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Lee JT, Abbas GM, Charous DD, Cuevas M, Göktas Ö, Loftus PA, Nachlas NE, Toskala EM, Watkins JP, Brehmer D. Two-Year Outcomes After Radiofrequency Neurolysis of Posterior Nasal Nerve in Chronic Rhinitis. Laryngoscope 2024; 134:2077-2084. [PMID: 37916848 DOI: 10.1002/lary.31120] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 09/22/2023] [Accepted: 10/04/2023] [Indexed: 11/03/2023]
Abstract
OBJECTIVE To assess the long-term safety and effectiveness of temperature-controlled radiofrequency (TCRF) neurolysis of the posterior nasal nerve (PNN), a minimally invasive treatment for chronic rhinitis. METHODS A prospective, single-arm study of 129 patients at 16 centers (United States, Germany) was conducted. Patient-reported outcome measures were the 24-h reflective total nasal symptom score (rTNSS) and mini rhinoconjunctivitis quality of life questionnaire (MiniRQLQ). Postnasal drip and cough symptoms were assessed using a 4-point scale. RESULTS The mean pretreatment rTNSS was 7.8 (95% CI, 7.5-8.1). The significant rTNSS treatment effect at 3 months (-4.2 [95% CI, -4.6 to -3.8]; p < 0.001) was sustained through 2 years (-4.5 [95% CI, -5.0 to -3.9]; p < 0.001), a 57.7% improvement. At 2 years, the proportion of patients with a minimal clinically important difference (MCID) of ≥30% improvement in rTNSS from baseline was 80.0% (95% CI, 71.4%-86.5%). Individual postnasal drip and cough symptom scores were significantly improved from baseline through 2 years. The proportion of patients who reached the MCID for the MiniRQLQ (≥0.4-point improvement) at 2 years was 77.4% (95% CI, 68.5%-84.3%). Of 81 patients using chronic rhinitis medications at baseline, 61.7% either stopped all medication use (28.4%) or stopped or decreased (33.3%) use of ≥1 medication class at 2 years. No device/procedure-related serious adverse events were reported throughout 2 years. CONCLUSION TCRF neurolysis of the PNN resulted in sustained improvements in chronic rhinitis symptom burden and quality of life through 2 years, accompanied by a substantial decrease in medication burden. LEVEL OF EVIDENCE 4 Laryngoscope, 134:2077-2084, 2024.
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Affiliation(s)
- Jivianne T Lee
- Department of Head and Neck Surgery, UCLA David Geffen School of Medicine, Los Angeles, California, U.S.A
| | | | - Daniel D Charous
- Arizona Desert Ear, Nose & Throat Specialists, Goodyear, Arizona, U.S.A
| | - Mandy Cuevas
- Department of Otorhinolaryngology Head and Neck Surgery, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Önder Göktas
- ENT-Center, HNO-Zentrum am Kudamm, Berlin, Germany
| | - Patricia A Loftus
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, California, U.S.A
| | - Nathan E Nachlas
- ENT and Allergy Associates of Florida, Boca Raton, Florida, U.S.A
| | - Elina M Toskala
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, U.S.A
| | | | - Detlef Brehmer
- Faculty of Medicine, University Witten/Herdecke, Witten, Germany
- Department of Electrical Engineering and Applied Natural Sciences, Westphalian University of Applied Sciences, Gelsenkirchen, Germany
- Department of Otorhinolaryngology, Private ENT Practice, Göttingen, Germany
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David AP, Loftus PA, Russell MS, Goldberg AN, El-Sayed IH, Jan TA, Roland LT. RNA Sequencing and Gene Ontology Analysis in Acute Invasive Fungal Sinusitis. Am J Rhinol Allergy 2022; 37:78-82. [DOI: 10.1177/19458924221134732] [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: 11/15/2022]
Abstract
Background Acute invasive fungal sinusitis (AIFS) is an aggressive and dangerous disease of the paranasal sinuses with high morbidity and mortality. The immune response at the level of the nasal mucosa, the site of entry, has not been previously evaluated. Objective To evaluate differential gene expression in the sinonasal mucosa of AIFS patients as compared to control patients using RNA sequencing. Methods Sinonasal tissue samples were prospectively obtained from consenting patients undergoing surgery between November, 2020 and November, 2021. RNA extraction and sequencing were performed and differential expression was analyzed to detect transcriptional differences between patient groups. Results Tissue samples were collected from 4 patients with active AIFS diagnoses, 2 patients with recovered AIFS, 1 patient with a diagnosis of non-invasive fungal ball, and 4 healthy controls. 255 genes were differentially expressed in AIFS patients as compared to control patients. Specific Gene Ontology (GO) biological processes that were identified as differentially expressed in AIFS patients as compared to controls included the following: 1. GO:0007155 (cell adhesion), 2. GO:0030199 (collagen fibril organization) and 3. GO:0001525 (angiogenesis). Conclusion Transcriptional differences were noted between AIFS and control patients in sinonasal tissue samples. Future work is necessary to determine causes of the differential gene expressions between AIFS and control patients, specifically those who are immunosuppressed, or with preexisting non-invasive forms of fungal sinusitis, to guide treatment and prevention strategies.
