should prioritize improved readability while maintaining high-quality, reliable information to better support patient decision-making for patients with Meniere's disease.

Importance: Epistaxis affects approximately 60% of the population over their lifetime. When conservative attempts fail, nasal tampons are often required to stop anterior bleeding. Health economics is critical in our publicly funded system. Determination of cost-effective interventions is crucial.

Objective: To compare the total cost of Merocel and Rapid Rhino from the perspective of a provincial payer and an academic hospital for the management of anterior epistaxis.

Design: Retrospective review.

Setting: London Health Sciences Centre emergency department (Victoria and University campus).

Participants: Patients ≥18 years of age presenting with anterior epistaxis. The participants were 67% men and 33% women. Approximately, 63% were on anticoagulant medication, and 35% used an ambulance to arrive at the hospital.

Intervention: Rapid Rhino or Merocele, which was dependent on the site of presentation.

Main outcome measures: Rebleed rate.

Results: The rate of rebleeds with Merocel was 42% (26/62), whereas it was 24% (4/17) with Rapid Rhino. The inverse probability weighted regression adjustment results show that patients receiving Rapid Rhino did not have a statistically significant difference in costs per patient ($62.40, 95% CI: -$25.75 to $150.55) from the hospital perspective or the provincial health care payer perspective ($78.25, 95% CI: -$18.38 to $174.89).

Conclusion and relevance: There was no significant difference in cost between Rapid Rhino and Merocel for anterior epistaxis from a hospital or provincial payer perspective.

ImportanceIdiopathic subglottic stenosis is a debilitating and recurrent disease, often requiring reintervention. Balloon dilation is a well-recognized, minimally invasive treatment to alleviate symptoms, and is typically performed in the operating room. In-office balloon dilation in the awake patient has rarely been reported, and may obviate the need for general anesthesia in this patient population.ObjectiveThis study aims to detail the safety and efficacy of in-office balloon dilation for mild to moderate subglottic stenosis.DesignMixed-methods study.SettingSingle tertiary-care institution in Montreal, Canada.Participants and InterventionAll adult patients with Cotton-Myer Grade I-II idiopathic subglottic stenosis undergoing in-office balloon dilation between June 1, 2022 and August 1, 2023 were prospectively recruited.Main Outcome MeasuresPre- and post-procedure validated dyspnea and voice scales, airway diameter and spirometry values were obtained. Patient- and physician-reported adverse events were thoroughly documented.ResultsEleven patients underwent in-office balloon dilation during the study period (F:M 10:1, mean age 55.8 years). The median Dyspnea Index and voice handicap index-10 scores both significantly decreased following the procedure. In-office balloon dilation improved airway patency, with an estimated median of 40% to 10% stenosis (median difference -25%, 95% CI (-45, -15), P = .003). The normalized peak expiratory flow percentage significantly increased from a median of 62% to 99% (median difference 27%, 95% CI (19, 40), P = .004). The median time to regular activities was one day. Six patients having previously undergone the procedure under general anesthesia indicated a preference for in-office dilation. There were no severe adverse events.Conclusion and RelevanceIn-office balloon dilation is a safe and effective option for the management of mild-moderate idiopathic subglottic stenosis, with demonstrated improvement in both patient-reported outcomes and objective measures.

ImportanceThe inclusion of depth of invasion (DOI) in the American Joint Committee on Cancer's staging system for oral tongue squamous cell carcinoma (OTSCC) has major clinical implications. Few studies have evaluated the accuracy of preoperative biopsy to predict DOI.ObjectiveTo evaluate the reliability of preoperative punch biopsy for measuring DOI in early OTSCC and compare it to evaluation by digital palpation. Secondarily, to assess the punch biopsy's ability to differentiate between carcinoma in situ (Tis) and invasive carcinoma.DesignA prospective single-center cohort study.SettingCenter Hospitalier de l'Université de Montréal, a tertiary center in Canada.ParticipantsPatients with suspected early stage OTSCC.InterventionPunch biopsy was used to sample the deepest part of tumors to measure biopsy-derived DOI (bDOI). In addition, DOI was estimated via digital palpation: clinical DOI (cDOI) by surgeons.Main Outcome MeasuresPathologic DOI (pDOI) from final histopathology reports was the gold standard. Spearman's correlations were calculated between cDOI, bDOI, and pDOI. Diagnostic performance metrics were calculated for the ability to distinguish pDOI of ≥2 mm, and to differentiate Tis from invasive carcinoma.ResultsAmong 27 patients, correlation coefficients between bDOI and pDOI, and cDOI and pDOI were 0.603 (95% CI: 0.202-0.884) and 0.894 (95% CI: 0.749-0.955), respectively. Punch biopsy sensitivity and specificity were 0.88 (95% CI: 0.62-0.98) and 0.91 (95% CI: 0.59-0.99) to detect pDOI ≥ 2 mm, and 0.89 (95% CI: 0.65-0.99) and 0.86 (95% CI: 0.42-1.00) for distinguishing Tis from invasive carcinoma. Digital palpation sensitivity and specificity for pDOI ≥ 2 mm were 0.86 (95% CI: 0.57-0.98) and 1.00 (95% CI: 0.63-1.00).ConclusionsPunch biopsy and clinical palpation demonstrate high diagnostic yield for identifying lesions with pDOI ≥ 2 mm. Punch biopsy appears to be reliable to distinguish Tis from invasive carcinoma.RelevanceLarger studies are needed to corroborate these findings and assess the role of punch biopsy in guiding elective neck dissection decisions.

