Juvenile nasopharyngeal angiofibroma: National practice patterns and resource utilization via HCUP KID

BACKGROUND

Juvenile nasopharyngeal angiofibroma (JNA) is a locally aggressive benign vascular tumor that typically afflicts young adolescent males. Historically removed via open approaches, these tumors are now being removed endoscopically. As the modern healthcare setting emphasizes value, efficient utilization of resources may lead to decreased cost while maintaining or improving patient outcomes.

OBJECTIVE

The objective of this study was to investigate how perioperative management of juvenile nasopharyngeal angiofibromas (JNAs) influence overall cost. We specifically investigate the effect of approach type (open, endoscopic, or combined) with regards to cost and length of stay. We also delineated practice patterns, analyzed safety profiles, and characterize clinical outcomes.

METHODS

The 2016 Healthcare Cost and Utilization Project Kids' Inpatient Database (HCUP-KID) was queried to identify males aged <21 years with an ICD-10-CM diagnosis code of D10.6 (benign neoplasm of nasopharynx) and ICD-10-PCS codes to determine whether an open, endoscopic or combined approach was performed. Univariate statistical analysis and multivariable logistic regression were performed to examine the effects of demographics, patient characteristics, procedure type, and complications on length of stay (LOS) and cost.

RESULTS

A total of 89 male patients were analyzed with a mean age of 14.8 years (range 8-20 years). Mean LOS was 3.4 days. Mean total charges were $128,780. Comparing open (n = 16), endoscopic (n = 65), and combined (n = 8) approaches, there was a significant difference in the need for fresh frozen plasma (p = 0.02) and packed red blood cell (pRBC) (p = 0.03) transfusion but no difference in preoperative embolization (p > 0.05) between approach types. LOS was associated with age (p = 0.02), pRBC transfusion (p = 0.04) and septal deviation (p = 0.03). Charges varied with LOS (p < 0.001) on linear regression analysis but not with other variables in this dataset.

CONCLUSION

Approach type for JNA appears to be unrelated to LOS or charges in this multi-site, population-based analysis. However, septal deviation, pRBC transfusion, and young age are associated with increased LOS in patients undergoing JNA resection.

Color Change of Intranasal Fluorescein Cannot Detect Cerebrospinal Fluid Leaks

BACKGROUND

The color change of topical intranasal fluorescein has been used to confirm the presence of cerebrospinal fluid (CSF) during endoscopic endonasal surgery. We aimed to validate the use of topical intranasal fluorescein for CSF detection.

METHODS

Blood, CSF, saliva, and normal saline were combined with decreasing fluorescein concentrations (from 10% to 0.1%). The solutions were photographed in high definition on nasal pledgets and in 1.5-mL Eppendorf tubes. The color difference (ΔE) was objectively measured via the International Commission on Illumination coordinates. Four otolaryngologists who were unaware of the study parameters also evaluated the samples for perceptible color differences. The human eye cannot detect color differences at an International Commission on Illumination ΔE of <5.

RESULTS

All otolaryngologists agreed a color difference could be seen with blood across all fluorescein concentrations. However, a perceptible color difference between the experimental samples that excluded blood was not appreciable. Objectively, the ΔE was <5 on average for all nonblood samples when mixed with 5% and 10% fluorescein in the Eppendorf experiment. The ΔE for the nonblood samples was >5 for the remaining tested. Similarly, the average ΔE for the nonblood samples in the pledget experiment was >5 across all fluorescein concentrations. The blood ΔE was consistently >50 throughout all fluorescein concentrations in the Eppendorf experiment and >20 throughout the pledget experiment, correlating with the subjective ease of discernment between blood and the control sample in both groups.

CONCLUSIONS

Color change alone is not sufficient to determine a difference between CSF, saliva, and saline. Blood, however, is readily identified using this method. Adjunct characteristics, in addition to the color change, are necessary to properly identify an active CSF leak.

Thyroid Dysfunction in Ménière's Disease: A Comprehensive Review

INTRODUCTION

The precise etiology of Ménière's disease (MD) remains unknown; however, given the association of MD with serum antibodies and human leukocyte antigen (HLA) complex, several studies have proposed a relationship between MD and thyroid disorders. Similarly, multiple hypotheses exist regarding the metabolic disturbances of fluctuating thyroid hormone as a potential contributing agent in the development of MD.

