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Murphy BL, Fischer JL, Tolisano AM, Navarro AI, Trinh L, Abuzeid WM, Humphreys IM, Akbar NA, Shah S, Schneider JS, Riley CA, McCoul ED. How Do Patients and Otolaryngologists Define Dizziness? Ann Otol Rhinol Laryngol 2024; 133:512-518. [PMID: 38375799 DOI: 10.1177/00034894241233949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2024]
Abstract
OBJECTIVE To assess for differences in how patients and otolaryngologists define the term dizziness. METHODS Between June 2020 and December 2022, otolaryngology clinicians and consecutive patients at 5 academic otolaryngology institutions across the United States were asked to define the term "dizziness" by completing a semantics-based questionnaire containing 20 common descriptors of the term within 5 symptom domains (imbalance-related, lightheadedness-related, motion-related, vision-related, and pain-related). The primary outcome was differences between patient and clinician perceptions of dizzy-related symptoms. Secondary outcomes included differences among patient populations by geographic location. RESULTS Responses were obtained from 271 patients and 31 otolaryngologists. Patients and otolaryngologists selected 7.7 ± 3.5 and 7.1 ± 4.3 symptoms, respectively. Most patients (266, 98.2%) selected from more than 1 domain and 17 (6.3%) patients identified symptoms from all 5 domains. Patients and clinicians were equally likely to define dizziness using terms from the imbalance (difference, -2.3%; 95% CI, -13.2%, 8.6%), lightheadedness (-14.1%; -29.2%, 1.0%), and motion-related (9.4; -0.3, 19.1) domains. Patients were more likely to include terms from the vision-related (23.6%; 10.5, 36.8) and pain-related (18.2%; 10.3%, 26.1%) domains. There were minor variations in how patients defined dizziness based on geographic location. CONCLUSIONS Patients and otolaryngologists commonly described dizziness using symptoms related to imbalance, lightheadedness, and motion. Patients were more likely to use vision or pain-related terms. Understanding of these semantic differences may enable more effective patient-clinician communication.
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Affiliation(s)
- Brianna L Murphy
- Department of Otolaryngology-Head and Neck Surgery, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Jakob L Fischer
- Department of Otolaryngology-Head and Neck Surgery, Walter Reed National Military Medical Center, Bethesda, MD, USA
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Anthony M Tolisano
- Department of Otolaryngology-Head and Neck Surgery, Walter Reed National Military Medical Center, Bethesda, MD, USA
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Alvaro I Navarro
- Department of Otolaryngology-Head and Neck Surgery, Tulane University, New Orleans, LA, USA
| | - Lily Trinh
- Department of Otolaryngology-Head and Neck Surgery, Tulane University, New Orleans, LA, USA
| | - Waleed M Abuzeid
- Division of Rhinology and Endoscopic Skull Base Surgery, Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, WA, USA
| | - Ian M Humphreys
- Division of Rhinology and Endoscopic Skull Base Surgery, Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, WA, USA
| | - Nadeem A Akbar
- Division of Rhinology and Skull Base Surgery, Department of Otorhinolaryngology-Head and Neck Surgery, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Sharan Shah
- Division of Rhinology and Skull Base Surgery, Department of Otorhinolaryngology-Head and Neck Surgery, Albert Einstein College of Medicine, Bronx, NY, USA
| | - John S Schneider
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Charles A Riley
- Department of Otolaryngology-Head and Neck Surgery, Walter Reed National Military Medical Center, Bethesda, MD, USA
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Edward D McCoul
- Department of Otolaryngology-Head and Neck Surgery, Tulane University, New Orleans, LA, USA
- Department of Otorhinolaryngology and Communication Sciences, Ochsner Clinic Foundation, New Orleans, LA, USA
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Hill GS, Noller MW, Olubajo CO, Tolisano AM, Riley CA, Fischer JL. Impact of dupilumab on medical readiness in a military population. Int Forum Allergy Rhinol 2024; 14:999-1001. [PMID: 37955607 DOI: 10.1002/alr.23300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Revised: 10/23/2023] [Accepted: 10/31/2023] [Indexed: 11/14/2023]
Abstract
KEY POINTS Military servicemembers reported high satisfaction rates of dupilumab treatment for CRSwNP. Some service members fear that dupilumab treatment may limit their career progression. Updated guidelines are needed for servicemembers to make decisions regarding dupilumab.
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Affiliation(s)
- Gregory S Hill
- Department of Otolaryngology-Head & Neck Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Michael W Noller
- Department of Otolaryngology-Head & Neck Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Cristianah O Olubajo
- School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Anthony M Tolisano
- Department of Otolaryngology-Head & Neck Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Charles A Riley
- Department of Otolaryngology-Head & Neck Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Jakob L Fischer
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Department of Otolaryngology-Head and Neck Surgery, University of California, Los Angeles, Los Angeles, California, USA
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Yang AW, Pillion EM, Riley CA, Tolisano AM. Differences in music appreciation between bilateral and single-sided cochlear implant recipients. Am J Otolaryngol 2024; 45:104331. [PMID: 38677147 DOI: 10.1016/j.amjoto.2024.104331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 04/21/2024] [Indexed: 04/29/2024]
Abstract
OBJECTIVE To compare changes in music appreciation after cochlear implant (CI) surgery for patients with bilateral and single-sided deafness (SSD). METHODS A retrospective cohort study was performed on all adult CI unilateral or bilateral recipients from November 2019 to March 2023. Musical questionnaire subset data from the Cochlear Implant Quality of Life (CIQOL) - 35 Profile Instrument Score (maximum raw score of 15) was collected. Functional CI assessment was measured with CI-alone speech-in-quiet (SIQ) scores (AzBio and CNC). RESULTS 22 adults underwent CI surgery for SSD and 21 adults for bilateral deafness (8 sequentially implanted). Every patient group had clinically significant improvements (p < 0.001) in mean SIQ scores in the most recently implanted ear (Azbio (% correct) SSD: 14.23 to 68.48, bilateral: 24.54 to 82.23, sequential: 6.25 to 82.57). SSD adults on average had higher music QOL scores at baseline (SSD: 11.05; bilateral: 7.86, p < 0.001). No group had significant increases in raw score at the first post-operative visit (SSD: 11.45, p = 0.86; bilateral: 8.15, p = 0.15). By the most recent post-implantation evaluation (median 12.8 months for SSD, 12.3 months for bilateral), SSD adults had a significant increase in raw score from baseline (11.05 to 12.45, p = 0.03), whereas bilaterally deafened (7.86 to 9.38, p = 0.12) adults had nonsignificant increases. CONCLUSIONS SSD patients demonstrate higher baseline music appreciation than bilaterally deafened individuals regardless of unilateral or bilateral implantation and are more likely to demonstrate continued improvement in subjective music appreciation at last follow-up even when speech perception outcomes are similar.
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Affiliation(s)
- Alex W Yang
- Department of Otolaryngology Head and Neck Surgery, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Elicia M Pillion
- Department of Audiology, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Charles A Riley
- Department of Otolaryngology Head and Neck Surgery, Walter Reed National Military Medical Center, Bethesda, MD, USA; Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Anthony M Tolisano
- Department of Otolaryngology Head and Neck Surgery, Walter Reed National Military Medical Center, Bethesda, MD, USA; Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.
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Ryan MT, Coulter M, Kim J, Noller M, Mack D, Huuki E, Riley CA, Tolisano AM. Hypoglossal Nerve Stimulator in the Active Duty Population: Military Readiness and Satisfaction. Mil Med 2024; 189:475-480. [PMID: 36892849 DOI: 10.1093/milmed/usad069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 01/13/2023] [Accepted: 02/24/2023] [Indexed: 03/10/2023] Open
Abstract
INTRODUCTION Because inadequate sleep impairs mission performance, the U.S. Army regards sleep as a core pillar of soldier readiness. There is an increasing incidence of obstructive sleep apnea (OSA) among active duty (AD) service members, which is a disqualifying condition for initial enlistment. Moreover, a new diagnosis of OSA in the AD population often prompts a medical evaluation board, and if symptomatic OSA proves refractory to treatment, this may result in medical retirement. Hypoglossal nerve stimulator implantation (HNSI) is a newer implantable treatment option, which requires minimal ancillary equipment to function and may provide a useful treatment modality to support AD service members while maintaining readiness in appropriate candidates. Because of a perception among AD service members that HNSI results in mandatory medical discharge, we aimed to evaluate the impact of HNSI on military career progression, maintenance of deployment readiness, and patient satisfaction. METHODS The Department of Research Programs at the Walter Reed National Military Medical Center provided institutional review board approval for this project. This is a retrospective, observational study and telephonic survey of AD HNSI recipients. Military service information, demographics, surgical data, and postoperative sleep study results were collected from each patient.Additional survey questions assessed each service member's experience with the device. RESULTS Fifteen AD service members who underwent HNSI between 2016 and 2021 were identified. Thirteen subjects completed the survey. The mean age was 44.8 years (range 33-61), and all were men. Six subjects (46%) were officers. All subjects maintained AD status following HNSI yielding 14.5 person-years of continued AD service with the implant. One subject underwent formal assessment for medical retention. One subject transferred from a combat role to a support role. Six subjects have since voluntarily separated from AD service following HNSI. These subjects spent an average of 360 (37-1,039) days on AD service. Seven subjects currently remain on AD and have served for an average of 441 (243-882) days. Two subjects deployed following HNSI. Two subjects felt that HSNI negatively affected their career. Ten subjects would recommend HSNI to other AD personnel. Following HNSI, of the eight subjects with postoperative sleep study data, five achieved surgical success defined as >50% reduction of apnea-hypopnea index and absolute apnea-hypopnea index value of <20. CONCLUSIONS Hypoglossal nerve stimulator implantation for AD service members offers an effective treatment modality for OSA, which generally allows for the ability to maintain AD status, however: The impact on deployment readiness should be seriously considered and tailored to each service member based on their unique duties before implantation. Seventy-seven percent of HNSI patients would recommend it to other AD service members suffering from OSA.
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Affiliation(s)
- Matthew T Ryan
- Department of Otolaryngology Head and Neck Surgery, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
| | - Michael Coulter
- Department of Otolaryngology Head and Neck Surgery, Naval Medical Center, San Diego, CA 92134, USA
| | - Jeeho Kim
- N9 Medical, Navy Operation Support Center, Washington DC, Joint Base Andrews, MD 20762, USA
| | - Michael Noller
- Department of Otolaryngology Head and Neck Surgery, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
| | - Douglas Mack
- Department of Otolaryngology Head and Neck Surgery, Brook Army Medical Center, San Antonio, TX 78234, USA
| | - Elizabeth Huuki
- School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Charles A Riley
- Department of Otolaryngology Head and Neck Surgery, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Anthony M Tolisano
- Department of Otolaryngology Head and Neck Surgery, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
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Fischer JL, Riley CA, Kacker A. Unique clinical and prognostic behavior of patients diagnosed with combined exophytic and inverted papilloma histologic subtype. Laryngoscope Investig Otolaryngol 2024; 9:e1191. [PMID: 38362195 PMCID: PMC10866596 DOI: 10.1002/lio2.1191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 10/15/2023] [Accepted: 11/15/2023] [Indexed: 02/17/2024] Open
Abstract
Objectives To evaluate the clinical and prognostic behaviors of sinonasal papillomas. Methods Patients diagnosed with sinonasal papilloma were reviewed between 2001 and 2016 at a tertiary rhinology practice. Using pathology-specific electronic medical record software, patients diagnosed with sinonasal papilloma were identified. Four subcategories of this lesion were identified: inverting (IP), exophytic (EP) oncocytic (OP) and inverting + exophytic (IP + EP) papillomas. Results A total of 107 patients were identified with unique sinonasal papilloma diagnoses. Of these, the majority were diagnosed with IP (87, 81.3%). The subpopulation of patients co-diagnosed with IP and EP (IP + EP) was unique with respect to clinical presentation and prognosis relative to both the IP and EP alone populations. IP + EP patients (5, 4.7%) were older with an average age of 75.25 years compared to 45 (EP) and 55.26 (IP), p < .0001. IP + EP patients more often presented with epistaxis (60%) compared to 33.3% (EP) and 4.6% (IP). Finally, all IP + EP patients had at least one recurrence of their disease, compared to 33.3% (EP) and 28.5% (IP). Conclusions Each histopathologic subtype of sinonasal papilloma has unique clinical characteristics and recurrence rates after surgical resection. The subpopulation of patients diagnosed with IP + EP tends to be older, more likely to present with epistaxis, and more likely to recur. Additional investigation and analysis of this subpopulation is warranted. Level of Evidence 4.
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Affiliation(s)
- Jakob L. Fischer
- Department of Otolaryngology—Head and Neck SurgeryWalter Reed National Military Medical CenterBethesdaMarylandUSA
- Department of SurgeryUniformed Services University of the Health SciencesBethesdaMarylandUSA
| | - Charles A. Riley
- Department of Otolaryngology—Head and Neck SurgeryWalter Reed National Military Medical CenterBethesdaMarylandUSA
- Department of SurgeryUniformed Services University of the Health SciencesBethesdaMarylandUSA
| | - Ashutosh Kacker
- Department of OtorhinolaryngologyWeill Cornell Medical CollegeNew YorkNew YorkUSA
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Fischer JL, Tolisano AM, Navarro AI, Trinh L, Abuzeid WM, Humphreys IM, Akbar NA, Shah S, Schneider JS, Riley CA, McCoul ED. Are you congested? A comparison of definitions between otolaryngologists and their patients. Int Forum Allergy Rhinol 2024; 14:86-95. [PMID: 37392085 DOI: 10.1002/alr.23228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 06/26/2023] [Accepted: 06/28/2023] [Indexed: 07/02/2023]
Abstract
OBJECTIVE To assess for differences of intended meaning in the description of congestion-related symptoms among otolaryngology patients and clinicians. MATERIALS AND METHODS Between June 2020 and October 2022, a questionnaire consisting of 16 common descriptors of congestion-related symptoms within four domains (obstructive-related, pressure-related, mucus-related, and other symptoms) was completed by patients and otolaryngologists at five tertiary otolaryngology practices. The primary outcome was to assess differences in patient and clinician perceptions of congestion-related symptoms. Differences based on geographic location was a secondary outcome. RESULTS A total of 349 patients and 40 otolaryngologists participated. Patients selected a median of 6.8 (standard deviation [SD] 3.0) terms compared with 4.0 (SD 1.6) terms for otolaryngologists (p < 0.001). Otolaryngologists were more likely to select obstruction-related symptoms (difference 6.3%; 95% confidence interval [CI] 3.8%, 8.9%). Patients were more likely to describe congestion using pressure-related (-43.7%; -58.9%, -28.5%), mucus-related (-43.5%; -59.3%, -27.8%), and other symptoms (-44.2; -51.3%, -37.1%) compared with otolaryngologists. There were no significant differences identified based on geographic location with regard to symptom domains on multivariate analysis. CONCLUSIONS There are differences between otolaryngologists and their patients in the interpretation of the symptoms of congestion. Clinicians tended to have a narrower interpretation of congestion that was limited to the obstruction-related symptom domain, while patients defined congestion more broadly. This has important counseling and communication implications for the clinician.
