Otolaryngology- Head and Neck Surgery最新文献

Objective: To analyze the utilization and reimbursement for tracheostomy.

Study design: Retrospective Cross-Sectional Study.

Setting: Centers for Medicare & Medicaid Services (CMS) Medicare Provider Utilization and Payment Data (2013 and 2021) and Part B Medicare Fee-For-Service National Summary Data (2000-2022).

Methods: Utilization, payment, and specialty breakdown were analyzed for planned tracheostomy (Current Procedural Terminology [CPT] codes 31600, 31601, 31610) and emergency tracheostomy (CPT codes 31603, 31605).

Results: From 2000 to 2022, there was a 48.9% decrease (40,754-20,812) in number of planned tracheostomies and a 75.3% decrease (3277-811) in number of emergency tracheostomies, leading to an overall decrease of 51%. Similarly, there was a 59.3% inflation-adjusted decrease ($13.4-$5.5 million) in total reimbursement for planned tracheostomies and an 82.1% inflation-adjusted decrease ($1.1 million-$205 thousand) in total reimbursement for emergency tracheostomies. There was a 20.3% inflation-adjusted decrease ($329-$262) in reimbursement per planned tracheostomy and a 27.7% inflation-adjusted decrease ($349-$252) in reimbursement per emergency tracheostomy. In our sample of 280 high-volume tracheostomy providers in 2021 (28.2% otolaryngology, 28.2% general surgery, 14.6% thoracic surgery, 14.3% pulmonary disease, 6.4% critical care), the average provider performed 15.8 tracheostomies and was reimbursed $5362.

Conclusion: Despite significant declines in tracheostomy utilization and reimbursement, understanding trends for these lifesaving procedures are critical for otolaryngologists and other providers in delivering high-quality care, and can be used by surgeons, hospital systems, and policymakers to guide future health care legislation.

Objective: To investigate the safety and effectiveness of dose-related ketorolac administration in children who underwent tonsillectomy.

Data sources: Data sourced from PubMed, SCOPUS, Embase, Web of Science, and Cochrane databases, encompassing literature from their inception until June 2024.

Review methods: The perioperative administration of ketorolac in comparison with a control group was included in this analysis. The outcomes assessed were postoperative pain levels; utilization patterns of analgesic medication in terms of quantity and frequency; and the incidence rates of postoperative nausea, vomiting, and bleeding.

Results: Eighteen studies with 11,729 patients that investigated. The ketorolac treatment group with postoperative bleeding had a higher incidence of primary bleeding (significant bleeding and operative bleeding control) compared to the control group. However, ketorolac treatment did not affect the risk of secondary bleeding. Subgroup analysis showed that 0.9 to 1 mg/kg of ketorolac significantly increases primary operative control (odds ratio [OR] = 4.0700 [1.6352; 10.1302]; I² = 0.0%) and primary significant bleeding (OR = 2.3200 [1.1322; 4.7538]; I² = 0.0%). On the other hand, 0.5 mg/kg ketorolac did not show any influence on primary operative control. The administration of ketorolac (both 0.9-1 and 0.5 mg/kg) led to a significant decrease in postoperative pain (2-24 hours), nausea, and vomiting compared to the control group.

Conclusion: Low-dose (0.5 mg/kg) ketorolac administration to children could significantly reduce the risk of primary significant bleeding and surgical hemostasis compared to high-dose administration (0.9-1.0 mg/kg). In addition, low-dose ketorolac administration could provide sufficient pain control and reduce postoperative nausea and vomiting.

The Pierre Robin Sequence is a rare craniofacial malformation that invariably combines retrognathism, glossoptosis, and upper airway obstruction, with a prevalence ranging from 1 in 8000 to 1 in 14,000 newborns. Although formally described by the French physician Pierre Robin in 1923, older and even ancient as far back as the Babylonian times, descriptions have been identified. Dr Pierre Robin's perspicacity lay in putting up a treatment for the patients presenting those symptoms. That is why his successors honored his work by naming this disease after him.

Objective: To review the literature on genetics of nonsyndromic microtia and congenital aural atresia (CAA).

Data sources: Embase, Ovid (Medline), and Web of Science.

Review methods: The search was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for scoping reviews. Included studies were original research studies discussing the genetics or pattern of inheritance of non-syndromic microtia and/or CAA, defined as microtia and/or CAA that was completely isolated except for the presence of hearing loss.

Results: Thirty studies met inclusion criteria, describing 40 unique genes and one susceptibility gene locus (4p15.32-4p16.2) associated with nonsyndromic microtia, CAA, or microtia and CAA. The 3 most cited genes describing microtia genetics alone were HOXA2, MUC6, and GSC. A single article describing nonsyndromic CAA alone identified the TSHZ1 as a candidate gene. Among 194 subjects from 18 manuscripts describing mendelian inheritance for non-syndromic microtia or microtia and CAA, 49% of the individuals were found to have autosomal dominant transmission, 4% had autosomal recessive, 5% had X-linked recessive, and 42% had no reported pattern of inheritance.