METHODS

A total of 171 abstracts were identified and screened by 2 independent reviewers. Based on inclusion and exclusion criteria, 8 studies were selected for final analysis. Due to heterogeneity of clinical data, meta-analysis was not feasible.

RESULTS

The prevalence of autoimmune thyroid disease and hypothyroidism in MD varied significantly from 1 to 38%. Notable bias was introduced given the lack of standardization of diagnostic criteria across studies. Articles that described autoimmune thyroid-specific antibodies and HLA types also presented inconclusive results. Multiple studies noted a potential etiologic role of hypothyroidism in MD, which was often confounded by thyroxine supplementation.

CONCLUSIONS

Despite a potential correlation in the medical literature between thyroid disorders and MD, there is currently no definitive causal relationship. Although most of the present medical literature focuses on autoimmunity, dysregulated thyroid hormone levels may also be implicated in the association of MD with thyroid disorders.

Complications in Pediatric Acute Mastoiditis: HCUP KID Analysis

OBJECTIVE

A small proportion of children with otitis media develop acute mastoiditis, which has the potential to spread intracranially and result in significant morbidity and mortality. The aim of this study was to evaluate the incidence and management of complications related to pediatric acute mastoiditis using a national database.

STUDY DESIGN

Retrospective review of 2016 Kids' Inpatient Database, part of the Healthcare Cost and Utilization Project.

SETTING

Academic, community, general, and pediatric specialty hospitals in the United States.

METHODS

International Classification of Diseases, Tenth Revision, Clinical Modification code H70.XXX was used to retrieve records for children admitted with a diagnosis of mastoiditis. Data included patient demographics, intracranial infections, procedures (middle ear drainage, mastoidectomy, and intracranial drainage), length of stay (LOS), and total charges.

RESULTS

In total, 2061 children aged ≤21 years were identified with a diagnosis of acute mastoiditis. Complications included subperiosteal abscess (6.90%), intracranial thrombophlebitis/thrombosis (5.30%), intracranial abscess (3.90%), otitic hydrocephalus (1.20%), encephalitis (0.90%), subperiosteal abscess with intracranial complication (0.60%), petrositis (0.60%), and meningitis (0.30%). Children with intracranial abscesses were more likely (P < .001) to undergo myringotomy ± ventilation tube insertion (63.7%), mastoidectomy (53.8%), mastoidectomy with ventilation tube or myringotomy (42.5%), intracranial drainage procedure (36.3%), or all 3 key procedures (15.0%). Children with any type of intracranial complication had a significantly longer LOS (P < .001) and higher total charges (P < .001). Both a diagnosis of bacterial meningitis and undergoing an intracranial drainage procedure (P < .001) contributed significantly to LOS and total charges.

CONCLUSION

Patients with intracranial complications are more likely to undergo surgical procedures; however, there is still wide variability in practice patterns, illustrating that controversies in the management of otitis media complications persist.

Middle Ear Viral Load Considerations in the COVID-19 Era: A Systematic Review

OBJECTIVE

To systematically review the available medical literature to investigate the viral load in the middle ear and mastoid cavity and the potential risk of exposure to airborne viruses during otologic surgery.

DATA SOURCES

PubMed, MEDLINE, and Cochrane databases.

STUDY SELECTION

This review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Protocol.

DATA EXTRACTION

Using the Boolean method and relevant search term combinations for terms "mastoid," "middle ear," "virus," "exposure" "COVID-19" "SARS-CoV-2." PubMed, MEDLINE, and Cochrane databases were queried. A total of 57 abstracts were identified and screened by two independent reviewers. Following inclusion and exclusion criteria, 18 studies were selected for the final analysis.

DATA SYNTHESIS

Due to the heterogeneity of clinical data, a meta-analysis was not feasible.

RESULTS

Rhinovirus, followed by respiratory syncytial virus are reported to be the most prevalent viruses in MEF samples but formal statistical analysis is precluded by the heterogeneity of the studies. Drilling was identified to have the highest risk for aerosol generation and therefore viral exposure during otologic Surgery.