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Affiliation(s)
- Jakob L Fischer
- Department of Otolaryngology-Head and Neck Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Anthony M Tolisano
- Department of Otolaryngology-Head and Neck Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Alvaro I Navarro
- Department of Otolaryngology-Head and Neck Surgery, Tulane University, New Orleans, Louisiana, USA
| | - Lily Trinh
- Department of Otolaryngology-Head and Neck Surgery, Tulane University, New Orleans, Louisiana, USA
| | - Waleed M Abuzeid
- Division of Rhinology and Endoscopic Skull Base Surgery, Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
| | - Ian M Humphreys
- Division of Rhinology and Endoscopic Skull Base Surgery, Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
| | - Nadeem A Akbar
- Division of Rhinology and Skull Base Surgery, Department of Otorhinolaryngology-Head and Neck Surgery, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Sharan Shah
- Division of Rhinology and Skull Base Surgery, Department of Otorhinolaryngology-Head and Neck Surgery, Albert Einstein College of Medicine, Bronx, New York, USA
| | - John S Schneider
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Charles A Riley
- Department of Otolaryngology-Head and Neck Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Edward D McCoul
- Department of Otolaryngology-Head and Neck Surgery, Tulane University, New Orleans, Louisiana, USA
- Department of Otorhinolaryngology and Communication Sciences, Ochsner Clinic Foundation, New Orleans, Louisiana, USA
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Riley CA, Gudis DA. Is There a Role for Adjuvant Therapy in Patients with Large Juvenile Nasopharyngeal Angiofibromas? Laryngoscope 2023; 133:2831-2833. [PMID: 37249201 DOI: 10.1002/lary.30797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 05/17/2023] [Accepted: 05/18/2023] [Indexed: 05/31/2023]
Affiliation(s)
- Charles A Riley
- Department of Otolaryngology-Head and Neck Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - David A Gudis
- Department of Otolaryngology - Head and Neck Surgery, Columbia University Medical Center, New York Presbyterian Hospital, New York City, New York, USA
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Andren KG, Duffin K, Ryan MT, Riley CA, Tolisano AM. Postoperative optimization of cochlear implantation for single sided deafness and asymmetric hearing loss: a systematic review. Cochlear Implants Int 2023; 24:342-353. [PMID: 37490782 DOI: 10.1080/14670100.2023.2239512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2023]
Abstract
OBJECTIVE Identify and evaluate the effectiveness of methods for improving postoperative cochlear implant (CI) hearing performance in subjects with single-sided deafness (SSD) and asymmetric hearing loss (AHL). DATA SOURCES Embase, PubMed, Scopus. REVIEW METHODS Systematic review and narrative synthesis. English language studies of adult CI recipients with SSD and AHL reporting a postoperative intervention and comparative audiometric data pertaining to speech in noise, speech in quiet and sound localization were included. RESULTS 32 studies met criteria for full text review and 6 (n = 81) met final inclusion criteria. Interventions were categorized as: formal auditory training, programming techniques, or hardware optimization. Formal auditory training (n = 10) found no objective improvement in hearing outcomes. Experimental CI maps did not improve audiologic outcomes (n = 9). Programed CI signal delays to improve synchronization demonstrated improved sound localization (n = 12). Hardware optimization, including multidirectional (n = 29) and remote (n = 11) microphones, improved sound localization and speech in noise, respectively. CONCLUSION Few studies meeting inclusion criteria and small sample sizes highlight the need for further study. Formal auditory training did not appear to improve hearing outcomes. Programming techniques, such as CI signal delay, and hardware optimization, such as multidirectional and remote microphones, show promise to improve outcomes for SSD and AHL CI users.
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Affiliation(s)
- Kristofer G Andren
- Department of Otolaryngology - Head & Neck Surgery, San Antonio Uniformed Services Health Education Consortium, San Antonio, TX, USA
| | - Kevin Duffin
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Matthew T Ryan
- Department of Otolaryngology - Head & Neck Surgery, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Charles A Riley
- Department of Otolaryngology - Head & Neck Surgery, Walter Reed National Military Medical Center, Bethesda, MD, USA
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Anthony M Tolisano
- Department of Otolaryngology - Head & Neck Surgery, Walter Reed National Military Medical Center, Bethesda, MD, USA
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
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Ryan M, Riley CA. What Is Sinus Surgery? JAMA Otolaryngol Head Neck Surg 2023; 149:947. [PMID: 37589981 DOI: 10.1001/jamaoto.2023.1949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Abstract
This Patient Page describes the risks and benefits of sinus surgery for acute or chronic sinusitis.
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Affiliation(s)
- Matthew Ryan
- Department of Otolaryngology-Head and Neck Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Charles A Riley
- Department of Otolaryngology-Head and Neck Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland
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Riley CA, Yang N, Gudis DA. Setting the Stage for Olfactory Neuroblastoma. JAMA Otolaryngol Head Neck Surg 2023; 149:845-846. [PMID: 37535387 DOI: 10.1001/jamaoto.2023.1943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2023]
Affiliation(s)
- Charles A Riley
- Department of Otolaryngology-Head and Neck Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Nathan Yang
- Department of Otolaryngology-Head and Neck Surgery, McGill University, Centre Intégré de Santé et des Services Sociaux de l'Outaouais, Gatineau, Quebec, Canada
| | - David A Gudis
- Department of Otolaryngology-Head and Neck Surgery, Columbia University Medical Center, New York Presbyterian Hospital, New York, New York
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Riley CA, Ramanathan M. Associations of Long-Term Environmental Exposures With Chronic Rhinosinusitis-Tilting at Windmills. JAMA Otolaryngol Head Neck Surg 2023; 149:781-782. [PMID: 37440223 DOI: 10.1001/jamaoto.2023.1570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/14/2023]
Affiliation(s)
- Charles A Riley
- Department of Otolaryngology-Head and Neck Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Murugappan Ramanathan
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
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Fischer JL, Tolisano AM, Navarro AI, Trinh L, Abuzeid WM, Humphreys IM, Akbar NA, Shah S, Schneider JS, Riley CA, McCoul ED. Layperson Perception of Reflux-Related Symptoms. OTO Open 2023; 7:e51. [PMID: 37181200 PMCID: PMC10167538 DOI: 10.1002/oto2.51] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 04/01/2023] [Indexed: 05/16/2023] Open
Abstract
Objective To assess for differences of intended meaning in the description of reflux-related symptoms among otolaryngology patients and clinicians. Study Design Cross-sectional survey-based study. Setting Five tertiary, academic otolaryngology practices. Methods Between June 2020 and July 2022, a questionnaire consisting of 20 common descriptors of reflux-related symptoms within four domains (throat-, chest-, stomach-, and sensory-related symptoms) was completed by patients. Attending otolaryngologists at five academic medical centers then completed the same survey. The primary outcome was to assess differences in patient and clinician perceptions of reflux-related symptoms. Differences based on geographic location was a secondary outcome. Results A total of 324 patients and 27 otolaryngologists participated. Patients selected a median of six terms compared with 10.5 for otolaryngologists (p < .001). Otolaryngologists were more likely to select sensory symptoms (difference: 35.8%; 95% confidence interval [CI]: 19.2%, 52.4%), throat-related symptoms (32.4%; 21.2, 43.6%), and chest-related symptoms (12.4%; 8.8, 15.9). Otolaryngologists and patients were equally likely to consider stomach symptoms as related to reflux (4.0%, -3.7%, 11.7%). No significant differences were identified based on geographic location. Conclusion There are differences between otolaryngologists and their patients in the interpretation of the symptoms of reflux. Patients tended to have a narrower interpretation of reflux with symptoms primarily limited to classic stomach-related symptoms, while clinicians tended to have a broader definition of reflux that included extra-esophageal manifestations of disease. This has important counseling implications for the clinician, as patients presenting with reflux symptoms may not comprehend the relationship of those symptoms to reflux disease.
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Affiliation(s)
- Jakob L. Fischer
- Department of Otolaryngology–Head and Neck SurgeryWalter Reed National Military Medical CenterBethesdaMarylandUSA
- Department of SurgeryUniformed Services University of the Health SciencesBethesdaMarylandUSA
| | - Anthony M. Tolisano
- Department of Otolaryngology–Head and Neck SurgeryWalter Reed National Military Medical CenterBethesdaMarylandUSA
- Department of SurgeryUniformed Services University of the Health SciencesBethesdaMarylandUSA
| | - Alvaro I. Navarro
- Department of Otolaryngology–Head and Neck SurgeryTulane UniversityNew OrleansLouisianaUSA
| | - Lily Trinh
- Department of Otolaryngology–Head and Neck SurgeryTulane UniversityNew OrleansLouisianaUSA
| | - Waleed M. Abuzeid
- Division of Rhinology and Endoscopic Skull Base Surgery, Department of Otolaryngology–Head and Neck SurgeryUniversity of WashingtonSeattleWashingtonUSA
| | - Ian M. Humphreys
- Division of Rhinology and Endoscopic Skull Base Surgery, Department of Otolaryngology–Head and Neck SurgeryUniversity of WashingtonSeattleWashingtonUSA
| | - Nadeem A. Akbar
- Division of Rhinology and Skull Base Surgery, Department of Otorhinolaryngology–Head and Neck SurgeryAlbert Einstein College of MedicineBronxNew YorkUSA
| | - Sharan Shah
- Division of Rhinology and Skull Base Surgery, Department of Otorhinolaryngology–Head and Neck SurgeryAlbert Einstein College of MedicineBronxNew YorkUSA
| | - John S. Schneider
- Department of Otolaryngology–Head and Neck SurgeryWashington University School of MedicineSt. LouisMissouriUSA
| | - Charles A. Riley
- Department of Otolaryngology–Head and Neck SurgeryWalter Reed National Military Medical CenterBethesdaMarylandUSA
- Department of SurgeryUniformed Services University of the Health SciencesBethesdaMarylandUSA
| | - Edward D. McCoul
- Department of Otolaryngology–Head and Neck SurgeryTulane UniversityNew OrleansLouisianaUSA
- Department of Otorhinolaryngology and Communication SciencesOchsner Clinic FoundationNew OrleansLouisianaUSA
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13
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Ryan MT, Montgomery EA, Fryer J, Yang AW, Mills C, Watson N, Noller M, Riley CA, Tolisano AM. Ergonomics in Otolaryngology: A Systematic Review and Meta-analysis. Laryngoscope 2023; 133:467-475. [PMID: 35575629 DOI: 10.1002/lary.30216] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 04/19/2022] [Accepted: 05/04/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVES To determine the proportion of otolaryngologists with work-related musculoskeletal discomfort (WRMD) and to review objective ergonomic data that contribute to WRMD. STUDY DESIGN Systematic review and meta-analysis. METHODS A comprehensive search of the literature identified 1121 articles for initial review of which 19 (3563 participants) met criteria for qualitative discussion and eight (2192 participants) met criteria for meta-analysis. Random effects meta-analyses were used to estimate the proportion of otolaryngologists reporting WRMD. RESULTS The overall proportion (95% confidence intervals [CI]) of general otolaryngologists reporting WRMD was 0.79 (0.66, 0.88) for any symptoms; 0.54 (0.40, 0.67) for neck symptoms; 0.33 (0.20, 0.49) for shoulder symptoms; and 0.49 (0.40, 0.59) for back symptoms. Surgeons performing primarily subspecialty cases had a lower estimated overall prevalence of WRMD versus those performing general ENT cases, however the odds ratio (OR) was not statistically significant (OR [95% confidence interval] 0.53 [0.22, 1.25]). 23%-84% of otolaryngologists underwent medical treatment for WRMD. 5%-23% took time off work and 1%-6% stopped operating completely as a result of WRMD. 23%-62.5% of otolaryngologists believed WRMD negatively impacted their quality of life. Objective measures of ergonomic posture indicate moderate to severe risk of injury during the routine clinic and surgical procedures with none found to be low risk. CONCLUSIONS Ergonomic stressors among otolaryngologists contribute to a high rate of WRMD across all subspecialties with notable impact on productivity, longevity, and quality of life. Laryngoscope, 133:467-475, 2023.
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Affiliation(s)
- Matthew T Ryan
- Department of Otolaryngology Head and Neck Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, U.S.A
| | - Emily A Montgomery
- School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, U.S.A
| | - Jacob Fryer
- School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, U.S.A
| | - Alex W Yang
- School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, U.S.A
| | - Channah Mills
- School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, U.S.A
| | - Nora Watson
- Department of Research Programs, Walter Reed National Military Medical Center, Bethesda, Maryland, U.S.A
| | - Michael Noller
- Department of Otolaryngology Head and Neck Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, U.S.A
| | - Charles A Riley
- Department of Otolaryngology Head and Neck Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, U.S.A.,Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, U.S.A
| | - Anthony M Tolisano
- Department of Otolaryngology Head and Neck Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, U.S.A.,Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, U.S.A
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14
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Riley CA, Soneru CP, Navarro A, Trinh L, Abuzeid WM, Humphreys IM, Akbar NA, Shah S, Lee JT, Wu TJ, Schneider JS, McCoul ED. Layperson Perception of Symptoms Caused by the Sinuses. Otolaryngol Head Neck Surg 2023; 168:1038-1046. [PMID: 36939435 DOI: 10.1002/ohn.197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 10/10/2022] [Accepted: 10/20/2022] [Indexed: 02/11/2023]
Abstract
OBJECTIVE To assess the perceived symptoms caused by the sinuses as defined by otolaryngology patients and clinicians. STUDY DESIGN Multi-institutional cross-sectional study. SETTING Six academic outpatient otolaryngology practices. METHODS We performed a multi-institutional, cross-sectional study using a semantics-based questionnaire. Consecutive patients were enrolled at 6 academic otolaryngology centers from June 2020 to May 2021. The primary outcome examined patient and provider definitions for the symptoms caused by the sinuses from a list of 28 proposed terms covering 6 general categories. These data were also collected from otolaryngology faculty at the same institutions. RESULTS Responses were obtained from 451 patients (54% female, mean age 48.3 years) and 29 otolaryngologists (38% female, mean age 37.4 years). Patients selected a median of 12 terms, compared to 8.5 for otolaryngologists. Among patients, the most frequently selected symptom domains were mucus (419, 92.9%), airflow (412, 91.4%), and pain (389, 86.3%). Compared to clinicians, patients more frequently selected symptoms related to the ear (difference, 48.3%; 95% confidence interval [CI], 34.8%-59.3%), throat (difference, 35.7%, 95% CI, 22.0%-47.5%), systemic (difference, 34.4%, 95% CI, 21.2%-46.0%), mucus (difference, 20.5%, 95% CI, 10.2%-30.6%), and airflow domains (difference, 19.0%, 95% CI, 8.4%-29.3%). Multiple domains were selected by 98% of patients and 79% of providers. CONCLUSION Semantic differences exist between patients and clinicians regarding the symptoms caused by the sinus with patients having a broader range of perceived symptoms. These differences may provide clues to improve communication between otolaryngologists and their patients.
