Otolaryngology- Head and Neck Surgery最新文献

Objective: Several approaches can be used in the surgical treatment of vestibular schwannoma (VS), and the best approach remains uncertain in the literature. This systematic review and meta-analysis aim to compare the translabyrinthine approach (TLA) with the retrosigmoid approach (RSA) for VS in terms of postoperative complications.

Data sources: PubMed, Web of Science, Embase, and Cochrane.

Review methods: The primary outcome was cerebrospinal fluid (CSF) leak; secondary outcomes were facial nerve dysfunction (FND), length of stay (LOS), and meningitis. Statistical analysis was performed using RStudio 2024.04.1 + 748. Heterogeneity was assessed with I² statistics. We performed sensitivity analysis with subgroup analysis and meta-regression. Risk of bias was assessed using ROBINS-I.

Results: Out of 1140 potential articles, 21 met the inclusion criteria. Among the 4572 patients, 2687 and 1885 patients in the TLA and RSA groups, respectively. No significant differences were found in CSF leak (odds ratio [OR] 1.03; 95% confidence interval [CI] 0.81,1.32; P = .794) or meningitis (OR 1.05; 95% CI 0.45, 2.43; P = .73). Meta-regression showed no association with CSF leak and the number of cases per center or publication year. The TLA is associated with a shorter LOS (MD -1.20; 95% CI -1.39, -1.01; P < .01) and a higher chance of having and HB 4 or lower compared to patients who underwent RSA (OR 0.30; 95% CI 0.10, 0.89; P = .03).

Conclusion: There was no difference in the odds of CSF leak or meningitis between the groups. In addition, the TLA has a shorter LOS and a higher chance of a better facial nerve outcome compared to the RSA.

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: 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 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.