Conclusion: Current literature on the genetics of microtia and CAA is largely derived from genetic analysis of syndromic patients. Despite comprising over half of the clinical population, available data on non-syndromic patients remains limited. Understanding genetic polymorphisms and their correlation to phenotypic data more readily available to otolaryngologists offers the prospect of categorizing severity of anatomic malformation and hearing loss to guide future intervention, and improve ability to provide patient- and family-centered counseling.

Objective: Prophylactic ligation of the external carotid artery (ECA) during oropharyngeal squamous cell carcinoma (OPSCC) resection is known to reduce severe postoperative oropharyngeal bleeding events, however, there is limited research on whether bleed rates vary between selective ligation of individual vessels or total ligation of the ECA. This study assesses outcomes related to total versus selective ligation of the ECA in patients who underwent transoral resection for OPSCC of the base of tongue or palatine tonsils.

Study design: Retrospective review.

Setting: Patients who underwent OPSCC resection of the base of tongue or palatine tonsils at a single institution between October 2019 and September 2023.

Methods: Bleeding events within 30 days of surgery from the oropharyngeal surgical site were analyzed as well as other potential complications including stroke. Descriptive statistics and Fisher's exact test or χ² testing were used to analyze the data.

Results: Of 140 patients, 51 underwent base of tongue resection, and 89 had tonsillar resection. Total ECA ligation was performed in 56 patients, while 80 had selective ligation. There was no significant difference in oropharyngeal bleeding between the 2 groups (total 3.8% vs selective 3.7% P > .05). One patient in the total ECA ligation group had a stroke after resection (1.9%). On multivariate analysis, age (P = .024) and radiation exposure (P = .011) were found to be significant risk factors for hemorrhage.

Conclusion: Selective ligation of external carotid vessels versus total ligation of the ECA shows similar rates of oropharyngeal bleeding without any significant risk of stroke.

Objective: To assess adherence to the 2019 American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNSF) guidelines for the diagnosis and management of sudden hearing loss (SHL) and sudden sensorineural hearing loss (SSNHL).

Study design: Retrospective cohort.

Setting: TriNetX, a de-identified healthcare database.

Methods: Evaluation focused on the percentage of patients undergoing proper guideline-adherent workup and treatment for SHL. Key measures include audiogram testing within 2 weeks for distinguishing SSNHL from CHL. For SSNHL patients, MRI or auditory brainstem response (ABR) testing should be obtained, and steroids and/or hyperbaric oxygen may be offered within 2 weeks.

Results: There were 24,203 SHL patients, 59.1% (n = 14,309) of whom underwent recommended audiogram testing, with 35.8% (n = 8,674) completing it within 2 weeks. Overall, 3,107 were diagnosed with unilateral SSNHL, 104 with unilateral conductive hearing loss (CHL), 121 with mixed hearing loss, and 10,977 were lost to follow-up. Among 3,107 SSNHL cases, just 25.5% (n = 791) obtained MRI/ABR within 1 month, and vestibular schwannoma was diagnosed in 3.5% (n = 28). Additionally, steroids were prescribed to 54.5% (n = 1,692), and <0.3% (n ≤ 10) received hyperbaric oxygen. In accordance with strong recommendations against or insufficient evidence to support the following diagnostics and treatments, 2.0% (n = 63) underwent a CT scan, less than 0.3% (n ≤ 10) were prescribed vasodilators or thrombolytics, and 3.5% (n = 108) were on antivirals.

Conclusion: There is a significant opportunity for improvement in evaluating patients with SHL, specifically SSNHL. Proper adherence to guidelines may improve screening, detection, and management of neurotologic pathologies, including vestibular schwannoma.

Objective: Although vocal fold hemorrhage (VFH) is a common injury among vocal performers, no evidence exists to guide safe return to performance (RTP). This study assesses VFH recurrence following RTP.

Study design: Retrospective cohort.

Setting: Academic institution.

Methods: Adult vocal performers with clearly documented dates of VFH and of RTP were retrospectively studied. Clinicodemographics, interventions, and recurrence of VFH within 30 days of RTP were noted. Cohorts with and without recurrence were compared.

Results: Thirty-two patients (median age: 36 years, 49% female, 76% musical theater performers) with 33 unique occurrences of VFH were included. Most hemorrhages (31; 94%) were unilateral. Twelve patients (36%) had varices, all of which were ipsilateral to the hemorrhage. Overall, median time from initial VFH to RTP was 12.0 days (range 3-29). Two patients (6%) had a recurrence within 30 days of RTP. Median time to RTP was 10 days for those with recurrence and 12 days for those without recurrence (P = .6398). There were no differences in age (37 vs 34 years; P = .8206), sex (0 vs 16 [49%] female; P = .4848), extent of hemorrhage (P = .1728), or presence of associated varices (1 [50%] vs 11 [35.5%]; P > .9999) between groups.

