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Clinical usefulness of labyrinthine three-dimensional fluid-attenuated inversion recovery magnetic resonance images in idiopathic sudden sensorineural hearing loss. Curr Opin Otolaryngol Head Neck Surg 2021; 29:349-356. [PMID: 34459797 DOI: 10.1097/moo.0000000000000744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Literature on the use of current magnetic resonance imaging (MRI) for patients with idiopathic sudden sensorineural hearing loss (ISSNHL) is reviewed, emphasizing the role of three-dimensional fluid-attenuated inversion recovery (3D-FLAIR) MRI. The discussion focuses on the diagnostic role of temporal bone MRI using 3D-FLAIR and the relationship between MRI findings, clinical symptoms, and hearing outcome. RECENT FINDINGS The currently suggested MRI protocol for SSNHL includes a 3D T2-weighted steady-state free procession sequence or its equivalent, pre and postcontrast T1-weighted, and pre and postcontrast 3D-FLAIR sequences. The 3D-FLAIR image identifies an underlying labyrinthine condition in 24-57% of patients with ISSNHL, contributing to understanding the pathophysiologic mechanisms (e.g., labyrinthitis or labyrinthine hemorrhage). Recent studies demonstrated consistent results that initial hearing loss could be related to the signal change on the 3D-FLAIR image. Various results on 3D-FLAIR image value prediction for the final hearing outcome were shown. SUMMARY 3D-FLAIR MRI application identifies an underlying labyrinthine condition. Abnormal MRI findings correlate with initial hearing loss and accompanying symptoms and hearing outcome. Performing temporal bone MRI with 3D-FLAIR sequence may clarify probable ISSNHL pathophysiology, improve diagnostic accuracy, provide prognostic information to physicians, and possibly guide toward a more specific treatment.
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Quality Indicators for the Diagnosis and Management of Sudden Sensorineural Hearing Loss. Otol Neurotol 2021; 42:e991-e1000. [PMID: 34049327 DOI: 10.1097/mao.0000000000003205] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Sudden sensorineural hearing loss (SSNHL) is an ideal entity for quality indicator (QI) development, providing treatment challenges resulting in variable or substandard care. The American Academy of Otolaryngology-Head and Neck Surgery recently updated their SSNHL guidelines. With SSNHL demonstrating a large burden of illness, this study sought to leverage the updated guidelines and develop QIs that support quality improvement initiatives at an individual, institutional, and systems level. METHODS Candidate indicators (CIs) were extracted from high-quality SSNHL guidelines that were evaluated using the Appraisal of Guidelines for Research and Evaluation II tool. Each CI and its supporting evidence were summarized and reviewed by a nine-member expert panel based on validity, reliability, and feasibility of measurement. Final QIs were selected from CIs using the modified RAND Corporation-University of California, Los Angeles appropriateness methodology. RESULTS Fifteen CIs were identified after literature review. After the first round of evaluations, the panel agreed on 11 candidate indicators as appropriate QIs with 2 additional CIs suggested for consideration. An expert panel meeting provided a platform to discuss areas of disagreement before final evaluations. The expert panel subsequently agreed upon 11 final QIs as appropriate measures of high-quality care for SSNHL. CONCLUSION The 11 proposed QIs from this study are supported by evidence and expert consensus, facilitating measurement across a wide breadth of quality domains. With the recently updated SSNHL guidelines, and a greater focus on quality improvement opportunities, these QIs may be used by healthcare providers for targeted quality improvement initiatives.
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Ng B, Crowson MG, Lin V. Management of sudden sensorineural hearing loss among primary care physicians in Canada: a survey study. J Otolaryngol Head Neck Surg 2021; 50:22. [PMID: 33795010 PMCID: PMC8015047 DOI: 10.1186/s40463-021-00498-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 02/17/2021] [Indexed: 02/15/2023] Open
Abstract
BACKGROUND Sudden Sensorineural Hearing Loss (SSNHL) is a medical emergency requiring immediate attention as delayed treatment can lead to permanent and devastating consequences. Primary care physicians are likely the first to be presented with SSNHL and therefore have the crucial role of recognizing it and initiating timely and appropriate management. The aim of this study was to gain insight into the current knowledge and practice trends pertaining to the diagnosis and management of SSNHL among family physicians in Canada. METHODS An 18-question survey targeting Canadian family physicians was marketed through two, physician-only discussion groups on the social media platform Facebook. Responses were collected between August 1st and December 22nd 2019 then aggregated and quantified. RESULTS 52 family physicians submitted responses. 94.2% (n = 49) reported that in their practice, unilateral SSNHL warrants urgent referral to otolaryngology and 84.6% (n = 44) reported that unilateral sudden-onset hearing loss warrants urgent referral for audiological testing. 73.1% of participants (n = 38) reported that they would attempt to differentiate between conductive and sensorineural hearing loss if presented with unilateral, acute or sudden-onset hearing loss. 61.5% (n = 32) would rely on tuning fork tests to inform management decisions, as compared to 94.2% (n = 49) relying on case history and 88.5% (n = 46) on otoscopy. 76.9% (n = 40) would prescribe corticosteroids if presented with confirmed, unilateral SSNHL. CONCLUSION The majority of family physicians in the study would make appropriate referral and treatment decisions in the management of SSNHL, understanding it is a medical emergency. Tuning fork tests are under-utilized for informing management decisions compared to other means of differentiating conductive and sensorineural hearing loss. Further research is needed to understand why some family physicians do not prescribe corticosteroids for treatment of SSNHL, which may then identify any gaps in knowledge or inform improvements in clinical protocol.
