Publications by authors named "Justin R Shinn"

30 Publications

  • Page 1 of 1

Impact of Preoperative Risk Factors on Inpatient Stay and Facility Discharge After Free Flap Reconstruction.

Otolaryngol Head Neck Surg 2021 Aug 17:1945998211037541. Epub 2021 Aug 17.

Division of Head and Neck, Vanderbilt University Medical Center, Nashville, Tennessee, USA.

Objective: To determine the preoperative risk factors most predictive of prolonged length of stay (LOS) or admission to a skilled nursing facility (SNF) or inpatient rehabilitation center (IPR) after free flap reconstruction of the head and neck.

Study Design: Retrospective cohort study.

Setting: Tertiary academic medical center.

Methods: Retrospective review of 1008 patients who underwent tumor resection and free flap reconstruction of the head and neck at a tertiary referral center from 2002 to 2019.

Results: Of 1008 patients (65.7% male; mean age of 61.4 years, SD 14.0 years), 161 (15.6%) were discharged to SNF/IPR, and the median LOS was 7 days. In multiple linear regression analysis, Charlson Comorbidity Index (CCI; < .001), American Society of Anesthesiologists (ASA) classification ( = .021), female gender ( = .023), and inability to tolerate oral diet preoperatively ( = .006) were statistically significantly related to increased LOS, whereas age, body mass index (BMI), modified frailty index (MFI), a history of prior radiation or chemotherapy, and home oxygen use were not. Multiple logistic regression analysis demonstrated that CCI (odds ratio [OR] = 1.119, confidence interval [CI] 1.023-1.223), age (OR = 1.082, CI 1.056-1.108), and BMI <19.0 (OR = 2.141, CI 1.159-3.807) were the only variables statistically significantly related to posthospital placement in an SNF or IPR.

Conclusion: Common tools for assessing frailty and need for additional care may be inadequate in a head and neck reconstructive population. CCI appears to be the best of the aggregate metrics assessed, with significant relationships to both LOS and placement in SNF/IPR.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/01945998211037541DOI Listing
August 2021

Impact of Race and Insurance Status on Primary Treatment for HPV-Associated Oropharyngeal Squamous Cell Carcinoma.

Otolaryngol Head Neck Surg 2021 Jul 13:1945998211029839. Epub 2021 Jul 13.

Department of Otolaryngology-Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.

Objective: To assess the impact of sociodemographic factors on primary treatment choice (surgery vs radiotherapy) in patients with human papillomavirus-associated (HPV+) oropharyngeal squamous cell carcinoma (OPSCC).

Study Design: Retrospective analysis of the National Cancer Database.

Setting: Data from >1500 Commission on Cancer institutions (academic and community) via the National Cancer Database.

Methods: Our sample consists of patients diagnosed with HPV+ OPSCC from 2010 to 2015. The primary outcome of interest was initial treatment modality: surgery vs radiation. We performed multivariable logistic models to assess the relationship between treatment choice and sociodemographic factors, including sex, race, treatment facility, and insurance status.

Results: Of the 16,043 patients identified, 5894 (36.7%) underwent primary surgery while 10,149 (63.3%) received primary radiotherapy. Black patients were less likely than White patients to receive primary surgery (odds ratio [OR], 0.80; 95% CI, 0.66-0.96). When compared with privately insured patients, those who were uninsured or on Medicaid or Medicare were also less likely to receive primary surgery (OR, 0.70 [95% CI, 0.56-0.86]; OR, 0.77 [95% CI, 0.65-0.91]; OR, 0.85 [95% CI, 0.75-0.96], respectively). Patients receiving treatment at an academic/research cancer program were more likely to undergo primary surgery than those treated at comprehensive community cancer programs (OR, 1.33; 95% CI, 1.14-1.56).

Conclusion: In this large sample of patients with HPV+ OPSCC, race and insurance status affect primary treatment choice. Specifically, Black and nonprivately insured patients are less likely to receive primary surgery as compared with White or privately insured patients. Our findings illuminate potential disparities in HPV+ OPSCC treatment.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/01945998211029839DOI Listing
July 2021

Locoregional Recurrence in p16-Positive Oropharyngeal Squamous Cell Carcinoma After TORS.

Laryngoscope 2021 Jun 2. Epub 2021 Jun 2.

Department of Otorhinolaryngology: Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A.

Objective: To analyze the patterns, risk factors, and salvage outcomes for locoregional recurrences (LRR) after treatment with transoral robotic surgery (TORS) for HPV-associated oropharyngeal squamous cell carcinoma (HPV+ OPSCC).

Study Design: Retrospective analysis of HPV+ OPSCC patients completing primary TORS, neck dissection, and NCCN-guideline-compliant adjuvant therapy at a single institution from 2007 to 2017.

Methods: Features associated with LRR, detailed patterns of LRR, and outcomes of salvage therapy were analyzed. Disease-free survival (DFS) and overall survival (OS) were calculated for subgroups of patients receiving distinct adjuvant treatments.

Results: Of 541 patients who completed guideline-indicated therapy, the estimated 5-year LRR rate was 4.5%. There were no identifiable clinical or pathologic features associated with LRR. Compared to patients not receiving adjuvant therapy, those who received indicated adjuvant radiation alone had a lower risk of LRR (HR 0.28, 95% CI [0.09-0.83], P = .023), but there was no difference in DFS (P = .21) and OS (P = .86) between adjuvant therapy groups. The 5-year OS for patients who developed LRR was 67.1% vs. 93.9% for those without LRR (P < .001). Patients who initially received adjuvant chemoradiation and those suffering local, in-field, and/or retropharyngeal node recurrences had decreased disease control after salvage therapy.

Conclusion: LRR rates are low for HPV+ OPSCCs completing TORS and guideline-compliant adjuvant therapy. Patients without indication for adjuvant therapy more often suffer LRR, but these recurrences are generally controllable by salvage therapy. Improved understanding of the patterns of recurrence most amenable to salvage therapy may guide treatment decisions, counseling, and adjuvant therapy de-escalation trials.

Level Of Evidence: 3 Laryngoscope, 2021.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/lary.29659DOI Listing
June 2021

An improved predictive model for postoperative pulmonary complications after free flap reconstructions in the head and neck.

Head Neck 2021 07 30;43(7):2178-2184. Epub 2021 Mar 30.

Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA.

Background: Commonly used predictive models for postoperative pulmonary complications (PPCs) do not perform when applied to head and neck cases. A head and neck-specific risk prediction tool is needed.