CONCLUSIONS

The medical literature has consistently demonstrated the presence of nucleic acids of respiratory viruses involving the middle ear, including SARS-CoV2 in a recent postmortem study. Although no in vivo studies have been conducted, due to the likely risk of transmission, middle ear and mastoid procedures, particularly involving the use of a drill should be deferred, if possible, during the pandemic and enhanced personal protective equipment (PPE) used if surgery is necessary.

30-Day Postoperative Outcomes Following Transcervical Zenker's Diverticulectomy in the Elderly: Analysis of the NSQIP Database

OBJECTIVE

To compare the effect of patient factors, including age, on 30-day postoperative outcomes and complications for patients undergoing transcervical Zenker's diverticulectomy.

STUDY DESIGN

Retrospective cross-sectional analysis.

SETTING

American College of Surgeons National Surgical Quality Improvement Program (NSQIP) Database.

METHODS

Patients who underwent open Zenker's diverticulectomy (Current Procedural Terminology code 43130) were queried via the NSQIP (2006-2018). Outcomes analyzed include patient demographics, medical comorbidities, admission type, operative characteristics, length of admission, postoperative complication, readmission, and reoperation.

RESULTS

A total of 614 patients were identified. Mean age at time of surgery was 71.1 years, with 13.4% older than 85 years. Outpatient procedures were performed in 29.8%. Postoperative complications occurred in 6.7%, with reoperation and readmission rates of 6.4% and 7.2%, respectively. A mortality rate of 0.3% was observed. Only smoking status (odds ratio, 2.94; P = .008) and history of congestive heart failure (odds ratio, 10.00; P = .014) were shown to have a significant effect on postoperative complications.

CONCLUSION

Smoking status confers a high risk for postoperative complication. Age was not an independent risk factor associated with adverse outcomes following open diverticulectomy, suggesting this procedure can be safely performed in patients with advanced age.

Relationship Between Parental Intolerance of Uncertainty and Decisional Conflict in Pediatric Otolaryngologic Surgery

OBJECTIVE

To assess the relationship between depression, anxiety, stress, worry, intolerance of uncertainty (IU), and shared decision making (SDM) in parents of pediatric otolaryngology surgical patients with their perceptions of decisional conflict (DC).

STUDY DESIGN

Cross-sectional.

SETTING

Academic pediatric otolaryngology outpatient clinic.

METHODS

Participants were legal guardians of pediatric patients who met criteria for otolaryngologic surgery. Participants completed a demographic survey as well as validated Decisional Conflict Scale (DCS); Shared Decision-Making Scale (SDMS); Depression, Anxiety and Stress Scale-21 (DASS-21); Penn State Worry Questionnaire (PSWQ); and short form of the Intolerance of Uncertainty Scale (IUS-12).

RESULTS

A total of 114 participants were enrolled. Respondents were predominantly female (93.0%) and married (60.5%). Most guardians had not consented previously for otolaryngologic surgery for their child (69.3%). Participants reported low levels of DC and depression as well as moderate levels of anxiety and stress. DC scores were not significantly correlated to DASS-21, PSWQ, or SDM. IUS-12 Total and subscale IUS-12 prospective negatively correlated with Total DC. DC was not related to age, sex, education level, previous otolaryngologic surgery, or type of surgery recommended.

CONCLUSION

In this group, an association was found between IU and DC. Clinicians should be aware that DC is not modified by previous surgical experience. Interventions aimed at addressing parental IU related to surgery may reduce DC. Further research efforts could help us understand how mental health relates to surgical decision making.

Optimal Timing of Palatoplasty in Infants With Comorbidities

Objective:

Ideal timing of palatoplasty continues to be debated given that early repair is thought to improve speech and hearing, whereas delayed repair is associated with less midface growth disruption. The purpose of this study is to elucidate optimal timing of palatoplasty in patients with comorbidities to mitigate perioperative complications.

Design:

Retrospective cohort study.

Setting:

Hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program Pediatric.

Patients:

Palatoplasty performed for children younger than the age of 2 years with comorbidities.

Outcomes:

Medical/surgical complications, reoperations, readmissions within 30 days postoperatively.

Results:

Patients with comorbidities having Veau I or II cleft palate were associated with significantly decreased risk of adverse events when performing palatoplasty after 125 days of age ( P < .001). Patients with comorbidities having Veau III cleft palate were associated with significantly decreased risk of adverse events when performing palatoplasty after 225 days of age ( P = .010). Patients with comorbidities having Veau IV cleft palate were associated with significantly decreased risk of adverse events when performing palatoplasty after 250 days of age ( P = .045).

