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Edwards MA, Brennan E, Rutt AL, Muraleedharan D, Casler JD, Spaulding A, Colibaseanu D. Venous Thromboembolism Prophylaxis in Otolaryngologic Patients Using Caprini Assessment. Laryngoscope 2024; 134:1169-1182. [PMID: 37740910 DOI: 10.1002/lary.31041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Revised: 08/13/2023] [Accepted: 08/28/2023] [Indexed: 09/25/2023]
Abstract
OBJECTIVE The aim was to determine the utilization of Caprini guideline-indicated venous thromboembolism (VTE) prophylaxis and impact on VTE and bleeding outcomes in otolaryngology (ORL) surgery patients. METHODS Elective ORL surgeries performed between 2016 and 2021 were retrospectively identified. Logistic regression models were used to examine the association between patient characteristics and receiving appropriate prophylaxis, inpatient, 30- and 90-day VTE and bleeding events. RESULTS A total of 4955 elective ORL surgeries were analyzed. Thirty percent of the inpatient cohort and 2% of the discharged cohort received appropriate risk-stratified VTE prophylaxis. In those who did not receive appropriate prophylaxis, overall inpatient VTE was 3.5-fold higher (0.73% vs. 0.20%, p = 0.015), and all PE occurred in this cohort (0.47% vs. 0.00%, p = 0.005). All 30- and 90-day discharged VTE events occurred in those not receiving appropriate prophylaxis. Inpatient, 30- and 90-day discharged bleeding rates were 2.10%, 0.13%, and 0.33%, respectively. Although inpatient bleeding was significantly higher in those receiving appropriate prophylaxis, all 30- and 90-day post-discharge bleeding events occurred in patients not receiving appropriate prophylaxis. On regression analysis, Caprini score was significantly positively associated with likelihood of receiving appropriate inpatient prophylaxis (odds ratio [OR] 1.05, confidence interval [CI] 1.03-1.07) but was negatively associated in the discharge cohort (OR 0.43, CI 0.36-0.51). Receipt of appropriate prophylaxis was associated with reduced odds of inpatient VTE (OR 0.24, CI 0.06-0.69), but not with risk of bleeding. CONCLUSION Although Caprini VTE risk-stratified prophylaxis has a positive impact in reducing inpatient and post-discharge VTE, it must be balanced against the risk of inpatient postoperative bleeding. LEVEL OF EVIDENCE 3 Laryngoscope, 134:1169-1182, 2024.
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Affiliation(s)
- Michael A Edwards
- Advanced GI and Bariatric Surgery Division, Department of Surgery, Mayo Clinic, Jacksonville, Florida, U.S.A
| | - Emily Brennan
- Division of Health Care Delivery Research, Mayo Clinic, Robert D. and Patricia E. Kern Center, Jacksonville, Florida, U.S.A
| | - Amy L Rutt
- Mayo Clinic, Department of Otolaryngology/Head and Neck Surgery, Jacksonville, Florida, U.S.A
| | - Divya Muraleedharan
- Advanced GI and Bariatric Surgery Division, Department of Surgery, Mayo Clinic, Jacksonville, Florida, U.S.A
| | - John D Casler
- Mayo Clinic, Department of Otolaryngology/Head and Neck Surgery, Jacksonville, Florida, U.S.A
| | - Aaron Spaulding
- Division of Health Care Delivery Research, Mayo Clinic, Robert D. and Patricia E. Kern Center, Jacksonville, Florida, U.S.A
| | - Dorin Colibaseanu
- Colon and Rectal Surgery Division, Mayo Clinic, Jacksonville, Florida, U.S.A
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Sun H, Xue S, Huang Y, Zhao Y, Tian X, Gao Z, Feng G. Stratifying the risks of venous thromboembolism in the lateral skull base surgery using Caprini risk assessment model. Eur Arch Otorhinolaryngol 2023; 280:3219-3228. [PMID: 37184665 DOI: 10.1007/s00405-023-07984-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 11/14/2022] [Indexed: 05/16/2023]
Abstract
PURPOSE To analyze and stratify the possible risk factors of venous thromboembolism (VTE) in lateral skull base surgery (LSBS) using the Caprini risk assessment model. METHODS In a single center, a retrospective study was conducted with patients who underwent LSBS from June 2016 to August 2021. The clinical characteristics and blood chemistry tests were collected. The incidence of VTE within 30 days of surgery was recorded. The Caprini risk score was calculated to assess the postoperative VTE risk. RESULTS Among the 123 patients in this study, the VTE incidence within 30 postoperative days was 8.9%. The total Caprini risk score in VTE patients (5.6 ± 1.9 points) was significantly higher than that of non-VTE patients (4.6 ± 1.4 points; p = 0.028). The binary logistic regression showed the total Caprini score as the only independent indicator of postoperative VTE. The receiver operating characteristic curve analysis showed that the Caprini score at 6.5 points had low sensitivity (36.4%) but high specificity (91.1%), with the largest area under the curve being 0.659. The VTE rate was significantly higher in patients with a total Caprini score ≥ 7 points (28.6%) compared to those with a total Caprini score ≤ 6 points (7.3%; p = 0.022). CONCLUSION LSBS patients have a high risk of developing postoperative VTE. Patients with a Caprini score ≥ 7 points had a significantly higher risk of developing VTE after LSBS. The Caprini risk system was useful in assessing the VTE risk in LSBS. However, more data, calibration, and validation are necessary to establish an exclusive Caprini risk system for LSBS.