Methods: Data on 794 free flap head and neck surgery cases at a single center were abstracted from the electronic medical record. Each case was reviewed for the development of PPCs. A predictive model was developed and was then compared to existing predictive models for PPCs.

Results: The least absolute shrinkage and selection operator procedure identified age, alcohol use, history of congestive heart failure, preoperative packed cell volume, preoperative oxygen saturation, and preoperative metabolic equivalents as predictors of PPCs in the head and neck population. The model demonstrated an area under the receiving operating characteristic curve of 0.75 (0.69-0.80) with moderately good calibration. Comparisons to the performance of existing models demonstrate superior performance.

Conclusions: The model for the development of PPCs developed in this article displays superior performance to existing models.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/hed.26689DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8197740PMC
July 2021

Oropharyngeal Squamous Cell Carcinoma With Discordant p16 and HPV mRNA Results: Incidence and Characterization in a Large, Contemporary United States Cohort.

Am J Surg Pathol 2021 07;45(7):951-961

Departments of Otolaryngology-Head and Neck Surgery.

Early studies estimate that 5% to 10% of oropharyngeal squamous cell carcinomas overexpress p16 but are unassociated with transcriptionally-active high-risk human papillomavirus (HPV). Patients with discordant HPV testing may experience clinical outcomes that differ from traditional expectations. To document the rate of p16 and HPV mRNA positivity, characterize patients with discordant testing, and identify features that may warrant selective use of HPV-specific testing after p16 IHC, a multi-institutional, retrospective review of oropharyngeal squamous cell carcinoma patients with p16 IHC and HPV mRNA testing by reverse transcriptase polymerase chain reaction was performed. Of the 467 patients, most had T1 or T2 tumors (71%), 82% were p16 positive, and 84% were HPV mRNA positive. Overall, most tumors were nonkeratinizing (378, 81%), which was strongly associated with p16 and HPV positivity (93% and 95%, respectively). Overall, 81% of patients were double positive, 14% double negative, and 4.9% discordant (3.4% p16 negative/HPV mRNA positive and 1.5% p16 positive/HPV mRNA negative). The survival rates of these discordant patient groups fell squarely between the 2 concordant groups, although in multivariate analysis for both disease-free survival and overall survival, discordant patients were not found to have statistically significantly different outcomes. Reclassifying patients by applying HPV mRNA testing when p16 results and morphology do not match, or when p16 results are equivocal, improved prognostication slightly over p16 or HPV mRNA testing alone. Patients with discordant testing demonstrate a borderline significant trend toward survival differences from those with concordant tests. When evaluated independently, patients who were p16 negative but HPV mRNA positive had a prognosis somewhat closer to double-positive patients, while those who were p16 positive, but HPV mRNA negative had a prognosis closer to that of double-negative patients. We suggest an algorithm whereby confirmatory HPV mRNA testing is performed in patients where p16 status is not consistent with tumor morphology. This captures a majority of discordant patients and improves, albeit modestly, the prognostication.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/PAS.0000000000001685DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8192336PMC
July 2021

Multi-Institutional Analysis of Outcomes in Supraglottic Jet Ventilation with a Team-Based Approach.

Laryngoscope 2021 Oct 20;131(10):2292-2297. Epub 2021 Feb 20.

Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, U.S.A.

Objectives/hypothesis: To evaluate the safety and complications of endoscopic airway surgery using supraglottic jet ventilation with a team-based approach.

Study Design: Retrospective cohort study.

Methods: Subjects at two academic institutions diagnosed with laryngotracheal stenosis who underwent endoscopic airway surgery with jet ventilation between January 2008 and December 2018 were identified. Patient characteristics (age, gender, race, follow-up duration) and comorbidities were extracted from the electronic health record. Records were reviewed for treatment approach, intraoperative data, and complications (intraoperative, acute postoperative, and delayed postoperative).

Results: Eight hundred and ninety-four patient encounters from 371 patients were identified. Intraoperative complications (unplanned tracheotomy, profound or severe hypoxic events, barotrauma, laryngospasm) occurred in fewer than 1% of patient encounters. Acute postoperative complications (postoperative recovery unit [PACU] rapid response, PACU intubation, return to the emergency department [ED] within 24 hours of surgery) were rare, occurring in fewer than 3% of patient encounters. Delayed postoperative complications (return to the ED or admission for respiratory complaints within 30 days of surgery) occurred in fewer than 1% of patient encounters. Diabetes mellitus, active smoking, and history of previous tracheotomy were independently associated with intraoperative, acute, and delayed complications.

Conclusions: Employing a team-based approach, jet ventilation during endoscopic airway surgery demonstrates a low rate of complications and provides for safe and successful surgery.

Level Of Evidence: 4 Laryngoscope, 131:2292-2297, 2021.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/lary.29431DOI Listing
October 2021

Human Papillomavirus Testing in Head and Neck Squamous Cell Carcinoma: Impact of the 2018 College of American Pathologists Guideline Among Referral Cases at a Large Academic Institution.

Arch Pathol Lab Med 2021 09;145(9):1123-1131

The Department of Pathology, Microbiology, and Immunology (Ferguson, Mehrad, Ely, Lewis Jr), Vanderbilt University Medical Center, Nashville, Tennessee.

Context.—: Given the growing clinical significance of human papillomavirus status in oropharyngeal squamous cell carcinoma, the College of American Pathologists established a set of evidence-based recommendations for high-risk human papillomavirus testing for publication in a guideline.

Objective.—: To evaluate the impact of the recommendations on human papillomavirus ancillary test ordering habits by comparing compliance before and after the guideline was published.

Design.—: We retrospectively reviewed head and neck squamous cell carcinoma biopsy or resection specimens from outside institutions during a 2.5-year period around guideline publication to determine whether human papillomavirus testing was performed in accordance with the guideline.

Results.—: Human papillomavirus testing deviated from the guideline in 45 of 107 cases (42.1%) before and 93 of 258 cases (36.0%) after its publication (P = .29). This included 6 of 26 cases of oropharyngeal squamous cell carcinoma (23.1%) before and 5 of 55 cases (9.1%) after (P = .16), with 5 of 5 (100.0%) after due to not performing p16 immunohistochemistry. This also included 30 of 68 cases of nonoropharyngeal carcinoma (44.1%) before and 69 of 163 (42.3%) after the guideline was published (P = .88), with 29 of 30 (96.7%) before and 67 of 69 (97.1%) after due to unnecessary use of p16 immunohistochemistry. Nodal metastasis testing deviated in 9 of 13 cases (69.2%) before and 19 of 40 cases (47.5%) after (P = .21) with marked variability in testing, including 3 of 9 (33.3%) before and 8 of 19 (42.1%) after, for not confirming certain p16 immunohistochemistry-positive tumors with human papillomavirus-specific testing.