Conclusions:

Infants with comorbidities having progressively increasing Veau classification demonstrate unique age-dependent perioperative thresholds, such that more extensive phenotypes are associated with better perioperative outcomes with older age at time of cleft palate repair.

Transoral floor of mouth lipoma resection: A technical multimedia analysis

Lipomas are common benign mesenchymal tumors that originate from mature adipocytes throughout the body, with 13-20% occurring in the head and neck region, however only 1-4.4% affect the oral cavity, where they are found predominately in the cheek, followed by the tongue, lips, palatal mucosa, gingiva, and floor of the mouth. Herein, we present a multimedia analysis of transoral floor of mouth lipoma resection in a 58-year-old female. Learning points include (1) Identification and stenting of Wharton's ducts in order to facilitate their functional preservation and to minimize risk of postoperative sialocele; (2) postoperative observation with airway monitoring due to expected floor of mouth edema; (3) utilization of a midline incision to minimize injury to Wharton's ducts and maximize bilateral access to the floor of mouth.

Postoperative Outcomes of Branchial Cleft Cyst Excision in Children and Adults: An NSQIP Analysis

OBJECTIVE

Identify risk factors and perioperative morbidity for patients undergoing branchial cleft cyst (BCC) excision.

STUDY DESIGN

Cross-sectional analysis.

SETTING

American College of Surgeons National Surgical Quality Improvement Program adult and pediatric databases (NSQIP and NSQIP-P).

SUBJECT AND METHODS

Patients who underwent BCC excision (Current Procedural Terminology 42810, 42815) were queried via NSQIP (2005-2016) and NSQIP-P (2012-2016). Outcomes analyzed include patient demographics, medical comorbidities, admission type, operative characteristics, length of hospital stay, postoperative complications, and readmission.

RESULTS

A total of 1775 children and 677 adults were identified. Mean age at time of surgery was 4.6 years for children and 38.6 years for adults. Outpatient procedures were performed in 87.1% of adults and 94.0% of children (P < .001). Postoperative complications were uncommon, occurring in <1% of adults and 3.9% of children (P < .001). Similarly, readmission occurred in 1.2% of adults and 1.1% of children. In adults, smoking status was shown to have a significant effect on postoperative complications (odds ratio, 6.25; P = .037). Age group did not have an effect on the complication rate in the pediatric population. Pediatric otolaryngologists had higher rates of postoperative complications (P = .001), prolonged operative times (P < .001), and fewer outpatient procedures (P < .001). Conversely, in adults, otolaryngologists had fewer postoperative complications.

CONCLUSION

Postoperative complications following BCC excision are relatively uncommon, demonstrating procedural safety when performed at any age.

Surgical Intervention for Laryngomalacia: Age-Related Differences in Postoperative Sequelae

OBJECTIVE

Identify risk factors and determine perioperative morbidity of children undergoing surgery for laryngomalacia (LM).

METHODS

A retrospective analysis of the multi-institutional American College of Surgeons National Surgical Quality Improvement Program-Pediatric Database (ACS-NSQIP-P) was performed to abstract patients aged <18 years with LM (ICD-10 code Q31.5) who underwent laryngeal surgery (CPT code 31541) from 2015 to 2017. Analyzed clinical variables include patient demographics, hospital setting, length of stay, medical comorbidities, postoperative complications, readmission, and reoperation.

RESULTS

A total of 491 patients were identified, 283 were male (57.6%) and 208 were female (42.4%). The mean age at time of surgery was 1.07 years (range .01-17 years). Younger patients were more likely to undergo surgery in the inpatient setting compared to their counterparts (P < .001). Infants were more likely to have prolonged duration of days from admission to surgery (P < .001), days from surgery to discharge (P < .001), and total length of stay (P<.0010). Finally, there was no significant difference between age groups with respect to 30-day general surgical complications (P = .189), with an overall low incidence of reintubation (1.2%), readmission (3.1%), and reoperation (1.6%).

