Annals of Otology Rhinology and Laryngology最新文献

Objectives: This study aims to analyze trends in utilization and reimbursement of soft palate surgery for OSA using the Medicare national database.

Methods: A retrospective analysis of the 2000 to 2021 Part B National Summery datafiles using current Procedural Terminology (CPT) codes 42145 (uvulopalatopharyngoplasty [UPPP]), 42950 (pharyngoplasty [PP]), and 42140 (uvulectomy [UVU]) was performed.

Results: Between 2000 and 2021, the number of OSA surgeries fell 65.7% from 4208 to 1443. UPPP fell 87.6% from 3455 in 2000 to 428 in 2021 (P < .001). UVU also fell in popularity, from 568 to 376 (33.8%; P < .001). In contrast, the performance of PP rose 245.4% over time, from 185 to 639 (P < .001). When comparing 2000 to 2009, both PP and UVU rose in relative use (from 4.4% to 12.3% and from 13.5% to 20.4% of all soft palate OSA surgeries, respectively), while UPPP fell (82.1% to 67.3%; P < .001). Total Medicare payments for all 3 procedures fell 57.2% from $1 658 844 to $633 091 (P < .001). Adjusted total UPPP payments fell 88.7% (P < .001). Adjusted total PP payment rose 137.5% to $262 538 in 2021 (P < .001).

Conclusion: Soft palate surgery for OSA has declined amongst the Medicare population over 21 years (2000-2021). The more individualized and tissue sparing PP has risen in popularity but did not overcome the large decline of the traditional UPPP. Accordingly, there was a 75.7% fall in inflation-adjusted reimbursements. Overall, our data indicates a decline in soft palate surgery in the management of geriatric OSA, with modest relative increase in pharyngoplasty procedures.

Objectives: Individuals with obstructive sleep apnea (OSA) suffer from a multitude of concurrent morbidities including cardiovascular disease (CVD). Limited data exists comparing long term cardiovascular disease (CVD) clinical outcomes for patients treated with surgical intervention versus continuous positive airway pressure (CPAP). The purpose of this study was to compare CVD outcomes at multiple time points comparing those treated with sleep surgery versus CPAP alone.

Methods: A research database was used to assess outcomes: death, myocardial infarction, atrial fibrillation, heart failure, essential hypertension, and pulmonary hypertension at 5, 8, and 20 years for patients with OSA treated with surgical interventions (upper airway stimulation [UAS], uvulopalatopharyngoplasty [UPPP], and tonsillectomy) or CPAP alone. Subjects were identified using ICD and CPT codes and analyses were conducted with and without propensity score matching for age, sex, race, BMI, myocardial infarction (MI), essential hypertension, pulmonary hypertension, atrial fibrillation, and heart failure.

Results: All surgical interventions demonstrated benefit over CPAP alone at most time points for most surgical interventions. At 8 years, for all sleep surgeries (UAS or UPPP or tonsillectomy) (n = 6627) versus treatment with CPAP alone (n = 6627), matched subjects demonstrated decreased risk (odds ratios) and superior survival (hazard ratios and log ranks tests) for death (OR = 0.49 [0.39, 0.62] P ≤ .0001, HR = 0.29 [0.23, 0.37], χ² = 109.58 P ≤ .0001), myocardial infarction (OR = 0.67 [0.54, 0.84] P = .0005*, HR = 0.48 [0.38, 0.60], χ² = 42.40 P ≤ .0001), atrial fibrillation (OR = 0.70 [0.59, 0.83] P ≤ .0001, HR = 0.54 [0.45, 0.64], χ² = 51.53 P ≤ .0001), heart failure (OR = 0.55 [0.47, 0.64] P ≤ .0001, HR = 0.41 [0.35, 0.47], χ² = 137.416 P ≤ .0001), essential hypertension (OR = 0.88 [0.82, 0.94] P = .0002, HR = 0.78 [0.74, 0.82], χ² = 76.38 P ≤ .0001), and pulmonary hypertension (OR = 0.51 [0.40, 0.65] P ≤ .0001, HR = 0.38 [0.29, 0.48], χ² = 60.67 P ≤ .0001) where P ≤ .00037 indicated statistical significance*.

