Otolaryngology- Head and Neck Surgery最新文献

Objectives: To investigate the influence of race and insurance type on speech delay rates and hearing rehabilitation access in children with bilateral hearing loss (HL).

Study design: Retrospective cross-sectional study of pediatric patients with bilateral HL who received cochlear implants (CIs) or hearing aids (HAs).

Setting: This study used the national Pediatric Health Information System (PHIS) database to identify patients with HL across 52 tertiary care pediatric hospitals in the United States.

Methods: Data collected included demographics, CI/HA use, speech delay/disorders, and type of insurance coverage.

Results: This study identified 18,422 patients with bilateral HL (40.1% female, 66.3% white, 66.3% on public insurance), with an average age of 5.21 ± 4.37 years. Patients with private insurance were more likely to be white than non-white (48.9% vs 27.5%, P < .001), more likely to receive CI (18.0% vs 14.7%, P < .001), more likely to receive HA (21.3% vs 17.9%, P <.001), and less likely to have speech delay diagnoses (74.9% vs 81.0%, P < .001) compared to patients with public insurance. Compared to non-white patients, white patients were more likely to have CI (16.8% vs 14.7%, P < .001), more likely to have HA (20.6% vs 17.0%, P < .001), and less likely to have speech delay diagnoses (81.1% vs 77.2%, P < .001). When adjusting for other variables, these associations with insurance type and race were still observed.

Conclusion: Disparities seen amongst different races and income groups can be observed at the population level and highlight an opportunity for policy interventions to secure equitable access for children with pediatric HL.

Objective: As wildfires worldwide increase in severity and frequency, fine particulate matter (PM 2.5), generated as a component of wildfire smoke, increasingly impacts air quality. Children are particularly vulnerable to poor air quality in numerous ways, including inhalation of more air in proportion to their body size than adults. Though its adverse impacts on the lower airway are well demonstrated, the clinical effects of PM 2.5 on the pediatric upper airway are poorly understood and warrant investigation.

Study design: Retrospective cohort study.

Setting: Tertiary academic medical center.

Methods: From 2014 to 2023, patient presentations to a pediatric emergency department in Northern California during exposure periods of elevated PM 2.5 burden associated with nearby wildfires were identified. Patient diagnoses, presenting symptoms, and management were analyzed. Comparison group patients were evaluated during date-matched control periods with confirmed normal air quality. Chi-squared analyses determined significance.

Results: During periods of increased wildfire-generated PM 2.5 burden, a significantly greater proportion of pediatric patients presented to the emergency department with upper airway pathology compared to matched control periods of healthy air quality. Further, a significantly greater proportion of patients were diagnosed with croup during wildfires. Of patients presenting with upper airway pathology, a significantly greater proportion experienced dysphonia during wildfires and had a negative strep test.

Conclusion: Wildfire-generated PM 2.5 may contribute to increased rates of croup presentations, and PM 2.5 may disproportionately affect the larynx in the pediatric upper airway. Larger population-based studies and preclinical models may clarify these clinical manifestations of a growing public health threat.

Objective: Reliable variables for detecting pediatric obstructive sleep apnea (OSA) using three-dimensional (3D) imaging are currently lacking. This study aimed to develop a novel predictor of OSA in children.

Study design: Prospective study.

Setting: Tertiary care children's hospital.

Methods: Pediatric patients (<18 years) with symptoms suggestive of OSA were enrolled. Polysomnography was used to categorize disease severities as primary snoring (apnea-hypopnea index, AHI < 1), mild OSA (AHI = 1-5), moderate OSA (AHI = 5-10), and severe OSA (AHI > 10). Cone-beam computed tomography was used to obtain 3D images. The minimal to mean airway area (AA) ratio was measured across the entire pharynx and its segment (nasopharynx, oropharynx, and hypopharynx).

Results: The study included 104 children. For the entire pharynx, the minimal to mean AA ratio was 0.41, 0.36, 0.35, and 0.25 in the primary snoring, mild OSA, moderate OSA, and severe OSA groups, respectively (P = .001). Pearson's correlation revealed an inverse relationship between the minimal to mean AA ratio and OSA severity. The receiver operating characteristic curve identified the optimal cutoff point for predicting AHI ≥ 1 as 0.34 in the oropharynx (area under the curve [AUC] = 71%) and 0.39 in the entire pharynx (AUC = 67%). The minimal to mean AA ratio in the nasopharynx or hypopharynx indicated no significant difference between OSA severities.

Conclusion: A minimal to mean airway AA ratio of less than one-third in the pharynx serves as a novel predictor of pediatric OSA in 3D imaging.

Objective: This study aims to explore outcomes among 2-stage paramedian forehead flaps (PFFs), 3-stage PFFs, and PFFs undergoing accelerated pedicle takedown.

Study design: A retrospective review.

Setting: A tertiary care institution.

Methods: Patients who underwent PFFs for nasal defects between 2017 and 2022 were identified. Demographic, clinical, and surgical characteristics were compared among groups. Surgical and cosmetic outcomes and revision procedures were evaluated.