CONCLUSION

This analysis supports laryngeal surgery as a safe surgical procedure for LM. However, younger children are more likely to undergo operative intervention in the inpatient setting, endure delays from hospital admission to surgical intervention, and experience a prolonged length of stay due to their overall medical complexity. Recognition of key factors may assist in optimizing perioperative risk assessment and promote timely procedural planning in this unique pediatric patient subpopulation.

Best Practice Recommendations for Pediatric Otolaryngology during the COVID-19 Pandemic

Objective

To review the impact of coronavirus disease 2019 (COVID-19) on pediatric otolaryngology and provide recommendations for the management of children during the COVID-19 pandemic.

Data Sources

Clinical data were derived from peer-reviewed primary literature and published guidelines from national or international medical organizations. Preprint manuscripts and popular media articles provided background information and illustrative examples.

Methods

Included manuscripts were identified via searches using PubMed, MEDLINE, and Google Scholar, while organizational guidelines and popular media articles were identified using Google search queries. Practice guidelines were developed via consensus among all authors based on peer-reviewed manuscripts and national or international health care association guidelines. Strict objective criteria for inclusion were not used due to the rapidly changing environment surrounding the COVID-19 pandemic and a paucity of rigorous empirical evidence.

Conclusions

In the face of the COVID-19 pandemic, medical care must be judiciously allocated to treat the most severe conditions while minimizing the risk of long-term sequelae and ensuring patient, physician, and health care worker safety.

Implications for Practice

The COVID-19 pandemic will have a profound short- and long-term impact on health care worldwide. Although the full repercussions of this disease have yet to be realized, the outlined recommendations will guide otolaryngologists in the treatment of pediatric patients in the face of an unprecedented global health crisis.

Commentary on the management of total laryngectomy patients during the COVID-19 pandemic

The coronavirus disease‐2019 (COVID‐19) pandemic has rapidly spread across the world, placing unprecedented strain on the health care system. Health care resources including hospital beds, ICUs, as well as personal protective equipment are becoming increasingly rationed and scare commodities. In this environment, the laryngectomee (patient having previously undergone a total laryngectomy) continues to represent a unique patient with unique needs. Given their surgically altered airway, they pose a challenge to manage for the otolaryngologist within the current COVID‐19 pandemic. In this brief report, we present special considerations and best practice recommendations in the management of total laryngectomy patients. We also discuss recommendations for laryngectomy patients and minimizing community exposures.

Impact of coronavirus (COVID-19) on otolaryngologic surgery: Brief commentary

Background

The Coronavirus disease—2019 (COVID‐19) pandemic is a global health crisis and otolaryngologists are at increased occupational risk of contracting COVID‐19. There are currently no uniform best‐practice recommendations for otolaryngologic surgery in the setting of COVID‐19.

Methods

We reviewed relevant publications and position statements regarding the management of otolaryngology patients in the setting of COVID‐19. Recommendations regarding clinical practice during the severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS) outbreaks were also reviewed.

Results

Enhanced personal protective equipment (N95 respirator and face shield or powered air‐purifying respirator, disposable cap and gown, gloves) is required for any otolaryngology patient with unknown, suspected, or positive COVID‐19 status. Elective procedures should be postponed indefinitely, and clinical practice should be limited to patients with urgent or emergent needs.

Conclusion

We summarize current best‐practice recommendations for otolaryngologists to ensure safety for themselves, their clinical staff, and their patients.

A Commentary on Safety Precautions for Otologic Surgery during the COVID-19 Pandemic

There are insufficient data regarding the safety of otologic procedures in the setting of the coronavirus disease 2019 (COVID-19) pandemic. Given the proclivity for respiratory pathogens to involve the middle ear and the significant aerosolization associated with many otologic procedures, safety precautions should follow current recommendations for procedures involving the upper airway. Until preoperative diagnostic testing becomes standardized and readily available, elective cases should be deferred and emergent/urgent cases should be treated as high risk for COVID-19 exposure. Necessary otologic procedures on positive, suspected, or unknown COVID-19 status patients should be performed using enhanced personal protective equipment, including an N95 respirator and eye protection or powered air-purifying respirator (PAPR, preferred), disposable cap, disposable gown, and gloves. Powered instrumentation should be avoided unless absolutely necessary, and if performed, PAPR or sealed eye protection is recommended.

