Otolaryngology- Head and Neck Surgery最新文献

Objective: The apnea-hypopnea index (AHI) quantifies obstructive sleep apnea (OSA) severity but has limited correlation with subjective symptoms and cardiovascular risk. Sleep parameters related to oxygenation status and hypoxic burden may offer utility as additional predictors of cardiovascular risk and the physiologic consequences of OSA. This study aims to assess the change in measures of oxygenation status following sleep surgery for OSA.

Study design: A retrospective cohort study.

Setting: A single-institution tertiary care center.

Methods: Patients who underwent hypoglossal nerve stimulator (HGNS) placement, expansion sphincter pharyngoplasty (ESP), or maxillomandibular advancement (MMA) for continuous positive airway pressure-intolerant OSA were included. The percentage of sleep time below SaO₂ 90% (pT90) was used to characterize oxygenation status. Wilcoxon signed-rank test compared changes in sleep metrics from preoperatively to postoperatively. Linear regression was performed to assess whether changes in pT90 were correlated with changes in AHI and Epworth Sleepiness Scale (ESS), respectively.

Results: A total of 219 patients were included (65% HGNS, 24% ESP, 11% MMA). The average decline in AHI and ESS was 11.9 events/h (standard deviation [SD] = 19.9, P < .001) and 3.2 points (SD = 4.7, P < .001), respectively. Among measures of sleep oxygenation, pT90 (11.5 → 8.9, P < .001), oxygen desaturation index (27.1 → 15.1, P < .001), and SpO₂ nadir (79.9 → 81.2, P = .03) improved significantly following surgery. On linear regression, changes in pT90 were significantly correlated with changes in AHI (β = 0.31, 95% confidence interval [CI] 0.18-0.45, P < .001) and ESS (β = .05, 95% CI 0.00, 0.09, P = .038), respectively.

Conclusion: Upper airway surgery improves metrics of oxygen status in addition to the AHI. Changes in pT90 correlate with subjective symptoms of OSA per ESS, suggesting utility in capturing disease burden.

Unlike pediatric care that often benefits from child-life services, adult hospitals rarely offer structured engagement activities for postsurgical patients. To address this, we conducted a prospective, randomized survey-based study to evaluate the impact of creative engagement activities on adult inpatient experiences. Patients undergoing surgery between January and September 2023 were randomly assigned to either standard postoperative course or one that received an entertainment packet. Both cohorts completed a survey about their hospital experience. The intervention group reported significantly higher satisfaction: 95% agreed or strongly agreed with "I am satisfied with my hospital experience," compared to 65% in the control group (P = .045). Additionally, 65% of the intervention cohort reported a positive postoperative experience and 80% found their stay engaging versus 30% in the control cohort (P = .028 and P = .001, respectively). These findings suggest that creative entertainment can improve the postoperative experience for adult patients.

Objective: This study examines whether the timing of botulinum toxin type A (BoNTA) treatments affects outcomes in patients with synkinesis, a sequela of Bell's Palsy characterized by disconjugate facial muscle movement.

Study design: A retrospective chart review.

Setting: An urban academic medical center.

Methods: We reviewed the charts of synkinesis patients treated from 2016 to 2022. Data included procedural notes, intervention dates, and scores from the House-Brackmann (HB), Facial Clinimetric Evaluation (FaCE), Synkinesis Assessment Questionnaire (SAQ), and Facial Grading System (FGS).

Results: Sixty-seven patients (median age 54 years, average palsy duration 5.7 years) received BoNTA. Patients treated within 12 months (n = 28), 13 to 24 months (n = 12), and after 24 months (n = 23) showed no significant differences in changes to HB, FaCE, or SAQ scores. However, patients treated within 1 year had significantly higher FGS improvement (36.3) than the other groups (P = .03).

Conclusion: While FaCE, HB, and SAQ scores showed no significant differences, early BoNTA treatment within 1 year significantly improved FGS scores, indicating better outcomes. Therefore, early treatment is ideal for optimal response.