Results: Among 52 patients analyzed, 39 underwent 2-stage PFFs, and 13 underwent 3-stage PFFs. There were no significant differences in demographics, comorbidities, or surgical risk factors between groups. Three-stage PFF patients were more likely to have a cartilaginous defect. Postoperative dyspigmentation was seen more frequently in the 3-stage group; otherwise, there were no significant differences in outcomes. In a subanalysis of 29 patients requiring cartilage grafting, dyspigmentation was again seen more commonly in the 3-stage group; outcomes otherwise did not favor either group. Within the 2-stage group, 7 patients underwent accelerated pedicle takedown (≤21 days). No failures were seen with accelerated takedown, including among those who also received cartilage grafting. Overall, accelerated takedown was not associated with poorer surgical or cosmetic outcomes or an increased revision rate compared to standard takedown. Logistic regression did not identify any independent predictors of complication.

Conclusion: Both 2- and 3-stage PFFs are effective tools in midface reconstruction, including when cartilage grafting is required. With 2-stage PFF, accelerated pedicle takedown is not associated with increased complications in appropriately selected patients.

Objective: Perioperative tobacco use is associated with poor wound healing postoperative complications. The purpose of this study is to use serum cotinine as a measure of tobacco consumption to evaluate complication rates and outcomes in patients undergoing septorhinoplasty procedures.

Study design: Prospective study.

Setting: Tertiary care academic center.

Methods: Patients >18 years old undergoing septorhinoplasty from December 2017 to January 2023 were included. Serum cotinine levels were obtained on the day of surgery. Preoperative and postoperative nasal obstruction and septoplasty effectiveness (NOSE) scores were assessed. Postoperative wound complications were categorized as mild, moderate, and severe. Chi-square, Fisher exact, and Kruskal-Wallis tests were used to analyze the data.

Results: Sixty-seven patients met inclusion criteria. Average age was 46 years, 31 patients were male, and 36 were female. Seven patients reported current tobacco use and 20 reported former use. Thirteen patients (19%) were cotinine-positive, with a median level of 190 ng/mL. None of the cotinine-positive patients had postoperative wound complications, whereas four of the cotinine-negative patients did. There was no significant difference in the change in NOSE scores between the cotinine-positive (-44.0) and cotinine-negative (-45.3) groups (P = .70). Of the cotinine-positive patients, the change in NOSE scores in patients who reported current tobacco use was -33.1 compared to -56.7 in patients who reported former tobacco use (P = .07).

Conclusion: Serum cotinine levels can be used for biochemical verification for tobacco use. Reported perioperative tobacco use may not be as predictive for effects on postoperative complications and functional outcomes in patients undergoing septorhinoplasty procedures.

Objective: This study aims to evaluate the long-term auditory performance at 5 years in patients with far advanced otosclerosis (FAO) after cochlear implantation compared to controls.

Study design: A retrospective cohort study.

Setting: This study was conducted at a single tertiary medical center.

Methods: Patients with FAO were compared to a control group of postlingually deafened patients, selected from the same cochlear implant database. The following data were collected from medical records: age, sex, etiology, duration of hearing deprivation, prior stapes surgery, age at implantation, side of implantation, computed tomography scan findings, surgery details, postoperative complications, and hearing test results.

Results: A total of 41 patients with otosclerosis and 73 control cases were included in this study. The mean speech comprehension score at 5 years was 48.63% ± 24.66 in the otosclerosis group compared to 48.17% ± 23.08 in the control group (P = .76). Cochleostomy (P = .01), scala vestibuli insertion (P < .001), and postoperative dizziness (P < .01) were more common in the otosclerosis group. Facial nerve stimulation was observed in both groups: otosclerosis group 4 cases (9.8%) and control group 4 cases (5.48%) (P = .39). In the otosclerosis group, at 5 years, the average speech comprehension in patients with a previous stapedotomy was 39.3% ± 23.9 and 57.52% ± 22.45 in patients without a previous stapedotomy (P = .02).

Conclusion: Cochlear-implanted patients with otosclerosis achieve satisfactory long-term audiometric outcomes, although with higher surgical challenges and complication rates compared to other etiologies. Notably, we found that a history of stapedotomy can negatively impact long-term auditory outcomes after cochlear implantation.

Objective: This study aims to compare the intraoperative ergonomics of tonsillectomies and adenoidectomies performed in seated versus standing positions for pediatric otolaryngology residents and attending physicians.

Study design: A randomized controlled trial.

Setting: A tertiary care center.

Methods: Intraoperative data were collected for 2 attending physicians and 13 residents as they performed adenoidectomies and tonsillectomies. Each tonsillectomy was randomized to either first tonsil sitting/second tonsil standing or vice versa. Adenoidectomies performed during the same anesthesia were performed in the second of the 2 positions, and thus also randomized. Isolated adenoidectomies were randomized to either the sitting or standing position. The rapid upper limb assessment (RULA) was used to quantify ergonomic risk for each operation on a 0 to 7 scale.