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Affiliation(s)
- Huiying Sun
- Department of Otorhinolaryngology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan, Wangfujing, DongCheng District, Beijing, 100730, China
| | - Songbo Xue
- Department of Otorhinolaryngology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan, Wangfujing, DongCheng District, Beijing, 100730, China
| | - Yu Huang
- Department of Otorhinolaryngology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan, Wangfujing, DongCheng District, Beijing, 100730, China
| | - Yang Zhao
- Department of Otorhinolaryngology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan, Wangfujing, DongCheng District, Beijing, 100730, China
| | - Xu Tian
- Department of Otorhinolaryngology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan, Wangfujing, DongCheng District, Beijing, 100730, China
| | - Zhiqiang Gao
- Department of Otorhinolaryngology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan, Wangfujing, DongCheng District, Beijing, 100730, China
| | - Guodong Feng
- Department of Otorhinolaryngology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan, Wangfujing, DongCheng District, Beijing, 100730, China.
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Chang MT, Jitaroon K, Song S, Roozdar P, Wangworat Y, Ibrahim N, Ma Y, Rao VK, Chang SD, Fernandez-Miranda JC, Patel ZM, Dodd RL, Hwang PH, Harsh GR, Nayak JV. Venous thromboembolism rates and risk factors following endoscopic skull base surgery. Int Forum Allergy Rhinol 2021; 12:935-941. [PMID: 34894093 DOI: 10.1002/alr.22943] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 11/05/2021] [Accepted: 12/08/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND Venous thromboembolism (VTE) is a potentially fatal perioperative complication. The objective of this study was to assess the rate and risk factors for VTE in endoscopic skull base surgery (ESBS). METHODS This was a retrospective review of adults undergoing ESBS at a tertiary academic center. Incidence of VTE in the 30-day postoperative period was recorded. Logistic regression analyses identified factors associated with VTE. RESULTS 1122 ESBS cases between 2009 and 2019 were studied. Almost no cases (96.1%) employed perioperative VTE chemoprophylaxis. The overall incidence of VTE was 2.3% (26/1122). Malignant pathologies had a higher rate of VTE compared to nonmalignant pathologies (4.5% vs 2.0%, OR 2.85, 95%CI 1.22-6.66). Factors associated with an increased risk of VTE included a Caprini score greater than 5 (OR 1.53, 95% CI 1.28-1.83); multiple preoperative endocrinopathies such as the syndrome of inappropriate antidiuretic hormone secretion (SIADH) (OR 22.48, 95% CI 3.93-128.70), adrenal insufficiency (OR 5.24, 95% CI 1.82-15.03), hypercortisolism (OR 4.46, 95% CI 1.47-13.56), and hypothyroidism (OR 3.69, 95% CI 1.66-8.20), each 10-hour increment of lumbar drain duration (OR 1.16, 95%CI 1.08-1.25), and each 10-hour increment for duration of hospitalization (OR 1.05, 95% CI 1.03-1.06). CONCLUSIONS The incidence of VTE following ESBS is relatively low. Factors with a higher association with VTE include malignancy, preoperative endocrinopathies, higher Caprini score, prolonged lumbar drain duration, and prolonged hospitalization. Further study is needed to validate these findings and to refine clinical decision making around perioperative VTE prophylaxis. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Michael T Chang
- Division of Rhinology/Endoscopic Skull Base Surgery, Department of Otolaryngology - Head & Neck Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Kawinyarat Jitaroon
- Department of Otolaryngology, Navamindradhiraj University, Bangkok, Thailand
| | - Sunhee Song
