Annals of Otology Rhinology and Laryngology最新文献

Background: Despite growing concern regarding over-prescription of narcotic pain medication following ambulatory surgery, little is known about the analgesic prescribing practices following endoscopic sinus surgery (ESS) in obese patients in comparison to non-obese patients.

Objective: To compare the rates of opioid versus non-opioid prescriptions, the need for steroids, and post-operative adverse events between obese and non-obese adult patients undergoing ESS.

Methods: Using TriNetX Live database, we identified all patients aged ≥18 years who underwent ESS (n = 1303) between 2014 and 2022 across several healthcare institutions across the state of Tennessee. We 1:1 propensity score-matched obese (BMI ≥ 30 kg/m²) and non-obese (18.5 kg/m² ≤ BMI < 30 kg/m²) cohorts for age, gender, race, and comorbidities including asthma, nicotine dependence, and sleep apnea. Rates of prescriptions and post-operative adverse events between cohorts were analyzed using risk ratios (RR) and confidence intervals (CI).

Results: A toal of 532 obese patients were compared to 532 propensity score-matched non-obese patients in the first 14 post-operative days following ESS. The obese cohort was significantly more likely to be prescribed analgesics generally (RR = 1.72; 95% CI = 1.20-2.47), non-opioid analgesics (RR = 1.73; 95% CI = 1.19-2.50), and opioid analgesics (RR = 1.64; 95% CI = 1.14-2.36) than non-obese patients. There was no difference in rates of antibiotic or antiemetic prescription, prednisone/methylprednisolone, dexamethasone, ED visits, critical care service, epistaxis, transfusion, anemia, revision sinus surgery, mechanical ventilation, CPAP, or inhalation airway treatments.

Conclusion: Obese patients undergoing ESS were significantly more likely to be prescribed non-opioid and opioid analgesia in the first 14 days post-operatively compared to non-obese patients. There were no differences in post-operative adverse events or other prescriptions. Otolaryngologists should be aware that obese patients are at increased risk of opioid induced airway obstruction and steroid induced hyperglycemia, especially in patients with comorbid sleep apnea or diabetes. Emphasis on non-opioid analgesics and multimodal pain management should be advocated for this population.

Objective: The objective of this study is to investigate various demographic, socioeconomic, COVID-related, and clinical factors associated with missed otolaryngology appointments in the outpatient setting at Boston Medical Center (BMC), an urban safety net hospital.

Methods: A retrospective chart review was conducted on adults (≥18 years old) with scheduled appointments in the otolaryngology department at BMC from May 1, 2015, to May 1, 2022. Data were extracted from the electronic medical record and included appointment-related factors (eg, status and type), demographic variables (eg, age, sex, race, and ethnicity), and socioeconomic factors (eg, employment and insurance). Statistical analyses utilized a binary mixed-effects model to identify predictors of appointment non-attendance, with pre-COVID, during COVID, and post-COVID periods defined for comparative analysis.

Results: Out of 14 050 patients, 5725 (40.8%) were classified as no-show. Older age decreased the likelihood of missing appointments (OR = 0.989, 95% CI = [0.986, 0.992]). Males (OR = 1.090, 95% CI = [1.022, 1.161]), Black/African American (OR = 2.047, 95% CI = [1.878, 2.231]), and Hispanic or Latino individuals (OR = 1.369, 95% CI = [1.232, 1.521]) were more likely to not show up. Retired participants (OR = 0.859, 95% CI = [0.753, 0.981]) and those with private insurance (OR = 0.698, 95% CI = [0.643, 0.758]) were less likely to miss appointments. During the COVID-19 pandemic, appointment attendance improved (OR = 0.865, 95% CI = [0.767, 0.976]). In-person appointments had a significantly higher non-attendance rate compared to telemedicine appointments (OR = 6.133, 95% CI = [5.248, 7.167]).

Conclusions: Appointment non-attendance in otolaryngology is influenced by various demographic and socioeconomic factors, with significant disparities observed among racial and ethnic groups. The COVID-19 pandemic altered attendance patterns, highlighting the potential benefits of telemedicine. These findings underscore the need for targeted interventions to address healthcare disparities and improve appointment adherence, particularly among minority and socioeconomically disadvantaged populations. Future research should incorporate patient perspectives to better understand barriers to appointment attendance.

