Otolaryngology- Head and Neck Surgery最新文献

Objective: To evaluate the predictive value of plasma matrix metalloproteinase-9 (MMP-9) level in determining the extent of tumor resection (EOR) and tumor adherence in vestibular schwannoma (VS) surgery.

Study design: Prospective cohort study.

Setting: Academic referral center.

Methods: Plasma and tumor samples were prospectively collected from patients with nonradiated, sporadic VS undergoing microsurgical resection from July 2022 to June 2023. Plasma MMP-9 levels were measured by enzyme-linked immunosorbent assay, and their association with tumor adherence and postoperative outcomes were evaluated.

Results: Thirty-three patients undergoing microsurgical resection agreed to participate (15 females, median age 54 years old, median tumor size 26.7 mm). A gross total resection (GTR) was performed in 18 patients (55%), and a near-total (NTR)/subtotal resection (STR) in 15 (45%). Tumor size was not significantly different between the GTR and NTR/STR groups (20.7 vs 24.8 mm, P= .185). Intraoperatively, a larger fraction of NTR/STR tumors were highly adherent to the brainstem and/or cranial nerves (93% vs 56%, P = .015). Preoperative plasma MMP-9 was higher in patients who underwent an NTR/STR compared to a GTR (229.9 vs 131.2ng/mL, P = .007). On multivariable logistic regression, preoperative plasma MMP-9 strongly predicted EOR by receiver operating characteristic analysis (area under the curve [AUC] = 0.77 P = .008). Combining plasma MMP-9 and age was an excellent predictor of EOR (AUC = 0.91, P = .0001).

Conclusion: Plasma MMP-9 levels strongly predicted intraoperative tumor adherence and postoperative extent of resection. This could provide crucial preoperative insights into surgical difficulty, potential complications, and the likelihood of gross total tumor removal, enhancing informed decision-making for both physicians/surgeons and patients.

Objective: To evaluate the efficacy, safety, and durability of temperature-controlled radiofrequency (TCRF) treatment of the nasal valve in patients with severe or extreme nasal airway obstruction (NAO).

Study design: A long-term, prospective, multicenter, single-blind, randomized controlled trial.

Setting: Sixteen otolaryngologic clinics and academic centers.

Methods: Patients received TCRF treatment on the lateral nasal valve. All patients were followed through 3 years. Outcome measures included the Nasal Obstruction Symptom Evaluation (NOSE) Scale, Epworth Sleepiness Scale (ESS), and adverse events (AEs). Treatment responders were defined as a ≥1 reduction in severity class or ≥20% reduction in NOSE score.

Results: Out of 108 patients who received TCRF treatment, 54 reached the 3-year follow-up timepoint. The baseline mean NOSE score was 76.3 (95% confidence interval [CI], 73.6 to 79.1). The 3-year NOSE score treatment effect was -49.4 ([95% CI, -56.5 to -42.4]; P < .001) a 64.7% improvement from baseline; 88.7% of patients were responders. Most patients reported significant improvements in sleep post-treatment with a mean ESS score of 4.5 (95% CI, 3.4 to 5.7) at 3 years compared to 10.3 (95% CI, 9.2 to 11.4) at baseline.

Conclusion: Treatment with the TCRF device for nasal valve obstruction resulted in sustained improvements in nasal obstruction symptoms and sleep quality over a 3-year period without any serious AEs. These findings support the long-term benefits and sustained improvements in symptoms in patients with NAO.

Objective: Facial trauma volume is difficult to predict accurately. We aim to understand the capacity of climate and regional events to predict daily facial trauma volume. This can provide epidemiologic understanding and subsequently tailor workforce distribution and scheduling.

Study design: Retrospective cohort study.

Setting: Single Tertiary Academic Medical Center.

Methods: Facial trauma consults between 2017 and 2023 were extracted from a single Level I Trauma Center. Publicly accessible data on local concerts, National Hockey League games, National Football League games, and weather data from the National Oceanic and Atmospheric Administration data were merged with trauma data. Machine-learning random-forest (RF) plot feature identification was used to identify variables to model high-volume facial trauma days (greater than 75th percentile).

Results: For analysis, 2342 days were included. The median number of facial trauma consults was 3.0 (interquartile range: 2.0-5.0). The month of May exhibited the highest rate of high-volume trauma days (13% of days, P < .001). On RF feature identification, the strongest predictive factors included weekend day status, average temperature, precipitation, hail, high/damaging winds, and holidays. Regional events were not included in the final models. On stepwise logistic regression modeling with pertinent variables, weekend day (odds ratio [OR]: 2.20, 95% confidence interval [CI]: 1.80-2.69, P < .001), average temperature (OR: 1.02, 95% CI: 1.01-1.02, P < .001), and wind speed (0.97, 0.93-1.00, P = .049) were the only statistically significant variables.

Conclusion: Climate data were the primary factor that had predictive capacity for high-volume facial trauma days, more so than regional events. Testing models prospectively will help validate such models and help inform staffing for facial trauma coverage.

Objective: Solid organ transplant (SOT) recipients carry a higher incidence of cutaneous squamous cell carcinoma (cSCC) with more aggressive features and worse outcomes compared to immunocompetent (IC) patients. The National Comprehensive Cancer Network advocates peripheral and deep en-face margin assessment such as Mohs micrographic surgery (MMS) for very-high-risk cSCC. We aim to assess the efficacy of MMS in the treatment of SOT immunosuppressed head and neck (HN) cSCC patients.

Study design: Cohort study with planned chart review enrolling HN cSCC patients (2004-2017).