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Affiliation(s)
- Abel P. David
- Department of Otolaryngology – Head and Neck Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Patricia A. Loftus
- Department of Otolaryngology – Head and Neck Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Matthew S. Russell
- Department of Otolaryngology – Head and Neck Surgery, Mass Eye and Ear, Boston, MA, USA
| | - Andrew N. Goldberg
- Department of Otolaryngology – Head and Neck Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Ivan H. El-Sayed
- Department of Otolaryngology – Head and Neck Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Taha A. Jan
- Department of Otolaryngology – Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Lauren T. Roland
- Department of Otolaryngology – Head and Neck Surgery, Washington University in St Louis, St Louis, MO, USA
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Choy W, Garcia J, Safaee MM, Rubio RR, Loftus PA, Clark AJ. Superior Laryngeal Nerve Palsy After Anterior Cervical Diskectomy and Fusion: A Case Report and Cadaveric Description. Oper Neurosurg (Hagerstown) 2022; 23:e152-e155. [PMID: 35838480 DOI: 10.1227/ons.0000000000000276] [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] [Received: 09/15/2021] [Accepted: 03/06/2022] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND AND IMPORTANCE Superior laryngeal nerve (SLN) injury after high cervical dissection can result in changes in vocal pitch due to cricothyroid denervation and dysphagia with aspiration risk because of decreased sensation of the supraglottic larynx. CLINICAL PRESENTATION We describe a 69-year-old singer with cervical spondylotic myelopathy who underwent elective C3/4 and C4/5 anterior cervical diskectomy and fusion. Postoperatively, the patient reported changes in his voice, most noticeable with higher registers. A number of studies confirmed severe right superior laryngeal neuropathy. A cadaveric description included to highlight anatomic relationships critical in minimizing risk of SLN injury during an anterior cervical diskectomy and fusion approach. CONCLUSION The SLN is a critical structure vulnerable to iatrogenic injury during high cervical dissections for anterior approaches to the spine. Therefore, it is critical for spine surgeons to have a firm understanding of SLN anatomy for these approaches.
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Affiliation(s)
- Winward Choy
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Joseph Garcia
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Michael M Safaee
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Roberto R Rubio
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Patricia A Loftus
- Department of Otolaryngology, Head and Neck Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Aaron J Clark
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
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4
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Lee JT, Abbas GM, Charous DD, Cuevas PDMM, Göktas PDMÖ, Loftus PA, Nachlas NE, Toskala EM, Watkins JP, Brehmer PDMD. Clinical and Quality of Life Outcomes Following Temperature-Controlled Radiofrequency Neurolysis of the Posterior Nasal Nerve (RhinAer) for Treatment of Chronic Rhinitis. Am J Rhinol Allergy 2022; 36:747-754. [PMID: 35818709 PMCID: PMC9548948 DOI: 10.1177/19458924221109987] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [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] [Indexed: 11/17/2022]
Abstract
Background Temperature-controlled radiofrequency (TCRF) neurolysis of the posterior
nasal nerve (PNN; RhinAer) is a minimally invasive treatment option for
patients with chronic rhinitis. Objective To determine clinical outcomes and quality of life (QoL) following TCRF
neurolysis of the PNN. Methods A prospective single-arm study of 129 patients with chronic rhinitis at 16
medical centers in the United States and Germany. Results The mean 24-h reflective total nasal symptom score (rTNSS) improved from 7.8
(95% CI, 7.5-8.1) at baseline to 3.6 (95% CI, 3.2-4.0) at 3 months and
continued to improve to 2.9 (95% CI, 2.5-3.3) at 6 months
(p < .001 comparing follow-up to baseline and
p = .002 comparing 3 and 6 months). This represents
53.8% improvement over baseline at 3 months and 62.8% improvement at 6
months. Rhinorrhea, congestion, sneezing, and itching subscores and
postnasal drip and cough scores were all significantly improved over
baseline at both timepoints. At 3 months, 76.2% (95% CI, 68.1%-82.8%) of
patients achieved a minimal clinically important difference of ≥30%
improvement in rTNSS over baseline and the percentage was higher at 6 months
(83.5% [95% CI, 75.8%-89.0%]). At 3 months, 80.3% (95% CI, 72.6%-86.3%)
reported a minimal clinically important difference of ≥0.4-point improvement
in the mini rhinoconjunctivitis quality of life questionnaire score, and the
percentage was higher at 6 months; 87.7% (95% CI, 80.7%-92.4%). There were
no serious adverse events with a relationship to the device/procedure
reported through 6 months. Conclusion In this large, multicenter study, TCRF neurolysis of the PNN was safe and
resulted in a significant reduction in rhinitis symptom burden at 3 months
that was sustained/improved through 6 months. The majority of patients
reported a clinically relevant improvement in QoL at 3 and 6 months
postprocedure.