Balloon Catheter Dilation in Pediatric Chronic Rhinosinusitis: A Meta-analysis

BACKGROUND

Paranasal sinus balloon catheter dilation (BCD) represents a tool that has been shown to be safe in the management of pediatric chronic rhinosinusitis (pCRS); however, its efficacy compared to standard treatment regimens has not been well established.

OBJECTIVE

The purpose of this meta-analysis was to evaluate the clinical utility of BCD in pCRS.

METHODS

Articles reporting BCD for pCRS in patients under 18 years of age were identified via the following search terms: sinusitis OR rhinosinusitis AND balloon dilatation OR balloon dilation OR balloon sinuplasty OR sinuplasty AND adolescent OR children OR infant OR pediatric OR toddler. The primary outcome analyzed includes quality of life improvement as measured via Sinus and Nasal Quality of Life Survey (SN-5) or Sino-nasal Outcome Test (SNOT-22) scores.

RESULTS

Eighty studies were abstracted; 10 studies were included for final qualitative analysis after dual investigator screening. Three studies described BCD with surgical controls, including adenoidectomy, saline irrigation, or maxillary antrostomy. Noninferiority was not demonstrated (ie, BCD is inferior) in 2 of 3 studies. Pooled analysis utilizing a random effects model revealed a decreased effect size yet no statistically significant difference between BCD and standard operative techniques as measured by quality of life measures (g = -0.04, I² = 41%).

CONCLUSION

This work highlights a lack of published evidence regarding the role of BCD in pCRS. Two of the 3 included studies demonstrated the inferiority of BCD when compared to other standard surgical interventions, whereas meta-analysis was unable to detect any statistically significant difference between standard treatment regimens. Future scientific investigations are necessary to assess the comparative effectiveness of BCD in pCRS.

Lateral cervical abscesses: NSQIP-P perspective on length of stay, readmission, and reoperation

OBJECTIVES

Identify risk factors and determine perioperative sequelae of children undergoing lateral cervical abscess incision and drainage.

METHODS

Pediatric patients who underwent lateral cervical abscess incision and drainage aged 1-18 years were retrospectively queried via ACS-NSQIP-P (2012-2016) utilizing CPT code 21501. Analyzed outcomes include age, time to surgery, operative time, total length of stay, readmission, and reoperation.

RESULTS

A total of 1917 children were identified, with a mean age at time of surgery of 4.05 years (95% CI 3.86-4.25). The mean number of days from hospital admission to operative intervention was 1.24 days (95% CI 1.16-1.31), with a mean total length of stay of 3.64 days (95% CI 3.46-3.82). The mean number of days from hospital admission to surgery was significantly lengthened in younger children (P = .0001) and pediatric patients of non-Caucasian origin (P < 0.001). Children with positive septic parameters not only had a prolonged time to surgery but also a significantly prolonged total length of stay (P < 0.001). Finally, a persistent requirement for postoperative mechanical ventilation and prolonged operative time (P = 0.003) was found to be related to reoperation.

CONCLUSION

Younger children are more likely to have delays from hospital admission to definitive surgical intervention, but this does not appear to affect total length of stay. Recognition of pertinent clinical factors may assist in optimizing perioperative risk assessment and promote timely procedural planning in the pediatric subpopulation.

Effect of Electrocautery Settings on Particulate Concentrations in Surgical Plume during Tonsillectomy

OBJECTIVES

To describe the effect of monopolar electrocautery (EC) settings on surgical plume particulate concentration during pediatric tonsillectomy.

STUDY DESIGN

Cross-sectional study.

SETTING

Tertiary medical center.

SUBJECTS AND METHODS

During total tonsillectomy exclusively performed with EC, air was sampled with a surgeon-worn portable particle counter. The airborne mean and maximum particle concentrations were compared for tonsillectomy performed with EC at 12 W vs 20 W, with smoke evacuation system (SES) and no smoke evacuation (NS).

RESULTS

A total of 36 children were included in this analysis: 9 cases with EC at 12 W and SES (12SES), 9 cases with EC at 20 W and SES (20SES), 9 cases with EC at 12 W without SES (12NS), and 9 cases with EC at 20 W without SES (20NS). Mean particle number concentration in the breathing zone during tonsillectomy was 1661 particles/cm³ for 12SES, 5515 particles/cm³ for 20SES, 8208 particles/cm³ for 12NS, and 78,506 particles/cm³ for 20NS. There was a statistically significant difference in the particle number concentrations among the 4 groups. The correlation between the particle number concentration and EC time was either moderate (for 12SES) or negative (for remaining groups).