Conclusions.—: Pathologists continue to deviate from the testing guideline significantly in everyday practice. Further education and discussion about the appropriate handling of head and neck cancer specimens may be needed.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.5858/arpa.2020-0220-OADOI Listing
September 2021

Enhanced recovery after surgery for head and neck free flap reconstruction: A systematic review and meta-analysis.

Oral Oncol 2021 02 23;113:105117. Epub 2020 Dec 23.

Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, United States; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, United States. Electronic address:

Introduction: Head and neck free flap reconstruction requires multidisciplinary and coordinated care in the perioperative setting to ensure safe recovery and success. Several institutions have introduced enhanced recovery after surgery (ERAS) protocols to attenuate the surgical stress response and improve postoperative recovery. With multiple studies demonstrating mixed results, the success of these interventions on clinical outcomes has yet to be determined.

Objective: To evaluate the impact of ERAS protocols and clinical care pathways for head and neck free flap reconstruction.

Methods: We searched PubMed, SCOPUS, EMBASE, and grey literature up to September 1st, 2020 to identify studies comparing patients enrolled in an ERAS protocol and control group. Our primary outcomes included hospital length of stay (LOS) and readmission. Mortality, reoperations, wound complication and ICU (intensive care unit) LOS comprised our secondary outcomes.

Results: 18 studies met inclusion criteria, representing a total of 2630 patients. The specific components of ERAS protocols used by institutions varied. Nevertheless, patients enrolled in ERAS protocols had reduced hospital LOS (MD -4.36 days [-7.54, -1.18]), readmission rates (OR 0.64 [0.45;0.92]), and wound complications (RR 0.41 [0.21, 0.83]), without an increase in reoperations (RR 0.65 [0.41, 1.02]), mortality (RR 0.38 [0.05, 2.88]), or ICU LOS (MD -2.55 days [-5.84, 0.74]).

Conclusion: There is growing body of evidence supporting the role of ERAS protocols for the perioperative management of head and neck free flap patients. Our findings reveal that structured clinical algorithms for perioperative interventions improve clinically-meaningful outcomes in patients undergoing complex ablation and microvascular reconstruction procedures.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.oraloncology.2020.105117DOI Listing
February 2021

Institution-Specific Strategies for Head and Neck Oncology Triage During the COVID-19 Pandemic.

Ear Nose Throat J 2020 Dec 4:145561320975509. Epub 2020 Dec 4.

Department of Otolaryngology, Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.

Background: This work seeks to better understand the triage strategies employed by head and neck oncologic surgical divisions during the initial phases of the coronavirus 2019 (COVID-19) outbreak.

Methods: Thirty-six American head and neck surgical oncology practices responded to questions regarding the triage strategies employed from March to May 2020.

Results: Of the programs surveyed, 11 (31%) had official department or hospital-specific guidelines for mitigating care delays and determining which surgical cases could proceed. Seventeen (47%) programs left the decision to proceed with surgery to individual surgeon discretion. Five (14%) programs employed committee review, and 7 (19%) used chairman review systems to grant permission for surgery. Every program surveyed, including multiple in COVID-19 outbreak epicenters, continued to perform complex head and neck cancer resections with free flap reconstruction.

Conclusions: During the initial phases of the COVID-19 pandemic experience in the United States, head and neck surgical oncology divisions largely eschewed formal triage policies and favored practices that allowed individual surgeons discretion in the decision whether or not to operate. Better understanding the shortcomings of such an approach could help mitigate care delays and improve oncologic outcomes during future outbreaks of COVID-19 and other resource-limiting events.

Level Of Evidence: 4.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/0145561320975509DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7720027PMC
December 2020

The authors reply.

Crit Care Med 2020 05;48(5):e431

Department of Otolaryngology, Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, TN Division of Allergy, Pulmonary, and Critical Care, Vanderbilt University Medical Center, Nashville, TN, and Tennessee Valley Veteran's Affairs Geriatric Research Education Clinical Center (GRECC), Nashville, TN, and Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN Department of Otolaryngology, Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, TN, and Division of Laryngology, Vanderbilt University Medical Center, Nashville, TN.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/CCM.0000000000004301DOI Listing
May 2020

Unilateral Vocal Fold Immobility-More Common Than We Think?-Reply.

JAMA Otolaryngol Head Neck Surg 2020 06;146(6):588

Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1001/jamaoto.2020.0138DOI Listing
June 2020

The authors reply.

Crit Care Med 2020 04;48(4):e338-e339

Department of Otolaryngology, Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, TN Division of Allergy, Pulmonary, and Critical Care, Vanderbilt University Medical Center, Nashville, TN, and Tennessee Valley Veteran's Affairs Geriatric Research Education Clinical Center (GRECC), Nashville, TN, and Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN Department of Otolaryngology, Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, TN, and Division of Laryngology, Vanderbilt University Medical Center, Nashville, TN.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/CCM.0000000000004253DOI Listing
April 2020

Risk Factors and Outcomes of Postoperative Recurrent Well-Differentiated Thyroid Cancer: A Single Institution's 15-Year Experience.

Otolaryngol Head Neck Surg 2020 Apr 18;162(4):469-475. Epub 2020 Feb 18.

Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA.

Objective: Identify risk factors and outcomes of recurrent well-differentiated thyroid cancer.

Study Design: Retrospective case-control analysis.

Setting: Tertiary care academic center in Nashville, Tennessee.

Subjects And Methods: This single-center analysis reviews 478 patients who underwent initial surgical management of well-differentiated thyroid carcinoma between 2002 and 2017. Patients were dichotomized with or without recurrent well-differentiated thyroid cancer. Demographic and clinicopathologic risk factors were carefully reviewed. Univariate, multiple regression, and survival analyses were used to evaluate predictors of recurrence.

Results: Thirty-eight patients (7.9%) who received initial surgical intervention for well-differentiated thyroid carcinoma at our institution recurred, with an average time to recurrence of 24 months. Male sex, tumor size, multifocality, extrathyroidal extension, lymphovascular invasion, number of positive lymph nodes, and low lymph node yield were all significantly associated with locoregional recurrence ( < .05). Multiple regression analysis showed that extrathyroidal extension, number of positive lymph nodes, and low lymph node yield were independent factors predictive of posttreatment recurrence ( < .05). Metastatic lymph node ratio, the ratio of positive lymph nodes extracted to lymph node yield, of ≥0.3 is associated with increased risk of recurrence ( < .001) and decreased 5-year recurrence free survival ( < .001).