Conclusion: This investigation suggests surgical management of obstructive sleep apnea may contribute to the mitigation of long-term clinical CVD morbidity.

Objectives: Tumors involving the vagus nerve are often clinically silent. We offer a case series with different clinical presentations and distinctive post-surgical sequelae that highlight some of the challenges associated with managing cervical vagal nerve tumors.

Methods: Single-institution, retrospective review of patients with tumors involving the vagus nerve. We describe clinical presentations and postoperative sequelae of five patients who underwent surgical management of vagal nerve pathology with atypical presentation or subsequent clinical course.

Results: Here, we present five patients treated at our institution for vagal tumors. In four of the five patients, the presenting symptoms resolved after surgery. Two patients presented with intractable neurogenic cough, and another two presented with autonomic symptoms, one with syncope/palpitations and the other with intractable sweating. The final patient presented with a rapidly enlarging vagal paraganglioma and developed intractable cough after resection. We present two patients with novel approach to vagal paragangliomas that underwent ligation of feeding blood supply without removing the tumor, resulting in resolution of an intractable cough in one patient and resolution of severe nighttime sweating in the other.

Conclusion: Management of tumors associated with the cervical vagus nerve that present with symptoms or rapid growth poses a clinical dilemma. Consideration of the tumor origin with either enucleation of schwannomas or ligation of feeding vessels may preserve function while addressing the presenting symptoms.

Objective: Physicians experience scary cases in the course of usual medical practice. Cases of near misses, legal and ethical dilemmas, or unique clinical challenges are great sources of education. However, there is no format for presentation and dissemination of cases that do not meet criteria for morbidity and mortality (M&M) conferences. The Scary Cases Conference is an innovative educational forum for scrutiny and analysis of these challenging clinical cases. Scary Cases differs from traditional Morbidity and Mortality conferences as it explores outcomes beyond the scope of medical or surgical errors.

Methods: From 2011 to 2021: 11 regional and 10 national "Otolaryngology Scary Cases" conferences and mini-seminars were held. The cases presented were analyzed for case specialty, area of management deemed troublesome, and compared to M&M conference criteria.

Results: 187 cases were presented. 62% percent of cases included traditional medical problems, whereas 21% involved legal issues, and 17% focused on ethical dilemmas. For the cases with medical problems, 31% involved airway obstruction, 17% nerve injuries, and 17% malignancy. 49% of cases would have met criteria for presentation at traditional M&M conferences. Of all the "scary cases," 25% were near misses and 26% represented ethical or legal dilemmas which would not be classified as morbitidy, mortality, or near miss.

Conclusions: The Scary Cases provides a forum conducive to learning amongst peers and experts. It allows medical and surgical specialties to share the cases deemed most impactful. The M&M conference would only include half of such cases, but could be expanded beyond the traditional scope in the future.

Objectives: To assess quality of life (QOL) outcomes after canal wall up (CWU) and canal wall down (CWD) tympanomastoidectomy in the pediatric population.

Methods: A retrospective review tabulated pediatric patients undergoing CWU and CWD tympanomastoidectomy for cholesteatoma by 2 senior surgeons at a single tertiary academic referral center between March 2017 and March 2023. Chronic Ear Survey (CES) and cosmetic survey outcomes were collected post-operatively.

Results: A total of 77 ears in 75 patients were identified, with 35 undergoing CWU and 42 undergoing CWD as the most recent (index) otologic surgery. Seventeen patients (23%) participated in the survey. Of this cohort, the mean age was 14.6 years, 12 (71%) were male, and 10 (59%) had CWD as the most recent otologic surgery. The mean time from index surgery to survey completion was 3.4 years (range, 0.1-6.7 years). Regarding QOL outcomes, there were no statistically significant differences in total CES score, CES subscores, and cosmetic survey scores between groups when categorizing by gender or index surgery. Total CES, symptom subscale, medical resource subscale, and cosmetic survey scores showed a tendency to decrease with an increasing number of surgeries (R = -.18, -.28, -.53, and -.56, respectively). Pediatric total CES scores appeared comparable to those reported in the published adult literature.