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Affiliation(s)
- Benjamin Ng
- Department of Otolaryngology-Head & Neck Surgery, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, Ontario, M4N 3M5, Canada.
| | - Matthew G Crowson
- Department of Otolaryngology-Head & Neck Surgery, Massachusetts Eye & Ear, Boston, MA, USA.,Department of Otolaryngology-Head & Neck Surgery, Harvard Medical School, Boston, MA, USA
| | - Vincent Lin
- Department of Otolaryngology-Head & Neck Surgery, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, Ontario, M4N 3M5, Canada
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Jin MC, Qian ZJ, Cooperman SP, Alyono JC. Trends in Use and Timing of Intratympanic Corticosteroid Injections for Sudden Sensorineural Hearing Loss. Otolaryngol Head Neck Surg 2020; 165:166-173. [PMID: 33287664 DOI: 10.1177/0194599820976177] [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] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Oral corticosteroids are treatment mainstays for idiopathic sudden sensorineural hearing loss (SSNHL). Recent studies suggest that intratympanic (IT) steroid injections may be effective as an alternate or adjunctive therapy. We sought to investigate nationwide trends in treatment patterns for SSNHL. STUDY DESIGN Retrospective cross-sectional study. SETTING A large nationwide health care claims database spanning 2007 to 2016. METHODS Patients with SSNHL were identified from the IBM Watson Health MarketScan Database. Multivariable logistic, linear, and Cox regression were used for demographic- and comorbidity-adjusted analyses. RESULTS Overall, 19,670 patients were included. Between 2007 and 2016, use of oral corticosteroids alone decreased (83.6% to 64.6%, P < .001), while use of IT corticosteroids alone and combination IT-oral corticosteroids increased (IT only, 7.9% to 15.1%, P = .002; IT-oral, 8.5% to 20.4%, P < .001). During the study period, time to treatment initiation decreased for both administration modalities, though more dramatically for IT corticosteroids (IT, 124.0 to 10.6 days, P < .001; oral, 42.6 to 12.7 days, P < .001). In patients receiving both IT and oral corticosteroids, concurrent first-line use increased (25.2% to 52.8%, P < .001). Repeat injections have also become more common but may raise risk of persistent tympanic membrane perforations (vs no injection; hazard ratio [first injection] = 7.95, 95% CI = 5.54-11.42; hazard ratio [fifth or higher injection] = 17.47, 95% CI = 6.93-44.05). CONCLUSION SSNHL management increasingly involves early IT steroids as an alternative or adjunctive option to oral steroids. Use of repeat IT corticosteroid injections has also increased but may raise risk of persistent tympanic membrane perforations and subsequent tympanoplasty. Future decision analysis and cost-effectiveness studies are necessary to identify an optimal care pattern for SSNHL.
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Affiliation(s)
- Michael C Jin
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Stanford University, Stanford, California, USA
| | - Z Jason Qian
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Stanford University, Stanford, California, USA
| | - Shayna P Cooperman
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Stanford University, Stanford, California, USA
| | - Jennifer C Alyono
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Stanford University, Stanford, California, USA
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Taufique Z, Timen M, Swartz JL, Friedmann DR. Adherence to Subspecialty Guidelines in the Emergency Department. Laryngoscope 2020; 131:1266-1270. [PMID: 33103763 DOI: 10.1002/lary.29202] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 09/21/2020] [Accepted: 10/09/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVES/HYPOTHESIS The American Academy of Otolaryngology-Head and Neck Surgery has published clinical practice guidelines (CPGs) to guide management of common otolaryngologic (ENT) conditions. While these CPGs have been disseminated within specialty journals, many patients' first presentation of certain ENT complaints is to primary and acute care settings, including the emergency department (ED). It is less clear whether practice in these settings is concordant with specialty CPGs. STUDY DESIGN Retrospective cohort study. METHODS A retrospective review of medical records was performed at an academic tertiary care center with ED diagnoses of 1) Bell's palsy/facial weakness (BP) or 2) acute otitis externa (AOE) from May 2014-June 2018. Individual chart abstraction was performed for all encounters with these diagnoses for the purpose of assessing providers' adherence to CPGs. RESULTS During the study period, 224 patients were diagnosed with BP and 465 patients were diagnosed with AOE. Of the patients diagnosed with BP, 94% (n = 211/224) were prescribed oral steroids, concordant with guidelines, while 36% of these patients received head computed tomography (CT) scans and 43% received laboratory tests, counter to the guidelines. For those with a diagnosis of AOE, 28.6% received topical antibiotics only as primary treatment (n = 133/465) in accordance with guidelines while systemic antibiotics were prescribed in 42.2% (n = 196/465) discordant with the guidelines and 29.2% received both topical and systemic antibiotics (n = 136/465). CONCLUSIONS CPGs developed by subspecialty societies provide evidence-based recommendations for the care of patients with particular conditions, but may not be disseminated broadly outside of the specialty. Further research is required to understand the reasons behind divergent management of such conditions. LEVEL OF EVIDENCE 3 Laryngoscope, 131:1266-1270, 2021.