Conclusion: Extrathyroidal extension, number of positive lymph nodes, and low lymph node yield are independent clinicopathologic risk factors for postoperative recurrence of well-differentiated thyroid cancer. Metastatic lymph node ratio is uncommonly used but can be an important prognosticator of recurrence. Patients with metastatic lymph node ratio ≥0.3 should be counseled on their increased risk of recurrence and should undergo close surveillance following surgery.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/0194599820904923DOI Listing
April 2020

Unilateral Vocal Fold Immobility After Prolonged Endotracheal Intubation.

JAMA Otolaryngol Head Neck Surg 2020 02;146(2):160-167

Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee.

Importance: Endotracheal intubation and mechanical ventilation are life-saving treatments for acute respiratory failure but are complicated by significant rates of dyspnea and dysphonia after extubation. Unilateral vocal fold immobility (UVFI) after extubation can alter respiration and phonation, but its incidence, risk factors, and pathophysiology remain unclear.

Objectives: To determine the incidence of UVFI after prolonged (>12 hours) mechanical ventilation in a medical intensive care unit and investigate associated clinical risk factors for UVFI after prolonged mechanical ventilation.

Design, Setting, And Participants: This subgroup analysis of a prospective cohort study was conducted in a single-center medical intensive care unit from August 17, 2017, through May 31, 2018, among 100 consecutive adult patients who were intubated for more than 12 hours. Patients were identified within 36 hours of extubation and recruited for study enrollment. Those with an established tracheostomy prior to mechanical ventilation, known laryngeal or tracheal pathologic characteristics, or a history of head and neck radiotherapy were excluded.

Exposure: Invasive mechanical ventilation via an endotracheal tube.

Main Outcomes And Measures: The incidence of UVFI as determined by flexible nasolaryngoscopy.

Results: One hundred patients (62 men [62%]; median age, 58.5 years [range, 19.0-87.0 years]) underwent endoscopic evaluation after extubation. Seven patients had UVFI, of which 6 cases (86%) were left sided. Patients with hypotension while intubated (odds ratio [OR], 10.8; 95% CI, 1.6 to ∞), patients requiring vasopressors while intubated (OR, 16.7; 95% CI, 2.4 to ∞), and patients with a preadmission diagnosis of peripheral vascular disease (OR, 6.2; 95% CI, 1.2-31.9) or coronary artery disease (OR, 5.1; 95% CI, 1.0-25.5) were more likely to develop UVFI.

Conclusions And Relevance: Unilateral vocal fold immobility occurred in 7 of 100 patients in the medical intensive care unit who were intubated for more than 12 hours. Unilateral vocal fold immobility was associated with inpatient hypotension and preadmission vascular disease, suggesting that ischemia of the recurrent laryngeal nerve may play a role in disease pathogenesis.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1001/jamaoto.2019.3969DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6990766PMC
February 2020

Incidence and Outcomes of Acute Laryngeal Injury After Prolonged Mechanical Ventilation.

Crit Care Med 2019 12;47(12):1699-1706

Department of Otolaryngology, Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, TN.

Objectives: Upper airway injury is a recognized complication of prolonged endotracheal intubation, yet little attention has been paid to the consequences of laryngeal injury and functional impact. The purpose of our study was to prospectively define the incidence of acute laryngeal injury and investigate the impact of injury on breathing and voice outcomes.

Design: Prospective cohort study.

Setting: Tertiary referral critical care center.

Patients: Consecutive adult patients intubated greater than 12 hours in the medical ICU from August 2017 to May 2018 who underwent laryngoscopy within 36 hours of extubation.

Interventions: Laryngoscopy following endotracheal intubation.

Measurements And Main Results: One hundred consecutive patients (62% male; median age, 58.5 yr) underwent endoscopic examination after extubation. Acute laryngeal injury (i.e., mucosal ulceration or granulation tissue in the larynx) was present in 57 patients (57%). Patients with laryngeal injury had significantly worse patient-reported breathing (Clinical Chronic Obstructive Pulmonary Disease Questionnaire: median, 1.05; interquartile range, 0.48-2.10) and vocal symptoms (Voice Handicap Index-10: median, 2; interquartile range, 0-6) compared with patients without injury (Clinical Chronic Obstructive Pulmonary Disease Questionnaire: median, 0.20; interquartile range, 0-0.80; p < 0.001; and Voice Handicap Index-10: median, 0; interquartile range, 0-1; p = 0.005). Multivariable logistic regression independently associated diabetes, body habitus, and endotracheal tube size greater than 7.0 with the development of laryngeal injury.

Conclusions: Acute laryngeal injury occurs in more than half of patients who receive mechanical ventilation and is associated with significantly worse breathing and voicing 10 weeks after extubation. An endotracheal tube greater than size 7.0, diabetes, and larger body habitus may predispose to injury. Our results suggest that acute laryngeal injury impacts functional recovery from critical illness.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/CCM.0000000000004015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7880159PMC
December 2019

Teacher Prescreening for Hearing Loss in the Developing World.

Ear Nose Throat J 2021 Jun 13;100(3_suppl):259S-262S. Epub 2019 Oct 13.

Department of Otolaryngology, 12328Vanderbilt University Medical Center, Nashville, TN, USA.

The goal of this prospective cohort study was to characterize the ability of teachers to identify schoolchildren at risk of hearing loss in order to maximize hearing screening efficiency in low-resource settings. At 4 semirural schools in Malindi, Kenya, preselected schoolchildren perceived as hearing impaired were compared to children thought to have normal hearing using portable audiometry. Eight of 127 children (54% male) failed hearing screening, all of who were identified by schoolteachers as having a high risk of hearing loss. Thus, for every 5 children prescreened by schoolteachers, an average of 1 child would be identified as having hearing loss. Overall, teacher prescreening had a 100% hearing loss identification rate and a 20% referral rate. In conclusion, in resource-limited settings, where universal hearing screening is challenging, teachers can effectively identify children with hearing loss for early intervention.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/0145561319880388DOI Listing
June 2021

Community health workers obtain similar results using cell-phone based hearing screening tools compared to otolaryngologists in low resourced settings.

