Current Opinion in Otolaryngology & Head and Neck Surgery最新文献

Purpose of review: Prior investigations in social determinants of health (SDoH) and their impact on pediatric head and neck cancers are limited by the narrow scope of cancer types and SDoH being studied while lacking inquiry on the interrelational contribution of varied SDoH in real-world contexts. The purpose of this review is to discuss the current research tackling these shortcomings of SDoH-based studies in head and neck cancer and to discuss means of applying these findings in prospective initiatives and implementations.

Recent findings: Through leveraging contemporary, large-data analyses measuring diverse social vulnerabilities, several studies have identified comprehensive delineations of which social disparities contribute the largest quantifiable impact on the care of head and neck cancer patients. Progressing from prior SDoH-based research of the decade, these studies contextualize the effect of social vulnerabilities and have laid the foundations to begin addressing these issues in the complex, modern-day environment of interrelatedsocial factors.

Summary: Social determinants of health markedly affect pediatric head and neck cancer care and prognosis in complex and surprising ways. Modern-day tools and analyses derived from large-data techniques have unveiled the quantifiable underpinnings of how SDoH impact these pathologies.

Purpose of review: The purpose of this review is to describe the development of pediatric skull base surgical techniques and illustrate the advantages of pediatric endonasal skull base surgery (ESBS) when applied in appropriate settings. Additionally, this manuscript endeavors to define the pediatric skull base team components, highlight circumstances amenable to the development of a pediatric skull base surgery team, and describe the relative advantages of independent pediatric teams versus incorporation with adult skull base practices.

Recent findings: Multiple series published within the last decade have described the application of ESBS to the pediatric population, demonstrating adoption of these interventions in many academic centers. Most series include relatively small numbers of patients, highlighting the relative infrequency of anterior skull base pathology in the pediatric patient. Given the relatively low volume and high technical demands of this skillset, general guidelines for the timing, suggested training, and volume necessary to support a pediatric skull base team are offered.

Summary: The interest in pediatric ESBS continues to expand though case volumes may limit maintenance of skills in lower volume centers. The development of a dedicated pediatric skull base team in areas where sufficient volume exists facilitates concentration of expertise and interdisciplinary relationships necessary to provide the highest level of care. Collaborating with adult skull base teams can enhance the pediatric team experience, increasing exposure to complex surgical planning and radiologic nuances. However, a pediatric-focused skull base team can tailor treatment to meet the specific psychosocial and developmental needs of children.

Purpose of review: Dysphagia affects at least 1% of the pediatric population. This prevalence further increases in patients who are born prematurely or who have underlying neuromuscular or cardiopulmonary disorders. A multidisciplinary team approach, including an Otolaryngologist, can help promote an expedited diagnosis and therapeutic regimen, ensuring that the patient receives adequate nutrition needed for growth and development.

Recent findings: The development and growth of multidisciplinary aerodigestive clinics have improved outcomes in pediatric patients with dysphagia. If a structural concern is noted on examination, there remain a multitude of medical and surgical options to help improve patient outcomes and swallow. These treatment options are usually multimodality and specific interventions may be employed to target a specific and notable abnormality.

Summary: Pediatric dysphagia is a complex concern. For the otolaryngologist, etiologies with surgical targets may include ankyloglossia, tonsillar hypertrophy, laryngomalacia, laryngo-esophageal cleft, vocal fold movement impairment, and cricopharyngeal achalasia. The development and formalization of a multidisciplinary approach has streamlined and broadened treatment options for these patients. An otolaryngologist is integral as part of the treatment team of these patients.

Purpose of review: With an increased need to decentralize and train more head and neck ablative and reconstructive surgeons in sub-Saharan Africa, we assess the realities and challenges of free flap reconstruction in sub-Saharan Africa to provide context of its use as a reconstructive option.