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Affiliation(s)
- Zahrah Taufique
- Department of Otolaryngology - Head and Neck Surgery, New York University Grossman School of Medicine, New York, New York, U.S.A.,Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine Health, New York, New York, U.S.A
| | - Micah Timen
- Department of Otolaryngology - Head and Neck Surgery, New York University Grossman School of Medicine, New York, New York, U.S.A.,Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine Health, New York, New York, U.S.A
| | - Jordan L Swartz
- Department of Otolaryngology - Head and Neck Surgery, New York University Grossman School of Medicine, New York, New York, U.S.A.,Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine Health, New York, New York, U.S.A
| | - David R Friedmann
- Department of Otolaryngology - Head and Neck Surgery, New York University Grossman School of Medicine, New York, New York, U.S.A.,Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine Health, New York, New York, U.S.A
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Ryan MA, Leu GR, Boss EF, Raynor EM, Walsh JM. Adherence to American Academy of Otolaryngology-Head and Neck Surgery Clinical Practice Guidelines: A Systematic Review. Otolaryngol Head Neck Surg 2020; 163:626-644. [PMID: 32450772 DOI: 10.1177/0194599820922155] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Clinical practice guidelines synthesize and disseminate the best available evidence to guide clinical decisions and increase high-quality care. Since 2004, the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) has published 16 guidelines. The objective of this review was to evaluate clinicians' adherence to these guidelines' recommendations as measured in the literature. DATA SOURCES We searched PubMed, Embase, and Web of Science on August 29, 2019, for studies published after June 1, 2004. REVIEW METHODS We systematically identified peer-reviewed studies in English that reported clinician adherence to AAO-HNSF guideline recommendations. Two authors independently reviewed and abstracted study characteristics, including publication date, population, sample size, guideline adherence, and risk of bias. RESULTS The search yielded 385 studies. We excluded 331 studies during title/abstract screening and 32 more after full-text review. The remaining 22 studies evaluated recommendations from 8 of the 16 guidelines. The Otitis Media with Effusion, Polysomnography, Tonsillectomy, and Sinusitis guidelines were studied most. Study designs included retrospective chart reviews (7, 32%), clinician surveys (7, 32%), and health care database analyses (8, 36%). Studies reported adherence ranging from 0% to 99.8% with a mean of 56%. Adherence varied depending on the recommendation evaluated, type of recommendation, clinician type, and clinical setting. Adherence to the polysomnography recommendations was low (8%-65.3%). Adherence was higher for the otitis media with effusion (76%-90%) and tonsillectomy (43%-98.9%) recommendations. CONCLUSIONS Adherence to recommendations in the AAO-HNSF guidelines varies widely. These findings highlight areas for further guideline dissemination, research about guideline adoption, and quality improvement.
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Affiliation(s)
- Marisa A Ryan
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Grace R Leu
- Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Emily F Boss
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Eileen M Raynor
- Department of Head and Neck Surgery & Communication Sciences, Duke University Durham, North Carolina, USA
| | - Jonathan M Walsh
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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Chandrasekhar SS, Tsai Do BS, Schwartz SR, Bontempo LJ, Faucett EA, Finestone SA, Hollingsworth DB, Kelley DM, Kmucha ST, Moonis G, Poling GL, Roberts JK, Stachler RJ, Zeitler DM, Corrigan MD, Nnacheta LC, Satterfield L, Monjur TM. Clinical Practice Guideline: Sudden Hearing Loss (Update) Executive Summary. Otolaryngol Head Neck Surg 2020; 161:195-210. [PMID: 31369349 DOI: 10.1177/0194599819859883] [Citation(s) in RCA: 76] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Sudden hearing loss is a frightening symptom that often prompts an urgent or emergent visit to a health care provider. It is frequently, but not universally, accompanied by tinnitus and/or vertigo. Sudden sensorineural hearing loss affects 5 to 27 per 100,000 people annually, with about 66,000 new cases per year in the United States. This guideline update provides evidence-based recommendations for the diagnosis, management, and follow-up of patients who present with sudden hearing loss. It focuses on sudden sensorineural hearing loss in adult patients aged 18 and over and primarily on those with idiopathic sudden sensorineural hearing loss. Prompt recognition and management of sudden sensorineural hearing loss may improve hearing recovery and patient quality of life. The guideline update is intended for all clinicians who diagnose or manage adult patients who present with sudden hearing loss. PURPOSE The purpose of this guideline update is to provide clinicians with evidence-based recommendations in evaluating patients with sudden hearing loss and sudden sensorineural hearing loss, with particular emphasis on managing idiopathic sudden sensorineural hearing loss. The guideline update group recognized that patients enter the health care system with sudden hearing loss as a nonspecific primary complaint. Therefore, the initial recommendations of this guideline update address distinguishing sensorineural hearing loss from conductive hearing loss at the time of presentation with hearing loss. They also clarify the need to identify rare, nonidiopathic sudden sensorineural hearing loss to help separate those patients from those with idiopathic sudden sensorineural hearing loss, who are the target population for the therapeutic interventions that make up the bulk of the guideline update. By focusing on opportunities for quality improvement, this guideline should improve diagnostic accuracy, facilitate prompt intervention, decrease variations in management, reduce unnecessary tests and imaging procedures, and improve hearing and rehabilitative outcomes for affected patients. METHODS Consistent with the American Academy of Otolaryngology-Head and Neck Surgery Foundation's Clinical Practice Guideline Development Manual, Third Edition, the guideline update group was convened with representation from the disciplines of otolaryngology-head and neck surgery, otology, neurotology, family medicine, audiology, emergency medicine, neurology, radiology, advanced practice nursing, and consumer advocacy. A systematic review of the literature was performed, and the prior clinical practice guideline on sudden hearing loss was reviewed in detail. Key action