Int J Pediatr Otorhinolaryngol 2019 Dec 5;127:109670. Epub 2019 Sep 5.

Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, TN, USA.

Objective: To establish community health workers as reliable hearing screening operators in a technology-based pre-surgical hearing screening program in a low and middle-income country (LMIC).

Methods: This is a cross sectional study that evaluated community health worker driven hearing screening that took place in semi-rural Malindi, Kenya during an annual two-week otolaryngology surgical training mission in October 2017. At five separate locations (four schools) near Malindi, Kenya, children between the ages of 2-16 underwent hearing screening using screening audiometry (Android-based HearX Group). Children were screened by a community health worker who underwent a short training course, a senior otolaryngology resident, or both. Hearing screening results were compared to determine the reliability and concordance between independent, blinded community health worker and otolaryngology resident testing.

Results: One hundred and four participants (53% males) underwent hearing screening. Hearing screening pass rate was 93%. Community health workers obtained a similar result to otolaryngology residents 96% of the time (McNemar test: p = 0.16, OR 0.96, 95% CI 0.9-1.0).

Conclusion: Community health workers can obtain reliable results using a technology-based, pre-surgical hearing screening platform when compared to otolaryngology residents. This finding has profound implications in low-resourced settings where hearing healthcare specialists (audiologists and otolaryngologists) are limited and can ultimately improve the surgical yield of patients presenting to local otolaryngologists in these settings.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ijporl.2019.109670DOI Listing
December 2019

Peri-Incisional Botulinum Toxin Therapy for Treatment of Intractable Head Pain After Lateral Skull Base Surgery: A Case Series.

Headache 2019 10 31;59(9):1624-1630. Epub 2019 Aug 31.

Department of Otolaryngology - Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.

Objective: The objective of this case series was to describe botulinum toxin therapy as a novel treatment of intractable head pain following lateral skull base surgery.

Background: Intractable headaches following lateral skull base surgery are described in 23%-75% of patients and can significantly impact quality of life. Currently, the etiology of the headaches is unclear and treatment options are limited. Botulinum toxin is indicated for a multitude of functional and cosmetic reasons, including chronic migraine, and has been further described in treatment of various postsurgical pain syndromes.

Methods: In this case series, 4 patients underwent subcutaneous peri-incisional injections of botulinum toxin for intractable headache and head pain syndromes. Three patients had undergone lateral skull base surgery and the fourth patient had undergone a temporoparietal fascial flap harvest. Average injection dose ranged from 20 to 60 units with an average duration of effect ranging from 2 weeks to 4 months.

Results: All patients experienced significant relief of chronic head pain and returned for additional peri-incisional botulinum toxin injections, suggesting meaningful patient-perceived value.

Conclusions: Botulinum toxin therapy may represent a novel treatment for intractable head pain following lateral skull base surgery and temporoparietal fascial flap harvest. This study represents a small case series and, although 100% of the patients who were treated significantly improved, future inquiry is necessary to confirm these findings.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/head.13616DOI Listing
October 2019

Existing Predictive Models for Postoperative Pulmonary Complications Perform Poorly in a Head and Neck Surgery Population.

J Med Syst 2019 Aug 26;43(10):312. Epub 2019 Aug 26.

Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, 1215 21st Avenue South, Nashville, TN, USA.

Postoperative pulmonary complications (PPCs) are common following major surgical procedures. Risk stratification tools have been developed to identify patients at risk for PPCs. While otolaryngology cases were included in the development of common predictive tools, they comprised small percentages in each tool. It is unclear how these tools perform in patients undergoing major head and neck surgery with free flap reconstruction. This retrospective review studied all free flap reconstructions in head and neck surgery over a 12-year period at a single institution in the southeastern US. Baseline demographic and medical information were included for each case. All cases were reviewed for development of major PPCs, including pneumonia and respiratory failure. The cohort underwent risk stratification using the ARISCAT and Gupta pulmonary risk indices. Performance of these predictive models for head and neck surgery was determined through receiver-operator curve comparison. 794 patients were identified with a median age of 62 years (IQR 41-83). Sixty-five percent were male. Forty-three (5.4%) developed pneumonia, 23 patients developed respiratory failure (2.9%), and 38 patients developed both (4.8%), resulting in a total PPC proportion of 13.1% (n = 104). Both ARISCAT and Gupta pulmonary risk indices demonstrated low discrimination to predict PPCs in head and neck free flap reconstruction, with areas under the curve of 0.60 and 0.65, respectively. Two major indices for prediction of postoperative pulmonary complications do not accurately identify risk in patients undergoing major head and neck surgery. Further studies are needed to develop predictive tools for PPCs in this high-risk population.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s10916-019-1435-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6800103PMC
August 2019

The impact of social determinants of health on laryngotracheal stenosis development and outcomes.

Laryngoscope 2020 04 29;130(4):1000-1006. Epub 2019 Jul 29.

Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee.

Objectives: The social determinants of health affect a wide range of health outcomes and risks. To date, there have been no studies evaluating the impact of social determinants of health on laryngotracheal stenosis (LTS). We sought to describe the social determinants in a cohort of LTS patients and explore their association with treatment outcome.

Methods: Subjects diagnosed with LTS undergoing surgical procedures between 2013 and 2018 were identified. Matched controls were identified from intensive care unit (ICU) patients who underwent intubation for greater than 24 hours. Medical comorbidities, stenosis characteristics, and patient demographics were abstracted from the clinical record. Tracheostomy at last follow-up was recorded from the medical record and phone calls. Socioeconomic data was obtained from the American Community Survey.

Results: One hundred twenty-two cases met inclusion criteria. Cases had significantly lower education compared to Tennessee (P = .009) but similar education rates as ICU controls. Cases had significantly higher body mass index (odds ratio [OR]: 1.04, P = .035), duration of intubation (OR: 1.21, P < .001), and tobacco use (OR: 1.21, P = .006) in adjusted analysis when compared to controls. Tracheostomy dependence within the case cohort was significantly associated with public insurance (OR: 1.33, P = .016) and chronic obstructive pulmonary disease (OR: 1.34, P = .018) in adjusted analysis.

Conclusion: Intubation practices, medical comorbidities and social determinants of health may influence the development of LTS and tracheostomy dependence after treatment. Identification of at-risk populations in ICUs may allow for prevention of tracheostomy dependence through the use of early tracheostomy and specialized follow-up.