Objective: This study aims to analyze disease and treatment patterns at a tertiary care center and propose guidelines for the management of canal cholesteatomas.

Study design: A retrospective cohort study.

Setting: This study involves patients diagnosed and treated with external auditory canal cholesteatomas (EACC) from January 1, 2010, to January 1, 2021 at the University of Florida, a tertiary care center.

Methods: Inclusion criteria included a diagnosis of EACC with at least 1 follow-up visit after diagnosis. Patient demographics, risk factors, etiology if acquired, EACC characteristics such as location and staging, and treatment modality were recorded and analyzed. The primary outcome was a recurrence of disease.

Results: Out of the 175 patients reviewed, 90 patients and 100 ears met the criteria. Most patients were treated with surgery (81%, N = 81) as opposed to medical management (ie, serial debridement). While there were no factors that were significant for higher odds of surgical intervention, all Stage IV (n = 9) and superior canal wall locations (n = 8) were treated with surgery. Mastoidectomy was more likely to be performed in higher staged cholesteatomas (χ² = 13.41, P = .0012) and posterior canal cholesteatoma location (odds ratio [OR] = 11.20, P = .0001), whereas anterior (OR = 0.11, P = .0390) and inferiorly located EACCs (OR = 0.22, P = .0169) had more odds of being treated with canalplasty/tympanoplasty. Recurrence was seen up to 4.78 years after surgery.

Conclusion: Disease location and staging and patient factors should be considered in the shared management decision-making of EACC treatment. Surveillance duration should be up to 5 years.

Objective: Stereotactic radiosurgery (SRS) is increasingly used for small-to-medium-sized sporadic vestibular schwannoma (VS) and is associated with good tumor control and low-risk of adverse radiation-associated events. The exact mechanism of VS tumor control is unknown but may relate to microvascular hyalinization and resultant tumoral ischemia. This study examined associations of microvascular risk factors with outcomes following SRS.

Design: Historical cohort of patients who underwent SRS for sporadic VS from 2000 to 2022.

Setting: Tertiary academic center.

Methods: Associations of microvascular risk factors with tumor control and complications were evaluated using Cox proportional hazards regression.

Results: In total 749 patients were studied, 31% with a history of smoking, 38% obesity, 19% hypertension, 8% diabetes, 3% peripheral vascular disease, and 2% history of coronary bypass. Regarding tumor control, no factor was associated with salvage treatment following SRS (n = 42). Hypertension (hazard ratio [HR] 2.81; P = .02) and coronary bypass (HR 6.91; P = .002) were significantly associated with developing facial nerve paresis (n = 22). No significant associations with new facial spasms (n = 53) were identified. Lastly, 191 of 294 patients with serviceable hearing at SRS progressed to nonserviceable hearing at a median 2.0 years (interquartile range: 1.0-5.0). After multivariable adjustment for age and ipsilateral hearing status, the HR for the association of smoking history with time to nonserviceable hearing was 1.46 (95% confidence interval 1.04-2.04; P = .03).

Conclusion: We demonstrate that hypertension and history of coronary bypass may be associated with development of facial nerve weakness, while smoking may be associated with accelerated hearing loss in patients undergoing SRS for sporadic VS. These data may help guide patient counseling and inform decision-making regarding treatment.

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: Examine the management and outcomes of pediatric head and neck lymphatic malformations (HNLMs).

Study design: Retrospective case series.

Setting: Tertiary academic hospital.

Methods: Patients aged 18 years or younger treated for HNLMs at Johns Hopkins Hospital from 2000 to 2023 were identified. Demographics, clinical characteristics, and treatment courses were recorded from charts. Outcome measures included estimated clinical post-treatment size reduction and complications. Fisher's exact test was performed for comparisons between treatments.