Objective: To evaluate the effectiveness of coordinated endoscopy with otolaryngology, pulmonology, and gastroenterology in diagnosing and managing recurrent croup in pediatric patients.

Methods: We reviewed our REDCap Pediatric Aerodigestive Database for patients with recurrent croup who underwent coordinated endoscopy between January 2013 and July 2023. We reviewed patient demographics, comorbidities, surgical findings, treatments, and outcomes.

Results: Twenty-five patients were identified with recurrent croup. Their mean (SD) age was 37 (27) months (range = 9-98 months) with half of the patients younger than 25 months. The most common findings noted on combined endoscopies were positive bacterial culture on BAL (n = 10), and tracheomalacia (n = 7), and subglottic stenosis (n = 4). A history of prematurity was significantly associated with the presence of SGS (p = 0.01). Snoring/sleep-disordered breathing (SDB) was associated with a positive bacterial BAL culture (p = 0.03). About half of our cohort (48%) had multiple abnormalities identified by at least 2 different specialists at the time of endoscopy.

Conclusions: For patients experiencing frequent or severe recurrent croup episodes, a thorough aerodigestive evaluation and management plan should be pursued. Coordinated endoscopy may be considered for select patients who do not respond to medical treatment.

Objectives: The primary objective of this case series is to assess the effectiveness of the off-label use of the PROPEL drug-eluting stent, traditionally FDA-approved for sinus surgery, in preventing restenosis following canalplasty in patients with chronic otologic conditions or congenital anomalies. The stent provides both mechanical support to maintain canal patency and localized steroid delivery to reduce inflammation and scarring.

Methods: Four patients with various otologic conditions underwent canalplasty, followed by the placement of drug-eluting stents into the external auditory canal. The stents were inserted to address postoperative stenosis. Clinical outcomes, including ear canal patency, hearing improvement, and the rate of restenosis, were evaluated through regular follow-ups.

Results: All patients showed improved ear canal patency, with minimal restenosis observed during follow-up. Hearing improvement was reported in 3 out of 4 patients. The pediatric case exhibited mild medial canal stenosis despite stent placement, but overall improvement was noted. No adverse effects were associated with the stent usage.

Conclusions: The off-label use of a drug-eluting stent in canalplasty appears to reduce restenosis rates and maintain canal patency in adults effectively. Further research is warranted to standardize protocols and expand its indications for otologic surgery, particularly in pediatric cases where outcomes may vary.

Objectives: The prevalence of obstructive sleep apnea (OSA) is known to be higher in children with Down syndrome (DS) than the general pediatric population, with lower rates of surgical cure. This study aims to determine the prevalence and predictors of OSA and evaluate the outcomes of surgical intervention for OSA in a cohort of Australian children with DS.

Methodology: A retrospective chart review was conducted on 156 patients with DS from 0 to 18 years who had undergone overnight, attended polysomnography (PSG) at Sydney Children's Hospital from January 2010 to July 2023. Logistic regression was used to assess associations between OSA and age, gender, body mass index (BMI), and tonsillar size. The outcomes of surgery were determined by comparing the pre-operative and post-operative PSG results.

Results: The prevalence of OSA at first PSG was 65.8%, defined by an obstructive apnea-hypopnea index (OAHI) ≥1 event/hour. Elevated BMI in children above 2 years was associated with the presence of OSA (odds ratio [OR] = 1.32; 95% confidence interval [CI] = 1.02-1.71). Male gender was a predictor for an OAHI >5 events/hour (OR = 4.01, 95% CI = 1.09-14.78). Among 35 patients who underwent adenotonsillectomy and had a valid pre-operative and post-operative PSG, median OAHI was reduced from 12.6 to 3.8 events/hour (P = .002). In 13 patients who had secondary upper airway surgery, median OAHI was reduced from 8.5 to 2.6 events/hour (P = .075).

Conclusion: Children with DS and OSA who undergo surgical intervention may experience improvements to their PSG parameters.

Background: Granulation tissue formation and tracheitis are common pediatric tracheostomy complications. Ciprofloxacin/dexamethasone is frequently prescribed, but the influence of social determinants on this topic is unexplored.