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Affiliation(s)
- Charles A Riley
- Department of Otolaryngology-Head and Neck Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Christian P Soneru
- Department of Otolaryngology-Head and Neck Surgery, Tufts Medical Center, Boston, Massachusetts, USA
| | - Alvaro Navarro
- Department of Otolaryngology-Head and Neck Surgery, Tulane University, New Orleans, Louisiana, USA
| | - Lily Trinh
- Department of Otolaryngology-Head and Neck Surgery, Tulane University, New Orleans, Louisiana, USA
| | - Waleed M Abuzeid
- Department of Otolaryngology-Head and Neck Surgery, Division of Rhinology and Endoscopic Skull Base Surgery, University of Washington, Seattle, Washington, USA
| | - Ian M Humphreys
- Department of Otolaryngology-Head and Neck Surgery, Division of Rhinology and Endoscopic Skull Base Surgery, University of Washington, Seattle, Washington, USA
| | - Nadeem A Akbar
- Department of Otorhinolaryngology-Head and Neck Surgery, Division of Rhinology and Skull Base Surgery, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Sharan Shah
- Department of Otorhinolaryngology-Head and Neck Surgery, Division of Rhinology and Skull Base Surgery, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Jivianne T Lee
- Department of Otolaryngology-Head and Neck Surgery, University of California Los Angeles, Los Angeles, California, USA
| | - Tara J Wu
- Department of Otolaryngology-Head and Neck Surgery, University of California Los Angeles, Los Angeles, California, USA
| | - John S Schneider
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri, USA
| | - Edward D McCoul
- Department of Otolaryngology-Head and Neck Surgery, Tulane University, New Orleans, Louisiana, USA.,Department of Otorhinolaryngology and Communication Sciences, Ochsner Clinic Foundation, New Orleans, Louisiana, USA
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Riley CA, Navarro AI, Trinh L, Abuzeid WM, Humphreys IM, Akbar NA, Shah S, Lee JT, Wu T, Schneider JS, Tolisano AM, McCoul ED. What do we mean when we have a "sinus infection?". Int Forum Allergy Rhinol 2023; 13:129-139. [PMID: 35841605 DOI: 10.1002/alr.23063] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 06/09/2022] [Accepted: 07/11/2022] [Indexed: 01/26/2023]
Abstract
INTRODUCTION Sinus infections are a common reason patients seek medical care. However, the intended meaning of the term sinus infection among patients and otolaryngologists is incompletely understood. METHODS In this multi-institutional cross-sectional study, a semantics-based questionnaire was provided to consecutive patients presenting to otolaryngology clinics at six academic centers from June 2020 until May 2021. The primary outcome was respondent definitions for sinus infection from a list of 28 proposed terms covering six general categories. Secondary outcome measures included differences between geographic regions. RESULTS Responses were obtained from 560 patients (54% female, mean age 48.9 years) and 29 otolaryngologists (42% female, mean age 37.4 years). Patients and otolaryngologists selected a median of 10 and 11 terms, respectively, to define a sinus infection. Among patients the most frequently selected symptom categories were mucus (500, 89.3%), pressure/pain (480, 85.7%), and airflow (468, 83.6%). Compared to patients, clinicians selected with greater frequency the symptom categories of pressure/pain (14.3% difference; 95% CI, 7.6% to 22.5%), mucus (10.7% difference; 95% CI, 4.7% to 18.3%) and airflow (13.0% difference; 95% CI, 4.8% to 21.7%). Multiple categories were selected by 96% of patients and 100% of providers. CONCLUSION The definition of sinus infection appears variable for both patients and otolaryngologists, though patients appear to apply a broader range of symptoms to the term sinus infection. There were no pronounced geographic differences in the description of a sinus infection in this US sample population. Patients commonly described sinus infection in the context of pain-related symptoms. Appreciation of these semantic differences may enable more effective patient-clinician communication.
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Affiliation(s)
- Charles A Riley
- Department of Otolaryngology, Head and Neck Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Alvaro I Navarro
- Department of Otolaryngology, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Lily Trinh
- Department of Otolaryngology, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Waleed M Abuzeid
- Division of Rhinology and Endoscopic Skull Base Surgery, Department of Otolaryngology - Head and Neck Surgery, University of Washington, Seattle, Washington, USA
| | - Ian M Humphreys
- Division of Rhinology and Endoscopic Skull Base Surgery, Department of Otolaryngology - Head and Neck Surgery, University of Washington, Seattle, Washington, USA
| | - Nadeem A Akbar
- Division of Rhinology and Skull Base Surgery, Department of Otorhinolaryngology - Head and Neck Surgery, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Sharan Shah
- Division of Rhinology and Skull Base Surgery, Department of Otorhinolaryngology - Head and Neck Surgery, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Jivianne T Lee
- Department of Head and Neck Surgery, University of California Los Angeles, Los Angeles, California, USA
| | - Tara Wu
- Department of Head and Neck Surgery, University of California Los Angeles, Los Angeles, California, USA
| | - John S Schneider
- Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Anthony M Tolisano
- Department of Otolaryngology, Head and Neck Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Edward D McCoul
- Department of Otolaryngology, Tulane University School of Medicine, New Orleans, Louisiana, USA.,Department of Otorhinolaryngology and Communication Sciences, Ochsner Clinic Foundation, New Orleans, Louisiana, USA
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16
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Morrison DA, Riley CA, Tolisano AM. Assessing the Impact of Military Service on Patient Health Literacy in an Otolaryngology Clinic. Mil Med 2023; 188:e333-e338. [PMID: 34190320 DOI: 10.1093/milmed/usab260] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 06/11/2021] [Accepted: 06/17/2021] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVE To examine the impact of military service on health literacy. STUDY DESIGN Prospective, cross-sectional study. SUBJECTS AND METHODS The validated Brief Health Literacy Screen (BHLS) with military supplement was administered to sequential adult patients (military and civilian) treated at two outpatient academic military otolaryngology clinics between November and December 2019. Inadequate health literacy, defined by a BHLS score ≤9, was the primary outcome measure. Secondary outcome measures included comparisons of inadequate BHLS scores with patient demographics and history of military service. RESULTS Three hundred and eighty-two patients were evaluated during the study period. The median age was 48-57 years, with a majority being male (230, 60.2%), White (264, 69.1%), married (268, 70.2%), and active duty military (303, 79.3%). A minority reported history of PTSD (39, 13%) or traumatic brain injury (29, 9.6%). Overall, very few subjects (10, 2.6%) demonstrated inadequate health literacy. Patients with prior (1.6% vs 6.3%, P < .05) or current (0% vs 5.0%, P < .05) military service had lower rates of inadequate health literary as compared to civilians. Gender, race, marital status, history of PTSD, and history of traumatic brain injury did not significantly impact health literacy. In a multivariate regression model exploring history of military service, age was not predictive of inadequate health literacy. CONCLUSIONS Both history of and current military service predict higher health literacy rates for patients treated at military otolaryngology clinics. Widely accessible health care and mandatory health evaluations for service members to maintain deployment readiness may contribute to this finding but warrant additional study.
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Affiliation(s)
- Danielle A Morrison
- Department of Otolaryngology-Head and Neck Surgery, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
| | - Charles A Riley
- Department of Otolaryngology-Head and Neck Surgery, Fort Belvoir Community Hospital, Fort Belvoir, VA 22060, USA
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Anthony M Tolisano
- Department of Otolaryngology-Head and Neck Surgery, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
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17
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Fischer JL, Riley CA, Kacker A. Sinonasal Complications Following the Sinus Lift Procedure. Ochsner J 2023; 23:147-151. [PMID: 37323513 PMCID: PMC10262945 DOI: 10.31486/toj.22.0125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023] Open
Abstract
Background: Although the incidence of postoperative acute and chronic rhinosinusitis in patients undergoing a sinus lift procedure is relatively high, a paucity of rhinology literature examines the management of and outcomes for this patient population. The objective of this study was to review the management and postoperative care of sinonasal complications and identify possible risk factors that should be considered prior to and following sinus augmentation. Methods: We identified sequential patients who had undergone a sinus lift procedure and were referred to the senior author (AK) at a tertiary rhinology practice for intractable sinonasal complications and reviewed their charts for demographic data, history of illness including prereferral treatment, examination findings, imaging results, treatment modalities, and culture results. Results: Nine patients were initially treated medically without improvement and subsequently underwent endoscopic sinus surgery. The sinus lift graft material remained intact in 7 patients. Two patients had extrusion of the graft material into the facial soft tissues, resulting in facial cellulitis requiring graft removal and debridement. Seven of the 9 patients had predisposing factors that could have prompted referral to an otolaryngologist for optimization prior to sinus lifting. The mean follow-up was 10 months, and all patients had full resolution of symptoms. Conclusion: Acute and chronic rhinosinusitis is a complication of the sinus lift procedure and is more commonly seen in patients with preexisting sinus disease, anatomic sinonasal obstruction, and Schneiderian membrane perforation. Preoperative evaluation by an otolaryngologist may improve outcomes in patients at risk of sinonasal complications from sinus lift surgery.
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Affiliation(s)
- Jakob L. Fischer
- Department of Otolaryngology, Walter Reed National Military Medical Center, Bethesda, MD
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Charles A. Riley
- Department of Otolaryngology, Walter Reed National Military Medical Center, Bethesda, MD
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Ashutosh Kacker
- Department of Otorhinolaryngology, Weill Cornell Medical College, New York, NY
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18
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Lewis RJ, Shih RY, Tolisano AM, Riley CA. Pterygopalatine Fossa Mucocele: A Common Paranasal Sinus Mass in an Uncommon Location. OTO Open 2022; 6:2473974X221121810. [PMID: 36247658 PMCID: PMC9554124 DOI: 10.1177/2473974x221121810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 08/07/2022] [Indexed: 11/05/2022] Open
Affiliation(s)
- Robert J. Lewis
- Department of Otolaryngology–Head and Neck Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA,Robert J. Lewis, MD, Department of Otolaryngology–Head and Neck Surgery, Walter Reed National Military Medical Center, 8901 Wisconsin Ave, Bethesda, MD 20889, USA.
| | - Robert Y. Shih
- Department of Radiology, Uniformed Services University, Bethesda, Maryland, USA,Department of Radiology, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Anthony M. Tolisano
- Department of Otolaryngology–Head and Neck Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA,Department of Surgery, Uniformed Services University, Bethesda, Maryland, USA
| | - Charles A. Riley
- Department of Otolaryngology–Head and Neck Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA,Department of Surgery, Uniformed Services University, Bethesda, Maryland, USA
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19
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Noller M, Fischer JL, Gudis DA, Riley CA. The Draf III procedure: A review of indications and techniques. World J Otorhinolaryngol Head Neck Surg 2022; 8:1-7. [PMID: 35619931 PMCID: PMC9126160 DOI: 10.1002/wjo2.6] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 07/04/2021] [Indexed: 11/09/2022] Open
Abstract
The Draf Ⅲ procedure involves the creation of a common frontal sinus cavity. The most common indication for the Draf Ⅲ procedure is chronic rhinosinusitis of the frontal sinuses despite the failure of more conservative interventions such as bilateral Draf Ⅱa procedures. Primary Draf Ⅲ may be indicated in patients with a high risk of failures such as those with severe polyposis and those with a frontal sinus opening less than 4 mm on computed tomography imaging. Other indications for the Draf Ⅲ include access for tumor removal and repair of traumatic fractures of the frontal sinus. The “inside‐out” Draf Ⅲ procedure is the standard approach when the frontal recess anterior–posterior diameter is wide enough for instrument access, usually larger than 4–5 mm. The “outside‐in” Draf Ⅲ procedure can be done when the frontal recess is too narrow to safely accommodate instruments. Regular follow‐up with debridement should be done to prevent neo‐ostium stenosis.
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Affiliation(s)
- Michael Noller
- Department of Otolaryngology‐Head and Neck Surgery Walter Reed National Military Medical Center Bethesda Maryland USA
| | - Jakob L. Fischer
- Department of Otolaryngology‐Head and Neck Surgery Walter Reed National Military Medical Center Bethesda Maryland USA
| | - David A. Gudis
- Department of Otolaryngology‐Head and Neck Surgery, Columbia University Medical Center New York Presbyterian Hospital New York New York USA
| | - Charles A. Riley
- Department of Otolaryngology‐Head and Neck Surgery Walter Reed National Military Medical Center Bethesda Maryland USA
- Department of Surgery Uniformed Services University of the Health Sciences Bethesda Maryland USA
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20
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Ryan MT, Malmrose J, Riley CA, Tolisano AM. Operating Room Waste Generated Across Otolaryngology Cases. Mil Med 2021; 188:usab548. [PMID: 34966924 DOI: 10.1093/milmed/usab548] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 12/02/2021] [Accepted: 12/21/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Hospital waste adds to the ecological footprint of the healthcare system, whereas inattention to recyclables may increase costs. The primary objective of this study was to assess the amount of recyclable and nonrecyclable intraoperative waste produced across representative otolaryngology surgical procedures. METHODS Representative surgical cases across four otolaryngology subspecialties at a tertiary care military medical institution were prospectively identified. Waste was collected, divided, and weighed across two categories: recyclable and nonrecyclable. This study was performed in conjunction with a hospital-approved quality improvement project. RESULTS The study included 22 otolaryngology surgeries performed across four otolaryngology subspecialties: facial plastics, pediatrics, otology, and head and neck oncology. Overall, 197.4 kg of waste was collected of which 40.2 kg (20%) was recyclable and 157.2 kg (80%) was nonrecyclable. An average of 1.8 kg of recyclable materials and 7.1 kg of nonrecyclable materials were collected per case. CONCLUSION This study supports that otolaryngology surgical procedures generate a significant amount of waste, a large component of which is recyclable. It highlights the need for proper disposal of this waste and the implementation of a recycling program at our institution with the potential for both ecologic and economic benefits.