statements (KASs) were updated with new literature, and evidence profiles were brought up to the current standard. Research needs identified in the original clinical practice guideline and data addressing them were reviewed. Current research needs were identified and delineated. RESULTS The guideline update group made strong recommendations for the following: clinicians should distinguish sensorineural hearing loss from conductive hearing loss when a patient first presents with sudden hearing loss (KAS 1); clinicians should educate patients with sudden sensorineural hearing loss about the natural history of the condition, the benefits and risks of medical interventions, and the limitations of existing evidence regarding efficacy (KAS 7); and clinicians should counsel patients with sudden sensorineural hearing loss who have residual hearing loss and/or tinnitus about the possible benefits of audiological rehabilitation and other supportive measures (KAS 13). These strong recommendations were modified from the initial clinical practice guideline for clarity and timing of intervention. The guideline update group made strong recommendation against the following: clinicians should not order routine computed tomography of the head in the initial evaluation of a patient with presumptive sudden sensorineural hearing loss (KAS 3); clinicians should not obtain routine laboratory tests in patients with sudden sensorineural hearing loss (KAS 5); and clinicians should not routinely prescribe antivirals, thrombolytics, vasodilators, or vasoactive substances to patients with sudden sensorineural hearing loss (KAS 11). The guideline update group made recommendations for the following: clinicians should assess patients with presumptive sudden sensorineural hearing loss through history and physical examination for bilateral sudden hearing loss, recurrent episodes of sudden hearing loss, and/or focal neurologic findings (KAS 2); in patients with sudden hearing loss, clinicians should obtain, or refer to a clinician who can obtain, audiometry as soon as possible (within 14 days of symptom onset) to confirm the diagnosis of sudden sensorineural hearing loss (KAS 4); clinicians should evaluate patients with sudden sensorineural hearing loss for retrocochlear pathology by obtaining a magnetic resonance imaging or auditory brainstem response (KAS 6); clinicians should offer, or refer to a clinician who can offer, intratympanic steroid therapy when patients have incomplete recovery from sudden sensorineural hearing loss 2 to 6 weeks after onset of symptoms (KAS 10); and clinicians should obtain follow-up audiometric evaluation for patients with sudden sensorineural hearing loss at the conclusion of treatment and within 6 months of completion of treatment (KAS 12). These recommendations were clarified in terms of timing of intervention and audiometry, as well as method of retrocochlear workup. The guideline update group offered the following KASs as options: clinicians may offer corticosteroids as initial therapy to patients with sudden sensorineural hearing loss within 2 weeks of symptom onset (KAS 8); clinicians may offer, or refer to a clinician who can offer, hyperbaric oxygen therapy combined with steroid therapy within 2 weeks of onset of sudden sensorineural hearing loss (KAS 9a); and clinicians may offer, or refer to a clinician who can offer, hyperbaric oxygen therapy combined with steroid therapy as salvage therapy within 1 month of onset of sudden sensorineural hearing loss (KAS 9b). DIFFERENCES FROM PRIOR GUIDELINE Incorporation of new evidence profiles to include quality improvement opportunities, confidence in the evidence, and differences of opinion Included 10 clinical practice guidelines, 29 new systematic reviews, and 36 new randomized controlled trials Highlights the urgency of evaluation and initiation of treatment, if treatment is offered, by emphasizing the time from symptom occurrence Clarification of terminology by changing potentially unclear statements; use of the term sudden sensorineural hearing loss to mean idiopathic sudden sensorineural hearing loss to emphasize that over 90% of sudden sensorineural hearing loss is idiopathic sudden sensorineural hearing loss and to avoid confusion in nomenclature for the reader Changes to the key action statements (KASs) from the original guideline: KAS 1: When a patient first presents with sudden hearing loss, conductive hearing loss should be distinguished from sensorineural. KAS 2: The utility of history and physical examination when assessing for modifying factors is emphasized. KAS 3: The word routine is added to clarify that this statement addresses a nontargeted head computed tomography scan that is often ordered in the emergency room setting for patients presenting with sudden hearing loss. It does not refer to targeted scans such as a temporal bone computed tomography scan to assess for temporal bone pathology. KAS 4: The importance of audiometric confirmation of hearing status as soon as possible and within 14 days of symptom onset is emphasized. KAS 5: New studies were added to confirm the lack of benefit of nontargeted laboratory testing in sudden sensorineural hearing loss. KAS 6: Audiometric follow-up is excluded as a reasonable workup for retrocochlear pathology. Magnetic resonance imaging, computed tomography scan if magnetic resonance imaging cannot be done, or, secondarily, auditory brainstem response evaluation are the modalities recommended. A time frame for such testing is not specified, nor is it specified which clinician should be ordering this workup; however, it is implied that it would be the general or subspecialty otolaryngologist. KAS 7: The importance of shared decision making is highlighted, and salient points are emphasized. KAS 8: The option for corticosteroid intervention within 2 weeks of symptom onset is emphasized. KAS 9: Changed to KAS 9a and 9b; hyperbaric oxygen therapy remains an option but only when combined with steroid therapy for either initial treatment (9a) or for salvage therapy (9b). The timing is within 2 weeks of onset for initial therapy and within 1 month of onset of sudden sensorineural hearing loss for salvage therapy. KAS 10: Intratympanic steroid therapy for salvage is recommended within 2 to 6 weeks following onset of sudden sensorineural hearing loss. The time to treatment is defined and emphasized. KAS 11: Antioxidants were removed from the list of interventions that the clinical practice guideline recommends against using. KAS 12: Follow-up audiometry at conclusion of treatment and also within 6 months posttreatment is added. KAS 13: This statement on audiologic rehabilitation includes patients who have residual hearing loss and/or tinnitus who may benefit from treatment. Addition of an algorithm outlining KASs Enhanced emphasis on patient education and shared decision making with tools provided to assist in the same.