ImportanceSeveral feasible management options exist for indeterminate thyroid nodules (ITNs), which can lead to decisional conflict (DC) and uncertainty in patients.ObjectiveTo investigate patient and physician participation in shared decision-making (SDM) during the management of ITNs and the association of SDM with patient-perceived DC.Study DesignMulti-institutional, cross-sectional, multiple methods study.SettingThe Queen Elizabeth II Health Science Centre (Halifax, Nova Scotia) from October 2020 to June 2023 and The Ottawa Hospital (Ottawa, Ontario) from November 2022 to June 2023.Intervention and ExposuresPatients with ITNs scheduled for an initial surgical consultation with an Otolaryngologist were included. Consultations were video-recorded using discreet cameras within clinic rooms at both sites. Management options discussed at both sites included repeat fine needle aspiration biopsy, ultrasound surveillance, surgery, and molecular testing.Main Outcome MeasuresPatient-perceived SDM was measured by the SDM Questionnaire-9 (SDM-Q-9) and perceived DC by the DC Scale (DCS). Surgeons' perceptions of SDM were measured by the SDM-Q-Doc. Observer-determined SDM was reported using the multifocal approach to sharing in SDM (MAPPIN'SDM) instrument.ResultsSeventy-seven patients and 6 surgeons were included. Patient-perceived SDM was high [mean = 94.38, standard deviation (SD) = 7.61], while physician-perceived SDM was lower in comparison (mean = 83.21, SD = 9.14). Observer-determined SDM involvement of the patient (mean = 0.73, SD = 1.08), physician (mean = 1.71, SD = 1.33), and patient-physician dyad (mean = 1.75, SD = 1.27) was low. Clinically significant DC (DCS score ≥25) was reported by 13.2% of patients. There was a medium negative correlation between patient-perceived SDM involvement and DC (Pearson r = -0.311, P = 0.008). Patient-perceived SDM did not differ by clinicodemographic factors.ConclusionWhile patients and physicians perceived high levels of SDM, patients with ITNs are faced with difficult management decisions leading to DC.RelevanceThese findings highlight the need for developing decision-aids to support SDM and reduce DC in the management of ITNs.

Background: A vestibular implant can partially restore vestibular function by providing motion information through implanted electrodes. During vestibular implantation, various obstructions of the semicircular canals, such as protein deposits, fibrosis, and ossification, can be encountered. The objective was to explore the relationship between preoperative imaging and intraoperative findings of semicircular canal obstruction and to develop surgical strategies for dealing with obstructions of the semicircular canal(s) in patients eligible for vestibular implantation.

Methods: Patients undergoing vestibulocochlear implantation (in an active clinical trial) were included in the current study when preoperative imaging indicated an obstruction in the semicircular canal. Preoperative imaging consisted of CT and MRI scans. During surgery, the bony semicircular canals were skeletonized ("bluelined") to identify the course of the canals and create a fenestration to insert the electrodes. The aim was to place the electrodes in the semicircular canal ampullae. Surgical strategies were developed to deal with the soft tissue obstructions. These procedures were evaluated intraoperatively with microscopic visualization, postoperatively with CT imaging.

Results: The three included patients suffered from bilateral vestibulopathy and hearing loss due to autosomal dominant nonsyndromic sensorineural deafness 9 (DFNA9). A soft tissue obstruction was predicted in one semicircular canal (2 patients) or two semicircular canals (1 patient), based on preoperative imaging. Intraoperatively, bluelining the semicircular canals aided in identifying these locations, by revealing a "whiteline" instead of blueline. Depending on the nature and location of the obstruction, different surgical procedures were employed to facilitate proper electrode insertion. These were as follows: a dummy electrode was used to probe the soft tissue, the obstructive tissue was removed, and/or a bypass fenestration was created. In all patients, the electrodes could be implanted in the semicircular canal ampullae. Based on these first experiences, a diagnostic and surgical guide to deal with obstructions of the semicircular canals during vestibular implantation was developed.