Setting: Patients were enrolled from a tertiary care medical center registry.

Methods: Patients with cSCC were categorized on the independent variable of immune status. The incidence of MMS was compared between IC and SOT patients. Subgroup analysis of a matched cohort of patients treated with only MMS was performed for patient demographics, tumor characteristics, recurrence rates, and survival.

Results: A total Of 178 HN cSCC patients met the criteria. SOT patients were more likely to be treated with MMS, P < .001. In the subgroup analysis, 34 matched patients were treated with MMS alone. There was homogeneity between groups regarding patient demographics and tumor characteristics. One patient developed local recurrence in the SOT cohort (P = .310). Compared to IC cSCC patients, SOT patients treated with MMS did not experience worse disease-free or overall survival (OS) (P = .540).

Conclusion: This study suggests that narrow-margin MMS is an appropriate treatment option for SOT cSCC patients. SOT patients were more likely to be treated with MMS and did not compromise local recurrence, disease-free, or OS.

Objective: To validate the use of neural radiance fields (NeRF), a state-of-the-art computer vision technique, for rapid, high-fidelity 3-dimensional (3D) reconstruction in endoscopic sinus surgery (ESS).

Study design: An experimental cadaveric pilot study.

Setting: Academic medical center.

Methods: Complete bilateral endoscopic sinus surgery was performed on 3 cadaveric specimens, followed by postsurgical nasal endoscopy using a 0° rigid endoscope. NeRF was utilized to generate 3D reconstructions from the monocular endoscopic video feed. Reconstructions were calibrated, scaled, and then co-registered to postoperative computed tomography (CT) image sets to assess accuracy. Reconstruction error was determined by comparing ethmoid sinus measurements on NeRF reconstructions and CT image sets.

Results: NeRF-based 3D scene reconstructions were successfully generated and co-registered to corresponding CT images for 5 out of 6 cadaveric nasal cavity sides. The mean reconstruction errors and standard error of the mean (SEM) for ethmoid length and height were 0.17 (SEM 0.59) and 0.70 (SEM 0.44) mm, respectively.

Conclusion: NeRF demonstrates significant potential for dynamic, high-fidelity 3D surgical field reconstruction in ESS, offering submillimeter accuracy comparable to postoperative CT data in cadaveric specimens. This innovative approach may ultimately augment dynamic real-time intraoperative navigation through co-registration of the 3D reconstruction with preoperative imaging to potentially reduce the risk of injury to critical structures, optimize surgical completeness and, thereby, improve surgical outcomes. Further refinement and validation in live surgical settings are necessary to fully realize its clinical utility.

Objective: Determine if a flexed-neck posture during flexible nasolaryngoscopy (FNL) improves visualization of the subglottis.

Study design: Retrospective review of children undergoing FNL in the neutral (FNL) and flexed-neck (FN-FNL) positions.

Setting: Tertiary children's hospital.

Methods: FNL was performed with each child's head in neutral and flexed-neck positions. Videos in each posture were captured and randomized. The most distal view of the subglottis in each position was evaluated with 4 rating scales: (1) subjective view (SV); of the subglottis and trachea, (2) airway grade (AG); most distal anatomical structure visualized, (3) airway area (AA); percentage of the subglottis visualized; and (4) modified Cormack-Lehane grade.

Results: Twenty children had 80 FNL views blindly evaluated by 5 pediatric otolaryngologists. The SV, AG, and AA were all significantly better with the neck flexed compared to a neutral position (7.3 vs 3.0, interquartile range [IQR]: 2.0-6.8, P < .001; 2.3 vs 1.5, IQR: 1.0-2.0, P < .001; 3.4 vs 1.7, IQR: 2.3-3.8, P = .001). There was no difference in the modified Cormack-Lehane grade between positions. Interrater reliability was excellent or strong (0.93-0.94, confidence interval: 0.91-0.93).

Conclusion: FN-FNL is a simple maneuver performed in children undergoing FNL that partially improves the subjective visualization of the subglottis.

Objective: To report the clinical and laryngeal electromyographic (LEMG) parameters of children with laryngeal dyskinesia (LD) and its prevalence among laryngeal mobility disorder (LMD) requiring full airway examination.

Study design: Retrospective uncontrolled study.

Setting: Tertiary pediatric center.

Methods: Eligible children (<17 years old) were stridulous patients suspected of LMD (16 years period). We included those diagnosed with LD according to previously described criteria by Denoyelle et al, followed up for at least 3 months, who were assessed endoscopically and LEMG.

Primary outcome: LEMG scores, and the prevalence of LD in all LMD who required airway exam under anesthesia.

Secondary outcomes: clinical resolution, McGill scores, and instrumental swallowing test.

Results: A total of 44 patients (<17 years) were identified. Of these, 29 were included (25 boys; median age: 9.83 months [0.42-116.58]). LD constituted 18.58% of all patients during the study period. Asymmetry of movement and LEMG between the 2 sides was noted (the right side was more affected). Seventeen had swallowing difficulties (13 abnormal instrumental tests), and 27 snored (mean McGill score 3). The median follow up was 49.96 months (range: 5.25-243.25). Symptoms improved in all patients, but one, by the last follow-up date.

Conclusion: LD is prevalent among LMD and is mostly self-limiting. We noted asymmetry of LEMG grades between the 2 sides of the larynx, male predominance, and functional deficits in sleep and swallowing. The diagnosis requires a complete endoscopic exam with LEMG. Conflating this entity with bilateral laryngeal paralysis has likely impacted the documented epidemiology and natural history.