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Affiliation(s)
- Sujana S Chandrasekhar
- 1 ENT & Allergy Associates, LLP, New York, New York, USA.,2 Zucker School of Medicine at Hofstra-Northwell, Hempstead, New York, USA.,3 Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Betty S Tsai Do
- 4 University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | | | - Laura J Bontempo
- 6 University of Maryland School of Medicine, Baltimore, Maryland, USA
| | | | - Sandra A Finestone
- 8 Consumers United for Evidence-based Healthcare (CUE), Baltimore, Maryland, USA
| | - Deena B Hollingsworth
- 9 Ear, Nose & Throat Specialists of Northern Virginia, P.C., Manassas, Virginia, USA
| | - David M Kelley
- 4 University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Steven T Kmucha
- 10 Gould Medical Group-Otolaryngology, Stockton, California, USA
| | - Gul Moonis
- 11 Columbia University Medical Center, New York, New York, USA
| | | | - J Kirk Roberts
- 11 Columbia University Medical Center, New York, New York, USA
| | | | | | - Maureen D Corrigan
- 14 American Academy of Otolaryngology-Head and Neck Surgery Foundation, Alexandria, Virginia, USA
| | - Lorraine C Nnacheta
- 14 American Academy of Otolaryngology-Head and Neck Surgery Foundation, Alexandria, Virginia, USA
| | - Lisa Satterfield
- 14 American Academy of Otolaryngology-Head and Neck Surgery Foundation, Alexandria, Virginia, USA
| | - Taskin M Monjur
- 14 American Academy of Otolaryngology-Head and Neck Surgery Foundation, Alexandria, Virginia, USA
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Chandrasekhar SS, Tsai Do BS, Schwartz SR, Bontempo LJ, Faucett EA, Finestone SA, Hollingsworth DB, Kelley DM, Kmucha ST, Moonis G, Poling GL, Roberts JK, Stachler RJ, Zeitler DM, Corrigan MD, Nnacheta LC, Satterfield L. Clinical Practice Guideline: Sudden Hearing Loss (Update). Otolaryngol Head Neck Surg 2020; 161:S1-S45. [PMID: 31369359 DOI: 10.1177/0194599819859885] [Citation(s) in RCA: 321] [Impact Index Per Article: 80.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Sudden hearing loss is a frightening symptom that often prompts an urgent or emergent visit to a health care provider. It is frequently but not universally accompanied by tinnitus and/or vertigo. Sudden sensorineural hearing loss affects 5 to 27 per 100,000 people annually, with about 66,000 new cases per year in the United States. This guideline update provides evidence-based recommendations for the diagnosis, management, and follow-up of patients who present with sudden hearing loss. It focuses on sudden sensorineural hearing loss in adult patients aged ≥18 years and primarily on those with idiopathic sudden sensorineural hearing loss. Prompt recognition and management of sudden sensorineural hearing loss may improve hearing recovery and patient quality of life. The guideline update is intended for all clinicians who diagnose or manage adult patients who present with sudden hearing loss. PURPOSE The purpose of this guideline update is to provide clinicians with evidence-based recommendations in evaluating patients with sudden hearing loss and sudden sensorineural hearing loss, with particular emphasis on managing idiopathic sudden sensorineural hearing loss. The guideline update group recognized that patients enter the health care system with sudden hearing loss as a nonspecific primary complaint. Therefore, the initial recommendations of this guideline update address distinguishing sensorineural hearing loss from conductive hearing loss at the time of presentation with hearing loss. They also clarify the need to identify rare, nonidiopathic sudden sensorineural hearing loss to help separate those patients from those with idiopathic sudden sensorineural hearing loss, who are the target population for the therapeutic interventions that make up the bulk of the guideline update. By focusing on opportunities for quality improvement, this guideline should improve diagnostic accuracy, facilitate prompt intervention, decrease variations in management, reduce unnecessary tests and imaging procedures, and improve hearing and rehabilitative outcomes for affected patients. METHODS Consistent with the American Academy of Otolaryngology-Head and Neck Surgery Foundation's "Clinical Practice Guideline Development Manual, Third Edition" (Rosenfeld et al. Otolaryngol Head Neck Surg. 2013;148[1]:S1-S55), the guideline update group was convened with representation from the disciplines of otolaryngology-head and neck surgery, otology, neurotology, family medicine, audiology, emergency medicine, neurology, radiology, advanced practice nursing, and consumer advocacy. A systematic review of the literature was performed, and the prior clinical practice guideline on sudden hearing loss was reviewed in detail. Key Action Statements (KASs) were updated with new literature, and evidence profiles were brought up to the current standard. Research needs identified in the original clinical practice guideline and data addressing them were reviewed. Current research needs were identified and delineated. RESULTS The guideline update group made strong recommendations for the following: (KAS 1) Clinicians should distinguish sensorineural hearing loss from conductive hearing loss when a patient first presents with sudden hearing loss. (KAS 7) Clinicians should educate patients with sudden sensorineural hearing loss about the natural history of the condition, the benefits and risks of medical interventions, and the limitations of existing evidence regarding efficacy. (KAS 13) Clinicians should counsel patients with sudden sensorineural hearing loss who have residual hearing loss and/or tinnitus about the possible benefits of audiologic rehabilitation and other supportive measures. These strong recommendations were modified from the initial clinical