Otolaryngology- Head and Neck Surgery最新文献

Objective: Timely initiation of postoperative radiotherapy (PORT) for head and neck squamous cell carcinoma (HNSCC) is associated with improved survival, but rates of timely PORT initiation are low. To support uptake in a tertiary academic center, we aimed to identify implementation determinants (eg, barriers and facilitators) to timely PORT initiation and to design context-specific implementation strategies.

Methods: We created an implementation blueprint through a sequential mixed-methods study where we (1) identified determinants by fielding a 15-item survey based on the Theoretical Domains Framework (TDF), (2) prioritized determinants through focus groups with relevant stakeholders, (3) mapped barriers to implementation strategies using the Consolidated Framework for Implementation Research (CFIR)-Expert Recommendations for Implementing Change (ERIC) matching tool, and (4) operationalized strategies using the Action, Actor, Context, Target, Time (AACTT) framework.

Results: Twenty-three participants from three departments (61% Radiation Oncology, 35% Otolaryngology, 4% Medical Oncology) in a variety of roles (35% physicians, 39% nurses or advanced practice providers, 22% radiation therapists or dosimetrists, and 4% research coordinators) completed surveys. Participants identified 10 determinants affecting timely PORT initiation. After strategy selection and operationalization by focus group participants (n = 13), three ERIC strategies were selected for clinical implementation: remind clinicians, conduct educational meetings, and facilitate relay of clinical data to providers.

Discussion: This work developed a menu of implementation strategies for future deployment to support timely PORT initiation. Codesign centered the voice of frontline workers, increasing the likelihood of successful implementation.

Implications for practice: The systematic approaches to development can serve as a model for process improvement in other contexts.

Objective: Compared with those of English language preference (ELP), patients of non-English language preference (NELP) are at increased risk of postoperative complications and health care utilization. A series of interventions were initiated to reduce utilization and improve post-tonsillectomy outcomes for NELP patients.

Methods: This quality improvement (QI) study was performed at a tertiary pediatric hospital. Data collection began in 2019 and interventions, including improving translated postoperative education materials, pain medication tracking charts, direct access to interpreters, consistent tonsillectomy technique, and routine postoperative nurse phone call for education, were initiated by December 2020. Postintervention data were collected through July 2024. The primary outcome measured was return to the emergency department (ED) or urgent care (UC) with same-day discharge within 30 days post-tonsillectomy. Additional data collected included demographics, language spoken, reason for surgery, and reason for return.

Results: Between January 2019 and July 2024, a total of 14,007 patients underwent tonsillectomy: 12,830 (91.6%) ELP and 1177 (8.4%) NELP. After interventions, there was a 70.2% reduction (7.73% in 2019 to 2.30% in 2024) in NELP patients who were seen and discharged same day. In 2019, NELP patients were seen significantly more often (P = .016). In 2023, there was not a statistically significant difference between the two groups (ELP = 1.28%; NELP = 2.30%, P = .55).

Discussion: In our patient population, a set of thoughtful interventions for NELP patients/caregivers reduced minor, potentially unnecessary, nonoperative returns to the ED/UC.

Implications for practice: Implementation may reduce complications, improve the postoperative experience for NELP patients, and reduce overall health care costs.

Objective: Although human papillomavirus (HPV) testing is fundamental to staging, accurate prognosis, patient management, and clinical trial eligibility in oropharyngeal squamous cell carcinoma (OPSCC), national testing patterns remain unclear. This study investigates temporal and geographic trends in HPV DNA-RNA and/or p16 immunohistochemistry testing for OPSCC in the United States.

Study design: Retrospective cohort study including patients with OPSCC between 2010 and 2021.

Setting: National Cancer Database (NCDB).

Methods: Logistic regression analyses were performed to characterize the association of temporal, demographic, and clinical factors with HPV testing rates.

Results: Among the 146,176 patients with OPSCC and known HPV testing included in the study, the overall HPV testing rate was 88.4% (N = 129,240/146,176). Testing for HPV mediation significantly increased during the study period from 56.0% to 93.6% (adjusted odds ratio [OR]: 1.23, 95% CI: 1.22-1.24, P < .001). Significant differences were measured between geographic regions within the United States (range: 85.6%-91.2%; P < .001). Additionally, demographic, socioeconomic, and hospital-related factors were significantly associated with variations in testing rates.

Conclusion: Despite significant disparities across categories, this study highlights a significant increase in HPV testing rates for OPSCC since 2010, indicating an expanded awareness of its importance in the diagnosis and management of OPSCC. Further research is warranted to address geographic and other disparities to optimize testing for refined patient outcomes.

Objective: Disparities have been described across racial and socioeconomic groups in adenotonsillectomy access and surgical outcomes, but little is known about the impact of language. We studied the effect of race, ethnicity, and language on the frequency of postoperative rates of visits to the emergency department, hospital admissions, and return to the operating room. We hypothesized that non-white, Hispanic, and patients speaking a non-English language would have higher rates of emergency department visits, readmissions, and return to the operating room.

Study design: Retrospective cohort analysis.