Methods: This study extends a prior cohort study of pediatric tracheostomy patients at a single academic institution from 2016 to 2020. Social determinants of health, including race, insurance status, and residence characteristics, including Area Deprivation Index (ADI), were evaluated. Logistic regression, Wilcoxon rank-sum, and log-rank tests (α = .05) analyzed relationships between these determinants and prescriptions and post-tracheostomy outcomes.

Results: This cohort included 182 patients; 98/182 (53.9%) were male, and 140/182 (76.9%) were White, non-Hispanic. Non-White race was associated with increased odds of receiving nebulized ciprofloxacin/dexamethasone (OR = 2.80, 95% CI = 1.25-6.29). In those with tracheal culture results available (n = 63), Staphylococcus aureus was more common with public insurance (29/47, 7 with MRSA, 61.7%) compared with private (5/16, 3 with MRSA, 31.3%; OR = 3.54, 95% CI = 1.05-11.9). ADI was greater in the 7 patients with Streptococcus pneumoniae (median = 95, IQR = 88-99) compared to without (median = 77, IQR = 65-81, P = .003). Patients with tracheitis lived further from our center (median = 44.7 miles, IQR = 27.7-91.4 miles) compared with those who did not develop tracheitis (median = 33.4 miles, IQR = 12.0-85.2 miles, P = .02). Antibiotic resistance was more prevalent in children discharged home (14/35, 40.0%) than to transitional care (3/28, 10.7%; OR = 5.56, 95% CI = 1.40-22.0) and was associated with longer hospital stays (median = 70 days, range = 34-152 vs median = 35 days, range = 15-75 days, P = .02). Non-White patients experience increased odds of decannulation over time compared with White patients (HR = 2.85, 95% CI = 1.21-6.70). Discharge locations and ADI were associated with dressing choice post-tracheostomy.

Discussion: This study revealed racial disparities in ciprofloxacin/dexamethasone usage, residence-related differences in tracheal culture results, and ADI-related dressing choices, which highlight the need for tailored, equitable care to optimize outcomes.

Level of evidence: 4.

Objective: Nasal airway surgery is often applied when treatment fails to relieve nasal obstruction. However, surgery that improves airflow does not always alleviate the symptoms of nasal obstruction. The perception of nasal breathing is likely more related to changes in mucosal temperature than the mechanical sensation of flow or pressure. This study aims to measure intranasal mucosal temperature pre-and post-surgery using endonasal thermal imaging, exploring its correlation with subjective nasal breathing and objective airflow measurements.

Methods: A prospective study of adult patients with nasal obstruction managed with nasal airway surgery was performed. Intranasal mucosal temperatures were determined using the thermal endonasal image of the nasal passage produced by the infrared radiometric thermal camera (FILR VS290). A comparison was made between the mean values of mid-expiration (ExT) and mid-inspiration (InT) temperature data (internal nasal valve, nasal cavity, inferior turbinate, and overall airway [mean value]) and visual analog scale (VAS), Nasal Obstruction Symptom Evaluation (NOSE) scale and nasal airway resistance (NAR) before and after surgery.

Results: Seven patients (35.14 ± 16.45 years, 57.14% female) were included. All NOSE, VAS, and NAR improved after surgery (59.29 ± 10.89 vs 17.14 ± 14.64; P < .001, 64.50 ± 26.79 vs 18.57 ± 19.99; P < .001, 0.82 ± 0.48 vs 0.34 ± 0.11 Pa/cm³/s; P = .002, respectively). ExT, InT, and the difference between ExT and InT of three areas and overall airway were similar between pre-and post-surgery. No statistically significant correlations were found between intranasal mucosal temperature, VAS, NOSE, and NAR at pre-and post-surgery except for the difference between ExT and InT of overall airway and NOSE pre-operative (Pearson r = 0.57; 95% CI 0.06-1.09; P = .03).

Conclusion: Endonasal thermal imaging can assess the intranasal mucosal temperature of a patient. However, more precise imaging of the nasal passages and data acquisition are required to establish mucosal temperature as an objective measure of nasal obstruction before and after nasal airway surgery in a clinical setting.

Objective: Oral corticosteroids (OCS) are frequently prescribed by otolaryngologists. However, there are limited quantitative data on OCS-related adverse events (AEs) in otolaryngology. We sought to quantify OCS-related AEs in otolaryngology.