Recent findings: Head and neck free flap reconstruction has been performed by local teams as well as visiting teams in Sub Saharan Africa with good results. Free flap success rates are similar to high income regions at 89% vs. 85-100%. However, flap salvage rates are significantly lower (45% compared to 64.1% reported in high income regions). This has been attributed to resource constraints.

Summary: With increasing efforts to increase free flap reconstructive capacity in sub-Saharan Africa, these efforts need to be in the context of available healthcare resources including infrastructure and workforce outside of the surgical team. As training of head and neck ablative and reconstructive surgeons is expanded, reconstructive training needs take the healthcare resource availability into account.

Purpose of review: The purpose of this review is to analyze and consolidate recently published literature to provide updated guidelines on the diagnosis and management of nontuberculous mycobacterial lymphadenitis (NTM LAD) in the pediatric population and to suggest areas of further research.

Recent findings: Diagnosis of NTM LAD relies on a detailed clinical history, physical examination, laboratory tests, and imaging techniques. Treatment strategies vary widely, with a shift towards complete surgical excision being observed due to its higher cure rate, improved aesthetic outcomes, and lower recurrence rates. However, patient-specific factors must be considered. The role of genetic factors, such as Mendelian susceptibility to mycobacterial disease (MSMD), is being increasingly recognized and could lead to targeted therapies.

Summary: Despite strides in the understanding and management of NTM LAD, substantial gaps remain in key areas such as the role of diagnostic imaging, optimal treatment parameters, postoperative care, and surveillance strategies. In this article, we explain our approach to NTM using the most relevant evidence-based medicine while offering directions for future work.

Purpose of review: Dementia and its variants, including Alzheimer's disease, become more prevalent with age. Dysphagia, that is, difficulty swallowing, also occurs with aging, and is often associated with dementia. Currently, there is no cure for dementia, and dysphagia, unrecognized or untreated, can have life-altering, even fatal consequences. Prolonged ability to eat safely and effectively could contribute to improved quality of life in a fragile population. In this review, difficulties associated with the management of dysphagia in individuals with dementia, as well as promising possibilities for continued investigation, will be discussed.

Recent findings: Recent reports point to unique problems related to understanding the comorbidities of dysphagia and dementia. These include delays in identifying dysphagia in affected individuals, as well as a lack of prevalence data for dysphagia in types and stages of dementia, or according to setting, for example, residential center, hospital. Emphasis on new tools, and new applications of existing tools, are needed.

Summary: New evidence not only underscores complexities and shortcomings of our understanding of dysphagia in dementia but also points to existing applications with potential for improving the situation, and new investigational directions that may elaborate our further understanding of these comorbidities.

Purpose of review: Pediatric decannulation failure can be associated with large morbidity and mortality, yet there are no published evidence-based guidelines for pediatric tracheostomy decannulation. Tracheostomy is frequently performed in medically complex children in whom it can be difficult to predict when and how to safely decannulate.

Recent findings: Published studies regarding pediatric decannulation are limited to reviews and case series from single institutions, with varying populations, indications for tracheostomy, and institutional resources. This article will provide a review of published decannulation protocols over the past 10 years. Endoscopic airway evaluation is required to assess the patency of the airway and address any airway obstruction prior to decannulation. There is considerable variability in tracheostomy tube modification between published protocols, though the majority support a capping trial and downsizing of the tracheostomy tube to facilitate capping. Most protocols include overnight capping in a monitored setting prior to decannulation with observation ranging from 24 to 48 h after decannulation. There is debate regarding which patients should have capped polysomnography (PSG) prior to decannulation, as this exam is resource-intensive and may not be widely available. Persistent tracheocutaneous fistulae are common following decannulation. Excision of the fistula tract with healing by secondary intention has a lower reported operative time, overall complication rate, and postoperative length of stay.

Summary: Pediatric decannulation should occur in a stepwise process. The ideal decannulation protocol should be safe and expedient, without utilizing excessive healthcare resources. There may be variability in protocols based on patient population or institutional resources, but an explicitly described protocol within each institution is critical to consistent care and quality improvement over time. Further research is needed to identify selection criteria for who would most benefit from PSG prior to decannulation to guide allocation of this limited resource.