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Affiliation(s)
- Jivianne T Lee
- Department of Head and Neck Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | | | - Daniel D Charous
- Arizona Desert Ear, Nose & Throat Specialists, Goodyear, AZ, USA
| | - Pd Dr Med Mandy Cuevas
- Department of Otorhinolaryngology, University Clinic Carl Gustav Carus, Technical University of Dresden, Dresden, Germany
| | | | - Patricia A Loftus
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, CA, USA
| | | | - Elina M Toskala
- Department of Otolaryngology - Head & Neck Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | | | - Prof Dr Med Detlef Brehmer
- Faculty of Medicine, University Witten/Herdecke, Witten, Germany.,Department of Electrical Engineering and Applied Natural Sciences, Westphalian University of Applied Sciences, Gelsenkirchen, Germany.,Department of Otorhinolaryngology, Private ENT Practice, Göttingen, Germany
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Gurrola JG, Chang JL, Roland LT, Loftus PA, Cheung SW. Short-term chemosensory distortions and phantoms in COVID-19. Laryngoscope Investig Otolaryngol 2021; 6:172-176. [PMID: 33821217 PMCID: PMC8014200 DOI: 10.1002/lio2.532] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [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: 10/20/2020] [Revised: 01/12/2021] [Accepted: 01/20/2021] [Indexed: 01/05/2023] Open
Abstract
Objective To identify differentiation features of chemosensory dysfunction in COVID-19 infection and their primary drivers. Study Design Cross-sectional cohort comparison. Methods A national anonymous survey was used to query participants regarding nasal symptoms and chemosensory dysfunction including sensitivity levels, and presence or absence of distortions and phantoms within the 6-week time window surrounding their COVID-19 testing and survey completion. Results Three-hundred and sixty-four respondents who reported COVID-19 positive (COVID+; n = 176) or COVID-19 negative (COVID-; n = 188) test results completed the survey. The COVID+ cohort had higher occurrence rates for: (a) chemosensory sensitivity impairments (67.0% vs 30.3%; P < .01), where the rate of complete loss of smell (anosmia) or taste (ageusia) was higher (35.8% vs 4.8%; P < .01), and (b) chemosensory distortions (39.8% vs 19.1%; P < .01), where the rate of anosmia or ageusia with distortions was also higher in the COVID+ cohort (19.9% vs 2.7%; P < .01). Occurrence rates in the two cohorts were similar for chemosensory phantoms (COVID+ 17.0%, COVID- 18.6%; P = .70) and nasal discharge or stuffiness in the presence of sensitivity impairment (COVID+ 63.6%, COVID- 52.6%; P = .17). Conclusion Chemosensory dysfunction in COVID-19 is associated with higher rates of smell or taste sensitivity impairments and distortions. Higher rates of anosmia and ageusia drive these key findings. Chemosensory phantoms and nasal symptoms in the presence of sensitivity impairment occur at rates that should demand clinical attention, but they do not appear to be specific to COVID-19 positivity. Level of Evidence 2b.