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Affiliation(s)
- Mathew T Ryan
- Department of Otolaryngology-Head and Neck Surgery, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
| | - Jonathan Malmrose
- School of Medicine, Uniformed Services University of Health Sciences, Bethesda, MD 20814, USA
| | - Charles A Riley
- Department of Otolaryngology-Head and Neck Surgery, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
- Department of Surgery, Uniformed Services University of Health Sciences, Bethesda, MD 20814, USA
| | - Anthony M Tolisano
- Department of Otolaryngology-Head and Neck Surgery, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
- Department of Surgery, Uniformed Services University of Health Sciences, Bethesda, MD 20814, USA
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21
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Ryan MT, Riley CA, Tolisano AM. Novel Case of Profound Hearing Loss and Cochlear Implantation From New-Generation Iron Chelation Therapy. OTO Open 2021; 5:2473974X211061408. [PMID: 34870066 PMCID: PMC8637715 DOI: 10.1177/2473974x211061408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 11/03/2021] [Indexed: 11/17/2022] Open
Affiliation(s)
- Mathew T Ryan
- Department of Otolaryngology-Head and Neck Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Charles A Riley
- Department of Otolaryngology-Head and Neck Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA.,Department of Surgery, Uniformed Services University of Health Sciences, Bethesda, Maryland, USA
| | - Anthony M Tolisano
- Department of Otolaryngology-Head and Neck Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA.,Department of Surgery, Uniformed Services University of Health Sciences, Bethesda, Maryland, USA
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22
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Fischer JL, Tolisano AM, Strausborger SL, Lewin-Smith MR, Olivier KN, Riley CA. A Novel Case of Clofazimine-Induced Purple Nasal Mucosal Discoloration. JAMA Otolaryngol Head Neck Surg 2021; 147:1005-1006. [PMID: 34529032 DOI: 10.1001/jamaoto.2021.2404] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Jakob L Fischer
- Department of Otolaryngology-Head and Neck Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Anthony M Tolisano
- Department of Otolaryngology-Head and Neck Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland.,Department of Surgery, Uniformed Services University of Health Sciences, Bethesda, Maryland
| | | | | | - Kenneth N Olivier
- Pulmonary Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Charles A Riley
- Department of Otolaryngology-Head and Neck Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland.,Department of Surgery, Uniformed Services University of Health Sciences, Bethesda, Maryland
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23
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Yang A, Lewis RJ, Watson N, Riley CA, Tolisano AM. The cell phone vibration test: A telemedicine substitute for the tuning fork test. Laryngoscope Investig Otolaryngol 2021; 6:1175-1181. [PMID: 34667863 PMCID: PMC8513443 DOI: 10.1002/lio2.665] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 08/11/2021] [Accepted: 09/09/2021] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE An at home-test for differentiating between conductive and sensorineural hearing loss remains elusive. Our goal was to validate the novel cell-phone vibration test (CPVT) against the Weber tuning fork test (WTFT) and to assess if the CPVT can be self-administered by patients reliably. STUDY DESIGN Cross-sectional. METHODS The CPVT involves placement of a vibrating cellphone on the center of the forehead to determine which ear perceives the sound louder. 40 consecutive adult patients with an audiogram within 6 months and no report of recent hearing changes were recruited. Group 1 consisted of 20 patients who were examined by the provider with the CPVT and WTFT using various tuning forks (256, 512, and 1024 Hz). Group 2 consisted of an additional 20 patients who received instructions on self-administering the CPVT. Kappa statistics were calculated to assess the strength of concordance between the CPVT, WTFT, and audiometric findings for group 1 and between patient self-administered and provider administered CPVT and WTFT for group 2. RESULTS Concordance between CPVT and WTFT in the entire cohort was substantial (Kappa coefficient: 0.81 for 256 Hz, 0.73 for 512 Hz, and 0.62 for 1024 Hz) with similar concordances between actual and expected results based on audiogram (Kappa coefficient: 0.52 for CPVT and 0.52 for WTFT). Concordance between patient-administered and provider-administered CPVT showed almost perfect agreement (Kappa coefficient: 0.92). CONCLUSIONS The CPVT provides consistent results when compared to a formal WTFT and can be reliably self-administered by patients with appropriate instructions.Level of evidence: 4.
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Affiliation(s)
- Alex Yang
- F. Edward Hebert School of MedicineUniformed Services University of the Health SciencesBethesdaMarylandUSA
| | - Robert J. Lewis
- Department of Otolaryngology—Head and Neck SurgeryWalter Reed National Military Medical CenterBethesdaMarylandUSA
| | - Nora Watson
- Department of Research ProgramsWalter Reed National Military Medical CenterBethesdaMarylandUSA
| | - Charles A. Riley
- Department of Otolaryngology—Head and Neck SurgeryWalter Reed National Military Medical CenterBethesdaMarylandUSA
- Department of SurgeryUniformed Services University of the Health SciencesBethesdaMarylandUSA
| | - Anthony M. Tolisano
- Department of Otolaryngology—Head and Neck SurgeryWalter Reed National Military Medical CenterBethesdaMarylandUSA
- Department of SurgeryUniformed Services University of the Health SciencesBethesdaMarylandUSA
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Miller N, Noller M, Yang A, McCoul ED, Tolisano AM, Riley CA. Lesser Known Uses of γ-Aminobutyric Acid Analogue Medications in Otolaryngology. Laryngoscope 2021; 132:954-964. [PMID: 34536232 DOI: 10.1002/lary.29855] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 08/17/2021] [Accepted: 08/27/2021] [Indexed: 12/20/2022]
Abstract
OBJECTIVES/HYPOTHESIS In otolaryngology, γ-aminobutyric acid (GABA) analogues have been previously analyzed for their roles in neuropathic pain, chronic cough, tinnitus, and perioperative analgesia. The primary aim of this study is to comprehensively summarize and synthesize the existing evidence for lesser known uses of gabapentin and pregabalin in otolaryngology. STUDY DESIGN A scoping review conducted of the available English-language literature was performed by two authors through April 1, 2021. METHODS The Preferred Reporting Items for Systematic Review and Meta-Analysis criteria were followed, and a quality assessment of included studies was performed using the Methodological Index for Non-Randomized Studies. RESULTS Ten studies met inclusion criteria. Three studies found that gabapentin may reduce gastrostomy tube usage and improve swallowing function in head and neck cancer patients undergoing radiation therapy (RT). Three studies suggested that gabapentin may help reduce opiate use when used as a primary analgesic in patients with radiation-induced mucositis. One study demonstrated that pregabalin-reduced trismus severity in patients with radiotherapy-induced trismus. One study demonstrated gabapentin may be useful in patients with phonasthenia. Two studies demonstrated that GABA analogues may be a useful adjunct in patients with globus pharyngeus in the context of likely laryngeal sensory neuropathy. CONCLUSIONS The most promising potential uses for GABA analogues identified in this review are for improving swallowing, trismus, and narcotic overuse after RT. The benefit of GABA analogues for improving nonorganic voice disorders is also promising while the benefit for globus pharyngeus when possibly related to laryngeal sensory neuropathy is inconclusive. Laryngoscope, 2021.
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Affiliation(s)
- Nathaniel Miller
- Department of Otolaryngology-Head and Neck Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, U.S.A
| | - Michael Noller
- Department of Otolaryngology-Head and Neck Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, U.S.A
| | - Alex Yang
- F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, U.S.A
| | - Edward D McCoul
- Department of Otorhinolaryngology-Head and Neck Surgery, Ochsner Clinic, New Orleans, Louisiana, U.S.A.,Ochsner Clinical School, University of Queensland School of Medicine, New Orleans, Louisiana, U.S.A
| | - Anthony M Tolisano
- Department of Otolaryngology-Head and Neck Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, U.S.A.,Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, U.S.A
| | - Charles A Riley
- Department of Otolaryngology-Head and Neck Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, U.S.A.,Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, U.S.A
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McLean J, Anderson D, Capra G, Riley CA. The Potential Effects of Burn Pit Exposure on the Respiratory Tract: A Systematic Review. Mil Med 2021; 186:672-681. [PMID: 33620077 DOI: 10.1093/milmed/usab070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 12/20/2020] [Accepted: 02/10/2021] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Burn pits (BPs) have been widely used by the U.S. military for waste disposal while in conflicts abroad. Significant adverse health effects are thought to be linked to BPs, but limited data exist examining the impact on the respiratory tract. The purpose of this systematic review is to characterize these effects on both the upper respiratory tract (URT) and lower respiratory tract (LRT). MATERIALS AND METHODS A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines on articles published from January 1, 2001, through November 2020. PubMed, EMBASE, and Ovid MEDLINE databases were queried for studies examining the effect of BPs on the URT and LRT of service members. RESULTS A total of 288 articles were identified, with nine meeting inclusion criteria. Eight of the nine articles assessed the LRT, one examined the URT alone, and two examined both the URT and LRT. Outcome measures were heterogeneous across all studies, precluding meta-analysis. Patient-reported LRT diagnoses appeared to increase as exposure to BPs increased. There are very limited data assessing the impact of BP exposure on the URT. No association between BP exposure and objective measures of LRT or URT disease was identified. CONCLUSION Service members deployed to combat zones seem to report a significant increase in respiratory diseases following exposure to BPs, although definitive conclusions are limited by multiple airborne exposures and varied reporting methods. Self-reported LRT diagnoses appear to be more prevalent. There is a paucity of data on the effects of BPs on the URT. Objective measures of disease do not appear to correlate with patient reports. Prospective, long-term, and outcome-based studies are necessary to examine the effects of BPs, and other airborne hazards related to deployment, on the URT and LRT of service members.
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Affiliation(s)
- James McLean
- Department of Otolaryngology-Head and Neck Surgery, Naval Medical Center Portsmouth, Portsmouth, VA 23708, USA
| | - Danielle Anderson
- Department of Otolaryngology-Head and Neck Surgery, James A. Lovell Federal Health Care Center, North Chicago, IL 60064, USA
| | - Gregory Capra
- Department of Otolaryngology-Head and Neck Surgery, Naval Medical Center Portsmouth, Portsmouth, VA 23708, USA
| | - Charles A Riley
- Division of Otolaryngology-Head and Neck Surgery, Fort Belvoir Community Hospital, Fort Belvoir, VA 22060, USA.,Department of Surgery, Uniformed Services University of Health Sciences, Bethesda, MD 20814, USA
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Riley CA, Tolisano AM, Gudis DA, Lawlor CM, Kimbrell T. A career-saving collaboration between human and veterinary medicine. Int Forum Allergy Rhinol 2021; 11:1707-1709. [PMID: 34101366 DOI: 10.1002/alr.22852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Revised: 05/22/2021] [Accepted: 05/25/2021] [Indexed: 11/07/2022]
Affiliation(s)
- Charles A Riley
- Department of Otolaryngology-Head and Neck Surgery, Walter Reed National Military, Medical Center, Bethesda, MD.,Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Anthony M Tolisano
- Department of Otolaryngology-Head and Neck Surgery, Walter Reed National Military, Medical Center, Bethesda, MD.,Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - David A Gudis
- Department of Otolaryngology-Head and Neck Surgery, Columbia University Medical Center, New York Presbyterian Hospital, New York, NY
| | - Claire M Lawlor
- Department of Otolaryngology-Head and Neck Surgery, Children's National Health System, Washington, DC
| | - Tiffany Kimbrell
- Division of Veterinary Medicine and Surgery, Fort Belvoir Community Hospital, Fort Belvoir, VA
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Riley PE, Fischer JL, Nagy RE, Watson NL, McCoul ED, Tolisano AM, Riley CA. Patient and Provider Satisfaction With Telemedicine in Otolaryngology. OTO Open 2021; 5:2473974X20981838. [PMID: 33474522 PMCID: PMC7797587 DOI: 10.1177/2473974x20981838] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 11/11/2020] [Indexed: 12/11/2022] Open
Abstract
Objective The objective of this study is to evaluate patient and provider satisfaction with telemedicine encounters across 3 otolaryngology practices. Study Design Cross-sectional survey. Setting A military community hospital, an academic military hospital, and a nonmilitary academic center. Methods A telephone-based survey of patients undergoing telemedicine encounters for routine otolaryngology appointments was performed between April and July 2020. Patients were asked about their satisfaction, the factors affecting care, and demographic information. A provider survey was emailed to staff otolaryngologists. The survey asked about satisfaction, concerns for reimbursement or liability, encounters best suited for telemedicine, and demographic information. The results were analyzed with descriptive statistics and a multivariable logistic linear regression model to determine odds ratios. Results A total of 325 patients were surveyed, demonstrating high satisfaction with telemedicine (average score, 4.49 of 5 [best possible answer]). Patients perceived “no negative impact” or “minor negative impact” on the encounter due to the lack of a physical examination or face-to-face interaction (1.86 and 1.95 of 5, respectively). High satisfaction was consistent across groups for distance to travel, age, and reason for referral. A total of 25 providers were surveyed, with an average satisfaction score of 3.44 of 5. Providers reported “slight” to “somewhat” concern about reimbursement (40%) and liability (32%). Conclusion Given patients’ and providers’ levels of satisfaction, there is likely a role for telemedicine in otolaryngology practice that may benefit patient care independent of the COVID-19 pandemic.
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Affiliation(s)
- Phoebe Elizabeth Riley
- Department of Otolaryngology-Head and Neck Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Jakob L Fischer
- Department of Otolaryngology-Head and Neck Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Ryan E Nagy
- School of Medicine, Tulane University, New Orleans, Louisiana, USA
| | - Nora L Watson
- Department of Research Programs, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Edward D McCoul
- Department of Otolaryngology-Head and Neck Surgery, Ochsner Medical Center, New Orleans, Louisiana, USA
| | - Anthony M Tolisano
- Department of Otolaryngology-Head and Neck Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA.,Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Charles A Riley
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.,Department of Otolaryngology-Head and Neck Surgery, Fort Belvoir Community Hospital, Fort Belvoir, Virginia, USA
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Fischer JL, Watson NL, Tolisano AM, Riley CA. Assessing health literacy in rhinologic patients. Int Forum Allergy Rhinol 2020; 11:818-821. [PMID: 33184981 DOI: 10.1002/alr.22733] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 10/15/2020] [Accepted: 10/20/2020] [Indexed: 11/08/2022]
Affiliation(s)
- Jakob L Fischer
- Department of Otolaryngology-Head and Neck Surgery, Walter Reed National Military Medical Center, Bethesda, MD
| | - Nora L Watson
- Department of Research Programs, Walter Reed National Military Medical Center, Bethesda, MD
| | - Anthony M Tolisano
- Department of Otolaryngology-Head and Neck Surgery, Walter Reed National Military Medical Center, Bethesda, MD.,Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Charles A Riley
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD.,Division of Otolaryngology-Head and Neck Surgery, Fort Belvoir Community Hospital, Fort Belvoir, VA
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Sommerfeldt JM, Fischer JL, Morrison DA, McCoul ED, Riley CA, Tolisano AM. A Dizzying Complaint: Investigating the Intended Meaning of Dizziness Among Patients and Providers. Laryngoscope 2020; 131:E1443-E1449. [PMID: 33185282 DOI: 10.1002/lary.29271] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 10/28/2020] [Accepted: 11/03/2020] [Indexed: 11/10/2022]
Abstract
OBJECTIVE/HYPOTHESIS To assess for semantic differences regarding the definition of dizziness among otolaryngology patients, otolaryngologists, and non-otolaryngologist providers. STUDY DESIGN Cross-sectional survey. METHODS Between March and May 2020, a survey consisting of 20 common descriptors for dizziness within five domains (lightheadedness, motion sensitivity, imbalance, vision complaints, and pain) was completed by patients at two outpatient otolaryngology clinics. Surveys were subsequently obtained from otolaryngology and non-otolaryngology providers attending a multidisciplinary dizziness lecture. The primary outcome measure was to assess for differences in definition of dizziness between patients and providers. Secondary outcome measures included assessing differences between otolaryngologists and non-otolaryngologists. RESULTS About 221 patients and 100 providers participated. Patients selected a median of 7 terms compared to 8 for providers (P = .375), although providers had a larger overall distribution of number of terms selected (P = .038). Patients were more likely than providers to define dizziness according to the following domains: lightheadedness (difference 15.0%; 95% confidence interval [CI] 5.5%-25.3%), vision complaints (difference 21.6%, 95% CI 12.0%-29.6%), and pain (difference 11.5%, 95% CI 4.7%-17.1%). Providers were more likely to define dizziness according to the motion sensitivity domain (difference 13.8%, 95% CI 6.8%-19.6%). Otolaryngology and non-otolaryngology providers defined dizziness similarly across symptom domains. CONCLUSION Although patients and providers both view dizziness as imbalance, patients more commonly describe dizziness in the context of lightheadedness, vision complaints, and pain, whereas providers more frequently define dizziness according to motion sensitivity. These semantic differences create an additional barrier to effective patient-provider communication. LEVEL OF EVIDENCE 4. Laryngoscope, 131:E1443-E1449, 2021.
