Annals of Otology Rhinology and Laryngology最新文献

Introduction: Vagal nerve stimulator (VNS) implantation is a vital therapy for epilepsy refractory to other treatments; however, it is associated with a very high rate of voice changes. Relatively few of these patients are evaluated for vocal fold motion impairments. In this series, we evaluate 5 such patients with a novel phenotype of forced abduction with VNS stimulation.

Methods: Retrospective case series.

Results: Five patients with a VNS implant who underwent operative direct or in-office rigid laryngoscopy and had vocal fold motion impairment associated with VNS activation are included. All 5 patients had vocal fold mobility with VNS off and a fixed with activation. All patients exhibited vocal fold abduction with VNS activation. Patient 2 has since undergone laryngeal reinnervation, which helped her intermittent dysphonia but left a small glottic gap. A type 1 thyroplasty corrected this gap and improved her voice further. Patient 3 has undergone laryngeal reinnervation for which early results show improvement in perceptual and patient reported outcomes. Patients 4 and 5 have both undergone laryngeal reinnervation with improvement in voice.

Conclusion: Previous reported cases of stimulated immobility associated with VNS use describe only adduction of the vocal fold. This series expands the previous work showing the VNS activation can also cause stimulated immobility in an abducted position, for which reinnervation and other medialization procedures offer promising treatment.

Objective: A new, active transcutaneous bone conduction device (BCD) was FDA-approved in 2019 in the USA. This systematic review sought to evaluate early outcomes associated with Osia implantation.

Methods: A systematic review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Four databases were reviewed: PubMed, Scopus, Cochrane CENTRAL, and CINAHL. Studies were included if they described audiometric, surgical characteristics/complications, or adverse events associated with the Osia BCD. Exclusion criteria: non-English language studies, animal investigations, reviews/meta-analyses, case reports, database studies.

Results: Eighteen studies with 336 patients were included. Mean age at implantation was 37.9 years. About 79.5% of patients had MHL/CHL and 19.5% had SSD/SHL. Mean operative time was 71.6 minutes. Mean PTA gain from unaided conditions was 35.4 dB. Mean functional gain at high frequency (6 kHz and above) from aided conditions was 16.1 dB. Mean improvement in speech recognition thresholds was 19.1 dB from unaided conditions. Adverse events (all types) were reported in 20.1% of cases. Across all studies, the postoperative infection rate was 5%. About 2% of patients reported magnet retention issues. About 1.65% of cases were complicated by hematomas.

Conclusions: Under systematic literature review, the Osia BCD has been associated with low complication rates, relatively short operative times, and good audiometric and speech outcomes, notably high frequency gain >6 kHz. More advanced audiometric outcome reporting remains limited and audiometric data and patient reported outcome measures were reported heterogeneously.

Background: Head and neck cancer (HNC) patients often have dysphagia following surgical and/or chemoradiation treatment, which can lead to reduced quality of life. Some patients suffer from decreased tongue strength and mobility that may cause discomfort and difficulty with swallowing. Our group has developed a patented genioglossus muscle strength trainer (GMST) to increase tongue protrusive force that has been used in patients with sleep apnea. We hypothesized that the GMST device would increase tongue strength in the HNC population.

Methods: We conducted an IRB approved, non-randomized, interventional clinical trial of HNC patients with dysphagia to determine the effect of GMST on tongue strength. Our secondary objective was to assess dysphagia quality of life, as determined by questionnaires. Genioglossus muscle strength measurements (measured in Newtons, N) and dysphagia quality of life scores (SWAL-QoL questionnaire) were obtained from enrolled patients at baseline and following 4 weeks of intervention. Treatment was at-home GMST exercise regimen 3 times daily, 5 days per week. Compliance was assessed via review of training logs. Two-sided paired t-tests at significance level α = .05 were performed to assess difference in mean GG muscle strength pre- and post-treatment.

Results: Out of 10 patients initially enrolled, 7 patients completed the trial. Eighty-six percent were male and the average age was 60. About 5 patients had surgery plus adjuvant radiation and 2 patients had primary radiation. All patients had baseline dysphagia as determined by patient complaint and/or objective measurement (prior modified barium swallow). No adverse events were reported. We observed a statistically significant increase in genioglossus muscle strength (mean change: 4.0 N, 95% CI 1.1-6.9, P = .015) after 4 weeks of treatment. Patients reported reduced swallowing burden and feeling of stigma around eating based on SWAL-QoL results.

Conclusions: Our data suggest that protrusive tongue-training exercises utilizing a novel tongue trainer device is well-tolerated and increases genioglossus muscle strength in treated HNC patients complaining of dysphagia. Patient-reported outcomes based on the SWAL-QoL survey indicate improvements in quality-of-life post-treatment, although our results are limited by small sample size. Larger studies are needed to see if this device could have clinically meaningful results for this difficult-to-treat patient population.

Objectives: Allergic fungal rhinosinusitis (AFRS) often results in expansion of disease beyond the paranasal sinuses, which may put important structures, such as the anterior ethmoid artery (AEA) or lateral lamella of the cribiform, at risk of injury during endoscopic sinus surgery (ESS). This study aims to compare the AEA to skull base (AEA-SB) length in patients with AFRS versus chronic rhinosinusitis with nasal polyps (CRSwNP), as well as additional anatomic variants.