- Department of Otolaryngology-Head & Neck Surgery, Daegu Veterans Hospital, Daegu, Republic of Korea
| | - Pooya Roozdar
- Division of Rhinology/Endoscopic Skull Base Surgery, Department of Otolaryngology - Head & Neck Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Yossawee Wangworat
- Department of Otolaryngology, Thammasat University, Pathumthani, Thailand
| | - Nour Ibrahim
- Department of Otolaryngology-Head and Neck Surgery, Galilee Medical Center, affiliated with Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
| | - Yifei Ma
- Division of Rhinology/Endoscopic Skull Base Surgery, Department of Otolaryngology - Head & Neck Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Vidya K Rao
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Steven D Chang
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | | | - Zara M Patel
- Division of Rhinology/Endoscopic Skull Base Surgery, Department of Otolaryngology - Head & Neck Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Robert L Dodd
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Peter H Hwang
- Division of Rhinology/Endoscopic Skull Base Surgery, Department of Otolaryngology - Head & Neck Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Griffith R Harsh
- Department of Neurosurgery, University of California-Davis, School of Medicine, Sacramento, CA, USA
| | - Jayakar V Nayak
- Division of Rhinology/Endoscopic Skull Base Surgery, Department of Otolaryngology - Head & Neck Surgery, Stanford University School of Medicine, Stanford, CA, USA.,Division of Otolaryngology - Head & Neck Surgery, Palo Alto VA Health Care System (PAVAHCS), Palo Alto, CA, USA
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Anderson BP, Sioshansi PC, Conway RM, Minutello K, Bojrab DI, Hong RS, Sargent EW, Schutt CA, Bojrab DI, Zappia JJ, Babu SC. Rate of Development of Venous Thromboembolism in Lateral Skull Base Surgery. Laryngoscope 2021; 132:662-667. [PMID: 34633085 DOI: 10.1002/lary.29889] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 09/10/2021] [Accepted: 09/21/2021] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Venous thromboembolism (VTE) is a major cause of morbidity and mortality for surgical patients. This article aims to determine factors that may have contributed to the development of VTE in patients undergoing lateral skull base surgery, to assess the validity of the Caprini Risk Assessment Model (RAM) score in this subset of patients, and to determine the efficacy of mechanical DVT prophylaxis alone in preventing VTE. STUDY DESIGN Retrospective chart review. METHODS A retrospective chart review was conducted of patients who underwent skull base surgery for vestibular schwannoma, and the rate of VTE was assessed. Patient demographics, comorbidities, and treatment factors were examined to determine risk factors associated with the development of a postoperative thrombotic event. Caprini RAM scores were compared for patients who developed a VTE. RESULTS Among 197 patients, the rate of VTE formation was 3.5%. No individual risk factor independently contributed to the development of a thrombotic event. The mean Caprini RAM score was 4.06 in patients who did not develop a VTE and 5.14 in the patients that did develop a VTE (P = .005). The Caprini score was significant for the risk of VTE formation, with an odds ratio of 2.8 (P = .009, 95% CI = 1.3-6.2). CONCLUSION Venous thromboembolism rates are relatively low following lateral skull base surgery. While there is no individual risk factor associated with increased VTE risk, the Caprini RAM score appears to be a useful predictor of risk. The Caprini score may be useful in identifying high-risk patients who may benefit from chemoprophylaxis for VTE prevention. LEVEL OF EVIDENCE Level III-This is a retrospective chart review study Laryngoscope, 2021.