Methods: All outpatient otolaryngology encounters in our healthcare system (2018-2023) at which an OCS was prescribed were identified via the electronic medical record. The diagnoses indicating OCS were categorized as sinonasal, otologic, pharyngo-laryngeal, and other. The medical record was subsequently examined to assess for OCS AEs during the 21-day period following the prescription. OCS AEs were grouped into (1) gastrointestinal, (2) metabolic, (3) bone/muscle, (4) ophthalmologic, and/or (5) psychiatric complications. The frequency and types of OCS related AEs were determined.

Results: A total of 20 746 otolaryngology encounters with OCS prescribed were examined. Seventy OCS courses had 1 or more AEs, implying a number needed to harm of 296.4 (240.2-386.8). There were 83 total OCS-related AEs, yielding an AE incidence rate of 4.0:1000 (95% CI, 3.0-5.0:1000) OCS prescriptions. The mean age of subjects with AEs (61.5 years) was significantly higher than those without (50.3 years; P < .001). Forty-seven (56.6%) of the complications were metabolic, with hyperglycemia and hypokalemia the most common, followed by gastrointestinal (26.5%), ophthalmologic (3.6%), psychiatric (2.4%), and musculoskeletal (2.4%).

Conclusion: AEs related to OCS prescribed by otolaryngologists occur at a rate of once per 296 courses of treatment and older populations may be at increased risk for AEs. Otolaryngologists should balance AE rates against anticipated benefits of steroid therapy.

Level of evidence: 3.

Introduction: Virtual endoscopy (VE) is the computer-based reprocessing of diagnostic imaging to simulate endoscopy of an anatomic region of interest. VE of the Frontal Sinus Outflow Tract (FSOT) may assist surgical planning and education.

Method: VE was performed on 16 normal sinus computed tomography (CT) scans for a total of 32 sides using the "path-to-target" tool on the TruDi surgical navigation system (ver. 2.3; Acclarent, Irving, CA, USA). To aid orientation during VE, planning points were placed on the middle turbinate, ethmoidal bulla, and skull base. The VE representation of anatomy and FSOT accuracy was manually confirmed by reviewing the corresponding orthogonal CT images and comparing them to the computed pathway.

Results: Of the 32 sides, the software successfully calculated the FSOT in 22 sides (69%). Of those 22 sides, the calculated FSOT, depicted in the VE sequences accurately represented the FSOT. Among sides with an accurately calculated FSOT, the VE sequences depicted a "fly-through" from a starting point in the middle meatus around various frontal recess cells to the end point in the frontal sinus.

Conclusion: This pilot study demonstrates that software-generated VE of the FSOT is indeed feasible but requires confirmation by the surgeon for accuracy. Instances in which the software did not achieve its objective may drive further refinements of the protocol. VE of the FSOT should be explored as a tool for preoperative planning and surgical education.

Introduction: Perforations of the tympanic membrane result mainly from otitis media or trauma, and we need grafting when a perforation is chronically persistent to prevent recurring infections and to enhance hearing. In the present study, we assessed the success rate, feasibility, and efficacy of endoscopic transcanal tympanoplasty using tragal cartilage grafts via the clip technique.

Methods: This prospective study was performed between September 2017 and December 2021 and was conducted in ENT departments in tertiary hospitals. Forty patients underwent endoscopic clip technique tragal cartilage type 1 tympanoplasty. Patients with dry (for 3 months at least) small (less than 3 mm), medium (3-5 mm), or large (more than 5 mm) central perforations but not marginal perforations.

Results: TM perforation healing following the procedure for 6 months was achieved in 100% of the patients with small perforations, 18 of 19 (94.73%) with medium perforations and 11 of 12 (91.6%) with large perforations. At 6 months post-surgery, hearing improvement, as confirmed by audiometric results, was approximately 12.41 ± 1.01 dB. There was a highly significant improvement in the A-B gap (air-bone gap).

Conclusion: Endoscopic chondro-perichondrial tragal graft with the clip technique for the repair of small-, medium-, and large-sized nonmarginal TM perforations is a minimally invasive, safe and effective technique compared with the conventional myringoplasty technique. It provided good results (closure of both the perforation and the air-bone gap), minimized morbidity, reduced the operative time, increased patient compliance, and reduced the duration of hospital admission.