Methods: A single institutional retrospective chart review of patients undergoing ESS for AFRS and CRSwNP was performed. AEA-SB length were compared between the 2 groups. Other anatomic variants, including Keros measurement and presence of supraorbital ethmoid air cells (SOEC), concha bullosa (CB), sphenoethmoidal, and infraorbital ethmoid cells were measured and compared between the 2 groups.

Results: Twenty-one patients were included in each cohort. The AFRS group was younger in age (P = .015) and had a significantly longer AEA-SB length (P = .014) compared to the CRSwNP group. No significant differences were observed between the 2 groups regarding Keros measurement, presence of concha bullosa, infraorbital ethmoid, sphenoethmoidal, or SOEC. No association was seen between AEA-SB length and Keros class in either group.

Conclusions: AFRS harbors anatomical differences when compared to CRSwNP, with the former associated with a longer AEA-SB length. This key difference should be considered in preoperative planning to prevent injury to the AEA in patients undergoing ESS for AFRS.

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.

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.

Objective: We present a case of phosphaturic mesenchymal tumor (PMT) in the left ethmoid without any nasal symptoms in a 63-year-old woman. Initially diagnosed with postmenopausal osteoporosis, 2-year history of hypophosphatemia and a significantly higher uptake of Fluorine-18 (¹⁸F)-AlF-NOTA-octreotide (¹⁸F-OC) in the left ethmoid sinus, provided crucial information for accurate diagnosis.

Methods: We presented a case with chart review and conducted review of the literature.

Results: The patient endured 1-year history of weakness and bone pain but without any nasal symptoms before a tissue diagnosis was eventually reached. It is a challenging diagnosis to make-patients present with non-specific clinical symptoms and the culprit neoplasm is often tiny in size and difficult to detect. It emphasizes the importance of thorough patient history-taking and the whole-body functional imaging.

Conclusions: Sinonasal PMTs are rare, and because of this most otolaryngologists are unfamiliar with its clinical presentation. This case highlights the importance of early diagnosis to enable prompt intervention and reduce the burden of associated symptoms.

Purpose: The endoscopic endonasal approach (EEA) has become the preferred treatment for pituitary tumors, with minimal sinonasal morbidity. However, patients with Cushing's disease (CD) may represent a subgroup with prolonged impairment of sinonasal quality of life (QOL).

Methods: We retrospectively identified patients with CD who underwent EEA at our institution. Control patients with non-functional tumors were matched by age, gender, and extent of EEA. The primary outcome was post-operative 22-item Sino-Nasal Outcome Test (SNOT-22) scores.

Results: Ten patients with CD met the selection criteria and 20 controls were selected for comparison. Nine of the CD patients achieved persistent endocrinologic remission post-operatively. Comparing the CD and control groups, there was no difference in post-operative SNOT-22 score at 1 or 3 months. At 6 months, SNOT-22 scores were significantly worse in the CD group (27.4 ± 21.6 vs. 2.8 ± 2.3, P = .039). SNOT-22 scores improved to normal from 1 to 6 months in the control cohort (P = .007), but not in the Cushing's group (P = .726). Morbidity was present across all SNOT-22 domains, but was highest in the sleep domain (P = .023). Only morbidity in the facial domain improved over time (P = .032).

Conclusions: Patients with CD have significantly prolonged postoperative sinonasal QOL impairment following EEA compared to patients with non-functioning tumors, who normalize within 6 months. In CD patients, only morbidity in the facial domain, likely related to post-operative pain and nasal packing, improved over time, while the sleep domain was the most affected.

Objective: Otoscopy is a key clinical examination used by multiple healthcare providers but training and testing of otoscopy skills remain largely uninvestigated. Simulator-based assessment of otoscopy skills exists, but evidence on its validity is scarce. In this study, we explored automated assessment and performance metrics of an otoscopy simulator through collection of validity evidence according to Messick's framework.

Methods: Novices and experienced otoscopists completed a test program on the Earsi otoscopy simulator. Automated assessment of diagnostic ability and performance were compared with manual ratings of technical skills. Reliability of assessment was evaluated using Generalizability theory. Linear mixed models and correlation analysis were used to compare automated and manual assessments. Finally, we used the contrasting groups method to define a pass/fail level for the automated score.

Results: A total of 12 novices and 12 experienced otoscopists completed the study. We found an overall G-coefficient of .69 for automated assessment. The experienced otoscopists achieved a significantly higher mean automated score than the novices (59.9% (95% CI [57.3%-62.6%]) vs. 44.6% (95% CI [41.9%-47.2%]), P < .001). For the manual assessment of technical skills, there was no significant difference, nor did the automated score correlate with the manually rated score (Pearson's r = .20, P = .601). We established a pass/fail standard for the simulator's automated score of 49.3%.

Conclusion: We explored validity evidence supporting an otoscopy simulator's automated score, demonstrating that this score mainly reflects cognitive skills. Manual assessment therefore still seems necessary at this point and external video-recording is necessary for valid assessment. To improve the reliability, the test course should include more cases to achieve a higher G-coefficient and a higher pass/fail standard should be used.

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.