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Affiliation(s)
- José G. Gurrola
- Department of Otolaryngology‐Head and Neck SurgeryUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
| | - Jolie L. Chang
- Department of Otolaryngology‐Head and Neck SurgeryUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
| | - Lauren T. Roland
- Department of Otolaryngology‐Head and Neck SurgeryUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
| | - Patricia A. Loftus
- Department of Otolaryngology‐Head and Neck SurgeryUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
| | - Steven W. Cheung
- Department of Otolaryngology‐Head and Neck SurgeryUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
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Loftus PA, Roland LT, Gurrola JG, Cheung SW, Chang JL. Temporal Profile of Olfactory Dysfunction in COVID-19. OTO Open 2020; 4:2473974X20978133. [PMID: 33330830 PMCID: PMC7724426 DOI: 10.1177/2473974x20978133] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 11/11/2020] [Indexed: 02/06/2023] Open
Abstract
Objective Coronavirus disease 2019 (COVID-19) is associated with olfactory dysfunction, but the evolution of the olfactory loss and timeline to recovery are largely unknown. This study examines changes in smell sensitivity in COVID-19-positive (COVID+) and COVID-19-negative (COVID-) viral illness during the initial weeks after infection. Study Design Cross-sectional cohort comparison. Setting National anonymous surveys. Methods Survey participants were queried about smell sensitivity and general health status at the time of COVID-19 testing and in the weeks that followed. Results In total, 375 (174 COVID+, 201 COVID-) participants completed the survey and 132 (62 COVID+, 70 COVID-) participants completed the 2-week follow-up survey. Normal smell in the COVID+ cohort was less frequent at the time of testing and at follow up (P < .05). Dynamic changes in smell sensitivity in the COVID+ cohort were more frequent in the initial weeks (P < .001). In those with normosmia at the start of infection, 38% of the COVID+ cohort reported worsening smell compared to only 8% in the COVID- cohort (P < .05). Recovery of overall health was associated with normosmia at the time of infection and improvement of smell sensitivity within weeks of infection. Conclusion The COVID+ cohort showed greater dynamic change in smell sensitivity and a higher rate of persistent olfactory dysfunction in the weeks after infection. Normal smell at the time of COVID-19 infection may still worsen before recovery. Overall health recovery after viral illness is associated with improvement in smell sensitivity and the absence of initial anosmia or hyposmia.
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Affiliation(s)
- Patricia A Loftus
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Lauren T Roland
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Jose G Gurrola
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Steven W Cheung
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Jolie L Chang
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, California, USA
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Abstract
PURPOSE OF REVIEW Eustachian tube dysfunction (ETD) presents with symptoms of aural fullness and pressure, muffled hearing, tinnitus, and otalgia. When severe, it can lead to many common ear disorders such as otitis media with effusion, tympanic membrane retraction/perforation, and cholesteatoma. These diseases are prevalent in both the pediatric and adult population and significantly impact quality of life. The pathophysiology of ETD in the absence of an obstructive lesion has long been debated but is thought to be related to functional obstruction (i.e., inefficient tensor veli palatini muscle) and/or nasal cavity and nasopharyngeal inflammation. In the acute setting, the most common cause of nasal inflammation is an upper respiratory infection. When symptoms become chronic, however, the inflammation is thought to be associated with nasal irritants such as nasal allergens, i.e., allergic rhinitis (AR). The purpose of this review is to summarize our current understanding of the relationship between allergy and ETD. RECENT FINDINGS Past studies are either lacking or have reported equivocal findings regarding the relationship between allergy and ETD, and the 2018 International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis has deemed the current level of evidence linking AR and ETD as low quality. A more recent study using a large adult population dataset did support an association between AR and ETD, but did not find that all cases of ETD are related to allergies. Furthermore, current evidence suggests that the use of medications that can decrease intranasal inflammation, such as intranasal corticosteroids or oral antihistamines, does not result in significant symptomatic improvement in patients with ETD. However, these studies included all patients with ETD, and evidence is lacking regarding the treatment effect of these medications on the subset of patients with concurrent AR and ETD. Current best evidence does support an association between AR and ETD; however, not all patients with ETD suffer from AR, and vice versa. Further research is necessary to understand the mechanism behind this positive association and to elucidate the cause of chronic ETD in patients without associated allergies.
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Affiliation(s)
| | - Patricia A Loftus
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, USA.