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Affiliation(s)
| | - Jakob L Fischer
- Department of Otolaryngology - Head and Neck Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, U.S.A
| | - Danielle A Morrison
- Department of Otolaryngology - Head and Neck Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, U.S.A
| | - Edward D McCoul
- Department of Otorhinolaryngology, Ochsner Clinic Foundation, New Orleans, Louisiana, U.S.A
| | - Charles A Riley
- Division of Otolaryngology - Head and Neck Surgery, Fort Belvoir Community Hospital, Fort Belvoir, Virginia, U.S.A.,Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, U.S.A
| | - Anthony M Tolisano
- Department of Otolaryngology - Head and Neck Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, U.S.A.,Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, U.S.A
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Tolisano AM, Blood TC, Riley CA, Ruhl DS, Hong SS. The COVID-19 Airway Management Isolation Chamber (CAMIC) for Ears. Laryngoscope 2020; 130:2690-2692. [PMID: 32602111 PMCID: PMC7361893 DOI: 10.1002/lary.28942] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 05/29/2020] [Accepted: 06/21/2020] [Indexed: 11/17/2022]
Affiliation(s)
- Anthony M Tolisano
- Department of Otolaryngology-Head and Neck Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, U.S.A.,Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, U.S.A
| | - Timothy C Blood
- Department of Otolaryngology-Head and Neck Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, U.S.A
| | - Charles A Riley
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, U.S.A.,Department of Otolaryngology-Head and Neck Surgery, Fort Belvoir Community Hospital, Fort Belvoir, Virginia, U.S.A
| | - Douglas S Ruhl
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, U.S.A.,Department of Otolaryngology-Head and Neck Surgery, Madigan Army Medical Center, Tacoma, Washington, U.S.A
| | - Steven S Hong
- Department of Otolaryngology-Head and Neck Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, U.S.A.,Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, U.S.A
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Abstract
Objective During the coronavirus pandemic (COVID-19), health care workers are innovating patient care and safety measures. Unfortunately, many of these are not properly tested for efficacy. The objective of this study was to determine the efficacy of the novel COVID-19 Airway Management Isolation Chamber (CAMIC) to contain and evacuate particulate. Study Design Multi-institutional proof-of-concept study. Setting Two academic institutions: Walter Reed National Military Medical Center (WRNMMC) and Madigan Army Medical Center (MAMC). Subjects and Methods Smoke, saline nebulizer, and simulated working port models were developed to assess the efficacy of the CAMIC to contain and remove ultrafine particles. Particulate counts were collected at set time intervals inside and outside the system. Results With the CAMIC on, smoke particulate counts inside the chamber significantly decreased over time: r(18) = −0.88, P < .001, WRNMMC; r(18) = −0.91, P < .001, MAMC. Similarly, saline nebulizer particulate counts inside the chamber significantly decreased over time: r(23) = −0.82, P < .001, WRNMMC; r(23) = −0.70, P < .001, MAMC. In the working port model, particulate counts inside the chamber significantly decreased over time: r(23) = −0.95, P < .001, WRNMMC; r(23) = −0.85, P < .001, MAMC. No significant leak was detected in the smoke, saline nebulizer, or working port model when the CAMIC was turned on. Conclusions The CAMIC system appears to provide a barrier that actively removes particles from within the chamber and limits egress. Further studies are necessary to determine clinical applicability. The CAMIC may serve as an adjunct to improve health care worker safety and patient outcomes.
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Affiliation(s)
- Timothy C Blood
- Department of Otolaryngology-Head and Neck Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Jonathan N Perkins
- Department of Otolaryngology-Head and Neck Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Paul R Wistermayer
- Department of Otolaryngology-Head and Neck Surgery, Madigan Army Medical Center, Tacoma, Washington, USA
| | - Joseph S Krivda
- F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Nathan T Fisher
- Telemedicine and Advanced Technology Research Center, US Army Medical Research and Development Command, Fort Detrick, Maryland, USA
| | - Charles A Riley
- Department of Otolaryngology-Head and Neck Surgery, Fort Belvoir Community Hospital, Fort Belvoir, Virginia, USA.,Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Douglas S Ruhl
- Department of Otolaryngology-Head and Neck Surgery, Madigan Army Medical Center, Tacoma, Washington, USA.,Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Steven S Hong
- Department of Otolaryngology-Head and Neck Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA.,Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
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Parsel SM, Riley CA, Todd CA, Thomas AJ, McCoul ED. Differentiation of Clinical Patterns Associated With Rhinologic Disease. Am J Rhinol Allergy 2020; 35:179-186. [PMID: 32664744 DOI: 10.1177/1945892420941706] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Common rhinologic diagnoses have similar presentations with a varying degree of overlap. Patterns may exist within clinical data that can be useful for early diagnosis and predicting outcomes. OBJECTIVE To explore the feasibility of artificial intelligence to differentiate patterns in patient data in order to develop clinically-meaningful diagnostic groups. METHODS A cross-sectional study of prospectively-acquired patient data at a tertiary rhinology clinic was performed. Data extracted included objective findings on nasal endoscopy, patient reported quality of life (PRQOL) instrument ratings, peripheral eosinophil fraction, and past medical history. Unsupervised non-hierarchical cluster analysis was performed to discover patterns in the data using 22 input variables. RESULTS A total of 545 patients were analyzed after application of inclusion and exclusion criteria yielding 7 unique patient clusters, highly dependent on PRQOL scores and demographics. The clusters were clinically-relevant with distinct characteristics. Chronic rhinosinusitis without nasal polyposis (CRSsNP) was associated with two clusters having low frequencies of asthma and low eosinophil fractions. Chronic rhinosinusitis with nasal polyposis (CRSwNP) was associated with high frequency of asthma, mean (standard deviation [SD]) NOSE scores of 66 (19) and SNOT-22 scores of 41 (15), and high eosinophil fractions. AR was present in multiple clusters. RARS was associated with the youngest population with mean (SD) NOSE score of 54 (23) and SNOT-22 score of 41 (19). CONCLUSION Broader consideration of initially available clinical data may improve diagnostic efficiency for rhinologic conditions without ancillary studies, using computer-driven algorithms. PRQOL scores and demographic information appeared to be useful adjuncts, with associations to diagnoses in this pilot study.
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Affiliation(s)
- Sean M Parsel
- Department of Otolaryngology-Head and Neck Surgery, Tulane University, New Orleans, Louisiana
| | - Charles A Riley
- Department of Otolaryngology, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Cameron A Todd
- Department of Otolaryngology, Wake Forest University, Winston-Salem, North Carolina
| | - Andrew J Thomas
- Department of Otorhinolaryngology, Ochsner Health System, New Orleans, Louisiana
| | - Edward D McCoul
- Department of Otolaryngology-Head and Neck Surgery, Tulane University, New Orleans, Louisiana.,Department of Otorhinolaryngology, Ochsner Health System, New Orleans, Louisiana.,Ochsner Clinical School, University of Queensland School of Medicine, New Orleans, Louisiana
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Zheng Z, Riley CA, Kim M, Sclafani A, Tabaee A. Opioid prescribing patterns and usage after rhinologic surgery: A systematic review. Am J Otolaryngol 2020; 41:102539. [PMID: 32451289 DOI: 10.1016/j.amjoto.2020.102539] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Revised: 04/30/2020] [Accepted: 05/03/2020] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Judicious management of analgesics following rhinologic surgery is important for curtailing over-prescription of opioids. Limited data exists defining expected pain levels and appropriate opioid requirements after rhinologic surgery. METHODS A systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. PubMed, Embase, Ovid MEDLINE, Cochrane Library databases were queried, and relevant articles were identified. RESULTS A total of 405 articles were identified, of which 13 met final inclusion criteria. Significant heterogeneity existed regarding type and quantity of opioid medication prescribed. Eight studies utilized a subjective patient-reported pain score as an outcome measure and reported mild to moderate postoperative pain that diminished over the first 3-6 days. Eight studies reported over-prescription of opioid medications with inappropriate storage of excess pills at home. Several factors were associated with an increased opioid requirement, including concurrent septoplasty, younger age, and current smoking status. CONCLUSION Rhinologic surgery is well tolerated with mild to moderate, short-lived postoperative pain. A limited amount and duration of opioid medications is required for routine management. Patients are frequently prescribed more opioids than is necessary for expected pain level, resulting in the potential for opioid misuse, abuse, and diversion. Current evidence is limited by a predominance of level 4 studies. Larger, higher quality studies with standardized reporting of pain score and opioid prescription quantity are needed.
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Affiliation(s)
- Zhong Zheng
- Department of Otolaryngology - Head and Neck Surgery, New York Presbyterian Hospital - Weill Cornell Medicine, New York, NY, USA
| | - Charles A Riley
- Department of Otolaryngology - Head and Neck Surgery, Fort Belvoir Community Hospital and Walter Reed National Military Medical Center, Fort Belvoir, VA, USA
| | - Matthew Kim
- Department of Otolaryngology - Head and Neck Surgery, New York Presbyterian Hospital - Weill Cornell Medicine, New York, NY, USA
| | - Anthony Sclafani
- Department of Otolaryngology - Head and Neck Surgery, New York Presbyterian Hospital - Weill Cornell Medicine, New York, NY, USA
| | - Abtin Tabaee
- Department of Otolaryngology - Head and Neck Surgery, New York Presbyterian Hospital - Weill Cornell Medicine, New York, NY, USA.
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Fischer JL, Riley CA, Hsieh MC, Marino MJ, Wu XC, McCoul ED. Prevalence of Eustachian Tube Dysfunction in the US Elderly Population. Otolaryngol Head Neck Surg 2020; 163:1169-1177. [DOI: 10.1177/0194599820932541] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Objective To investigate the prevalence of eustachian tube dysfunction (ETD) in elderly adults in the United States and its association with other upper aerodigestive inflammatory processes. Study Design Cross-sectional study. Setting Population based. Subjects and Methods In total, 147,805 patients without malignancy were compared to 13,804 demographically matched patients with malignancy of the upper aerodigestive tract (UADT) by querying the Surveillance, Epidemiology, and End Results (SEER)–Medicare linked database for patients aged 66 to 99 years between 2003 and 2011. The prevalence of ETD and inflammatory diseases among these patients was compared. Association between ETD, other upper aerodigestive inflammatory processes, and UADT malignancies was evaluated. Results The prevalence of ETD was 5.44% among patients without malignancy and 9.08% in those with cancer (odds ratio [OR], 1.73; 95% CI, 1.63-1.84). Patients with ETD in the control population were more likely (OR, 95% CI) to be diagnosed with chronic rhinitis (5.00, 4.70-5.33), chronic sinusitis (4.20, 3.98-4.43), allergic rhinitis (4.27, 4.08-4.47), and gastroesophageal reflux disease (GERD) (2.42, 2.31-2.53). Patients with ETD and chronic rhinitis (1.43, 1.24-1.65), chronic sinusitis (1.57, 1.38-1.78), and acute otitis media (1.33, 1.08-1.65) were associated with higher rates of UADT malignancy. Conclusion Over 5% of patients older than 65 in the United States are diagnosed with ETD in the absence of UADT malignancy. Associations between ETD and chronic rhinitis, chronic sinusitis, allergic rhinitis, and GERD in the absence of UADT malignancy suggest that some patients may benefit from treatment of inflammatory disease as a cause of ETD.
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Affiliation(s)
- Jakob L. Fischer
- Department of Otolaryngology–Head and Neck Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Charles A. Riley
- Division of Otolaryngology–Head and Neck Surgery, Fort Belvoir Community Hospital, Fort Belvoir, Virginia, USA
- Department of Surgery, Uniformed Services University of Health Sciences, Bethesda, Maryland, USA
| | - Mei-Chin Hsieh
- Louisiana Tumor Registry/Epidemiology Program, School of Public Health, Louisiana State University Health Sciences Center, New Orleans, Louisiana, USA
| | - Michael J. Marino
- Department of Otolaryngology–Head and Neck Surgery, Mayo Clinic Foundation, Phoenix, Arizona, USA
| | - Xiao-Cheng Wu
- Louisiana Tumor Registry/Epidemiology Program, School of Public Health, Louisiana State University Health Sciences Center, New Orleans, Louisiana, USA
| | - Edward D. McCoul
- Department of Otolaryngology–Head and Neck Surgery, Tulane University School of Medicine, New Orleans, Louisiana, USA
- Department of Otorhinolaryngology, Ochsner Clinic Foundation, New Orleans, Louisiana, USA
- Ochsner Clinical School, University of Queensland School of Medicine, New Orleans, Louisiana, USA
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Tunkel DE, Anne S, Payne SC, Ishman SL, Rosenfeld RM, Abramson PJ, Alikhaani JD, Benoit MM, Bercovitz RS, Brown MD, Chernobilsky B, Feldstein DA, Hackell JM, Holbrook EH, Holdsworth SM, Lin KW, Lind MM, Poetker DM, Riley CA, Schneider JS, Seidman MD, Vadlamudi V, Valdez TA, Nnacheta LC, Monjur TM. Clinical Practice Guideline: Nosebleed (Epistaxis). Otolaryngol Head Neck Surg 2020; 162:S1-S38. [PMID: 31910111 DOI: 10.1177/0194599819890327] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Nosebleed, also known as epistaxis, is a common problem that occurs at some point in at least 60% of people in the United States. While the majority of nosebleeds are limited in severity and duration, about 6% of people who experience nosebleeds will seek medical attention. For the purposes of this guideline, we define the target patient with a nosebleed as a patient with bleeding from the nostril, nasal cavity, or nasopharynx that is sufficient to warrant medical advice or care. This includes bleeding that is severe, persistent, and/or recurrent, as well as bleeding that impacts a patient's quality of life. Interventions for nosebleeds range from self-treatment and home remedies to more intensive procedural interventions in medical offices, emergency departments, hospitals, and operating rooms. Epistaxis has been estimated to account for 0.5% of all emergency department visits and up to one-third of all otolaryngology-related emergency department encounters. Inpatient hospitalization for aggressive treatment of severe nosebleeds has been reported in 0.2% of patients with nosebleeds. PURPOSE The primary purpose of this multidisciplinary guideline is to identify quality improvement opportunities in the management of nosebleeds and to create clear and actionable recommendations to implement these opportunities in clinical practice. Specific goals of this guideline are to promote best practices, reduce unjustified variations in care of patients with nosebleeds, improve health outcomes, and minimize the potential harms of nosebleeds or interventions to treat nosebleeds. The target patient for the guideline is any individual aged ≥3 years with a nosebleed or history of nosebleed who needs medical treatment or seeks medical advice. The target audience of this guideline is clinicians who evaluate and treat patients with nosebleed. This includes primary care providers such as family medicine physicians, internists, pediatricians, physician assistants, and nurse practitioners. It also includes specialists such as emergency medicine providers, otolaryngologists, interventional radiologists/neuroradiologists and neurointerventionalists, hematologists, and cardiologists. The setting for this guideline includes any site of evaluation and treatment for a patient with nosebleed, including ambulatory medical sites, the emergency department, the inpatient hospital, and even remote outpatient encounters with phone calls and telemedicine. Outcomes to be considered for patients with nosebleed include control of acute bleeding, prevention of recurrent episodes of nasal bleeding, complications of treatment modalities, and accuracy of diagnostic measures. This guideline addresses the diagnosis, treatment, and prevention of nosebleed. It focuses on nosebleeds that commonly present to clinicians via phone calls, office visits, and emergency room encounters. This guideline discusses first-line treatments such as nasal compression, application of vasoconstrictors, nasal packing, and nasal cautery. It also addresses more complex epistaxis management, which includes the use of endoscopic arterial ligation and interventional radiology procedures. Management options for 2 special groups of patients-patients with hereditary hemorrhagic telangiectasia syndrome and patients taking medications that inhibit coagulation and/or platelet function-are included in this guideline. This guideline is intended to focus on evidence-based quality improvement opportunities judged most important by the guideline development group. It is not intended to be a comprehensive, general guide for managing patients with nosebleed. In this context, the purpose is to define useful actions for clinicians, generalists, and specialists from a variety of disciplines to improve quality of care. Conversely, the statements in this guideline are not intended to limit or restrict care provided by clinicians based on their experience and assessment of individual patients. ACTION STATEMENTS The guideline development group made recommendations for the following key action statements: (1) At the time of initial contact, the clinician should distinguish the nosebleed patient who requires prompt management from the patient who does not. (2) The clinician should treat active bleeding for patients in need of prompt management with firm sustained compression to the lower third of the nose, with or without the assistance of the patient or caregiver, for 5 minutes or longer. (3a) For patients in whom bleeding precludes identification of a bleeding site despite nasal compression, the clinician should treat ongoing active bleeding with nasal packing. (3b) The clinician should use resorbable packing for patients with a suspected bleeding disorder or for patients who are using anticoagulation or antiplatelet medications. (4) The clinician should educate the patient who undergoes nasal packing about the type of packing placed, timing of and plan for removal of packing (if not resorbable), postprocedure care, and any signs or symptoms that would warrant prompt reassessment. (5) The clinician should document factors that increase the frequency or severity of bleeding for any patient with a nosebleed, including personal or family history of bleeding disorders, use of anticoagulant or antiplatelet medications, or intranasal drug use. (6) The clinician should perform anterior rhinoscopy to identify a source of bleeding after removal of any blood clot (if present) for patients with nosebleeds. (7a) The clinician should perform, or should refer to a clinician who can perform, nasal endoscopy to identify the site of bleeding and guide further management in patients with recurrent nasal bleeding, despite prior treatment with packing or cautery, or with recurrent unilateral nasal bleeding. (8) The clinician should treat patients with an identified site of bleeding with an appropriate intervention, which may include one or more of the following: topical vasoconstrictors, nasal cautery, and moisturizing or lubricating agents. (9) When nasal cautery is chosen for treatment, the clinician should anesthetize the bleeding site and restrict application of cautery only to the active or suspected site(s) of bleeding. (10) The clinician should evaluate, or refer to a clinician who can evaluate, candidacy for surgical arterial ligation or endovascular embolization for patients with persistent or recurrent bleeding not controlled by packing or nasal cauterization. (11) In the absence of life-threatening bleeding, the clinician should initiate first-line treatments prior to transfusion, reversal of anticoagulation, or withdrawal of anticoagulation/antiplatelet medications for patients using these medications. (12) The clinician should assess, or refer to a specialist who can assess, the presence of nasal telangiectasias and/or oral mucosal telangiectasias in patients who have a history of recurrent bilateral nosebleeds or a family history of recurrent nosebleeds to diagnose hereditary hemorrhagic telangiectasia syndrome. (13) The clinician should educate patients with nosebleeds and their caregivers about preventive measures for nosebleeds, home treatment for nosebleeds, and indications to seek additional medical care. (14) The clinician or designee should document the outcome of intervention within 30 days or document transition of care in patients who had a nosebleed treated with nonresorbable packing, surgery, or arterial ligation/embolization. The policy level for the following recommendation, about examination of the nasal cavity and nasopharynx using nasal endoscopy, was an option: (7b) The clinician may perform, or may refer to a clinician who can perform, nasal endoscopy to examine the nasal cavity and nasopharynx in patients with epistaxis that is difficult to control or when there is concern for unrecognized pathology contributing to epistaxis.