Level Of Evidence: Level 3, retrospective review comparing cases and controls Laryngoscope, 130:1000-1006, 2020.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/lary.28208DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7808241PMC
April 2020

Hypopharyngeal Skin Cancer Following Total Laryngectomy and Pectoralis Flap Reconstruction: Case Report and Literature Review.

Head Neck Pathol 2019 Dec 19;13(4):643-647. Epub 2019 Mar 19.

Department of Otolaryngology - Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.

Although early complications of microvascular free flaps and regional pedicled flaps of the head and neck are well described in the literature, there is relatively limited knowledge regarding their long-term complications. We describe the case of a 62-year-old gentleman who underwent primary resection and adjuvant radiation therapy for supraglottic squamous cell carcinoma who subsequently underwent salvage total laryngectomy with pectoralis major muscle flap reconstruction. During a later esophageal dilation for complaints of dysphagia, a new exophytic lesion of the hypopharynx was biopsied on endoscopy. The lesion was excised via transoral robotic surgery with final pathology revealing squamous cell carcinoma completely confined to the skin paddle of the pectoralis flap and arising from the epidermis of the skin flap. No further therapy was undertaken and there has been no evidence of recurrence 2 years after resection. Synchronous cutaneous malignancy is a rare complication of free and pedicled flap reconstruction, however its diagnosis is increasing. Given the concern for recurrent mucosal tumors arising in the upper aerodigestive tract which may require extensive resection with or without adjuvant therapy, it is important to determine the etiology of the underlying malignancy to guide appropriate treatment.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s12105-019-01029-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6854126PMC
December 2019

Treatment Patterns and Outcomes in Botulinum Therapy for Patients With Facial Synkinesis.

JAMA Facial Plast Surg 2019 May;21(3):244-251

Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, Tennessee.

Importance: In the last decade, there has been a significant increase in the number of practitioners administering botulinum toxin for facial synkinesis. However, there are few resources available to guide treatment patterns, and little is known about how these patterns are associated with functional outcomes and quality of life.

Objective: To evaluate botulinum treatment patterns, including the dosing and frequency of muscle targeting, for treatment of facial synkinesis and to quantify patient outcomes.

Design, Setting, And Participants: This prospective cohort study of 99 patients treated for facial synkinesis was conducted from January 2016 through December 2018 at the Vanderbilt Bill Wilkerson Center in Nashville, Tennessee, a tertiary referral center.

Intervention: Onabotulinum toxin A treatment of facial synkinesis.

Main Outcomes And Measures: Patient-reported outcomes on the Synkinesis Assessment Questionnaire and botulinum treatment patterns, including the dosages and frequency of injection for each facial muscle, were compared at the initiation of treatment and at the end of recorded treatment.

Results: In total, 99 patients (80 female patients [81%]) underwent botulinum injections for treatment of facial synkinesis. The median (interquartile range) age was 54.0 (43.5-61.5) years, and the median (interquartile range) follow-up was 27.1 (8.9-59.7) months. Most patients underwent injections after receiving a diagnosis of Bell palsy (41 patients, 41%) or after resection of vestibular schwannoma (36 patients [36%]). The patients received a total of 441 treatment injections, and 369 pretreatment and posttreatment Synkinesis Assessment Questionnaire scores were analyzed. The mean botulinum dose was 2 to 3 U for each facial muscle and 9 to 10 U for the platysma muscle. The dose increased over time for the majority of all muscles, with steady state achieved after a median of 3 treatments (interquartile range, 2-3). Linear regression analysis for cluster data of the mean total questionnaire score difference was -14.2 (95% CI, -17.0 to -11.5; P < .001). There was a significant association of postinjection questionnaire score with younger patients, female sex, total dose, and synkinesis severity. Oculo-oral synkinesis may respond more to treatment compared with oro-ocular synkinesis.

Conclusion And Relevance: Patients with facial synkinesis responded significantly to botulinum treatment. Treatment began with 6 core facial muscles that were injected during most treatment sessions, and dosages increased after the first injection until steady state was achieved. Those with a greater degree of morbidity, younger patients, and females showed significant improvement, and the larger the dose administered, the greater the response. Oculo-oral synkinesis may be more responsive than oro-ocular synkinesis.

Level Of Evidence: 3.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1001/jamafacial.2018.1962DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6537828PMC
May 2019

Contemporary Review and Case Report of Botulinum Resistance in Facial Synkinesis.

Laryngoscope 2019 10 28;129(10):2269-2273. Epub 2018 Dec 28.

Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, Tennessee, U.S.A.

Background: Botulinum resistance poses significant treatment challenges for both patients and healthcare practitioners. We first present a case highlighting botulinum resistance in a patient who failed to respond to alternative formulations but who responded remarkably to incobotulinum toxinA, an identical toxin free of complexing proteins. Secondly, we provide a treatment algorithm and a review of the literature detailing clinical and immunochemical botulinum resistance.

Results: Patients with botulinum resistance show a predisposition to failure on subsequent injections and possess a propensity toward neutralizing and nonneutralizing antibody development. The mechanisms of resistance are not entirely understood but thought to be secondary to an immunologic response. Risk factors for resistance include higher botulinum doses, more frequent injections, and high total lifetime dosage. Patients may still respond to other botulinum formulations or subtypes; however, this effect may be temporary.

Conclusion: This case report describes a patient who responded to incobotulinum toxinA after failing treatment with the identical toxin compounded with buffer proteins, ultimately supporting the possibility of immune-mediated resistance to the surrounding proteins and not the toxin itself. Often, impending treatment resistance is preceded by a poor or limited clinical response. Antibody testing is not indicated because it is neither sensitive nor specific and does not change clinical practice. Initially, higher doses of botulinum may overcome resistance without increasing treatment frequency, and side effects are far less common in those with clinical resistance. If higher dosages fail to produce a response, alternative botulinum formulations or subtypes can be considered. Laryngoscope, 129:2269-2273, 2019.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/lary.27709DOI Listing
October 2019

Cumulative incidence of neck recurrence with increasing depth of invasion.

Oral Oncol 2018 12 20;87:36-42. Epub 2018 Oct 20.

Department of Otolaryngology, Vanderbilt University Medical Center, 7209 Medical Center East - South Tower, 1215 21st Avenue South, Nashville, TN 37232-8605, USA; Division of Head and Neck Surgery, Vanderbilt Bill Wilkerson Center, 1215 21st Ave South, Nashville, TN 37232, USA.

Objective: To determine if there is a critical depth of invasion that predicts micrometastasis in early oral tongue cancer.