CONCLUSION

Airborne particle concentrations during tonsillectomy are over 9.5 times higher when EC is set at 20 W vs 12 W with NS, which is mitigated to 3.3 times with SES. Applying lower EC settings with SES during pediatric tonsillectomy significantly reduces surgical plume exposure for patients, surgeons, and operating room personnel, which is a well-known occupational health hazard.

Using a 4K-3D Exoscope for Upper Airway Stimulation Surgery: Proof-of-Concept

OBJECTIVE

Demonstrate the potential of the 4K-3D exoscope during upper airway stimulation surgery (UAS).

METHODS

A proof-of-concept study was performed to evaluate the feasibility of the exoscope during three consecutive UAS.

RESULTS

The exoscope was employed during UAS including cuff electrode and sensing lead placement. Three cases were successfully completed without adverse perioperative event; mean operative time was 200 minutes (range 188-218 minutes) with a successive reduction in operative time.

CONCLUSION

This experience demonstrates the potential viability of the exoscope for UAS; it is a safe, innovative, and effective alternative or adjunct to existing visualization modalities. Notable advantages include improved ergonomics, unobstructed surgical field access, wide depth of field visualization, and short learning curve. Future technological enhancements could allow the exoscope to become a promising next-generation tool in the armamentarium of the contemporary sleep surgeon.

Economic implications of localization strategies for cerebrospinal fluid rhinorrhea

BACKGROUND

The direct costs associated with different diagnostic algorithms to localize cerebrospinal fluid (CSF) rhinorrhea have not been described.

METHODS

A decision-tree analysis of imaging modalities used to localize CSF rhinorrhea was performed to compare associated direct costs. The primary outcome was cost, which was determined based on reimbursement data published by the Centers for Medicare and Medicaid Services in 2018. The model was parameterized after a literature review of published studies was performed from 1990 to 2018 to estimate the sensitivity CSF rhinorrhea localization of the following radiographic modalities: high-resolution computed tomography (HRCT), magnetic resonance cisternography (MRC), and CT cisternography (CTC). In addition to base case analysis, 1-way sensitivity analyses were also performed to evaluate the robustness of results to changes in model parameters.

RESULTS

Among patients with a high suspicion for CSF rhinorrhea, use of HRCT followed by exploration in the operating room if preliminary HRCT was negative was found to be the optimal localization modality from a cost perspective ($172.25). The next least costly algorithm was HRCT followed by MRC ($294.10). Imaging algorithms beginning with CTC were the next least costly modality ($727.37). Sensitivity analyses generally supported HRCT to be the optimal initial radiographic strategy over a wide range of parameter values.

CONCLUSION

This work advocates HRCT as first-line modality to localize CSF rhinorrhea from a cost perspective. Although algorithms beginning with MRC were on average $35 more expensive than those starting with CTC, associated risks of CTC were not modeled and may play a role in decision making.

Pediatric Thyroidectomy: NSQIP-P Analysis of Adverse Perioperative Outcomes

Background:

This study identifies risk factors and 30-day adverse outcomes of pediatric patients undergoing thyroidectomy.

Methods:

Retrospective analysis utilizing the American College of Surgeons National Surgical Quality Improvement–Pediatric Database (2015-2016). Study population includes pediatric patients (≤18 years) who underwent hemithyroidectomy (HT), total thyroidectomy (TT), and total thyroidectomy with central neck dissection (TT+ND).

Results:

A total of 720 cases were identified; mean age at time of surgery was 14.1 years, with a female-to-male ratio of 3.4:1. Following hospital discharge, there were 10 related readmissions, with 1 patient requiring reoperation for neck hematoma evacuation. Regression analysis revealed anesthesia time had a significant impact on total length of stay ( P = .0020).

Conclusion:

Contemporary pediatric thyroidectomy has a low incidence of 30-day general surgical postoperative complications. Future research efforts are necessary once thyroidectomy specific variables are incorporated into ACS-NSQIP-P, which will provide further insights into managing this unique patient population.