practice guideline for clarity and timing of intervention. The guideline update group made strong recommendations against the following: (KAS 3) Clinicians should not order routine computed tomography of the head in the initial evaluation of a patient with presumptive sudden sensorineural hearing loss. (KAS 5) Clinicians should not obtain routine laboratory tests in patients with sudden sensorineural hearing loss. (KAS 11) Clinicians should not routinely prescribe antivirals, thrombolytics, vasodilators, or vasoactive substances to patients with sudden sensorineural hearing loss. The guideline update group made recommendations for the following: (KAS 2) Clinicians should assess patients with presumptive sudden sensorineural hearing loss through history and physical examination for bilateral sudden hearing loss, recurrent episodes of sudden hearing loss, and/or focal neurologic findings. (KAS 4) In patients with sudden hearing loss, clinicians should obtain, or refer to a clinician who can obtain, audiometry as soon as possible (within 14 days of symptom onset) to confirm the diagnosis of sudden sensorineural hearing loss. (KAS 6) Clinicians should evaluate patients with sudden sensorineural hearing loss for retrocochlear pathology by obtaining magnetic resonance imaging or auditory brainstem response. (KAS 10) Clinicians should offer, or refer to a clinician who can offer, intratympanic steroid therapy when patients have incomplete recovery from sudden sensorineural hearing loss 2 to 6 weeks after onset of symptoms. (KAS 12) Clinicians should obtain follow-up audiometric evaluation for patients with sudden sensorineural hearing loss at the conclusion of treatment and within 6 months of completion of treatment. These recommendations were clarified in terms of timing of intervention and audiometry and method of retrocochlear workup. The guideline update group offered the following KASs as options: (KAS 8) Clinicians may offer corticosteroids as initial therapy to patients with sudden sensorineural hearing loss within 2 weeks of symptom onset. (KAS 9a) Clinicians may offer, or refer to a clinician who can offer, hyperbaric oxygen therapy combined with steroid therapy within 2 weeks of onset of sudden sensorineural hearing loss. (KAS 9b) Clinicians may offer, or refer to a clinician who can offer, hyperbaric oxygen therapy combined with steroid therapy as salvage therapy within 1 month of onset of sudden sensorineural hearing loss. DIFFERENCES FROM PRIOR GUIDELINE Incorporation of new evidence profiles to include quality improvement opportunities, confidence in the evidence, and differences of opinion Included 10 clinical practice guidelines, 29 new systematic reviews, and 36 new randomized controlled trials Highlights the urgency of evaluation and initiation of treatment, if treatment is offered, by emphasizing the time from symptom occurrence Clarification of terminology by changing potentially unclear statements; use of the term sudden sensorineural hearing loss to mean idiopathic sudden sensorineural hearing loss to emphasize that >90% of sudden sensorineural hearing loss is idiopathic sudden sensorineural hearing loss and to avoid confusion in nomenclature for the reader Changes to the KASs from the original guideline: KAS 1-When a patient first presents with sudden hearing loss, conductive hearing loss should be distinguished from sensorineural. KAS 2-The utility of history and physical examination when assessing for modifying factors is emphasized. KAS 3-The word "routine" is added to clarify that this statement addresses nontargeted head computerized tomography scan that is often ordered in the emergency room setting for patients presenting with sudden hearing loss. It does not refer to targeted scans, such as temporal bone computerized tomography scan, to assess for temporal bone pathology. KAS 4-The importance of audiometric confirmation of hearing status as soon as possible and within 14 days of symptom onset is emphasized. KAS 5-New studies were added to confirm the lack of benefit of nontargeted laboratory testing in sudden sensorineural hearing loss. KAS 6-Audiometric follow-up is excluded as a reasonable workup for retrocochlear pathology. Magnetic resonance imaging, computerized tomography scan if magnetic resonance imaging cannot be done, and, secondarily, auditory brainstem response evaluation are the modalities recommended. A time frame for such testing is not specified, nor is it specified which clinician should be ordering this workup; however, it is implied that it would be the general or subspecialty otolaryngologist. KAS 7-The importance of shared decision making is highlighted, and salient points are emphasized. KAS 8-The option for corticosteroid intervention within 2 weeks of symptom onset is emphasized. KAS 9-Changed to KAS 9A and 9B. Hyperbaric oxygen therapy remains an option but only when combined with steroid therapy for either initial treatment (9A) or salvage therapy (9B). The timing of initial therapy is within 2 weeks of onset, and that of salvage therapy is within 1 month of onset of sudden sensorineural hearing loss. KAS 10-Intratympanic steroid therapy for salvage is recommended within 2 to 6 weeks following onset of sudden sensorineural hearing loss. The time to treatment is defined and emphasized. KAS 11-Antioxidants were removed from the list of interventions that the clinical practice guideline recommends against using. KAS 12-Follow-up audiometry at conclusion of treatment and also within 6 months posttreatment is added. KAS 13-This statement on audiologic rehabilitation includes patients who have residual hearing loss and/or tinnitus who may benefit from treatment. Addition of an algorithm outlining KASs Enhanced emphasis on patient education and shared decision making with tools provided to assist in same.