Methods: Retrospective series identifying patients undergoing primary surgical resection of T1 or T2 oral tongue cancer who elected against neck treatment between 2000 and 2015. Cox proportional-hazard model compared the relative hazard and cumulative incidence of recurrence to depth of invasion. The model used a 2 parameter quadratic effect for depth that was chosen based on Akaike's information criterion.

Results: Ninety-three patients were identified with T1 or T2 oral tongue squamous cell carcinoma and clinically N0 neck undergoing glossectomy without elective neck treatment. 61% were male and median age was 60 years. Median follow up was 45 months, and 76 patients had at least two years of follow up. Thirty-six of 76 patients recurred (47.4%), with 15 recurring in the oral cavity (19.7%) and 21 developing nodal metastasis (27.6%). Cox proportional-hazards quadratic polynomial showed increasing hazard of recurrence with depth of invasion and the cumulative incidence increased sharply within the range of data from 2 to 6 mm depth of invasion.

Conclusions: Depth of invasion is significantly associated with nodal metastasis and has been added to the 8th AJCC staging guidelines. Variable depths of invasion have been associated with regional metastasis; however, there is likely not a critical depth that predicts neck recurrence due to progressive hazards and cumulative risk of occult metastasis. The risk of regional metastasis is likely much greater than previously believed and increases progressively with increasing depth.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.oraloncology.2018.10.015DOI Listing
December 2018

Risk of plate removal in free flap reconstruction of the mandible.

Oral Oncol 2018 08 15;83:91-95. Epub 2018 Jun 15.

Vanderbilt University Medical Center, Department of Otolaryngology - Head and Neck Surgery, Nashville, TN, United States.

Objectives: To evaluate the factors associated with need for removal of fixation plates in mandibular free flap reconstruction.

Methods: This retrospective cohort analysis reviews patients undergoing mandibular free flap reconstruction at a tertiary care center from 2005 to 2016. Patients requiring removal of fixation plates were identified through electronic medical records. Factors including demographics, adjuvant therapy, surgical site infection (SSI) and fistula rates were compared. Removal rates based on flap type were determined.

Results: Between 2004 and 2016, 307 patients underwent osteocutaneous mandibular free flap reconstruction. 83 required removal of their fixation plates (27%). Age, tobacco use, and BMI were similar between patients requiring removal versus not requiring removal. Primary indications for removal were plate exposure (n = 41), and/or chronic drainage (n = 31), infection (n = 25), and pain (n = 17). Patients undergoing removal were significantly more likely to have had adjuvant radiation therapy (OR 2.09, CI 1.82-3.81), surgical site infection (OR 13.9, CI 5.15-43.2), and post-operative fistula (OR 13.0, 6.85-24.8). 35% of all fibula flaps (n = 52), 21% of osteocutaneous radial forearm (n = 21), and 11% of osteocutaneous scapular flaps (n = 6) required removal. 90% of patients (n = 75) had resolution of their symptoms following hardware removal.

Conclusion: Surgical site infection and fistula are strongly associated with the need for plate removal. Fibular free flaps carry the highest rate of plate removal. Plate removal leads to resolution of plate-associated symptoms in a majority of cases.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.oraloncology.2018.06.008DOI Listing
August 2018

Educational Exposure to Transgender Patient Care in Otolaryngology Training.

J Craniofac Surg 2018 Jul;29(5):1252-1257

Department of Otolaryngology - Head and Neck Surgery, University of Washington School of Medicine, Seattle, WA.

Objective: Gender dysphoria is estimated to occur in over 1 million people in the United States. With decreasing stigma regarding the transgender population, it is likely more patients will seek medical and surgical gender transition as parts of their treatment. However, otolaryngologists may lack training in gender-confirming surgery. This study aims to determine the current state of transgender-related education in the United States otolaryngology training programs and to evaluate trainee perceptions regarding the importance of such training.

Methods: A cross-sectional survey was performed among the United States otolaryngology training programs. A representative sample of 22 training programs divided within 4 US Census regions completed a cross-sectional 9-question survey between March and May 2017. Respondents were queried regarding demographics, transgender curricular exposure (didactic and/or clinical), and perceived importance of training in transgender patient care.

Results: A total of 285 trainees responded (69.3% response rate). Thirty percent of respondents reported education on or direct exposure to transgender care during residency. Among those with experiences in gender-confirming surgery, more than half were exposed to facial (masculinization or feminization) or pitch alteration surgery. Overall, the majority of respondents believed training in gender-confirming surgery is somewhat important and 63.2% supported incorporation of transgender patient care in existing subspecialty fellowship training.

Conclusion: Less than one-third of otolaryngology trainees are exposed to transgender patient care. The majority of trainees endorsed the importance of residency and subspecialty fellowship training in gender-confirming surgery. To better serve the transgender population, formal didactics on gender-confirming surgery should be offered.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/SCS.0000000000004609DOI Listing
July 2018

Progression of Unilateral Hearing Loss in Children With and Without Ipsilateral Cochlear Nerve Canal Stenosis: A Hazard Analysis.

Otol Neurotol 2017 07;38(6):e138-e144

*Department of Otolaryngology †Division of Pediatric Otolaryngology, Seattle Children's Hospital ‡Department of Biostatistics §Department of Radiology, University of Washington, Seattle, Washington.

Objective: To investigate the risk of hearing loss progression in each ear among children with unilateral hearing loss associated with ipsilateral bony cochlear nerve canal (BCNC) stenosis.

Setting: Tertiary pediatric referral center.

Patients: Children diagnosed with unilateral hearing loss who had undergone temporal bone computed tomography imaging and had at least 6 months of follow-up audiometric testing were identified from a prospective audiological database.

Interventions: Two pediatric radiologists blinded to affected ear evaluated imaging for temporal bone anomalies and measured bony cochlear canal width independently. All available audiograms were reviewed, and air conduction thresholds were documented.

Main Outcome Measure: Progression of hearing loss was defined by a 10 dB increase in air conduction pure-tone average.

Results: One hundred twenty eight children met inclusion criteria. Of these, 54 (42%) had a temporal bone anomaly, and 22 (17%) had ipsilateral BCNC stenosis. At 12 months, rates of progression in the ipsilateral ear were as follows: 12% among those without a temporal bone anomaly, 13% among those with a temporal bone anomaly, and 17% among those with BCNC stenosis. Children with BCNC stenosis had a significantly greater risk of progression in their ipsilateral ear compared with children with no stenosis: hazard ratio (HR) 2.17, 95% confidence interval (CI) (1.01, 4.66), p value 0.046. When we compared children with BCNC stenosis to those with normal temporal bone imaging, we found that the children with stenosis had nearly two times greater risk estimate for progression, but this difference did not reach significance, HR 1.9, CI (0.8, 4.3), p = 0.1. No children with BCNC stenosis developed hearing loss in their contralateral year by 12 months of follow-up.

