Otolaryngology- Head and Neck Surgery最新文献

Objective: To assess the effects of localized subglottic knockout of E-cadherin (CDH1^-/-) on survival, tracheal luminal thickness, and fibrotic gene expression in a mouse model of subglottic stenosis.

Study design: Case-control in vivo mouse study.

Setting: Tertiary care academic hospital.

Methods: Mice with loxP sites flanking E-cadherin underwent extratracheal placement of a fibrin-plasmin gel embedded with either CRE-expressing or control adenovirus. Mice then underwent chemomechanical injury to induce laryngotracheal stenosis, with harvest of subglottis/tracheas 21 days later. Immunofluorescence and Western blotting were used to confirm E-cadherin knockout. Outcomes of interest included Kaplan-Meier survival curves (n = 40), lamina propria thickness on hematoxylin-eosin (H&E) histology (n = 8), and fibrotic gene expression (n = 3).

Results: Immunofluorescence and Western blotting confirmed decreased E-cadherin expression in CDH1^-/-. On H&E, lamina propria thickness was greater in CDH1^-/- mice (mean difference [95% CI] in μm, 107.2 [74.8-139.7], P < .001). Survival was significantly shorter for knockout mice relative to control (median survival in days, 5.0 vs 8.5; P = .007). Further, fibrotic gene expression of COL1 (mean difference [95% CI] in log-fold change, 11.5 [1.9-21.0]; P = .03), COL3 (31.0 [11.5-50.5]; P = .01), COL5 (6.8 [3.1-10.4]; P = .007), and FN1 (6.9 [1.3-12.6]; P = .03) was significantly greater relative to control.

Conclusion: CDH1^-/- results in greater fibrosis and increased mortality, further supporting the role of epithelial barrier dysfunction in the pathogenesis of subglottic stenosis. Therapies that restore epithelial integrity may therefore represent a rational pharmacologic target.

Objective: This study aims to examine outcomes following single-stage laryngotracheal reconstruction (SSLTR) using a "no look" philosophy.

Study design: Case series with chart review.

Setting: Two urban, tertiary, children's hospitals.

Methods: Patients underwent primary or revision open SSLTR by 1 of 3 surgeons at 2 institutions. After a period of planned postoperative intubation, patients were extubated in the pediatric intensive care unit (PICU), with operative inspection of the airway deferred for 6 weeks unless symptoms of stridor or distress developed postoperatively. Short-term and long-term clinical outcome metrics were examined.

Results: From 2011 to 2021, 47 consecutive SSLTRs were completed, following which patients were extubated in the PICU without antecedent inspection of the airway. The mean age was 30.8 months (range: 3-130 months), and the mean preoperative stenosis grade was 2.1. There were 17 anterior grafts, 1 isolated posterior graft, and 29 A/P graft procedures; 19% of surgeries were revisions of prior open procedures. The mean PICU and hospital length of stay were 10.1 and 12.5 days, respectively. The failure rate following extubation was 4% (0% primary and 22% revision, P < .003), and 23% of patients had an unplanned return to the operating room for airway symptoms (21% primary and 33% revision, P = .44). Secondary endoscopic interventions were performed in 47% of cases; when required, the mean number of dilations was 2.2 (1.6 primary and 3.7 revision, P < .05). Long-term outcomes compared favorably with historical standards.

Conclusion: In select patients undergoing SSLTR, a "no look" philosophy may eliminate unnecessary surgical procedures without compromising short-term or long-term clinical outcomes.

Objective: The evidence supporting endoscopic transsphenoidal pituitary adenoma resection (TSPR) is predominantly from skull base centers in high-resource settings (HRSs). This study is the first comparative analysis of TSPR performed at a low-resource setting (LRS), Korle Bu Teaching Hospital (KBTH), a public hospital in Accra, Ghana, versus HRS.

Study design: Cohort study.

Setting: Tertiary skull base surgery centers in Ghana, the United States, Canada, and Australia.

Methods: Patients who underwent TSPR at KBTH from 2021 to 2023 were compared to a multi-institutional cohort of TSPR patients from skull base centers in the United States, Canada, and Australia. Univariate and multivariate analyses were performed controlling for available demographic characteristics and medical history.

Results: The KBTH cohort included 93 patients, and the HRS cohort included 1112 patients of similar age. The HRS cohort had higher incidences of diabetes (P = .013) and cancer history (P = .012). There were two deaths in the KBTH cohort (one intracranial bleed, one meningitis) versus five in the HRS cohort (odds ratio [OR] = 8.07, 95% CI 1.28, 50.98). There were no differences in rates of other postoperative complications.