Conclusions: Preoperative imaging can indicate locations of obstructions in the SCCs. Different surgical procedures can be applied to enable appropriate electrode positioning in the SCC ampulla. This article describes the first experiences with obstructions of the semicircular canals during intralabyrinthine vestibular implantation and presents a diagnostic and surgical guide.

Trial registration: ABR NL73492.068.20, METC20-087 (Maastricht University Medical Center) and NAC 11-080 (Geneva University Hospitals).

ImportanceRecently, the Québec public health care system established a pilot project to cover costs of molecular testing for select patients with cytologically-indeterminate thyroid nodules.ObjectiveThis study aimed to evaluate the clinical utility of the ThyroSeqv3 molecular test pilot project at McGill University in surgical management of thyroid nodules within Canada's single-payer health care system.DesignMulticenter cohort study, in liaison with the Québec Health Ministry.SettingJewish General Hospital and Royal Victoria Hospital in Montreal, Canada.ParticipantsPatients with a Bethesda III or IV and TIRADS 3 or 4 thyroid nodule measuring between 1 and 4 cm in size on ultrasound were analyzed across pre- and post-pilot project phases.InterventionThe pre-pilot project surgical control group included patients who underwent surgical intervention, excluding those who opted for out-of-pocket molecular testing. The post-pilot project surgical exposure group encompassed participants in the pilot project, undergoing publicly-funded ThyroSeqv3 molecular testing and subsequent surgical intervention.Main Outcome MeasuresSurgical malignancy/noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP) rate.ResultsA total of 314 patients qualified for the pilot project, with 207 (65.9%) having Bethesda III nodules and 107 (34.1%) having Bethesda IV nodules. Molecular testing yielded a result of negative in 238 (75.8%) cases and positive in 76 (24.2%) cases. Histopathology reports of positive patients who opted for surgery revealed a surgical malignancy/NIFTP rate of 73.1%. The surgical malignancy/NIFTP rate at our institution prior to the implementation of the pilot project for patients adhering to the inclusion criteria was statistically significantly lower at 47.9% (P = .0025).ConclusionsThe ThyroSeqv3 molecular test pilot project has improved upon physicians' traditional clinical practice by enabling a wider patient population to access this otherwise costly technology. It not only curtailed futile diagnostic hemithyroidectomies but also led to a more discerning allocation of surgeries, as corroborated by an increased surgical malignancy/NIFTP rate post-implementation.RelevanceThe results of our study suggest that publicly-funded molecular testing could contribute positively to the Canadian single-payer health care system by optimizing patient outcomes as well as fiscal policy.

ImportanceThis study investigates the potential of brain-derived neurotrophic factor (BDNF) as treatment for sensorineural hearing loss (SNHL) in a guinea pig model to potentially advance hearing restoration strategies. The correlation between oxidation-reduction (REDOX) potential in blood and perilymph is evaluated to confirm using blood as a proxy for perilymph in further study.ObjectivesTo evaluate hearing following 2 intracochlear applications of BDNF as a therapy for hearing loss. To evaluate for correlation in REDOX potential of perilymph and auditory brainstem response (ABR).Study DesignPositive-control animal preclinical study.SettingTranslational laboratory science.ParticipantsAnimal model (guinea pigs).Intervention or ExposuresSNHL was created in 15 guinea pigs using intraperitoneal cisplatin (CDDP). SNHL was confirmed via ABR testing. Left ears received 2 intracochlear applications of BDNF in varying doses, 30 days apart. Right ears received saline as controls.Main Outcome MeasuresHearing threshold was determined using ABR testing. Animals underwent terminal surgery to measure the REDOX potential in cerebrospinal fluid (CSF) and blood. Analysis of variance for repeated measures using the SPSS v27 software was employed.ResultsVariable, subtotal hearing loss was established utilizing CDDP. Animal ABR thresholds after CDDP, prior to first BDNF application, were worse than baseline. There was no improvement in hearing thresholds when treated and nontreated ears were compared. Varying doses of BDNF did not produce differences in hearing thresholds. The REDOX potential of perilymph, blood, and CSF correlate in the same animal; however, the values themselves were significantly different.Conclusions and RelevanceThere is no improvement in guinea pig hearing with 2 intracochlear applications of BDNF when applied as described in this paper. Previous work suggested possible subclinical gain with 1 application; however, with 2 applications we found no improvement. The REDOX potential of blood and CSF correlates within an animal, suggesting blood may be used as a proxy for REDOX measures in perilymph.