Conclusions: It does not appear that there are worse QOL outcomes for pediatric patients who undergo CWD tympanomastoidectomy compared to those who undergo CWU tympanomastoidectomy. There appears to be no difference in QOL outcomes between pediatric and adult patients undergoing tympanomastoidectomy.

Objective: There is often unfamiliarity with the care of artificial airway devices (ie, endotracheal tubes, tracheostomies, and laryngectomies). The objective of this study was to design an Airway Quality Improvement Program (AQIP) to improve airway care.

Methods: This was a retrospective chart review of a prospectively-initiated AQIP. The AQIP has 3 parts: 1) Mandatory "airway signs" 2) In-service teaching with a corresponding order set and 3) an overhead "Surgical Airway Emergency" page involving automatic pages to Anesthesia, Otolaryngology, and Respiratory Therapy. Pre- and post-intervention survey data was collected. The incidence of airway emergency was the primary patient outcome and was hypothesized to decrease after AQIP intervention.

Results: Airway emergencies decreased 8.4% after AQIP (P = .45). Length of stay decreased after AQIP, 47.0 ± 76.5 days compared to 23.5 ± 23.6 (P = .004). Two hundred eight-one nurses and 76 respiratory therapists were educated. Pre-AQIP comfortability scores improved for the routine care of endotracheal tubes, tracheostomies, and laryngectomies, 4.3 ± 0.9, 4.3 ± 0.8, and 3.5 ± 1.2, compared to 4.7 ± 0.6, 4.5 ± 0.7, and 4.4 ± 0.7 post-AQIP (P = .0006, P = .02, P = .0001). The same improvement was noted for emergency airway care. Tracheostomy vs. laryngectomy recognition increased from 66.5 to 97.0% (P = .0001). Quiz questions regarding emergency airway management for laryngectomies improved from 76.2 to 93.8% (P = .0001).

Conclusion: The AQIP was associated with decreased length of hospital stay and improved competency in airway care among hospital staff. Further application of AQIP is needed for replication in other institutions and long-term application.

Objectives: A pyriform sinus fistula (PSF) is a rare congenital anomaly due to failed obliteration of the third or fourth pharyngeal pouch. Diagnosis and management of PSF remains controversial. We present a case of PSF and discuss its diagnosis and management.

Methods: Case report and literature review.

Results: A 26-year-old female with a chronic left lateral neck abscess was diagnosed with a left PSF. She underwent surgery through a combined approach to close the openings of the PSF, internally and externally. We first placed a blunted ET tube into the internal opening of the PSF. We then performed an external transcervical approach to close the PSF at the cricothyroid membrane. Briefly, after a neck debridement and washout of the chronic neck infection, we identified the recurrent laryngeal nerve (RLN) in Lore's triangle. We performed left hemithyroidectomy to facilitate the dissection and protection of the RLN to its entrance into the larynx. A flexible laryngoscope was then inserted into the left piriform sinus through the ET tube to guide external dissection by transillumination. The scar tissue attached to the superior pole of the left thyroid lobe was then ligated and divided along the cricothyroid membrane. Lastly, we cauterized the internal opening of the PSF. The patient has remained recurrence-free for 1.5 years with normal vocal cord mobility. Histopathology revealed presence of a squamous-lined tract adjacent to the thyroid tissue.

Conclusions: Surgical treatment for patients with PSF should be aimed at closing the internal and external openings of the PSF, debriding chronic neck infection, and protecting the laryngeal nerves, instead of removing the entire tract. A concurrent hemithyroidectomy facilitates the identification and protection of the RLN, as well as excision of the tract. Differentiation between third and fourth branchial cleft fistulae may not be clinically necessary, as it is unlikely to alter the therapeutic plan.