Setting: Tertiary care academic center.

Methods: Demographic and encounter data were abstracted from the hospital's data warehouse for patients who underwent adenotonsillectomy over 12 years (May 2011-June 2023). Continuous variables were compared using the Kruskal-Wallis test or Mann-Whitney U test as indicated. Categorical variables were compared using Fisher's exact test.

Results: Our study included 7945 patients. Non-white patients had higher 30-day emergency department visit rates than white patients (8.6% vs 6.8%; P = .003) but comparable 30-day hospital admissions and 30-day return to the operating room rates. Hispanic and other ethnic groups had higher rates of postoperative emergency department visits (8.0%, 8.6%) compared to non-Hispanic white patients (6.8%; P = .026). Patients speaking Spanish or a different non-English language had higher 30-day emergency department visits (8.7%, 10.6%) than English-speaking patients (7.3%; P = .038). Rates of hospital admission and return to the operating room were similar across race and ethnic groups.

Conclusion: Higher rates of postoperative emergency department visits were present for our patient population across racial, ethnic, and linguistic cohorts.

Objective: To report the odds of dysphagia treatment among adults with self-reported dysphagia before and after the implementation of the Affordable Care Act (ACA).

Study design: Cross-sectional analysis.

Setting: National Health Interview Survey (NHIS).

Methods: Multivariate logistic regression.

Results: This study included 490 million individuals from the 2012 and 2022 NHIS in weighted responses. Among 235 million individuals in 2012, 9.4 million (4.0%) reported dysphagia (median age, 56.0 years; interquartile range [IQR], 40.0-68.0 years; 60% female). Among 255 million adults in 2022, 15 million (5.9%) reported dysphagia (median age, 58.0 years; IQR, 40.0-71.0 years; 57% female). After adjusting for sociodemographic factors, adults in 2022 were significantly more likely than those in 2012 to report dysphagia (adjusted odds ratio [aOR], 1.64; CI, 1.43-1.87). However, there was no significant difference in the odds of reporting dysphagia treatment between 2012 and 2022. Subgroup analyses by age, race and ethnicity, and insurance type also revealed no significant differences when comparing the 2012 and 2022 cohorts. When examining general access to care, adults reporting dysphagia in 2022 were significantly less likely to delay medical care due to the cost compared to adults reporting dysphagia in 2012 (aOR, 0.52; 95% CI, 0.43-0.62).

Conclusion: Although more adults reported dysphagia in 2022 than in 2012, our results show no significant improvement in access to dysphagia treatment. This suggests that, although the ACA reduced cost-related barriers, it has not adequately addressed access to dysphagia care.

Level of evidence: IV.

Objective: This study aims to describe current practices among otolaryngology-trained microtia surgeons in the United States.

Study design: Survey.

Setting: A tertiary care center.

Methods: A 22-question anonymous digital survey of practice patterns and surgical methods was distributed to all members of the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) and the American Society of Pediatric Otolaryngology (ASPO). Responses were analyzed using descriptive statistics and linear regression models.

Results: Of 1730 eligible members, 83 (4.8%) responses were collected. Forty-three (51.8%) were AAFPRS members, 39 (47.0%) were ASPO members, and 1 (1.2%) reported dual membership. Respondents had multiple practice settings, were at different stages in their experience, and were well-distributed geographically. Forty (48.2%) don't perform microtia repair and half (52.5%) refer to an FPRS-trained colleague. Among microtia surgeons, most (N = 30, 69.8%) received fellowship training. Autologous reconstruction was the most popular method for training and practice; however, most perform multiple methods (N = 33, 76.7%). Autologous rib training was positively correlated with experience of >20 years. Those with combined autologous/alloplastic practice were more frequently trained by PO fellowship. Surgical site infection was the most frequent complication and was seen more often by those trained via residency alone (OR 12.8, P < .05). Those who trained in autologous rib alone were less likely to encounter postoperative graft exposure (OR 5.0, P < .05); however, they were more likely to encounter skin and soft tissue infection (OR 0.07, P < .05).

Conclusion: Otolaryngology-trained microtia surgeons come from a variety of academic backgrounds and progress to varied practices. They are trained and practice both alloplastic and autologous repair methods, although autologous methods remain the most common.

Objective: This study aims to investigate the characteristics of hearing loss associated with MYO15A mutations and to analyze the longitudinal prognosis over a 4-year period using different treatment modalities, including cochlear implants (CIs), hearing aids (HAs), and conservative management.

Study design: A retrospective case review.

Setting: A tertiary referral center.

Methods: Sequencing was performed to recruit patients with potentially pathogenic MYO15A mutation-induced hearing loss. Audiological data, radiological imaging, and assessment of hearing and speech performance before and after different treatments were analyzed in combination with patients' genotypes.

