Otolaryngology- Head and Neck Surgery最新文献

Surgical coaching has made a positive contribution to surgical training and practice; however, the otolaryngology-head and neck surgery literature is lacking. The operating environment for practicing surgeons, and specifically otolaryngologists, is continually changing due to advancements in technology and new practice patterns. These changes in practice, however, have not come with a coordinating system for operative feedback once surgical training is completed. In this commentary, we explore surgical coaching, its applicability to otolaryngology, and encourage its more widespread acceptance and implementation.

Objective: The extent of parotidectomy for benign tumors has de-escalated in the United States. We aim to define modern benchmarks for operative time and hospital length of stay (LOS) in parotidectomy and identify risk factors that may prolong these benchmarks.

Study design: This is a retrospective cross-sectional study of all adults who underwent parotidectomy for a primary parotid neoplasm between January 2011 and December 2021 using the American College of Surgeons National Surgical Quality Improvement Program database.

Methods: The extent of parotidectomy was defined using Current Procedural Terminology codes. Prolonged operative time and LOS were defined as above the 75th percentile (longer than 194 minutes and more than 1 day, respectively). Multivariable logistic regression was used to identify patient and surgical risk factors that predict prolonged operative time or LOS.

Results: Benign parotidectomies are mostly performed as outpatient procedures in the United States (average LOS <1 day). Prolonged operative time was independently associated with malignant tumors versus benign tumors (adjusted odds ratio [aOR]: 2.7, 95% confidence interval [CI]: 2.4-3.0), total parotidectomy with facial nerve sacrifice versus lesser extent of parotidectomy (aOR: 2.3, 95% CI: 1.7-3.0), and simultaneous reconstructive procedures versus none (P < .001 for all). These features were similarly independently associated with prolonged LOS (P < .001 for all). Complication rates were universally low.

Conclusion: The majority of superficial parotidectomies in this country are performed as outpatient procedures requiring <3 hours of operative time, with low complication rates. Malignant tumors, greater extent of parotidectomy, and simultaneous procedures were independently associated with prolonged operative time and LOS. These national benchmarks can inform operating room and hospital bed resource assignments.

Objective: To compare reflux symptoms, Zenker's diverticulum recurrence, and clinical outcomes in patients with and without a history of hiatal hernia who underwent Zenker's diverticulotomy (ZD).

Study design: Single institution retrospective review.

Setting: Tertiary care academic hospital.

Methods: A retrospective review of patients with and without a history of hiatal hernia who underwent ZD via an open stapler, rigid endoscopic CO₂ laser, stapler, or harmonic scalpel technique from January 2006 to December 2020 was performed. Data were abstracted for patient demographics, reflux symptoms, and rates of adverse events and symptomatic recurrence.

Results: A total of 426 patients were included in the study, 97 (22.8%) of which had a history of hiatal hernia. Eleven patients (11.3%) with a history of hiatal hernia had undergone Nissen fundoplication prior to ZD. Patients with a history of hiatal hernia showed less symptomatic improvement postoperatively. Significant differences were noted in the change in the Eating Assessment Tool (EAT-10) (P < .01) and Reflux Symptom Index (RSI) (P = .03) where patients without a history of hiatal hernia improved more than hiatal hernia patients. Despite these differences in symptom relief, rates of postoperative complications and rates of recurrence did not significantly differ between groups. The median time to recurrence was similar for both groups.

Conclusion: Patients without a history of hiatal hernia had significantly larger improvements in EAT-10 and RSI scores compared to patients with a history of hiatal hernia. However, these differences in scores may not represent clinically meaningful differences. There were no significant differences in postoperative adverse events or in recurrence of the Zenker's diverticulum between groups.

Objective: To investigate alterations in the expression of circadian clock and Toll-like receptor (TLR) genes in peripheral blood (PB) leukocytes of patients with Meniere's disease (MD) and vestibular migraine (VM), and determine whether these gene expressions can differentiate MD from VM.

Study design: Observational prospective study.

Setting: Tertiary academic medical center.

Methods: PB leukocytes were collected from patients diagnosed with MD and VM during recent vertigo attacks, as well as from healthy controls. The expression levels of 9 circadian clock genes and 6 TLR genes were analyzed using real-time quantitative reverse transcriptase-polymerase chain reaction.

Results: Sixty-nine participants were enrolled, including 28 patients with MD, 14 patients with VM, and 27 healthy controls. Both MD and VM groups showed lower expression of PER1 compared to the control group (P < .01). The VM group exhibited significantly lower expression of PER1, PER2, CRY1, BMAL1, CLOCK, and TIM compared to the MD group (all P < .001). The MD group had higher TLR9 expression than the control group, and elevated TLR4, TLR8, and TLR9 expression compared to the VM group (P < .05). In the VM group, patients with severe dizziness handicaps had significantly lower expression of PER2, CRY1, CRY2, and CK1ε compared to those with mild to moderate handicaps (P < .05).

Conclusion: This study identifies distinct alterations in the circadian clock and TLR gene expression in MD and VM, suggesting potential differences in the pathogenesis of these 2 vertiginous disorders and highlighting the possibility of these gene expressions as biomarkers for differentiation.

Objective: Enhanced recovery after surgery (ERAS) protocols are designed to improve postoperative outcomes. In this study, we compare outcomes for patients undergoing head and neck free flap surgery at a quaternary care institution before and after an ERAS protocol was implemented.

Study design: Retrospective study.

Setting: Single quaternary care center.

Methods: Retrospective evaluation of outcomes from patients who underwent head and neck surgery with free flap reconstruction prior to ERAS (January 2018 to May 2022, baseline) with patient outcomes after implementation (June 2022 to September 2023, ERAS). Outcomes studied included length of stay (LOS), opioid utilization, postoperative emesis, readmission, and mortality.