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Affiliation(s)
- David E Tunkel
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - Spencer C Payne
- University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Stacey L Ishman
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | | | | | | | | | - Rachel S Bercovitz
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | | | | | | | - Jesse M Hackell
- Pomona Pediatrics, Boston Children's Health Physicians, Pomona, New York, USA
| | | | | | | | - Meredith Merz Lind
- Nationwide Children's Hospital/The Ohio State University, Columbus, Ohio, USA
| | | | | | - John S Schneider
- Washington University School of Medicine, St Louis, Missouri, USA
| | - Michael D Seidman
- AdventHealth Medical Group, Celebration, Florida, USA.,University of Central Florida, Orlando, Florida, USA.,University of South Florida, Tampa, Florida, USA
| | | | | | - Lorraine C Nnacheta
- American Academy of Otolaryngology-Head and Neck Surgery Foundation, Alexandria, Virginia, USA
| | - Taskin M Monjur
- American Academy of Otolaryngology-Head and Neck Surgery Foundation, Alexandria, Virginia, USA
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Tunkel DE, Anne S, Payne SC, Ishman SL, Rosenfeld RM, Abramson PJ, Alikhaani JD, Benoit MM, Bercovitz RS, Brown MD, Chernobilsky B, Feldstein DA, Hackell JM, Holbrook EH, Holdsworth SM, Lin KW, Lind MM, Poetker DM, Riley CA, Schneider JS, Seidman MD, Vadlamudi V, Valdez TA, Nnacheta LC, Monjur TM. Clinical Practice Guideline: Nosebleed (Epistaxis) Executive Summary. Otolaryngol Head Neck Surg 2020; 162:8-25. [PMID: 31910122 DOI: 10.1177/0194599819889955] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Nosebleed, also known as epistaxis, is a common problem that occurs at some point in at least 60% of people in the United States. While the great majority of nosebleeds are limited in severity and duration, about 6% of people who experience nosebleeds will seek medical attention. For the purposes of this guideline, we define the target patient with a nosebleed as a patient with bleeding from the nostril, nasal cavity, or nasopharynx that is sufficient to warrant medical advice or care. This includes bleeding that is severe, persistent, and/or recurrent, as well as bleeding that impacts a patient's quality of life. Interventions for nosebleeds range from self-treatment and home remedies to more intensive procedural interventions in medical offices, emergency departments, hospitals, and operating rooms. Epistaxis has been estimated to account for 0.5% of all emergency department visits and up to one-third of all otolaryngology-related emergency department encounters. Inpatient hospitalization for aggressive treatment of severe nosebleeds has been reported in 0.2% of patients with nosebleeds. PURPOSE The primary purpose of this multidisciplinary guideline is to identify quality improvement opportunities in the management of nosebleeds and to create clear and actionable recommendations to implement these opportunities in clinical practice. Specific goals of this guideline are to promote best practices, reduce unjustified variations in care of patients with nosebleeds, improve health outcomes, and minimize the potential harms of nosebleeds or interventions to treat nosebleeds. The target patient for the guideline is any individual aged ≥3 years with a nosebleed or history of nosebleed who needs medical treatment or seeks medical advice. The target audience of this guideline is clinicians who evaluate and treat patients with nosebleed. This includes primary care providers such as family medicine physicians, internists, pediatricians, physician assistants, and nurse practitioners. It also includes specialists such as emergency medicine providers, otolaryngologists, interventional radiologists/neuroradiologists and neurointerventionalists, hematologists, and cardiologists. The setting for this guideline includes any site of evaluation and treatment for a patient with nosebleed, including ambulatory medical sites, the emergency department, the inpatient hospital, and even remote outpatient encounters with phone calls and telemedicine. Outcomes to be considered for patients with nosebleed include control of acute bleeding, prevention of recurrent episodes of nasal bleeding, complications of treatment modalities, and accuracy of diagnostic measures. This guideline addresses the diagnosis, treatment, and prevention of nosebleed. It will focus on nosebleeds that commonly present to clinicians with phone calls, office visits, and emergency room encounters. This guideline discusses first-line treatments such as nasal compression, application of vasoconstrictors, nasal packing, and nasal cautery. It also addresses more complex epistaxis management, which includes the use of endoscopic arterial ligation and interventional radiology procedures. Management options for 2 special groups of patients, patients with hemorrhagic telangiectasia syndrome (HHT) and patients taking medications that inhibit coagulation and/or platelet function, are included in this guideline. This guideline is intended to focus on evidence-based quality improvement opportunities judged most important by the working group. It is not intended to be a comprehensive, general guide for managing patients with nosebleed. In this context, the purpose is to define useful actions for clinicians, generalists, and specialists from a variety of disciplines to improve quality of care. Conversely, the statements in this guideline are not intended to limit or restrict care provided by clinicians based upon their experience and assessment of individual patients. ACTION STATEMENTS The guideline development group made recommendations for the following key action statements: (1) At the time of initial contact, the clinician should distinguish the nosebleed patient who requires prompt management from the patient who does not. (2) The clinician should treat active bleeding for patients in need of prompt management with firm sustained compression to the lower third of the nose, with or without the assistance of the patient or caregiver, for 5 minutes or longer. (3a) For patients in whom bleeding precludes identification of a bleeding site despite nasal compression, the clinician should treat ongoing active bleeding with nasal packing. (3b) The clinician should use resorbable packing for patients with a suspected bleeding disorder or for patients who are using anticoagulation or antiplatelet medications. (4) The clinician should educate the patient who undergoes nasal packing about the type of packing placed, timing of and plan for removal of packing (if not resorbable), postprocedure care, and any signs or symptoms that would warrant prompt reassessment. (5) The clinician should document factors that increase the frequency or severity of bleeding for any patient with a nosebleed, including personal or family history of bleeding disorders, use of anticoagulant or antiplatelet medications, or intranasal drug use. (6) The clinician should perform anterior rhinoscopy to identify a source of bleeding after removal of any blood clot (if present) for patients with nosebleeds. (7a) The clinician should perform, or should refer to a clinician who can perform, nasal endoscopy to identify the site of bleeding and guide further management in patients with recurrent nasal bleeding, despite prior treatment with packing or cautery, or with recurrent unilateral nasal bleeding. (8) The clinician should treat patients with an identified site of bleeding with an appropriate intervention, which may include 1 or more of the following: topical vasoconstrictors, nasal cautery, and moisturizing or lubricating agents. (9) When nasal cautery is chosen for treatment, the clinician should anesthetize the bleeding site and restrict application of cautery only to the active or suspected site(s) of bleeding. (10) The clinician should evaluate, or refer to a clinician who can evaluate, candidacy for surgical arterial ligation or endovascular embolization for patients with persistent or recurrent bleeding not controlled by packing or nasal cauterization. (11) In the absence of life-threatening bleeding, the clinician should initiate first-line treatments prior to transfusion, reversal of anticoagulation, or withdrawal of anticoagulation/antiplatelet medications for patients using these medications. (12) The clinician should assess, or refer to a specialist who can assess, the presence of nasal telangiectasias and/or oral mucosal telangiectasias in patients who have a history of recurrent bilateral nosebleeds or a family history of recurrent nosebleeds to diagnose hereditary hemorrhagic telangiectasia syndrome (HHT). (13) The clinician should educate patients with nosebleeds and their caregivers about preventive measures for nosebleeds, home treatment for nosebleeds, and indications to seek additional medical care. (14) The clinician or designee should document the outcome of intervention within 30 days or document transition of care in patients who had a nosebleed treated with nonresorbable packing, surgery, or arterial ligation/embolization. The policy level for the following recommendation about examination of the nasal cavity and nasopharynx using nasal endoscopy was an option: (7b) The clinician may perform, or may refer to a clinician who can perform, nasal endoscopy to examine the nasal cavity and nasopharynx in patients with epistaxis that is difficult to control or when there is concern for unrecognized pathology contributing to epistaxis.
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Affiliation(s)
- David E Tunkel
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - Spencer C Payne
- University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Stacey L Ishman
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | | | | | | | | | - Rachel S Bercovitz
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | | | | | | | - Jesse M Hackell
- Pomona Pediatrics, a Division of Boston Children's Health Physicians, Pomona, New York, USA
| | | | | | | | - Meredith Merz Lind
- Nationwide Children's Hospital/The Ohio State University, Columbus, Ohio, USA
| | | | | | - John S Schneider
- Washington University School of Medicine, St Louis, Missouri, USA
| | - Michael D Seidman
- AdventHealth Medical Group, Celebration, Florida, USA.,University of Central Florida, Orlando, Florida, USA.,University of South Florida, Tampa, Florida, USA
| | | | | | - Lorraine C Nnacheta
- American Academy of Otolaryngology-Head and Neck Surgery Foundation, Alexandria, Virginia, USA
| | - Taskin M Monjur
- American Academy of Otolaryngology-Head and Neck Surgery Foundation, Alexandria, Virginia, USA
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Nesbitt NB, Noller MW, Watson NL, Soneru CP, McCoul ED, Riley CA. Outcomes and Complications with Topical Epinephrine in Endoscopic Sinus Surgery: A Systematic Review and Meta-analysis. Otolaryngol Head Neck Surg 2020; 163:410-417. [PMID: 32284027 DOI: 10.1177/0194599820915478] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To assess the safety and efficacy of topical epinephrine in adults undergoing endoscopic sinus surgery (ESS). DATA SOURCES PubMed, Embase, and Ovid MEDLINE online databases. REVIEW METHODS Non-case report English articles studying the effects of topical epinephrine as the topical vasoconstrictor used in adult ESS were found from the online databases through January 2019. The PRISMA literature selection process was used (Preferred Reporting Items for Systematic Reviews and Meta-analyses). RESULTS An overall 2216 articles were identified, with 9 meeting inclusion criteria involving a total of 5043 patients. All 9 studies assessed the safety of topical epinephrine, while 5 examined efficacy. Intraoperative average blood loss (ABL) ranged from 60 to 426 mL. Topical epinephrine concentrations varied from 1:1000 to 1:100,000, and 3 major complications were found for a rate of 0.06%. There were no reports of ophthalmic, orbital, or skull base injury, nor were there reports of cerebrospinal fluid leaks. A meta-analysis was performed on the 4 studies examining ABL. Estimated mean (95% CI) ABL was 119.4 mL (39.1-199.6) in the higher-concentration cohort (>1:10,000) and 372.2 mL (296.8-447.5) in the lower-concentration cohort (≤1:10,000) (P = .001). CONCLUSION Topical epinephrine is generally safe and provides acceptable hemostasis during ESS, with higher concentrations (>1:10,000) providing improved hemostasis. Caution is advised for its use in patients with preexisting cardiovascular disease or in combination with other topical or injected vasoconstrictive agents. More prospective comparative studies are necessary to determine the ideal hemostatic concentration of epinephrine in ESS.