Conclusion: Rate of VFH recurrence following RTP at a median of 12 days after initial injury was 6%, regardless of age, sex, hemorrhage extent, or associated varices. Although the interval between VFH and RTP was shorter in patients with recurrence, this was not statistically significant. These findings guide counseling and set expectations among vocal performers faced with VFH.

Level of evidence: IV.

Objective: High-pitched voice disorders can present notable social and professional obstacles for cisgender and transgender men. Our study aims to conduct a comprehensive meta-analysis assessing the efficacy of type III thyroplasty, also known as relaxation thyroplasty, for different populations with high-pitched voice disorders.

Data sources: A systematic literature review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, searching Medline/Pubmed, Embase, Cochrane, Science Direct, Scielo, LILACS, and Google Scholar databases from inception to April 2024.

Review methods: Studies included patients undergoing type III thyroplasty for high-pitched voice disorders. The primary outcome was the change in fundamental frequency postintervention. Subgroup analyses compared the following: (1) cisgender versus transgender populations, (2) primary versus secondary causes of high-pitched voice disorders, and (3) unilateral versus bilateral vertical stripe resection techniques.

Results: The initial search yielded 284 articles, 9 studies, including 69 unique patients, were included in the analysis. All studies provided level 4 evidence. Most patients were cisgender men with primary mutational dysphonia (66.7%, n = 46). The meta-analysis showed a significant reduction in fundamental frequency after surgery, with a mean difference of -75.9 Hz (95% confidence interval [CI]: -91.5 to -60.3). Cisgender men and patients submitted to unilateral resection had higher preoperative fundamental frequency and showed a more pronounced reduction in fundamental frequency. There were no significant differences between primary and secondary mutational dysphonia.

Conclusion: Type III thyroplasty effectively lowers vocal pitch in patients with high-pitched voice disorders. The procedure is viable for both cisgender and transgender men, as well as for primary and secondary voice disorders.

Objective: To assess the added benefit of newborn genetic screening for GJB2 and SLC26A4 variants in conjunction with newborn hearing screening.

Study design: Retrospective cohort study.

Methods: Children with known variants of GJB2 and SLC26A4 were identified from 485 children with hearing loss who underwent testing with Next Generation Sequencing (NGS) between January 2015 and February 2018, prior to expanded screening for genetic variants and congenital CMV. Children with two pathogenic or likely pathogenic variants of GJB2 or SLC26A4 were considered to have genetic hearing loss. NGS genetic data were compared to variants included in the expanded genetic screen for all newborns in Ontario and newborn hearing screening results.

Setting: Canadian tertiary pediatric hospital.

Results: Thirty-five children with GJB2 and SLC26A4-associated hearing loss were identified by NGS (n = 27 GJB2-HL; n = 8 SLC26A4-HL). Of these, 20 (57%) had been identified by newborn hearing screening (14/27 52% GJB2-HL; 6/8 75% SLC26A4-HL). Ten of the 20 (50%) would also have been identified by genetic screening if it had been available (9/14 64% GJB2-HL; 1/6 17% SLC26A4-HL). An additional 8 children with GJB2 or SLC26A4-associated hearing loss passed their newborn hearing screen but showed hearing loss later; three of these children (38%) would have been identified by newborn genetic screening (3/6 GJB2-HL; 0/2 SLC26A4-HL).

Conclusion: Genetic and hearing screening modalities in Ontario's expanded newborn hearing screening program improve early identification of children with hearing loss including those at risk of being missed by hearing screening alone. This was most clear for children with GJB2-hearing loss.

Objective: This study aims to determine the representation of women among most-cited facial plastic and reconstructive surgery articles.

Study design: A bibliometric analysis of the most-cited articles from 9 high-impact facial plastic surgery journals.

Setting: Online database.

Methods: A retrospective analysis of the 100 most-cited articles in facial plastic surgery was conducted using the Elsevier Scopus database. The representation of women among first, senior, and corresponding authors was assessed using the US Social Security Baby Names Database. Accredited websites were utilized for further clarification of gender, professional background, and title. A 2-tailed t-test was performed to compare the average number of citations by gender, while chi-square analysis was used to compare the relative number of women authors between 5-year intervals, citation rank, and nationalities. A significance level of 0.05 was used.

Results: The top 100 most-cited articles had the highest total number of citations between 2000 and 2004. US institutions published 71% of these articles. The gender of 99% of first authors, 94% of senior authors, and 94% of corresponding authors was identified. Among these, 11% of first authors, 14% of senior authors, and 10% of corresponding authors were women. Of the 19 women authors, 11 were physicians. No statistically significant difference in the relative number of first, senior, and corresponding women authors was observed between years of publication, citation quartile, and article nationality.

Conclusion: Despite increasing women facial plastic surgery trainees, women's academic contributions continue to trail. Additional efforts are needed to support and highlight academic achievements of women facial plastic surgeons.