Otolaryngology- Head and Neck Surgery最新文献

Objective: To review speaking valve (SV) use at a tertiary academic medical center and determine whether a multidisciplinary team implementation of SV protocols increased SV use and decreased time to SV trials.

Methods: Retrospective case series of patients who underwent a tracheostomy between 2017 and 2023 before and after the dissemination of new protocols from a new multidisciplinary tracheostomy care initiative in 2019. The calendar days between meeting SV eligibility criteria and initial trial of SV were compared. Eligibility criteria for SV was defined as any patient ≥48 hours posttracheotomy who can breathe unassisted, off mechanical ventilation, tolerate a deflated cuff, and participate in an evaluation. Interrupted time series analysis using segmented negative binomial regression assessed the change in time to SV placement before and after protocol implementation.

Results: A total of 421 patients were identified. After new protocols were disseminated, eligible patients with a SV trial increased from 75% to 95% with an increase in percentage of patients who tolerated the SV on their first attempt from 60% to 75%. Interrupted time series analysis demonstrated protocol implementation was associated with an overall 80% decrease in time to SV placement.

Discussion: Continued barriers to SV implementation such as elevated tracheal pressures due to large tracheostomy sizes, or inappropriately early consultations with patients unable to participate in SV exam, may be amenable to further institution-level quality improvement initiatives.

Implications for practice: A multidisciplinary initiative's dissemination of protocols with algorithms for SLP consultation and SV use can help standardize post-operative tracheostomy care.

Objective: To examine the cost-effectiveness of hypoglossal nerve stimulation (HGNS) implantation at an early age in simulated pediatric cohorts with Down Syndrome (DS) and severe obstructive sleep apnea (OSA).

Study design: Cost-utility analysis.

Setting: Hypothetical cohort.

Methods: A Markov model simulated 3 pediatric cohorts with DS and OSA beginning at age 4 years until 21 years. Cohorts received HGNS implants in early childhood, late childhood, or adulthood at age 4, 13 (current FDA-approved age), or 18 years, respectively. Input model parameters were obtained from the literature and our institution. Outcomes were measured with an incremental cost-effectiveness ratio (ICER), measured in dollars per quality-adjusted life-year (QALY). Deterministic 1-way sensitivity analyses were conducted to evaluate the effects of parameter uncertainty.

Results: Results (total costs; total QALYs) across the time horizon were determined for each cohort: early implantation ($83,300.35; 15.79), late ($48,319.09; 14.98), and adult ($38,721.07; 14.55). ICERs were $48,892.47 per QALY for early vs late implantation, $43,471.15 per QALY for early vs adult implantation, and $30,959.58 per QALY for late vs adult implantation. All ICERs were below a willingness-to-pay threshold of $50,000 per QALY. Varying the discount rate and utility expectedly varied the ICERs and cost-effectiveness. Threshold analysis showed early implantation to be cost-effective for a HGNS implantation cost up to $62,230 compared to late implantation.

Conclusion: The current study suggests HGNS is a cost-effective treatment strategy for pediatric patients with DS and severe OSA. Our findings also suggest cost-effectiveness at ages younger than 13, the current age of FDA approval.

Objective: Prolonged intubation often leads to laryngeal injuries such as subglottic stenosis (SGS), especially in neonates with prematurity and congenital defects key for tissue healing. Recognizing at risk patients in the neonatal intensive care unit (NICU) is not well studied. The study's goals were to determine intubation risk factors, characterize laryngeal injuries, and calculate the incidence of intervention.

Study design: Retrospective case review.

Setting: Quaternary pediatric referral center.

Methods: This retrospective study included all intubated patients in the NICU from April 1, 2020 to 2023. Electronic records were reviewed for demographics and intubation details. Patients were categorized to into intubation only or intervention groups, including direct laryngoscopy and bronchoscopy (DLB) and tracheostomy history.

Results: A total of 441 patients were identified with 94 (21%) neonates undergoing DLB. Characteristics impacting intervention included older gestational age, genetic syndromes, and congenital heart disease. Significant risk factors were older age at first intubation, recurrent intubation events, longer intubation duration, and larger endotracheal tube (ETT) diameter, but not birth weight or intubation attempts. Otolaryngology was more likely to intubate the intervention cohort. SGS overall incidence was 2.95% with balloon dilation in 6.4%. Two-thirds of neonates with DLB ultimately required tracheostomy, in which all variables remained significant risk factors except for gestational age.

Conclusion: Older age at first intubation, more intubation events, longer intubation duration, and larger ETT increased risk for future DLB and tracheostomy but not birth weight or number of intubation attempts. Most NICU patients selected for DLB ultimately required further procedures.

Objective: Computed tomography (CT) imaging of the temporal bone constitutes an integral element in the diagnostic workup of superior canal dehiscence (SCD). This study explores the utility of a clinically efficient method of manually estimating SCD size on CT imaging in predicting surgical outcomes.

Study design: Cohort study.

Setting: Tertiary center.

Methods: Consecutive middle fossa repairs of SCD between 2011 and 2022 were included. Measurements of approximate dehiscence area (ADA), a previously established estimation method, on temporal bone CT imaging were performed by trained raters blind to clinical information. Surgical outcomes, evaluated with symptom resolution and audiometric improvement following repair, were assessed in multivariable regression models with ADA as the primary predictor and patient demographics and other history factors as covariates.

Results: Among 311 cases included, mean ADA was 2.68 mm², and 71% of cases achieved overall symptom improvement (OSI). Every 1 mm² rise in ADA predicted on average 3 dB greater narrowing of low-frequency air-bone gap (β 95% confidence interval, CI [-5.4, -0.7]) but 50% lower odds of OSI (adjusted odds ratio: 95% CI [0.32, 0.78]) among unilateral SCD cases. A model incorporating ADA, patient demographics, and history factors predicted OSI with a sensitivity, specificity combination as high as 85%, 73% and a positive predictive value, negative predictive value combination as high as 85%, 82% (area under the curve: 95% CI: 0.76-0.93).