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Affiliation(s)
- Brian P Anderson
- Department of Otolaryngology-Head and Neck Surgery, Ascension Macomb-Oakland Hospital, Madison Heights, Michigan, U.S.A
| | - Pedrom C Sioshansi
- Michigan Ear Institute, Farmington Hills, Michigan, U.S.A.,Department of Otolaryngology-Head and Neck Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina, U.S.A
| | - Robert M Conway
- Department of Otolaryngology-Head and Neck Surgery, Ascension Macomb-Oakland Hospital, Madison Heights, Michigan, U.S.A
| | - Katrina Minutello
- Department of Otolaryngology-Head and Neck Surgery, McLaren Oakland Hospital, Pontiac, Michigan, U.S.A
| | | | - Robert S Hong
- Michigan Ear Institute, Farmington Hills, Michigan, U.S.A
| | - Eric W Sargent
- Michigan Ear Institute, Farmington Hills, Michigan, U.S.A
| | | | | | - John J Zappia
- Michigan Ear Institute, Farmington Hills, Michigan, U.S.A
| | - Seilesh C Babu
- Michigan Ear Institute, Farmington Hills, Michigan, U.S.A
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Naeem K, Bhargava M, Bohl M, Porter RW. Posterior Fossa Hemorrhage Following the Use of Low-Molecular-Weight Heparin: Lessons Learned and Recommendations for the Treatment and Prophylaxis of Postoperative Venous Thromboembolism. Cureus 2021; 13:e15404. [PMID: 34249552 PMCID: PMC8253580 DOI: 10.7759/cureus.15404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 04/30/2021] [Indexed: 11/16/2022] Open
Abstract
Introduction Venous thromboembolism (VTE) is the most common preventable cause of morbidity and mortality among neurosurgery patients. Several studies have concluded that the use of chemical prophylaxis among patients undergoing a craniotomy reduces the incidence of VTE, and it is presumed to be safe. However, these studies do not differentiate between a supratentorial and posterior fossa craniotomy. Furthermore, the prophylactic or therapeutic use of low-molecular-weight heparin (LMWH) has been reported to increase the risk of intracranial hemorrhage. In this study, we describe the clinical details and outcomes for all patients who underwent posterior fossa craniotomy and developed posterior fossa hemorrhage secondary to postoperative use of LMWH during the study period. We also propose recommendations pertaining to postoperative heparin use after posterior fossa surgeries. Methods Data were retrospectively collected for patients presenting with posterior fossa hemorrhage following anticoagulant use among those who previously underwent posterior fossa craniotomy by the senior author (R.W.P.) from January 1, 2011, through December 31, 2018. Results We identified five patients who experienced postoperative hemorrhage while receiving LMWH in the initial setting of posterior fossa craniotomy. After hemorrhaging, four patients had low Glasgow Outcome Scale (GOS) scores (≤3) and failed to return to their baseline neurological status. These four patients had a Glasgow Coma Scale (GCS) score of 15/15 in the immediate postoperative period and received heparin within 72 hours of surgery. Conclusions Based on our findings, there is a possible association between the increased risk of hemorrhage and the early postoperative use of LMWH. The debilitating outcomes among the majority of these patients warrant the cautious use and further investigation of postoperative LMWH to appropriately quantify the risk. Further comparative studies with a larger sample size are required to provide insight into the pathophysiology of our findings.
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Affiliation(s)
- Komal Naeem
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, USA
| | - Malika Bhargava
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, USA
| | - Michael Bohl
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, USA
| | - Randall W Porter
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, USA
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Muelleman TJ, Alonso J, Barnard ZR, Maxwell AK, Mahboubi H, Stefan M, Lekovic GP, Slattery WH, Brackmann DE. Hypercoagulability in Vestibular Schwannoma Surgery. Otol Neurotol 2021; 42:e222-e226. [PMID: 33065597 DOI: 10.1097/mao.0000000000002934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Patients with vestibular schwannoma who harbor a genetic predisposition for venous thromboembolism require special consideration when determining optimal therapeutic management. The primary objective of the current study was to provide recommendations on treatment of hypercoagulable patients with vestibular schwannoma through a case series and review of the literature. PATIENTS Two patients who underwent resection of vestibular schwannomas. INTERVENTIONS Surgical resection and diagnostic testing. MAIN OUTCOME MEASURES Postoperative venous thromboses. RESULTS One patient who underwent resection of vestibular schwannoma and suffered several postoperative thrombotic complications consistent with a clinical thrombophilia. One patient with known Factor V Leiden deficiency who underwent resection of vestibular schwannoma followed by postoperative chemoprophylaxis with a direct factor Xa inhibitor and experienced an uneventful postoperative course. CONCLUSIONS In patients with a known propensity for venous thromboembolism, the skull base surgeon should consider nonsurgical management. If the patient undergoes surgical resection, we recommend careful effort to minimize trauma to the sigmoid sinus. In addition, the surgeon may consider retrosigmoid or middle fossa approaches. Best practice recommendations include the use of pneumatic compression devices, early ambulation, and consideration of postoperative prophylactic anticoagulation in patients with a known genetic predisposition.