Results: Patients in the ERAS group had significantly lower opioid utilization (206.84 ± 217 morphine milligram equivalent vs 415.53 ± 431, P < .01) and significantly lower rates of postoperative emesis (1.74% vs 28.27%, P < .01). This difference in emesis remained significant in the subgroup of patients who underwent total laryngectomy. The decreases in opioid use and emesis remained significant in multivariate analyses controlling for demographic factors and surgery type. We found no significant decrease in LOS or mortality.

Conclusion: In the year after implementing an ERAS protocol for head and neck free flap surgery, we found significantly lower opioid utilization and the unique finding of lower postoperative emesis overall, including in the laryngectomy subgroup for whom emesis-induced fistula is most impactful. No difference was noted in LOS or mortality. To our knowledge, this is the first study of an ERAS protocol for head and neck surgery to show a decrease in postoperative emesis.

Objective: To ascertain pathogenic variants frequency and type in the COCH gene among Cantabrian patients with nonsyndromic hereditary hearing loss (HL), and to understand their cochleovestibular manifestations.

Study design: An observational study on patients with postlingual nonsyndromic sensorineural hearing loss (SNHL), who underwent a genetic study using next-generation sequencing (gene panel) in the otolaryngology clinics between January 2019 and December 2023.

Setting: Referral center Marqués de Valdecilla University Hospital in Santander (Spain).

Methods: A cohort of 248 otolaryngologic clinic-referred patients suspected of genetic SNHL underwent sequencing analysis targeting 231 genes.

Results: A likely pathogenic or pathogenic variant causing HL was found in 57 (22.8%) patients. Among them, 7 (2.8%) were heterozygous carriers of the c.263G>C variant in the LCCL domain of the COCH gene, included as index cases. Subsequent familial segregation studies were performed. A total of 22 genetically and clinically studied patients were included. All but 3 family members displayed bilateral progressive SNHL starting in adulthood. Thirteen patients reported instability, but none met Meniere's disease criteria.

Conclusion: COCH gene variants are frequent in Cantabria. A variant with pathogenic evidence (c.263G>C in the LCCL domain) was detected. The phenotype observed is similar to a subgroup of patients with other variants described in the same functional domain: progressive SNHL and instability secondary to vestibular hypofunction.

Objective: Surgical treatment of non-obstructive sleep apnea (OSA) pathology poses the risk of inappropriate surgical indications. Herein, we sought to determine the prevalence of non-OSA respiratory disorders, specifically central sleep apnea (CSA), in new referrals to a Sleep Surgery Clinic.

Study design: Prospective observational review.

Setting: Tertiary care academic medical center.

Methods: In a sleep surgery clinic cohort, the presence of clinically significant CSA was defined as having >25% of the total apnea-hypopnea index (AHI) being central and/or mixed events. Demographics, comorbid disorders, patient-reported outcome measurements, and sleep study results were compared among patients using linear or logistic regression analysis, unadjusted and adjusted for age, sex, and body mass index (BMI).

Results: On average, the cohort (n = 295) was male (74%), middle-aged (mean [±SD] 54.2 ± 13.9 years), and overweight (BMI 30.3 ± 5.4), with severe sleep apnea (AHI 30.6 ± 22.6 events/h). Twenty-nine patients (9.8%) were found to have clinically significant CSA yet only 10% of these cases carried a diagnosis of CSA upon presentation. The remainder were identified by reviewing the pre-visit sleep study tables (35%), raw data (17%), and tables and raw data of a repeat post-visit study (38%). Patients with CSA were older and had evidence of more cardiac comorbidities.

Conclusion: The prevalence of CSA in new referrals to a Sleep Surgery Clinic was nearly 1 in 10 despite only 1% (3 of 295) with a known diagnosis upon presentation. Sleep surgeons must remain vigilant for patients with occult CSA, especially in older patients with a history of significant cardiovascular disease.

It is estimated that 1 in every 200 US newborns has congenital cytomegalovirus (cCMV). Delayed identification of cCMV in newborns precludes timely intervention to mitigate sequelae of the infection such as hearing loss and other neurological complications. Newborn testing for cCMV enables appropriate diagnosis and intervention by multidisciplinary teams to properly manage the immediate sequelae of cCMV, avoid unnecessary additional testing that can result from delayed diagnosis, and monitor for future complications. It is the position of the American Cochlear Implant Alliance, the National CMV Foundation, and the American Academy of Otolaryngology-Head and Neck Surgery that universal newborn cCMV screening is necessary to best accomplish these goals.

This report synthesizes the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) Task Force's guidance on the integration of artificial intelligence (AI) in otolaryngology-head and neck surgery (OHNS). A comprehensive literature review was conducted, focusing on the applications, benefits, and challenges of AI in OHNS, alongside ethical, legal, and social implications. The Task Force, formulated by otolaryngologist experts in AI, used an iterative approach, adapted from the Delphi method, to prioritize topics for inclusion and to reach a consensus on guiding principles. The Task Force's findings highlight AI's transformative potential for OHNS, offering potential advancements in precision medicine, clinical decision support, operational efficiency, research, and education. However, challenges such as data quality, health equity, privacy concerns, transparency, regulatory gaps, and ethical dilemmas necessitate careful navigation. Incorporating AI into otolaryngology practice in a safe, equitable, and patient-centered manner requires clinician judgment, transparent AI systems, and adherence to ethical and legal standards. The Task Force principles underscore the importance of otolaryngologists' involvement in AI's ethical development, implementation, and regulation to harness benefits while mitigating risks. The proposed principles inform the integration of AI in otolaryngology, aiming to enhance patient outcomes, clinician well-being, and efficiency of health care delivery.