Conclusion: Increased ADA predicts more pronounced audiometric improvement but poorer symptomatic response among unilateral SCD cases. ADA is an efficient and practical method of estimating SCD size and demonstrated clinical utility in accurately predicting surgical outcomes.

The persistent challenge of high pharmaceutical prices has led to the emergence of vertically integrated direct-to-consumer distributors like Mark Cuban Cost Plus Drug Company (MCCPDC). This study aims to evaluate a cost-saving alternative method for medication sourcing. The most frequently prescribed medications by otolaryngologists were identified through analysis of Medicare Part D data, utilizing prescriber type as a filter. Medications were assessed for availability on the MCCPDC website and drug form consistency. Cost analysis was conducted comparing current pharmaceutical spending against MCCPDC pricing. Potential otolaryngology-driven savings were estimated at $55.6 million and $1 billion if in effect across all specialties. Our findings suggest considerable potential savings for Medicare by purchasing generic medications at MCCPDC prices.

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.

Objective: This study aimed to assess the prognostic value of early posttreatment initiation audiometry findings in patients with idiopathic sudden sensorineural hearing loss (ISSHL).

Study design: A retrospective cohort study.

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

Methods: A review was conducted on 299 ISSHL patients treated between 2007 and 2023. Patients underwent audiometry on Days 2 to 3 and 5 to 7 posttreatment initiation. Data on demographics, medical history, audiometry results, and prognosis were collected. Prognosis was categorized based on hearing recovery at 1 year postdiagnosis.

Results: Older age, worse initial speech reception threshold (SRT), ischemic heart disease, cerebrovascular accidents/transient ischemic attacks, hypertension, and diabetes were associated with a poorer prognosis. Posttreatment initiation audiometry findings on Days 2 to 3 and 5 to 7 significantly correlated with prognosis. Patients with a ≥30% improvement had substantial or complete recovery in over 80% of cases, while those with <10% had <30% recovery. Multivariate analysis identified a significant improvement on days 5 to 7 as an independent predictor of complete recovery (odds ratio = 4.25 [95% confidence interval 1.96-9.23], P = .0002).

Conclusion: Posttreatment initiation audiometry findings, particularly on Days 5 to 7, hold significant prognostic value in ISSHL patients. A substantial improvement during this timeframe is strongly associated with favorable outcomes. These findings emphasize the potential of posttreatment initiation audiometry as a valuable tool for clinicians in counseling patients with ISSHL.

Objective: The primary objective was to characterize the abundance and architecture of collagen in the extracellular matrix in vestibular schwannoma (VS). The secondary objective was to investigate the association between collagen architecture and tumor size.

Study design: Retrospective cohort study.

Setting: Academic referral center.

Methods: Tumor samples were obtained from patients with sporadic VS undergoing microsurgical resection. Histological analyses were performed including picrosirius red (PSR) staining under polarized light. Collagen architecture was quantified using an automated fiber detection software. Second Harmonic Generation (SHG) microscopy and immunofluorescence (IF) were utilized to characterize collagen architecture.

Results: Eleven tumor specimens were included (mean tumor diameter = 2.80 cm, range 1.5-4.0 cm), and were divided into large (mean diameter = 3.5 ± 0.4 cm) and small (mean tumor diameter = 2.0 ± 0.4 cm) cohorts based on size. The large VS cohort showed significantly higher collagen density (27.65% vs 12.73%, P = .0043), with more thick fibers (mature Type I, 24.54% vs 12.97%, P = .0022) and thin fibers (immature Type I or mature Type III, 23.55% vs 12.27%, P = .026). Tumor volume correlated with greater degree of collagen fiber disorganization (P = .0413, r² = 0.298). Specifically, collagen type I intensity was significantly higher in large VS compared to small tumors (P < .001) and peripheral nerve (P = .028).

Conclusion: Larger VS exhibit increased collagen abundance in the tumor stroma, and a more disorganized collagen architecture compared to smaller VS and normal peripheral nerve tissue. This finding indicates that collagen organization may play a significant role in extracellular matrix remodeling and the progression of VS.

Objective: Synkinesis is estimated to impact 10% to 50% of those with facial palsy. We aim to identify the incidence and factors associated with anxiety and depression in the facial synkinesis population.

Study design: Prospective cohort study.

Setting: Patients aged 18 and older with a diagnosis of facial synkinesis at a tertiary medical center were eligible for inclusion.

Methods: Demographic variables were collected, and the following surveys were distributed: Synkinesis Assessment Questionnaire, Facial Clinimetric Evaluation Scale, Facial Disability Index, Center for Epidemiological Studies Depression Scale, and Fear of Negative Appearance Evaluation Scale. Patient videos were graded for physician perceived severity using the Electronic Facial Paralysis Assessment and Sunnybrook scale. Analysis of the overall incidence of anxiety and depression symptoms as well as the impact of demographic factors was performed using Pearson product moment correlation and regression modeling.

Results: One-hundred patients met inclusion criteria. Over 25% of patients met criteria for possible or probable depression and the most common appearance-related anxiety score was 30, indicating severe anxiety. Female gender, younger age, and previous history of anxiety and depression were associated with increased depression and anxiety scores at baseline with shorter duration of synkinesis also trending toward higher scores. Worse patient reported severity was also associated with increased depression and appearance-related anxiety scores.

Conclusion: The overall prevalence of depression and appearance-related anxiety is relatively high in patients with facial synkinesis.