Conclusion: These findings demonstrate the capacity of LRSs to perform endoscopic pituitary surgery and highlight the need for building rhinologic and skull base surgery capacity around the world. This study was unable to control for important factors including tumor size, postoperative access to health care resources, availability of adjuvant treatments such as neuro-interventional radiology and stereotactic radiation therapy, and others.

Objective: The objective of this study is to determine if a history of traumatic brain injury (TBI) degrades postoperative the audiological performance of patients with cochlear implantation (CI).

Study design: Retrospective review.

Setting: Department of Defense-wide database.

Methods: International Classification of Diseases, Ninth Revision (ICD-9) and ICD-10 codes were used to identify patients that were diagnosed with TBI prior to CI between 2005 and 2023. They were matched 2:1 with controls without TBI based on age and sex. Preoperative and postoperative pure tone average (PTA) thresholds and AzBio scores were compared.

Results: Nineteen TBI patients representing 20 implanted ears were identified and matched with 39 patients without TBI representing 40 implanted ears. Thirteen ears carried a diagnosis of mild TBI, and seven were diagnosed with moderate to severe TBI. The average follow-up period was 44 months. The TBI group attained mean postoperative PTA and AzBio scores of 37 dB (SD 24) and 67% (SD 28). The non-TBI group attained scores of 31 dB (SD 12) and 69% (SD 26). P-values for the PTA and AzBio intergroup comparisons were .93 and .88, respectively. All TBI ears attained at least sound awareness after implantation, with 79% achieving open-set speech perception compared to 82% of non-TBI ears.

Conclusion: CI after TBI of any severity provides hearing rehabilitation comparable to patients without a prior diagnosis of TBI.

Objective: Cochlear implant (CI) electrode array tip fold-overs occur at an increased rate with perimodiolar electrode arrays, necessitating removal and re-insertion. The degree to which an intra-operative correction of tip fold-over affects CI performance and hearing preservation has not been previously reported.

Study design: Retrospective chart review of CI recipients receiving a slim perimodiolar electrode array from 2016 to 2023.

Setting: Tertiary referral center.

Methods: Low-frequency pure tone average (LFPTA) was defined as the average of thresholds at 125, 250, and 500 Hz. We defined hearing preservation candidacy as LFPTA < 60 dB HL preoperatively, and successful hearing preservation was defined as LFPTA < 80 dB HL at activation. Consonant-nucleus-consonant (CNC) word recognition and AzBio scores in quiet and in +10 dB signal-to-noise ratio (SNR) were collected preoperatively, and at 3- and 6-months postoperatively.

Results: From 663 implants, 35 (5.3%) experienced tip fold-over that was identified and corrected intra-operatively. There was no significant difference in 3-month CNC scores between those with fold-overs (44.9%, SD 20.9%) and those without (46.2%, SD 21.0%; P = .98). Similarly, there was no difference in AzBio in quiet (53.1%, SD 21.7% vs 60.8%, SD 28.0%; P = .26) or in AzBio +10 dB SNR (19.1%, SD 23.7% vs 31.5%, SD 27.2%; P = .60). Of 19 hearing preservation candidates that experienced tip fold-over, 6 (31.6%) had preserved hearing at activation compared to 31 of 59 candidates (52.5%; P = .11) without fold-over.

Conclusion: While tip fold-over remains a clinical concern, speech performance does not appear to be negatively affected if the fold-over is identified and corrected.

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: Evaluate rates of adverse outcomes among patients with a history of head and neck cancer undergoing myringotomy with or without tube placement for middle ear effusion.

Study design: Retrospective chart review.

Setting: Academic medical center.

Methods: Retrospective chart review was performed on patients undergoing myringotomy with or without tube placement for middle ear effusion between 2018 and 2022. Data reviewed included demographics, cancer history, audiometry, and clinical course.

Results: In total, 578 patients (736 ears) had a mean follow-up of 36.6 months: 84 (14.53%) were in the cancer cohort. On average, cancer patients were older (62.6 vs 59.3 years, P < .05) but had similar rates of overall adverse outcomes (44.05% vs 44.13%, P = 1.0). Rates of persistent perforation were higher among cancer patients (14.29% vs 2.43%, P < .001); there was no significant difference in rates of recurrent effusion (5.95% vs 4.66%; P = .81). Postpropensity score matching, perforation rates reached statistical significance (14.29% vs 1.22%, P < .01). There was no difference in rate of adverse events for overall events (44.05% vs 47.56%, P = .77) or recurrent effusion (5.95% vs 1.22%, P = .22).

Conclusion: Patients with a history of head and neck cancer or radiation have a three-to-five-fold risk of persistent tympanic membrane perforation after myringotomy with or without tube placement and a higher rate of recurrent effusion that is not significant. In multivariate analysis, perforation risk was revealed to be multifactorial.