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Affiliation(s)
- Thomas J Muelleman
- Division of Neurotology, House Ear Institute
- Department of Head and Neck Surgery, UCLA Medical Center
| | - Jose Alonso
- Department of Head and Neck Surgery, UCLA Medical Center
| | | | - Anne K Maxwell
- Division of Neurotology, House Ear Institute
- Department of Head and Neck Surgery, UCLA Medical Center
| | - Hossein Mahboubi
- Division of Neurotology, House Ear Institute
- Department of Head and Neck Surgery, UCLA Medical Center
| | | | - Gregory P Lekovic
- Division of Neurosurgery, House Ear Institute, Los Angeles, California
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Increasing Frailty, Not Increasing Age, Results in Increased Length of Stay Following Vestibular Schwannoma Surgery. Otol Neurotol 2020; 41:e1243-e1249. [DOI: 10.1097/mao.0000000000002831] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Killeen DE, Isaacson B. Deep Venous Thrombosis Chemoprophylaxis in Lateral Skull Base Surgery for Vestibular Schwannoma. Laryngoscope 2020; 130:1851-1853. [PMID: 32031688 DOI: 10.1002/lary.28542] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 12/31/2019] [Accepted: 01/10/2020] [Indexed: 11/06/2022]
Affiliation(s)
- Daniel E Killeen
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, U.S.A
| | - Brandon Isaacson
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, U.S.A
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Ali NES, Alyono JC, Song Y, Kouhi A, Blevins NH. Postoperative Venous Thromboembolism after Neurotologic Surgery. J Neurol Surg B Skull Base 2019; 82:378-382. [PMID: 34026416 DOI: 10.1055/s-0039-3400223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 09/28/2019] [Indexed: 10/25/2022] Open
Abstract
Objective This study aimed to determine the incidence of postoperative venous thromboembolism (VTE) in adults undergoing neurotologic surgery at a single center. Methods The records of adults undergoing neurotologic surgery from August 2009 to December 2016 at a tertiary care hospital were reviewed for VTE within 30 postoperative days. Particular attention was focused on postoperative diagnosis codes, imaging, and a keyword search of postoperative notes. Caprini risk scores were calculated. Results Among 387 patients, 5 experienced postoperative VTE including 3 cases of pulmonary embolism (PE) and 2 cases of isolated deep vein thrombosis (DVT). All patients were given sequential compression devices perioperatively, and none received preoperative chemoprophylaxis. Patients with Caprini score > 8 had a significantly higher rate of VTE compared with those < 8 (12.5 vs. 1%, p = 0.004). Receiver operating characteristic analysis revealed the Caprini risk assessment model to be a fair predictor of VTE, with a C-statistic of 0.70 (95% confidence interval [CI]: 0.49-0.92). Conclusion While no specific validated VTE risk stratification scheme has been widely accepted for patients undergoing neurotologic surgery, the Caprini score appears to be a useful predictor of risk. The benefits of chemoprophylaxis should be balanced with the risks of intraoperative bleeding, as well as the potential for postoperative intracranial hemorrhage.
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Affiliation(s)
- Noor-E-Seher Ali
- Department of Otolaryngology, Stanford University, Stanford, California, United States
| | - Jennifer C Alyono
- Department of Otolaryngology, Stanford University, Stanford, California, United States
| | - Yohan Song
- Department of Otolaryngology, Stanford University, Stanford, California, United States
| | - Ali Kouhi
- Department of Otolaryngology, Stanford University, Stanford, California, United States
| | - Nikolas H Blevins
- Department of Otolaryngology, Stanford University, Stanford, California, United States
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