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Affiliation(s)
- Nicholas B Nesbitt
- Department of Otolaryngology-Head and Neck Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Michael W Noller
- Department of Otolaryngology-Head and Neck Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Nora L Watson
- Department of Research Programs, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Christian P Soneru
- Division of Otolaryngology-Head and Neck Surgery, Beth Israel Lahey Health, Boston, Massachusetts, USA
| | - Edward D McCoul
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Tulane University New Orleans, Louisiana, USA.,Department of Otorhinolaryngology, Ochsner Clinic Foundation, New Orleans, Louisiana, USA.,Ochsner Clinical School, University of Queensland School of Medicine, New Orleans, Louisiana, USA
| | - Charles A Riley
- Division of Otolaryngology-Head and Neck Surgery, Fort Belvoir Community Hospital, Fort Belvoir, Virginia, USA.,Department of Surgery, Uniformed Services University of Health Sciences, Bethesda, Maryland, USA
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Riley CA, Soneru CP, Overdevest JB, Otten ML, Gudis DA. Pediatric sinonasal and skull base lesions. World J Otorhinolaryngol Head Neck Surg 2020; 6:118-124. [PMID: 32596657 PMCID: PMC7296510 DOI: 10.1016/j.wjorl.2020.01.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 01/18/2020] [Indexed: 12/13/2022] Open
Abstract
Pediatric skull base lesions are complex and challenging disorders. Safe and comprehensive management of this diverse group of disorders requires the expertise of an experienced multidisciplinary skull base team. Adult endoscopic skull base surgery has evolved due to technologic and surgical advancements, multidisciplinary team approaches, and continued innovation. Similar principles continue to advance the care delivered to the pediatric population. The approach and management of these lesions varies considerably based on tumor anatomy, pathology, and surgical goals. An understanding of the nuances of skull base reconstruction unique to the pediatric population is critical for successful outcomes.
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Affiliation(s)
- Charles A Riley
- Department of Otolaryngology, Head and Neck Surgery, New York Presbyterian Hospital - Columbia University Medical Center, New York, NY, USA
| | - Christian P Soneru
- Department of Otolaryngology, Head and Neck Surgery, New York Presbyterian Hospital - Columbia University Medical Center, New York, NY, USA
| | - Jonathan B Overdevest
- Department of Otolaryngology, Head and Neck Surgery, New York Presbyterian Hospital - Columbia University Medical Center, New York, NY, USA
| | - Marc L Otten
- Department of Neurological Surgery, New York Presbyterian Hospital - Columbia University Medical Center, New York, NY, USA
| | - David A Gudis
- Department of Otolaryngology, Head and Neck Surgery, New York Presbyterian Hospital - Columbia University Medical Center, New York, NY, USA
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Riley CA, Zheng Z, Williams N, Smith TL, Orlandi RR, Tabaee A. Concordance of self‐reported practice patterns of American Rhinologic Society members with the International Consensus Statement of Allergy and Rhinology: Rhinosinusitis. Int Forum Allergy Rhinol 2020; 10:665-672. [DOI: 10.1002/alr.22533] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 11/29/2019] [Accepted: 01/09/2020] [Indexed: 11/08/2022]
Affiliation(s)
- Charles A. Riley
- Department of Otolaryngology–Head and Neck SurgeryFort Belvoir Community Hospital and Walter Reed National Military Medical Center Fort Belvoir VA
| | - Zhong Zheng
- Department of Otolaryngology–Head and Neck SurgeryNew York Presbyterian Hospital‒Weill Cornell Medicine New York NY
| | - Nicholas Williams
- Division of Biostatistics and EpidemiologyDepartment of Healthcare Policy and ResearchWeill Cornell Medicine New York NY
| | - Timothy L. Smith
- Division of Rhinology and Sinus Surgery, Oregon Sinus CenterDepartment of Otolaryngology–Head and Neck SurgeryOregon Health and Science University Portland OR
| | - Richard R. Orlandi
- Division of Otolaryngology–Head and Neck SurgeryUniversity of Utah Salt Lake City UT
| | - Abtin Tabaee
- Department of Otolaryngology–Head and Neck SurgeryNew York Presbyterian Hospital‒Weill Cornell Medicine New York NY
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Lawlor CM, Riley CA, Carter JM, Rodriguez KH. Association Between Age and Weight as Risk Factors for Complication After Tonsillectomy in Healthy Children. JAMA Otolaryngol Head Neck Surg 2019; 144:399-405. [PMID: 29543971 DOI: 10.1001/jamaoto.2017.3431] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Importance The 1996 Tonsillectomy and Adenoidectomy Inpatient Guidelines of the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) Pediatric Otolaryngology Committee recommended that children younger than 3 years be admitted following tonsillectomy. Recommendations for hospital observation were not included as a key action statement in the 2011 AAO-HNS Clinical Practice Guidelines for Tonsillectomy in Children. Objective To examine the association between posttonsillectomy complication rate and the age and weight of the child at the time of surgery. Design, Setting, and Participants This was a multicenter case series study with medical record review of 2139 consecutive children ages 3 to 6 years who underwent tonsillectomy at 1 tertiary care academic center and 5 acute care centers in New Orleans, Louisiana, between 2005 and 2015. Children with moderate to severe developmental delay, bleeding disorders, and other major medical comorbidities were excluded. Main Outcomes and Measures Complications examined included respiratory distress, dehydration requiring intravenous fluids, and bleeding. Results Of the 2139 patients, 1817 met inclusion criteria. A total of 1011 (55.6%) were male. The mean (SD) age at the time of the procedure was 46 (14) months (range, 12-72 months). The mean weight at the time of the procedure was 17 (5) kg (range, 9-43 kg). A total of 95 patients (5.2%) had a postoperative complication. Of the 455 children younger than 3 years in the study, 32 (7.0%) had complications compared with 63 (4.6%) of the 1362 patients 3 years or older. The odds of having a complication in children younger than 3 years was 1.5 times greater than it was in children 3 years or older (odds ratio [OR], 1.56; 95% CI, 1.00-2.42). When examining total complications, children younger than 3 years were more likely to experience a complication within the first 24 hours after surgery than children 3 years or older (25% vs 9.5%; OR, 3.17; 95% CI, 1.00-10.11). The children admitted to the hospital had a greater risk of complication than those treated as an outpatient, independent of age (6.9% vs 93.0%; OR, 3.49; 95% CI, 2.0.18-6.05). No association between weight and complications was found on logistic regression (area under the curve = 0.5268; P = .66). Conclusions and Relevance Healthy children younger than 3 years may be at an increased risk for complication following tonsillectomy. Those children may also be at increased risk for complications within the first 24 hours after surgery compared with children 3 years or older. Our data suggest that complications are independent of weight in these patients. In our cohort, those patients selected for overnight observation were associated with an increased number of adverse events following tonsillectomy, suggesting that clinician judgment is crucial in determining which patients are safe for outpatient tonsillectomy.
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Affiliation(s)
- Claire M Lawlor
- Department of Otolaryngology-Head and Neck Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - Charles A Riley
- Department of Otolaryngology-Head and Neck Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - John M Carter
- Department of Otolaryngology-Head and Neck Surgery, Tulane University School of Medicine, New Orleans, Louisiana.,Department of Otorhinolaryngology, Ochsner Clinic Foundation, New Orleans, Louisiana.,University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, Louisiana
| | - Kimsey H Rodriguez
- Department of Otolaryngology-Head and Neck Surgery, Tulane University School of Medicine, New Orleans, Louisiana.,Department of Otorhinolaryngology, Ochsner Clinic Foundation, New Orleans, Louisiana.,University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, Louisiana
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Riley CA, Wu EL, Hsieh MC, Marino MJ, Wu XC, McCoul ED. Association of Gastroesophageal Reflux With Malignancy of the Upper Aerodigestive Tract in Elderly Patients. JAMA Otolaryngol Head Neck Surg 2019; 144:140-148. [PMID: 29270624 DOI: 10.1001/jamaoto.2017.2561] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Importance Chronic inflammatory states have been linked to the development of malignancy. Gastroesophageal reflux disease (GERD) is a known risk factor for esophageal adenocarcinoma as the end result of chronic inflammatory changes. Objective To investigate the association of GERD with the risk of malignancy in the upper aerodigestive tract (UADT). Design, Setting, and Participants We used the Surveillance, Epidemiology, and End Results (SEER)-Medicare database to conduct a case-control study of individuals in the United States who had been added from January 2003 through December 2011 and were 66 years or older. The study included patients diagnosed with malignancy of the larynx, hypopharynx, oropharynx, tonsil, nasopharynx, and paranasal sinuses. GERD was examined as an exposure. Controls were matched from a 5% random sample of Medicare beneficiaries without cancer. Multivariable unconditional logistic regression was performed. Main Outcomes and Measures Incidence of invasive malignancies of the UADT. Results A total of 13 805 patients (median [range] age, 74 [66-99] years; 3418 women [24.76%] and 10 387 men [75.24%]) with malignancy of the UADT were compared with 13 805 patients without disease and were matched for sex, age group, and year of diagnosis. GERD was associated with a greater odds of developing malignancy of the larynx (adjusted odds ratio [aOR], 2.86; 95% CI, 2.65-3.09), hypopharynx (aOR, 2.54; 95% CI 1.97-3.29), oropharynx (aOR, 2.47; 95% CI, 1.90-3.23), tonsil (aOR, 2.14; 95% CI, 1.82-2.53), nasopharynx (aOR, 2.04; 95% CI, 1.56-2.66), and paranasal sinuses (aOR, 1.40; 95% CI, 1.15-1.70). Conclusions and Relevance GERD is associated with the presence of malignancy of the UADT in the US elderly population. This epidemiological association requires further examination to determine causality and diagnostic utility.
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Affiliation(s)
- Charles A Riley
- Department of Otolaryngology-Head and Neck Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - Eric L Wu
- Department of Otolaryngology-Head and Neck Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - Mei-Chin Hsieh
- Louisiana Tumor Registry, School of Public Health, Louisiana State University Health Sciences Center, New Orleans
| | - Michael J Marino
- Department of Otolaryngology-Head and Neck Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - Xiao-Cheng Wu
- Louisiana Tumor Registry, School of Public Health, Louisiana State University Health Sciences Center, New Orleans
| | - Edward D McCoul
- Department of Otolaryngology-Head and Neck Surgery, Tulane University School of Medicine, New Orleans, Louisiana.,Department of Otorhinolaryngology, Ochsner Clinic Foundation, New Orleans, Louisiana.,Ochsner Clinical School, University of Queensland School of Medicine, New Orleans, Louisiana
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Soneru CP, Riley CA, Minkowitz S, Tabaee A, Anand VK, Schwartz TH. Adherus Dural Sealant in Endoscopic Skull Base Surgery: Safety, Imaging Characteristics, and Sinonasal Quality of Life. J Neurol Surg B Skull Base 2019; 81:659-663. [PMID: 33381370 DOI: 10.1055/s-0039-1694048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 06/11/2019] [Indexed: 10/26/2022] Open
Abstract
Objective This study was aimed to compare the safety profiles, magnetic resonance imaging (MRI) findings, and sinonasal outcome test (SNOT-22) scores of Adherus dural sealant, a novel tissue glue designed for skull base surgery. Design Present study is a prospective case series. Setting The research work took place at a tertiary-care academic medical center. Participants Consecutive series of 26 patients undergoing endoscopic skull base surgery (ESBS) with Adherus was compared with a control group of 24 patients matched for tumor type and size with DuraSeal as a sealant. Main Outcome Measures Postoperative complication rates, imaging characteristics, and postoperative SNOT-22 scores were measured and compared. Results No postoperative cerebrospinal fluid (CSF) leaks, intracranial hemorrhages, or mucoceles were observed in either cohort. Adherus was more likely to be identifiable on immediate postoperative MRI (50 vs. 20.8%, p = 0.032). In patients in whom a nasoseptal flap was utilized, the flap was opposed to the skull base in all cases regardless of sealant selected. Postoperative SNOT-22 total (17.25 [±10.81] vs. 14.85 [±14.22], p = 0.609) and subdomain scores were similar between the two groups. Conclusions Adherus dural sealant appears to be a safe alternative to Duraseal in ESBS with comparable quality of life outcomes and imaging findings. These preliminary results are promising but should be examined in a larger population with long-term follow-up.
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Affiliation(s)
- Christian P Soneru
- Departments of Otolaryngology-Head and Neck Surgery, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, United States
| | - Charles A Riley
- Departments of Otolaryngology-Head and Neck Surgery, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, United States
| | - Shlomo Minkowitz
- Departments of Radiology, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, United States
| | - Abtin Tabaee
- Departments of Otolaryngology-Head and Neck Surgery, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, United States
| | - Vijay K Anand
- Departments of Otolaryngology-Head and Neck Surgery, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, United States
| | - Theodore H Schwartz
- Departments of Neurosurgery, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, United States
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Soneru CP, Riley CA, Hoffman K, Tabaee A, Schwartz TH. Intra-operative MRI vs endoscopy in achieving gross total resection of pituitary adenomas: a systematic review. Acta Neurochir (Wien) 2019; 161:1683-1698. [PMID: 31139934 DOI: 10.1007/s00701-019-03955-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 05/16/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND Intraoperative magnetic resonance imaging (iMRI) is a technology that may improve rates of gross total resection (GTR) for pituitary adenomas. The endoscope is another less expensive technology, which also may maximize resection rates. A direct comparison of these approaches and their additive benefit has never been performed. METHODS A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) standard. PubMed and Embase databases were searched for studies that examined GTR for pituitary adenoma resection with either endoscopic transsphenoidal surgery (eTSS), microscopic transsphenoidal surgery with iMRI (mTSS + iMRI), or endoscopic transsphenoidal surgery with iMRI (eTSS + iMRI). RESULTS Eighty-five studies that reported GTR rates in 7124 pituitary adenoma patients were identified. For all pituitary adenomas, eTSS had a pooled proportion of GTR of 68.9% (95% CI 64.7-73.0%) which was similar to that of mTSS + iMRI (GTR 68.3%; 95% CI = 59.4-76.5%) and eTSS + iMRI (GTR 70.7%; 95% CI = 56.9-89.6%). For the subgroup of pituitary macroadenomas, pooled proportions for GTR were similar between eTSS and mTSS + iMRI (eTSS: GTR 59.4%; 95% CI = 49.6-68.7% vs mTSS + iMRI: GTR 68.8%; 95% CI = 57.3-79.3%), and higher for eTSS + iMRI (81.1%; 95% CI = 75.5-86.2%). The post-operative CSF leak proportion for eTSS (4.7%; 95% CI = 3.6-5.9%) was similar to that for eTSS + iMRI (3.7%; 95% CI = 1.6-6.5%) and mTSS + iMRI (4.6%; 95% CI = 2.0-8.3%). No direct statistical comparisons could be performed. CONCLUSION Final GTR proportions are similar whether the surgeon uses a microscope supplemented with iMRI or endoscope with or without iMRI. The benefit of the two technologies may be complementary for macroadenomas. These findings are important to consider when comparing the efficacy of different technical strategies in the management of pituitary adenomas.