Conclusion: Children with bony cochlear nerve canal stenosis may be at increased risk for progression in their ipsilateral ear. Audiometric and medical follow-up for these children should be considered.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/MAO.0000000000001452DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5639713PMC
July 2017

Children with unilateral hearing loss may have lower intelligence quotient scores: A meta-analysis.

Laryngoscope 2016 Mar 9;126(3):746-54. Epub 2015 Oct 9.

Department of Otolaryngology, Seattle Children's Hospital, Seattle, Washington, U.S.A.

Objectives/hypothesis: In this meta-analysis, we reviewed observational studies investigating differences in intelligence quotient (IQ) scores of children with unilateral hearing loss compared to children with normal hearing.

Data Sources: PubMed Medline, Cumulative Index to Nursing and Allied Health Literature, Embase, PsycINFO.

Methods: A query identified all English-language studies related to pediatric unilateral hearing loss published between January 1980 and December 2014. Titles, abstracts, and articles were reviewed to identify observational studies reporting IQ scores.

Results: There were 261 unique titles, with 29 articles undergoing full review. Four articles were identified, which included 173 children with unilateral hearing loss and 202 children with normal hearing. Ages ranged from 6 to 18 years. Three studies were conducted in the United States and one in Mexico. All were of high quality. All studies reported full-scale IQ results; three reported verbal IQ results; and two reported performance IQ results. Children with unilateral hearing loss scored 6.3 points lower on full-scale IQ, 95% confidence interval (CI) [-9.1, -3.5], P value < 0.001; and 3.8 points lower on performance IQ, 95% CI [-7.3, -0.2], P value 0.04. When investigating verbal IQ, we detected substantial heterogeneity among studies; exclusion of the outlying study resulted in significant difference in verbal IQ of 4 points, 95% CI [-7.5, -0.4], P value 0.028.

Conclusions: This meta-analysis suggests children with unilateral hearing loss have lower full-scale and performance IQ scores than children with normal hearing. There also may be disparity in verbal IQ scores. Laryngoscope, 126:746-754, 2016.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/lary.25524DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4755927PMC
March 2016

Nasoseptal flap reconstruction of pediatric sellar defects: a radiographic feasibility study and case series.

Otolaryngol Head Neck Surg 2015 Apr 24;152(4):746-51. Epub 2015 Feb 24.

Department of Otolaryngology, University of Washington, Seattle, Washington, USA Division of Pediatric Otolaryngology, Seattle Children's Hospital, Seattle, Washington, USA.

Objectives: In this study, we used computed tomography measurements to investigate the feasibility of nasoseptal flap reconstruction of sellar defects in children, and we reviewed our institutional experience with the procedure.

Study Design: Cross-sectional and case series.

Setting: Pediatric tertiary care facility.

Methods: We obtained 10 normal maxillofacial scans for each year of age from birth to 18. Computer-assisted nasal and skull-base measurements were performed. Patients with incomplete pneumatization were excluded from analysis. Reconstruction was presumed feasible if the ratio of nasoseptal flap length to associated sellar defect length was greater than 1. Chart review identified surgical patients.

Results: Of 190 scans, 125 had complete pneumatization. Of these, 120 (96%) displayed a ratio of nasoseptal flap length to sellar defect length greater than 1, suggesting that reconstruction would be feasible. Mean ratio of flap length to defect length for all subjects was 1.47 (SD 0.33; 95% CI, 1.41-1.53). Only 5 of 125 patients (4%) had a ratio less than 1; the median age for these patients was 15 years, which is older than the median age of 12 years for subjects with a ratio greater than 1 (P = .02). An inverse relationship was identified between age and ratio of flap length to defect length (r = -0.49, P < .001). Case series identified 6 children, ages 5 to 17; flap length was never described as a limitation.

Conclusions: Nasoseptal flap length is not a limiting factor for reconstruction of pediatric sellar defects. When compared with older patients, younger patients tend to have greater nasoseptal flap length relative to sellar defect length.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/0194599815571284DOI Listing
April 2015

First branchial cleft anomalies: otologic manifestations and treatment outcomes.

Otolaryngol Head Neck Surg 2015 Mar 18;152(3):506-12. Epub 2014 Dec 18.

Department of Otolaryngology, University of Washington, Seattle, Washington, USA Division of Pediatric Otolaryngology, Seattle Children's Hospital, Seattle, Washington, USA.

Objective: This study describes the presentation of first branchial cleft anomalies and compares outcomes of first branchial cleft with other branchial cleft anomalies with attention to otologic findings.

Study Design: Case series with chart review.

Setting: Pediatric tertiary care facility.

Methods: Surgical databases were queried to identify children with branchial cleft anomalies. Descriptive analysis defined sample characteristics. Risk estimates were calculated using Fisher's exact test.

Results: Queries identified 126 subjects: 27 (21.4%) had first branchial cleft anomalies, 80 (63.4%) had second, and 19 (15.1%) had third or fourth. Children with first anomalies often presented with otologic complications, including otorrhea (22.2%), otitis media (25.9%), and cholesteatoma (14.8%). Of 80 children with second branchial cleft anomalies, only 3 (3.8%) had otitis. Compared with children with second anomalies, children with first anomalies had a greater risk of requiring primary incision and drainage: 16 (59.3%) vs 2 (2.5%) (relative risk [RR], 3.5; 95% confidence interval [CI], 2.4-5; P<.0001). They were more likely to have persistent disease after primary excision: 7 (25.9%) vs 2 (2.5%) (RR, 3; 95% CI, 1.9-5; P=.0025). They were more likely to undergo additional surgery: 8 (29.6%) vs 3 (11.1%) (RR, 2.9; 95% CI, 1.8-4.7; P=.0025). Of 7 persistent first anomalies, 6 (85.7%) were medial to the facial nerve, and 4 (57.1%) required ear-specific surgery for management.

Conclusions: Children with first branchial cleft anomalies often present with otologic complaints. They are at increased risk of persistent disease, particularly if anomalies lie medial to the facial nerve. They may require ear-specific surgery such as tympanoplasty.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/0194599814562773DOI Listing
March 2015
-->