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Affiliation(s)
- Sujana S Chandrasekhar
- 1 ENT & Allergy Associates, LLP, New York, New York, USA.,2 Zucker School of Medicine at Hofstra-Northwell, Hempstead, New York, USA.,3 Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | | | - Laura J Bontempo
- 6 University of Maryland School of Medicine, Baltimore, Maryland, USA
| | | | - Sandra A Finestone
- 8 Consumers United for Evidence-Based Healthcare, Baltimore, Maryland, USA
| | | | - David M Kelley
- 10 University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Steven T Kmucha
- 11 Gould Medical Group-Otolaryngology, Stockton, California, USA
| | - Gul Moonis
- 12 Columbia University Medical Center, New York, New York, USA
| | | | - J Kirk Roberts
- 12 Columbia University Medical Center, New York, New York, USA
| | | | | | - Maureen D Corrigan
- 15 American Academy of Otolaryngology-Head and Neck Surgery Foundation, Alexandria, Virginia, USA
| | - Lorraine C Nnacheta
- 15 American Academy of Otolaryngology-Head and Neck Surgery Foundation, Alexandria, Virginia, USA
| | - Lisa Satterfield
- 15 American Academy of Otolaryngology-Head and Neck Surgery Foundation, Alexandria, Virginia, USA
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9
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Improvement or Recovery From Sudden Sensorineural Hearing Loss With Steroid Therapy Does Not Preclude the Need for MRI to Rule Out Vestibular Schwannoma. Otol Neurotol 2019; 40:674-680. [DOI: 10.1097/mao.0000000000002171] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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10
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Hamidi AK, Yazdani N, Seyedjavadi KH, Ahrabi NZ, Tajdini A, Aghazadeh K, Amoli MM. MTHFR AND ApoE genetic variants association with sudden sensorineural hearing loss. Am J Otolaryngol 2019; 40:260-264. [PMID: 30477909 DOI: 10.1016/j.amjoto.2018.10.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 10/28/2018] [Indexed: 12/27/2022]
Abstract
HYPOTHESIS Although the pathogenesis of sudden sensorineural hearing loss (SSNHL) is not clear, however several causes including genetic factors seems to be implicated. We hypothesized that common genetic variants might be involved in SSNHL. BACKGROUND SSNHL is known to be an idiopathic disease because the causative factors have not been identified. Several causes including genetic and viral infection besides immune system reaction, neurological disorders, medications, etc. have been previously reported. We examined the association between ApoE and MTHFR gene variants in SSNHL. METHODS This study includes case-control scheme encompassing a total of 177 individuals, include patients inflicted with SSNHL and healthy subjects as control group. Genotyping of MTHFR and ApoE variants was conducted by PCR - RFLP method. RESULT Our study showed that MTHFR rs1801133 allele frequency is significantly different between cases and controls. Also genotype distribution of ApoE was significantly different between patients and healthy controls. CONCLUSIONS MTHFR C677T and ApoE gene variant may be associated with sudden sensorineural hearing loss in an Iranian population.
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11
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Schwartz SR, Almosnino G. The Value of Clinical Practice Guidelines in Otolaryngology. CURRENT OTORHINOLARYNGOLOGY REPORTS 2018. [DOI: 10.1007/s40136-018-0205-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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12
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Witsell DL, Mulder H, Rauch S, Schulz KA, Tucci DL. Steroid Use for Sudden Sensorineural Hearing Loss: A CHEER Network Study. Otolaryngol Head Neck Surg 2018; 159:895-899. [DOI: 10.1177/0194599818785142] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective The objective of this study was to describe patterns of corticosteroid treatment for sudden sensorineural hearing loss and to evaluate effectiveness based on delivery mode (oral vs intratympanic vs both). Study Design Cross-sectional repeated measures. Setting Patients were recruited from practices within the Creating Healthcare Excellence through Education and Research (CHEER) Network. CHEER is a National Institutes of Health–funded nationwide network of 30 community and academic otolaryngology practice sites. Subjects and Methods A subset of 117 patients who had been treated with steroids for sudden sensorineural hearing loss were recruited from within a larger initial CHEER Network study on clinical practice guideline compliance. Outcomes included audiometric and speech scores and patient-perceived improvement. Descriptive analyses, Wilcoxon rank-sum tests, and Fisher exact tests were run. Results Two categories (oral and simultaneous oral + intratympanic) had adequate sample sizes to support statistical comparison of treatment results. Improvements were seen in both audiometry and speech testing scores; 57% of patients self-reported improvement perceived as either minor or major. There were no significant differences in degree of improvement between these treatment groups. Conclusions We observed that a majority of steroid-treated patients demonstrated hearing improvement, but this improvement did not meet criteria for statistical significance. As in other studies on this topic, the relatively small sample size may have prevented differentiation of effectiveness among steroid treatments. We propose that the use of alternative approaches, such as pragmatic clinical trials and multidisciplinary electronic health record systems and megadatabases, may hold the most promise for an approach to best practice development.
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Affiliation(s)
- David L. Witsell
- Division of Head and Neck Surgery and Communication Sciences, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Hillary Mulder
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Steven Rauch
- Massachusetts Eye & Ear Institute, Boston, Massachusetts, USA
| | - Kristine A. Schulz
- Division of Head and Neck Surgery and Communication Sciences, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Debara L. Tucci
- Division of Head and Neck Surgery and Communication Sciences, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
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13
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Xiao CC, Anderson M, Harless LD, Liang J. Shortcomings in the diagnosis of chronic rhinosinusitis: evaluating diagnosis by otolaryngologists and primary care physicians. Int Forum Allergy Rhinol 2018; 8:1107-1113. [DOI: 10.1002/alr.22165] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 05/08/2018] [Accepted: 05/24/2018] [Indexed: 01/08/2023]
Affiliation(s)
- Christopher C. Xiao
- Department of Otolaryngology-Head and Neck Surgery; Kaiser Permanente Medical Center; Oakland CA
| | | | - Lucas D. Harless
- Department of Otolaryngology-Head and Neck Surgery; Kaiser Permanente Medical Center; Oakland CA
| | - Jonathan Liang
- Department of Otolaryngology-Head and Neck Surgery; Kaiser Permanente Medical Center; Oakland CA
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14
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Affiliation(s)
- Jennifer J Shin
- Division of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
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15
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Abstract
Clinical practice guidelines are designed to synthesize and disseminate the best available evidence to guide clinical practice. The goal is to increase high-quality care and reduce inappropriate interventions. Clinical practice guidelines that systematically review evidence and synthesize it into recommendations are important because the available scientific evidence is normally neither rapidly nor broadly incorporated into practice. It is important to understand and improve the impact of our American Academy of Otolaryngology-Head and Neck Surgery Foundation clinical practice guidelines on this uptake of scientific knowledge. Considering the barriers to guideline adherence is a central part of this. This understanding can guide clinicians, future guideline authors, and researchers when using guidelines, writing them, and planning clinically relevant research.