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Marino MJ, Riley CA, Wu EL, Weinstein JE, McCoul ED. The Unified Airway: Does Asthma Influence Paranasal Sinus Pneumatization? Ear Nose Throat J 2019; 99:89-93. [PMID: 31064242 DOI: 10.1177/0145561319848992] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Asthma has been implicated as a driving force in lower airway remodeling; however, its effect on upper airway development has not been studied. Clinical disease, particularly cystic fibrosis (CF), has been associated with anatomical paranasal sinus variation, although the mechanism for these variations remains unclear. The purpose of this study was to determine whether asthma is associated with altered sinus pneumatization. Five hundred ninety-one computed tomography scans, including 303 adolescents (age 13-18) and 288 adults (age > 18), were evaluated using the Assessment of Pneumatization of the Paranasal Sinuses (APPS) instrument. The APPS score is validated for assessing anatomical variation and total sinus volume. A diagnosis of asthma was ascertained from the medical record, and patients with CF were included as a positive control group. Patients with asthma had mean APPS score of 9.66, compared to 9.85 for participants without asthma (P = .585). Subgroup analysis demonstrated similar findings among adults (P = .817) and adolescents (P = .585). Patients with a diagnosis of CF had significant sinus hypoplasia according to a mean APPS scores of 3.50 (P < .001). Sinus hypoplasia persisted in both adults (P < .001) and adolescents (P < .001) with CF. The presence of asthma is not associated with altered paranasal sinus pneumatization. In contrast, CF is associated with significantly reduced sinus pneumatization. These findings suggest that aberrant sinus pneumatization may not be a feature of asthma and that chronic mucosal respiratory disease is not a generalizable cause for altered paranasal sinus pneumatization.
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Affiliation(s)
- Michael J Marino
- Department of Otorhinolaryngology, Mayo Clinic, Phoenix, AZ, USA
| | - Charles A Riley
- Division of Otolaryngology, Fort Belvoir Community Hospital, Fort Belvoir, VA, USA
| | - Eric L Wu
- Department of Otolaryngology-Head and Neck Surgery, Tulane University School of Medicine, New Orleans, LA, USA
| | - Jacqueline E Weinstein
- Benioff Children's Hospital, Division of Pediatric Otolaryngology-Head and Neck Surgery, University of California-San Francisco, San Francisco, CA, USA
| | - Edward D McCoul
- Department of Otolaryngology-Head and Neck Surgery, Tulane University School of Medicine, New Orleans, LA, USA.,Department of Otorhinolaryngology, Ochsner Clinic Foundation, New Orleans, LA, USA.,Ochsner Clinical School, University of Queensland School of Medicine, New Orleans, LA, USA
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Soneru CP, Riley CA, Tabaee A, Kacker A, Anand VK, Schwartz TH. The Challenge of Skull Base Closure: Methods for Reducing Postoperative Cerebrospinal Fluid Leak. World Neurosurg 2019. [DOI: 10.1016/j.wneu.2019.01.121] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Marino MJ, Hsieh MC, Wu EL, Riley CA, Wu XC, McCoul ED. Early Versus Late Computed Tomography and Nasal Endoscopy in the Diagnosis of Nasopharyngeal and Paranasal Sinus Malignancy. Am J Rhinol Allergy 2019; 33:388-394. [PMID: 30900468 DOI: 10.1177/1945892419838106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background Chronic rhinosinusitis (CRS) and allergic rhinitis (AR) may be associated with an increased risk of subsequent diagnosis of nasopharyngeal carcinoma (NPC) or paranasal sinus cancer (PSC) in elderly Americans. The clinical utility of this association remains uncertain. Objective To compare early computed tomography (CT) or nasal endoscopy (NE) with late diagnostic studies for the diagnosis of NPC or PSC in elderly Americans with CRS or AR. Methods The Surveillance, Epidemiology, and End Results (SEER)-Medicare database was queried from 2003 to 2011 and included 150 088 Medicare beneficiaries. Patients with a diagnosis of CRS or AR were examined for either NE or CT performed within 6 months of the exposure diagnosis. The risk of a cancer diagnosis was determined between the early and the late diagnostic groups. Results The relative risk of early cancer diagnosis with NE was 1.98 (95% confidence interval [CI], 1.60–2.43). The number needed to detect (NND) a case of cancer with NE was 503 (95% CI, 387–718). The relative risk of an early cancer diagnosis using CT was 3.40 (95% CI, 2.85–4.06) and NND was 221 (95% CI, 194–255). The stage of NPC or PSC for the late diagnostic group was not different from those with early NE ( P = .458) or CT ( P = .497). Overall survival was not different between diagnostic groups for NE ( P = .789) or CT ( P = .425). Conclusions Early NE or CT is associated with a higher likelihood of cancer diagnosis in elderly individuals with a diagnosis of CRS or AR. The clinical utility of this association is limited due to the low prevalence of these malignancies and lack of difference in disease stage and overall survival between diagnostic groups.
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Affiliation(s)
- Michael J Marino
- 1 Department of Otorhinolaryngology, Mayo Clinic, Phoenix, Arizona
| | - Mei-Chin Hsieh
- 2 Louisiana Tumor Registry, Louisiana State University Health Sciences Center, School of Public Health, New Orleans, Louisiana
| | - Eric L Wu
- 3 Department of Otolaryngology-Head and Neck Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - Charles A Riley
- 4 Division of Otolaryngology, Fort Belvoir Community Hospital, Fort Belvoir, Virginia
| | - Xiao-Cheng Wu
- 2 Louisiana Tumor Registry, Louisiana State University Health Sciences Center, School of Public Health, New Orleans, Louisiana
| | - Edward D McCoul
- 3 Department of Otolaryngology-Head and Neck Surgery, Tulane University School of Medicine, New Orleans, Louisiana.,5 Department of Otorhinolaryngology, Ochsner Clinic Foundation, New Orleans, Louisiana.,6 Ochsner Clinical School, University of Queensland School of Medicine, New Orleans, Louisiana
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Wu EL, Harris WC, Babcock CM, Alexander BH, Riley CA, McCoul ED. Epistaxis Risk Associated with Intranasal Corticosteroid Sprays: A Systematic Review and Meta-analysis. Otolaryngol Head Neck Surg 2019; 161:18-27. [DOI: 10.1177/0194599819832277] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Objective Intranasal corticosteroids (INCSs) are widely utilized for the treatment of allergic rhinitis. Epistaxis is a known adverse effect of INCSs, but it is not known if the risk of epistaxis differs among INCSs. Data Sources Systematic review of primary studies identified through Medline, Embase, Web of Science, PubMed Central, and Cochrane databases. Review Methods Systematic review was conducted according to the PRISMA standard. English-language studies were queried through February 1, 2018. The search identified randomized controlled trials of INCSs for treatment of allergic rhinitis that reported incidence of epistaxis. An itemized assessment of the risk of bias was conducted for each included study, and meta-analysis was performed of the relative risk of epistaxis for each INCS. Results Of 949 identified studies, 72 met the criteria for analysis. Meta-analysis demonstrated an overall relative risk of epistaxis of 1.48 (95% CI, 1.32-1.67) for all INCSs. The INCSs associated with the highest risk of epistaxis were beclomethasone hydrofluoroalkane, fluticasone furoate, mometasone furoate, and fluticasone propionate. Beclomethasone aqueous, ciclesonide hydrofluoroalkane, and ciclesonide aqueous were associated with the lowest risk of epistaxis. Conclusions about epistaxis with use of budesonide, triamcinolone, and flunisolide are limited due to the low number of studies and high heterogeneity. Conclusions While a differential effect on epistaxis among INCS agents is not clearly demonstrated, this meta-analysis does confirm an increased risk of epistaxis for patients using INCSs as compared with placebo for treatment of allergic rhinitis.
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Affiliation(s)
- Eric L. Wu
- Department of Otolaryngology–Head and Neck Surgery, School of Medicine, Tulane University, New Orleans, Louisiana, USA
| | - William C. Harris
- Department of Otolaryngology–Head and Neck Surgery, School of Medicine, Tulane University, New Orleans, Louisiana, USA
| | - Casey M. Babcock
- Department of Otolaryngology–Head and Neck Surgery, School of Medicine, Tulane University, New Orleans, Louisiana, USA
| | - Bailin H. Alexander
- Department of Otolaryngology–Head and Neck Surgery, School of Medicine, Tulane University, New Orleans, Louisiana, USA
| | - Charles A. Riley
- Department of Otolaryngology–Head and Neck Surgery, Weill Cornell Medical College, New York, New York, USA
| | - Edward D. McCoul
- Department of Otolaryngology–Head and Neck Surgery, School of Medicine, Tulane University, New Orleans, Louisiana, USA
- Department of Otorhinolaryngology, Ochsner Clinic Foundation, New Orleans, Louisiana, USA
- Ochsner Clinical School, School of Medicine, University of Queensland, New Orleans, Louisiana, USA
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Riley CA, Marino MJ, Hsieh MC, Wu EL, Wu XC, McCoul ED. Detection of laryngeal carcinoma in the U.S. elderly population with gastroesophageal reflux disease. Head Neck 2019; 41:1434-1440. [PMID: 30681216 DOI: 10.1002/hed.25600] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 12/03/2018] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND An association is suggested between gastroesophageal reflux disease (GERD) or laryngopharyngeal reflux (LPR) and malignancy of the larynx in elderly patients in the United States. Early detection with flexible fiberoptic laryngoscopy (FFL) or CT remains poorly defined. METHODS The Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database was queried from 2003 to 2011.A case-cohort design evaluated patients aged 66 and older with a diagnosis of GERD and/or LPR for the occurrence of FFL or CT within 6 months of the exposure diagnosis. RESULTS Of a total 156 426 Medicare beneficiaries, the relative risk of early cancer diagnosis with FFL was 14.61(95% confidence interval [CI], 13.59-15.70), corresponding to a number needed to detect (NND) a case of cancer of 13(95% CI, 13-14). The relative risk of an early cancer diagnosis with CT was 31.83 (95% CI, 29.57-34.26), with a NND of 5 (95% CI, 5-5). CONCLUSIONS Early FFL and CT are associated with a higher likelihood of laryngeal cancer diagnosis in elderly individuals with a diagnosis of reflux. Screening trials are necessary to establish this relationship.
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Affiliation(s)
- Charles A Riley
- Department of Otolaryngology-Head and Neck Surgery, Weill Cornell Medical Center, New York, New York
| | - Michael J Marino
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic Foundation, Phoenix, Arizona
| | - Mei-Chin Hsieh
- Louisiana Tumor Registry, Louisiana State University Health Sciences Center, School of Public Health, New Orleans, Louisiana
| | - Eric L Wu
- Department of Otolaryngology-Head and Neck Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - Xiao-Cheng Wu
- Louisiana Tumor Registry, Louisiana State University Health Sciences Center, School of Public Health, New Orleans, Louisiana
| | - Edward D McCoul
- Department of Otolaryngology-Head and Neck Surgery, Tulane University School of Medicine, New Orleans, Louisiana.,Department of Otorhinolaryngology, Ochsner Clinic Foundation, New Orleans, Louisiana.,Ochsner Clinical School, University of Queensland School of Medicine, New Orleans, Louisiana
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Safi C, Li C, Tabaee A, Ramakrishna R, Riley CA. Outcomes and imaging findings of respiratory epithelial adenomatoid hamartoma: a systematic review. Int Forum Allergy Rhinol 2019; 9:674-680. [DOI: 10.1002/alr.22298] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 12/16/2018] [Accepted: 01/03/2018] [Indexed: 12/12/2022]
Affiliation(s)
- Chetan Safi
- Department of Otolaryngology–Head and Neck SurgeryNew York Presbyterian Hospital–Weill Cornell Medicine New York NY
| | - Carol Li
- Department of Otolaryngology–Head and Neck SurgeryNew York Presbyterian Hospital–Weill Cornell Medicine New York NY
| | - Abtin Tabaee
- Department of Otolaryngology–Head and Neck SurgeryNew York Presbyterian Hospital–Weill Cornell Medicine New York NY
| | - Rohan Ramakrishna
- Department of Neurological SurgeryNew York Presbyterian Hospital–Weill Cornell Medicine New York NY
| | - Charles A. Riley
- Department of Otolaryngology–Head and Neck SurgeryNew York Presbyterian Hospital–Weill Cornell Medicine New York NY
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Riley CA, Tabaee A, Conley L, Amine M, Soneru CP, Anand VK, Schwartz TH. Long-term sinonasal outcomes after endoscopic skull base surgery with nasoseptal flap reconstruction. Laryngoscope 2018; 129:1035-1040. [PMID: 30569585 DOI: 10.1002/lary.27637] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Revised: 09/14/2018] [Accepted: 10/04/2018] [Indexed: 11/08/2022]
Abstract
OBJECTIVES The utilization of the nasoseptal flap (NSF) in endoscopic anterior skull base surgery (EASB) has resulted in reduced rates of postoperative cerebrospinal fluid leak (CSF). The long-term impact on sinonasal function after surgery remains incompletely defined. METHODS A consecutive series of patients undergoing EASB with NSF and with at least 3 years follow-up was prospectively evaluated. Patient demographics, pre- and postoperative Sino-nasal Outcome Test-22 (SNOT-22) scores, Lund-Mackay scores (LMS), CSF leak, and sinonasal complications were analyzed. RESULTS A total of 46 patients undergoing EASB with NSF met inclusion criteria. The mean follow-up was 67.4 months (range 39-90, standard deviation [SD] 14.2 months). No statistically significant differences were noted between the mean overall pre- (16) and postoperative SNOT-22 scores (18). SNOT-22 scores improved in 27 patients (58.7%), deteriorated in 17 patients (37.0%) and stayed the same in two patients (4.3%). Deterioration in SNOT-22 scores was greater in younger (mean change + 7.2 [SD17.4] vs. older patients -3.4 [SD 7.5], P = 0.010). A statistically significant increase in LMS was noted (mean preoperative LMS0.9 vs. mean postoperative LMS 2.2, P = 0.001). The LMS decreased in nine patients (19.6%), increased in 22 patients (47.8%), and remained the same in 15 patients (32.6%). One patient (2.2%) developed a postoperative CSF leak following resection of metastatic skull base lesion and was successfully treated with placement of a lumbar drain, Foley catheter balloon, and strict bed rest. One patient (2.2%) developed a postoperative mucocele requiring decompression 3 years after initial surgery. CONCLUSION Whereas long-term sinonasal quality of life is overall improved in the majority of patients following NSF use for EASB, younger patients show higher incidence of deterioration. Increased sinus opacification on imaging is generally noted and may require continued follow-up and management. The incidence of reoperation for symptomatic mucocele formation is low. LEVEL OF EVIDENCE 4 Laryngoscope, 129:1035-1040, 2019.
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Affiliation(s)
- Charles A Riley
- Department of Otolaryngology-Head and Neck Surgery, New York Presbyterian Hospital-Weill Cornell Medicine, New York, New York, U.S.A
| | - Abtin Tabaee
- Department of Otolaryngology-Head and Neck Surgery, New York Presbyterian Hospital-Weill Cornell Medicine, New York, New York, U.S.A
| | - Lindsey Conley
- Department of Radiology, New York Presbyterian Hospital-Weill Cornell Medicine, New York, New York, U.S.A
| | - Muhamad Amine
- Department of Otolaryngology-Head and Neck Surgery, New York Presbyterian Hospital-Weill Cornell Medicine, New York, New York, U.S.A
| | - Christian P Soneru
- Department of Otolaryngology-Head and Neck Surgery, New York Presbyterian Hospital-Weill Cornell Medicine, New York, New York, U.S.A
| | - Vijay K Anand
- Department of Otolaryngology-Head and Neck Surgery, New York Presbyterian Hospital-Weill Cornell Medicine, New York, New York, U.S.A
| | - Theodore H Schwartz
- Department of Neurosurgery, New York Presbyterian Hospital-Weill Cornell Medicine, New York, New York, U.S.A
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