Results: We identified 101 pediatric patients (50.5% female) with HNLMs. Fifty-two received unimodal treatment, 11 received multimodal treatment, and 38 underwent active observation or no treatment. Of those who received treatment, 44% had their first treatment before 2 years of age. 54.5% of all patients received sclerotherapy. Sclerotherapy caused nearly complete or complete resolution in 52.2% (n = 24) of low-stage (de Serres Stages 1-3) HNLMs and complete resolution in 26.1%. Most (71.4%) high-stage (de Serres Stages 4-5) malformations demonstrated limited size reduction response to all treatments. Surgery had a higher all-inclusive complication rate (25%) compared to sclerotherapy (17%). Multimodal treatment strategies were most often used to treat microcystic malformations of all stages, achieving a 42.9% nearly complete or complete resolution rate.

Conclusion: Low-stage and macrocystic pediatric HNLMs respond well to treatment. Sclerotherapy had the lowest complication rate. High-stage malformations had limited size reduction response to multimodal treatment. As new medical therapies continue to develop, opportunities for improved treatment algorithms will emerge.

Objective: Electrode array design may impact hearing outcomes in patients who receive cochlear implants. The goal of this work was to assess differences in post operative speech perception among patients who received cochlear implants of differing designs and lengths.

Study design: Retrospective chart review.

Setting: Tertiary Care Hospital.

Methods: Patients (n = 129) received 1 of 9 electrode arrays, which were categorized by design: Lateral wall electrodes (n = 36) included CI522, CI622 (Cochlear Americas), Flex24, and Flex28 (Med El). Midscala electrodes (n = 16) included HiRes Ultra 3D (Advanced Bionics). Perimodiolar electrodes (n = 77) included CI512, CI532, CI612, and CI632 (Cochlear Americas). Speech perception was evaluated using consonant-nucleus-consonant (CNC) tests and at 3, 6, 12, and 24 months postimplantation.

Results: Perimodiolar electrodes showed significantly higher CNC scores compared to lateral wall electrodes at 6 and 24 months. Perimodiolar electrodes also outperformed midscala electrodes at 12 months. An inverse relationship was observed between electrode length and CNC scores noted at 6, 12, and 24 months.

Conclusion: Perimodiolar electrode arrays, which tend to be shorter, demonstrated better speech perception outcomes compared to the longer lateral wall and midscala arrays at some timepoints. These findings suggest a potential advantages of perimodiolar electrodes for optimizing hearing outcomes.

Objective: To evaluate the clinical efficacy of vidian neurectomy (VN) or posterior nasal neurectomy (PNN) combined with endoscopic sinus surgery (ESS) in patients with chronic rhinosinusitis with nasal polyps (CRSwNP).

Data sources: A systematic search of six databases (PubMed, SCOPUS, Embase, Web of Science, Google Scholar, and Cochrane) was conducted to identify relevant studies up to May 2024.

Review methods: The effects of combining VN or PNN with ESS were evaluated in comparison to ESS alone. Outcomes were assessed by evaluating changes in Lund-Kennedy score, patient-reported symptom scores (VAS), quality of life, as well as adverse effects and recurrence rate of CRSwNP.

Results: A total of 6 studies, comprising 407 patients, were included in the analysis. The neurectomy group showed significant improvements in Lund-Kennedy score (SMD = 0.7276 [0.5695; 0.8857]), with statistically significant improvements maintained at 6, 12, and 24 months postoperatively. The treatment group maintained better improvements in sinusitis-related quality of life (SMD = 0.4540 [0.1784; 0.7297]) and VAS (SMD = 0.7096 [0.4356; 0.9837]) until 12 months postoperatively, but not at 24 months. Regarding adverse effects, additional neurectomy did not significantly induce epistaxis (odds ratio [OR] = 0.9806 [0.2348; 4.0960]) or dry eye (OR = 2.4194 [0.1114; 52.5255]) compared to the control group. On the other hand, there was no difference in the recurrence rate of CRSwNP between the 2 groups during the follow-up periods.

Conclusion: Additional neurectomy shows better efficacy in improving endoscopic findings and symptoms in patients with CRSwNP and appears to be a safe and effective treatment.