Objective: Hypoglossal nerve stimulation (HNS) is an increasingly used therapy. However, not all patients undergoing HNS implantation benefit from the treatment, making an improved patient selection a priority. This study investigates whether backscattered ultrasonographic imaging (BUI) can predict the response to HNS therapy.

Study design: Cross-sectional study.

Setting: Secondary and tertiary hospital.

Methods: In this multicenter cross-sectional study, we recruited patients who had undergone HNS implantation during their scheduled follow-up consultation. HNS therapy parameters were collected. Standardized submental ultrasonographic examination and home sleep apnea testing were performed. The primary outcome was assessing the response to HNS therapy using ultrasonographic features and preoperative patient characteristics.

Results: In total, 62 participants, 49 male, with a median (interquartile range [IQR]) age of 62 (55-67) and a median (IQR) body mass index of 27.6 (25.2-29.7). The follow-up was a median (IQR) of 19.5 (4.8-41.4) months after implantation. The apnea-hypopnea index (AHI) was preoperatively 40.5 (29.8-58.0) and reduced at follow-up to 21.0 (11.0-35.3). In total, 42% were responders to HNS. Preoperative AHI (34.8/hour vs 49.3/hour, r = 0.44) was significantly higher in nonresponders than in responders. The average prediction accuracy of HNS therapy based on baseline AHI alone was 71%. A lower backscatter signal, indicating less fat deposition in the tissue, was observed in the responder group. When the baseline AHI and backscatter signal were combined, the prediction accuracy of response to the HNS reached 78%.

Conclusion: The combination of tissue composition analyzed using the backscattered signal and the preoperative AHI is highly predictive for determining the HNS treatment response.

Trial registration: ClinicalTrials.gov identifier NCT06154577.

Objective: To assess relations between Ménière's disease and suicidality, measured by suicidal ideation, suicidal behaviors, and death by suicide.

Data sources: CINAHL, Cochrane Library, PubMed, PsycINFO, and SCOPUS databases were searched from inception through July 2, 2024.

Review methods: Observational studies related to suicidality in patients with Ménière's disease were included. Non-English language papers, editorials, and studies on vestibular disorders not specified as Ménière's disease were excluded. The Risk Of Bias In Nonrandomized Studies-of Exposure tool was used for cohort and qualitative studies, and the Joanna Briggs Institute critical appraisal checklist was used for case-control studies.

Results: Four studies (n = 168,566) were included in our review. Two cohort studies found significantly increased adjusted hazard ratios of 2.1 (95% CI: 2.0-2.2) for death by suicide and 7.6 (95% CI: 4.4-13.3) for suicidal behaviors, respectively, in patients with Ménière's disease compared to the control population after their diagnosis. However, a case-control study found no significant difference in the prevalence of suicidal ideation or behaviors prior to the date of diagnosis in patients with Ménière's disease compared to the control population (0.9% vs 0.8%; P = .44). In addition, one patient with Ménière's disease expressed suicidal ideation in the qualitative study.

Conclusion: Patients may experience variable responses to Ménière's disease. Thus, otolaryngologists should be mindful of the potential for suicidality in patients with Ménière's disease.

Objective: NCCN guidelines recommend a neck dissection addressing at least levels II-IV for high-grade mucoepidermoid carcinoma (MEC) and close observation of the lymphatic basins for low-grade MEC. However, no guidelines exist for intermediate-grade MEC with clinically and radiologically uninvolved cervical lymph nodes.

Study design: Retrospective analysis.

Setting: Patients with intermediate-grade MEC with a clinically N0 neck from our tertiary academic institution from 2015 to 2023.

Methods: Evaluation for histologic lymphatic metastases was performed when surgeons elected to perform neck dissection. For patients who did not receive a neck dissection, review of medical records to document the results of clinical observation, and specifically regional lymphatic recurrence, on long-term follow-up.

Results: Thirty-five patients with N0 intermediate grade MEC were included, composed of 26 patients who underwent primary tumor resection and neck dissection and 9 patients who received resection of the primary tumor without neck dissection. One out of 26 patients receiving neck dissection was found to have lymphatic metastasis. Watchful waiting of 9 patients demonstrated no recurrence at a mean follow up of 40 months. Thus, 1 out of 35 patients (2.9% [95% confidence interval: 2.7%-3.1%]) had documented metastatic disease in the lymphatics.

Conclusions: For patients presenting with intermediate-grade MEC, there was a low chance (2.9%) of positive histologic or clinical lymphatic metastases in the neck. Given this low risk, we believe the potential benefit of neck dissection may be outweighed by the potential morbidity. Careful consideration of the clinical behavior of the lesion could be considered along with a more selective approach toward elective lymphadenectomy in intermediate-grade MEC.