Results: Sixteen patients with MYO15A mutation-induced deafness from 14 unrelated pedigrees were enrolled, carrying 5 previously unreported mutations: c.3660_3666delinsAA (p.Glu1221fs), c.4635delG (p.Val1545fs), c.6664A>G (p.Met2222Val), c.8215delG (p.Ala2739fs), and c.8897delG (p.Gly2966fs). Inner ear malformations were observed in 3 patients. CI recipients exhibited significant improvements in hearing and speech abilities 1-year post-implantation, while individuals using HAs showed a gradual improvement trend over a 4-year period. Notably, even those with bilateral cochlear aperture atresia achieved satisfactory hearing and speech outcomes following early CIs.

Conclusion: Patients with MYO15A mutations who underwent CIs generally demonstrated earlier improvements in hearing and speech development compared to those using HAs. Early genetic detection and timely implementation of assistive acoustic stimulation are recommended for optimal outcomes.

Objective: The purpose of this study is to evaluate the long-term usage of the hypoglossal nerve stimulator and identify predictors of usage over time.

Study design: Retrospective chart review.

Setting: Tertiary academic medical center and database.

Methods: Single institution retrospective chart review was merged with Inspire SleepSync device usage data. Growth curve modeling was performed with a linear mixed-effects model to evaluate usage hours over time. A logistic regression analysis was also performed to assess the relationship between early adherence and adherence at 1 and 2 years.

Results: A total of 352 patients were included in the study. Seventy percent were male and the mean age was 64 ± 12 years. Adherence at 6 months was significantly predictive of adherence at 12 (odds ratio [OR] 9.42, CI 3.23-28.76, P < .001) and 24 (OR 3.03, CI 0.96-9.05, P = .049) months. Older age (estimate = 0.019, SE 0.006, P = .002) and greater days of use per biweekly period (estimate = 0.142, SE 0.004, P < .001) were positive predictors of usage. Insomnia (estimate = -0.386, SE 0.128, P = .003) and higher device mean voltage amplitude (estimate = -0.348, SE 0.020, P < .001) were negative predictors.

Conclusion: Time since activation does not appear to have an impact on hypoglossal nerve stimulator therapy usage. Insomnia and higher device voltage were associated with a statistically significant negative trend in therapy usage, whereas older age and greater number of days used may be predictive of higher therapy usage. Identifying predictors of usage will enable identification of at-risk patients and allow for early implementation of targeted interventions to improve patient adherence and optimize long-term health outcomes.

Objective: In 2020, the Food and Drug Administration (FDA) approved Merck's GARDASIL 9 for prevention of certain human papillomavirus (HPV)-related head and neck cancer. This study characterizes the sentiment and themes of HPV vaccination online discourse surrounding the 2020 FDA recommendation.

Study design: Retrospective cohort.

Setting: Data from 2018 to 2022: Reddit, Teen VaxView (Centers for Disease Control and Prevention), and Google Trends.

Methods: Online public discourse was assessed by searching Reddit for user submitted posts using relevant keywords. Reddit posts were categorized by a trained machine learning classifier. Natural language processing calculated positive/negative sentiment, polarity, and frequent nonstop words. Google Trends assessed relative search popularity, and TeenVaxView assessed HPV vaccinations among adolescents. Statistical relationships were assessed using linear and logarithmic regression models.

Results: Analysis of 2751 Reddit posts demonstrated a balanced overall positive/negative sentiment, with a substantial positive trend over the study period (P = .05). Most posts were personal stories/questions (n = 1997, 72.6%) and conspiracy posts made up a just a small minority (n = 186, 6.8%). Discussion including head and neck anatomical and cancer terms significantly increased (P = .01). Vaccination coverage trended upward significantly for males and females (P < .01). A significant relationship was found between positive sentiment trend and vaccination coverage (P = .02).

Conclusion: Discourse surrounding the HPV vaccine has been increasingly positive in sentiment and changes in FDA guidelines correlated with increased discussion of HPV-related head and neck cancer. There was a concurrent increased adolescent vaccination rate.

Objective: Features that cause gender incongruence (gender identity not aligning with assumptions based on sex assigned at birth) in transgender individuals often motivate them to seek out gender-affirming treatments. Voice has rarely been included as a major contributor to gender dysphoria. The primary objective of this study is to understand the significance of dysphoria related to voice compared to dysphoria secondary to other features.

Study design: Prospective population-based survey study.

Setting: Social media.

Methods: The survey requested a ranking of features that contribute to gender dysphoria, whether the features were bothersome due to external or internal perception, and self-reported ideal order for pursuing gender-affirming treatments. The categories of features that were ranked included upper body, lower body, face, neck, voice, and height.

Results: In total, 79% of respondents experience gender incongruence secondary to their voice. Voice was the second most important feature contributing to gender dysphoria, only after upper body. In transgender men (29.4%) and transgender women (25%), voice was both the second most important feature contributing to gender dysphoria and the second most important intervention to alleviate gender dysphoria. Specifically, vocal incongruence is largely due to perception by others, as opposed to lower body which contributes to incongruence due to perception by self.

Conclusion: Voice is the second most common contributor to gender dysphoria after upper body. Due to self-rated importance of voice to gender incongruence, health care providers must be aware that voice interventions are critical to improve gender dysphoria experienced by transgender individuals.