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Affiliation(s)
- Marisa A Ryan
- 1 Division of Head and Neck Surgery and Communication Sciences, Department of Surgery, Duke University Hospital, Durham, North Carolina, USA.,2 Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
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16
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Conte G, Di Berardino F, Sina C, Zanetti D, Scola E, Gavagna C, Gaini L, Palumbo G, Capaccio P, Triulzi F. MR Imaging in Sudden Sensorineural Hearing Loss. Time to Talk. AJNR Am J Neuroradiol 2017; 38:1475-1479. [PMID: 28546251 DOI: 10.3174/ajnr.a5230] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Accepted: 03/20/2017] [Indexed: 11/07/2022]
Abstract
Sudden sensorineural hearing loss is defined as acute hearing loss of the sensorineural type of at least 30 dB over 3 contiguous frequencies that occurs within a 72-hour period. Although many different causative factors have been proposed, sudden sensorineural hearing loss is still considered "idiopathic" in 71%-85% of cases, and treatments are empiric, not based on etiology. MR imaging implemented with a 3D FLAIR sequence has provided new insights into the etiology of sudden sensorineural hearing loss. Herein, we review the current management trends for patients with sudden sensorineural hearing loss, from the initial clinical diagnosis to therapeutic strategies and diagnostic work-up. We focused primarily on MR imaging assessment and discuss the relevance that MR imaging findings might have for patient management, pointing out different perspectives for future clinical research.
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Affiliation(s)
- G Conte
- From the Postgraduation School of Radiodiagnostics (G.C.)
| | | | - C Sina
- Neuroradiology (C.S., E.S., C.G., F.T.)
| | | | - E Scola
- Neuroradiology (C.S., E.S., C.G., F.T.)
| | - C Gavagna
- Neuroradiology (C.S., E.S., C.G., F.T.)
| | - L Gaini
- Otolaryngology (L.G., P.C.) Units, Department of Clinical Sciences and Community Health, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico
| | | | - P Capaccio
- Otolaryngology (L.G., P.C.) Units, Department of Clinical Sciences and Community Health, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico
| | - F Triulzi
- Neuroradiology (C.S., E.S., C.G., F.T.).,Department of Pathophysiology and Transplantation (F.T.), Università degli Studi di Milano, Milan, Italy
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17
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Chapurin N, Pynnonen MA, Roberts R, Schulz K, Shin JJ, Witsell DL, Parham K, Langman A, Carpenter D, Vambutas A, Nguyen-Huynh A, Wolfley A, Lee WT. CHEER National Study of Chronic Rhinosinusitis Practice Patterns: Disease Comorbidities and Factors Associated with Surgery. Otolaryngol Head Neck Surg 2017; 156:751-756. [PMID: 28195023 DOI: 10.1177/0194599817691476] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Objectives (1) Describe national patterns of chronic rhinosinusitis (CRS) care across academic and community practices. (2) Determine the prevalence of comorbid disorders in CRS patients, including nasal polyposis, allergic rhinitis, asthma, and cystic fibrosis. (3) Identify demographic, clinical, and practice type factors associated with endoscopic sinus surgery (ESS). Study Design Multisite cross-sectional study. Setting Otolaryngology's national research network CHEER (Creating Healthcare Excellence through Education and Research). Subjects and Methods A total of 17,828 adult patients with CRS were identified, of which 10,434 were seen at community practices (59%, n = 8 sites) and 7394 at academic practices (41%, n = 10 sites). Multivariate logistic regression was used to evaluate the association between demographic, practice type, and clinical factors and the odds of a patient undergoing ESS. Results The average age was 50.4 years; 59.5% of patients were female; and 88.3% were Caucasian. The prevalence of comorbid diseases was as follows: allergic rhinitis (35.1%), nasal polyposis (13.3%), asthma (4.4%), and cystic fibrosis (0.2%). In addition, 24.8% of patients at academic centers underwent ESS, as compared with 12.3% at community sites. In multivariate analyses, nasal polyposis (odds ratio [OR], 4.28), cystic fibrosis (OR, 2.42), and academic site type (OR, 1.86) were associated with ESS ( P < .001), while adjusting for other factors. Conclusions We describe practice patterns of CRS care, as well as demographic and clinical factors associated with ESS. This is the first study of practice patterns in CRS utilizing the CHEER network and may be used to guide future research.
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Affiliation(s)
- Nikita Chapurin
- 1 Division of Head and Neck Surgery and Communication Sciences, Duke University Medical Center, Durham, North Carolina, USA
| | - Melissa A Pynnonen
- 2 Department of Otolaryngology, University of Michigan, Ann Arbor, Michigan, USA
| | - Rhonda Roberts
- 3 Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Kristine Schulz
- 1 Division of Head and Neck Surgery and Communication Sciences, Duke University Medical Center, Durham, North Carolina, USA
| | - Jennifer J Shin
- 4 Division of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - David L Witsell
- 1 Division of Head and Neck Surgery and Communication Sciences, Duke University Medical Center, Durham, North Carolina, USA
| | - Kourosh Parham
- 5 Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Connecticut Health Center, Farmington, Connecticut, USA
| | - Alan Langman
- 6 Department of Otolaryngology, University of Washington, Seattle, Washington, USA
| | - David Carpenter
- 1 Division of Head and Neck Surgery and Communication Sciences, Duke University Medical Center, Durham, North Carolina, USA
| | - Andrea Vambutas
- 7 Department of Otolaryngology, Hofstra North Shore-LIJ School of Medicine, Long Island Jewish Medical Center, New Hyde Park, New York, USA
| | - Anh Nguyen-Huynh
- 8 Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland, Oregon, USA
| | - Anne Wolfley
- 3 Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Walter T Lee
- 1 Division of Head and Neck Surgery and Communication Sciences, Duke University Medical Center, Durham, North Carolina, USA
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