Objectives: The digastric muscles have important roles in swallowing, chewing, speech, and landmark identification during neck dissection. The posterior belly of the digastric muscle (PBDM) is often useful for defining boundaries in surgical neck dissection as it contributes to the carotid, submandibular, and submental triangles. The cadaveric prevalence rate of anatomic variations in the digastrics has been reported to be 31.4% of the population with most occurring in relation to the anterior belly of the digastric muscle (ABDM). Few reports describe variations in the PBDM. While anatomic variants of the digastric muscles do not present with clinical manifestations, they can be mistaken as neck masses and contribute to intraoperative complications.

Methods: We present a case report of a 73-year-old male with a past medical history significant for Parkinson's Disease, who was incidentally found to have a duplicate PBDM intraoperatively while receiving surgical management of a left buccal squamous cell cancer.

Results: Nine months prior to surgery, the patient began experiencing trismus and some mild dysphagia that were eventually worked up to reveal left buccal squamous cell carcinoma (SCC). Prior to this, the patient did not have clinical symptoms demonstrating dysfunction that could be related to or indicative of this anatomical abnormality preceding symptoms related to left buccal SCC growth. The procedure included a wide local excision, left modified radical neck dissection and left submental artery island flap with suprahyoid neck dissection. The superior duplicate PBDM was found to be overlying the stylohyoid muscle.

Conclusions: It is important for surgeons operating in the head and neck to be aware of the possibility of this rare variation, and to be conscientious when it is identified so that it does not prohibit or limit a thorough dissection of the neck structures where oncologic clearance is paramount.

Objective: This case series describes the outcomes of airway management, including airway reconstruction, in 6 patients with campomelic dysplasia and tracheostomy/ventilator dependence secondary to multilevel airway obstruction.

Methods: Case series and clinical guidelines are provided for the airway management of patients with campomelic dysplasia.

Results: Average age of individuals is 19.4 years. Mean follow-up was 12.2 years. Four individuals underwent open airway reconstruction and achieved decannulation. One patient underwent airway reconstruction with improvement of a complete subglottic stenosis but remains ventilator dependent due to severe scoliosis. The remaining 2 patients did not require additional airway reconstruction, have been liberated from ventilator support, and are under evaluation for tracheostomy tube decannulation.

Conclusion: Although campomelic dysplasia was historically considered a lethal form of congenital skeletal dysplasia, with many patients succumbing to respiratory failure due to tracheobronchomalacia in the neonatal period, airway reconstruction and long-term survivorship is feasible in children with campomelic dysplasia and significant airway disease.

Objectives: Photoangiolytic lasers have yielded significant innovation in laryngeal surgery in the last 25 years. After the discontinuation of the potassium titanyl phosphate (KTP) laser, a novel 445-nm blue laser was developed. The optimal balance between a laser's desired tissue effects and collateral tissue damage is a major determinant of laser selection in microlaryngeal surgery. The shell-less incubation system for the chick chorioallantoic membrane (CAM) simulates the microvasculature of the human vocal fold and is useful for testing effects of laser settings and in simulated surgery. The aim of this study is to compare the tissue effects of the KTP and blue lasers using the shell-less CAM model.

Methods: The shell-less incubation system contains: polymethylpentene film (used as a culture vessel), calcium lactate and distilled water supplementations. By using this system, the chick chorioallantoic membrane (CAM) can be fully exposed with a good field for surgery simulation. The effects of the 2 lasers (532 nm KTP and 445 nm blue) were quantified at clinically relevant energy settings and laser distances from target. Measures included imaging real-time vascular reactions in the CAM model, post-procedure histologic analysis of CAM tissue and temperature changes.

Results: Vessel coagulation and rupture rates were less common with the blue laser compared with the KTP laser. Histologic analysis demonstrated less tissue disruption with the blue laser. Temperature changes were less with the blue laser.

Conclusion: In this CAM model with specific conditions, the blue laser reveals less tissue damage than the KTP laser. Suitable working distance and power setting of the laser are necessary for desired tissue effects.Level of Evidence: Level 3.