Purpose of review: Tonsillectomy is one of the most common surgical procedures performed on children in the United States. Since 2002, the intracapsular technique has been studied as a safer and less painful alternative to total tonsillectomy. Concerns have been raised, however, as to the potential for regrowth and long-term outcomes regarding this technique.

Recent findings: Studies support the use of intracapsular tonsillectomy in the management of sleep disordered breathing, including in syndromic populations, as well as for tonsillitis. In addition, safety profiles continue to be improved over that of extracapsular dissection. While the incidence of regrowth ranges depending on the study and duration of follow up, it remains acceptably low. The most consistent independent risk factor for revision surgery includes young age.

Summary: While total tonsillectomy is more thoroughly studied historically, an important absence in the literature is a definitive superiority over the intracapsular technique. With continued high-level studies, as well as additional examination of long-term outcomes, we should continue to see greater acceptance of intracapsular tonsillectomy as a standard of practice in a vulnerable population.

Purpose of review: Congenital cytomegalovirus infection (cCMV) is a major cause of childhood hearing loss and neurodevelopmental delay. Early identification of cCMV allows for interventions that improve outcomes, particularly for cCMV-related hearing loss that develops in early childhood. Most cCMV is asymptomatic at birth and is rarely diagnosed without newborn screening. Therefore, various approaches to cCMV screening are increasingly being adopted.

Recent findings: Both universal screening (testing all newborns) and targeted screening (testing triggered by failed hearing screening) for cCMV appear valuable, feasible and cost-effective, though universal screening is predicted to have greatest potential overall benefits. CMV PCR testing of newborn oral swabs is sensitive and practical and is therefore widely used in targeted screening programs. In contrast, PCR using dried-blood spots (DBS) is less sensitive but was adopted by current universal cCMV screening initiatives because DBS are already collected from all newborns in high-income countries, which circumvents large-scale oral swab collection.

Summary: Targeted screening is widely recommended as standard of care, while universal screening is less common but is progressively considered as the optimal strategy for identification of children with cCMV. As with all screening programs, cCMV screening requires commitments to equitable and reliable testing, follow-up and services.

Purpose of review: Graves' disease (GD) constitutes a significant proportion of thyroid disorders seen during childhood. Several specialties may be closely involved in the management of pediatric patients with GD and emerging research in each field contributes to variations in the approach over time. Here we review the recent literature on the management of the disease, with the hope that this can be a valuable resource for treating specialists who need to be continuously updated on new data obtained in relevant fields.

Recent findings: Genetic, postinfectious and environmental factors may play a role in the immunological pathophysiology of GD. Research performed during the COVID-19 pandemic supports that viral-induced immune dysregulation may be a possible trigger for the disease. The various current treatment options all have positive and negative factors to consider. Antithyroidal drug therapy (ATD) is generally recommended as the initial treatment, although remission rates are only 20-30% at 2 years and 75% at 9 years. Unfortunately, about half of patients will relapse within 1 year of discontinuing therapy. Radioactive iodine therapy (RAI) is an effective treatment option and can be considered in certain pediatric patients. There continues to be no definitive evidence that the doses used for GD lead to a higher risk of cancer. Surgical treatment via thyroidectomy is effective and safe when performed by a high-volume surgeon. Recent studies show improvement in quality-of-life after surgery in adolescents and young adults. Future medical treatment options for GD currently being studied include antigen-specific immunotherapy and monoclonal antibodies.

Summary: Although the future holds promising new therapeutic options for autoimmune diseases including GD, the current choices continue to be ATD, usually first-line, and definitive treatments including RAI and surgery. While all three offer the possibility of remission or cure, drug therapy and RAI have a possibility of relapse. Risks of each approach should be broached in detail with patients and their families, and the nuances of treating this disease specifically in children should be familiar to all treating providers.