Results: Univariate analysis demonstrated a significant difference between sitting and standing positions (P < .001), with the sitting position exhibiting lower mean total RULA scores (mean = 3.26, median = 3.00) compared to standing (mean = 3.76, median = 4.00). This was confirmed using a multi-variable analysis adjusting for demographic variables. Univariate analysis showed that PGY1 residents had the lowest total RULA scores, whereas attending physicians had the highest total RULA scores. However, this was not confirmed by multi-variable analysis. Upper arm, lower arm, and trunk body region scores were higher in the sitting position, while wrist and neck scores were higher in the standing position. These conclusions were drawn from both univariate and multi-variable analysis.

Conclusion: Sitting during adenotonsillectomy may mitigate ergonomic risk. Further research is needed to identify ways in which intraoperative ergonomics can be optimized. This study may also have implications for similar intraoral procedures.

Objective: Granulomatosis with polyangiitis (GPA) is a rare multisystem autoimmune vasculitis. 10-20% of patients suffer life-threatening obstruction of their proximal airways. Although progress has been made in the treatment of systemic disease, ameliorating airway disease in GPA remains an unmet need arising from limited understanding of disease pathogenesis. We sought to characterize the cellular constituents of the affected proximal airway mucosa in GPA airway scar.

Study design: Basic/translational study.

Setting: Single tertiary care center.

Methods: Using single-cell RNA sequencing, we profiled the cellular constituents of proximal airway samples from GPA and disease comparators (GPA; n = 9, idiopathic subglottic stenosis: iSGS; n = 7, post-intubation proximal stenosis: PIPS; n = 5, and control; n = 10). We report transcriptomes for subglottic epithelial, immune, endothelial, and stromal cell types and map expression of GPA risk genes to tissue types present in the proximal airway. We compared differential gene expression across immune cell populations and performed pseudotime analysis using Monocle 3.

Results: Similar to iSGS and PIPS, the subglottic mucosa of GPA patients demonstrated an abundant immune infiltrate. 71% of the established GPA risk genes (10 of 14) localized to T cells and macrophages. Differential gene expression and pseudotime analysis revealed a sub-population of CD4-/CD8- inflammatory T cells that only originated from GPA.

Conclusion: We characterized the cellular composition of GPA airway disease and demonstrated that the expression of GPA risk alleles is predominantly localized to immune cell populations. We also identified a subset of inflammatory T cells that is unique to GPA.

Objective: This study aims to characterize how often otolaryngologists disclose relevant industry payments in publications and identify characteristics of these industry relationships.

Study design: A cross-sectional database and bibliometric analysis.

Setting: Open Payments Database and PubMed.

Methods: Publications by the 10 highest-compensated otolaryngologists from each of 12 representative medical device and drug companies from 2018 to 2020 were assessed for disclosure of potential conflicts of interest in the years following payment through 2023.

Results: After excluding 52 physicians who did not publish in this period, 102 individuals received a combined $8,473,091.68, with an individual median of 15 payments (interquartile range [IQR] = 47) and median compensation of $18,522.77 (IQR = $53,965.52) from 1 or more of the 12 companies analyzed. The median number of publications per author was 10 (IQR = 25), and the median h-index of the authors was 16 (IQR = 28). Of the 1735 publications, 114 were classified as relevant, either because the study involved the evaluation of a device manufactured by one of the analyzed companies or because one of the companies funded the study. Of these, 23 (20.1%) were missing personal disclosure by the author. Of the physicians analyzed, the most represented subspecialty was rhinology (n = 47, 31%) followed by otology (n = 18, 11.8%).

Conclusion: Although most publications in the years following payments from device companies were not deemed to have potential conflicts of interest, a notable proportion of those with authors who received payments lacked relevant financial disclosure. As transparency of relevant industry relationships has received increased attention, appropriate disclosure is recommended.

Objective: To examine changes in trends of the incidence and characteristics of pediatric complicated rhinosinusitis with respect to the coronavirus disease 2019 (COVID-19) pandemic.

Study design: Retrospective cohort.

Setting: Single tertiary-care center.

Methods: A review of patients who presented to St. Louis Children's Hospital (SLCH) with complicated rhinosinusitis from 2017 to 2022 was performed. Clinical and follow-up data were analyzed in association with COVID-19.

Results: Eighty-three patients with complicated rhinosinusitis were identified and analyzed according to hospitalization before or after March 2020. No differences in demographic variables were found between the two groups. More patients had developmental comorbidities in the COVID-19 group (7 vs 1, P = .049). More patients with intracranial complications (55% vs 45%, P = .48) and Pott's puffy tumor (78% vs 22%, P = .13) were observed in the COVID-19 era group; however, this difference was not statistically significant. In the COVID-19 group, more patients were found to have Streptococcus anginosus growth in their surgical cultures (67% vs 33%, P = .03). The incidence of complicated sinusitis correlated with the incidence of all viral cases at SLCH, particularly in 2021 and 2022, and increased following COVID-19.

Conclusion: Trends in complicated sinusitis vary before and after the onset of the COVID-19 pandemic. There was an increase in complications of sinusitis due to S. anginosus species in the COVID-19 era and trends towards increased intracranial complications and Pott's puffy tumor. After an initial decrease, the incidence of complicated sinusitis per year increased following COVID-19.