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Roland LT, Loftus PA, Chang JL. Reply to: Challenges in interpreting the diagnostic performance of symptoms to predict COVID-19 status: the case of anosmia. Int Forum Allergy Rhinol 2020; 10:1116-1117. [PMID: 32583946 PMCID: PMC7361774 DOI: 10.1002/alr.22648] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Accepted: 06/22/2020] [Indexed: 11/12/2022]
Affiliation(s)
- Lauren T Roland
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, CA
| | - Patricia A Loftus
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, CA
| | - Jolie L Chang
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, CA
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9
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Roland LT, Gurrola JG, Loftus PA, Cheung SW, Chang JL. Smell and taste symptom-based predictive model for COVID-19 diagnosis. Int Forum Allergy Rhinol 2020; 10:832-838. [PMID: 32363809 PMCID: PMC7267242 DOI: 10.1002/alr.22602] [Citation(s) in RCA: 79] [Impact Index Per Article: 19.8] [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: 04/20/2020] [Revised: 04/27/2020] [Accepted: 05/01/2020] [Indexed: 11/09/2022]
Abstract
Background The presentation of coronavirus 2019 (COVID‐19) overlaps with common influenza symptoms. There is limited data on whether a specific symptom or collection of symptoms may be useful to predict test positivity. Methods An anonymous electronic survey was publicized through social media to query participants with COVID‐19 testing. Respondents were questioned regarding 10 presenting symptoms, demographic information, comorbidities, and COVID‐19 test results. Stepwise logistic regression was used to identify predictors for COVID‐19 positivity. Selected classifiers were assessed for prediction performance using receiver operating characteristic (ROC) curve analysis. Results A total of 145 participants with positive COVID‐19 testing and 157 with negative results were included. Participants had a mean age of 39 years, and 214 (72%) were female. Smell or taste change, fever, and body ache were associated with COVID‐19 positivity, and shortness of breath and sore throat were associated with a negative test result (p < 0.05). A model using all 5 diagnostic symptoms had the highest accuracy with a predictive ability of 82% in discriminating between COVID‐19 results. To maximize sensitivity and maintain fair diagnostic accuracy, a combination of 2 symptoms, change in sense of smell or taste and fever was found to have a sensitivity of 70% and overall discrimination accuracy of 75%. Conclusion Smell or taste change is a strong predictor for a COVID‐19–positive test result. Using the presence of smell or taste change with fever, this parsimonious classifier correctly predicts 75% of COVID‐19 test results. A larger cohort of respondents will be necessary to refine classifier performance.
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Affiliation(s)
- Lauren T Roland
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, CA
| | - Jose G Gurrola
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, CA
| | - Patricia A Loftus
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, CA
| | - Steven W Cheung
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, CA
| | - Jolie L Chang
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, CA
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Strohl MP, Choy W, Clark AJ, Mummaneni PV, Dhall SS, Tay BK, Loftus PA, El-Sayed IH, Russell MS. Immediate Voice and Swallowing Complaints Following Revision Anterior Cervical Spine Surgery. Otolaryngol Head Neck Surg 2020; 163:778-784. [PMID: 32482158 DOI: 10.1177/0194599820926133] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To report on the incidence of dysphagia, dysphonia, and acute vocal fold motion impairment (VFMI) following revision anterior cervical spine surgery, as well as to identify risk factors associated with acute VFMI in the immediate postoperative period. STUDY DESIGN Retrospective cohort study. SETTING Tertiary care center. SUBJECTS AND METHODS All patients who underwent 2-team reoperative anterior cervical discectomy and fusion (ACDF) were retrospectively reviewed. Incidence of dysphonia, dysphagia, and acute VFMI was noted. Patient and operative factors were evaluated for association with risk of acute VFMI. RESULTS The incidence of postoperative dysphonia and dysphagia was 25% (18/72) and 52% (37/72), respectively. The incidence of immediate VFMI was 21% (15/72). Subjective postoperative dysphonia (odds ratio, [OR] 8; 95% CI, 2.2-28; P = .001) and dysphagia (OR, 22; 95% CI, 2.5-168; P = .005) were significantly associated with increased risk of VFMI. Three patients with VFMI required temporary injection medialization for voice complaints and/or aspiration. Infection (OR, 14; 95% CI, 1.4-147, P = .025) and level C7/T1 (OR, 5.5; 95% CI, 1.3-23, P = .02) were significantly associated with an increased risk of acute VFMI on multivariate logistic regression analysis. Number of prior surgeries, laterality of approach, side of approach relative to prior operations, and number of levels exposed were not significant. CONCLUSION Early involvement of an otolaryngologist in the care of a patient undergoing revision ACDF can be helpful to the patient in anticipation of voice and swallowing changes in the postoperative period. This may be particularly important in those being treated at C7/T1 or those with spinal infections.
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Affiliation(s)
- Madeleine P Strohl
- Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, San Francisco, California, USA
| | - Winward Choy
- Department of Neurological Surgery, University of California-San Francisco, San Francisco, California, USA
| | - Aaron J Clark
- Department of Neurological Surgery, University of California-San Francisco, San Francisco, California, USA
| | - Praveen V Mummaneni
- Department of Neurological Surgery, University of California-San Francisco, San Francisco, California, USA
| | - Sanjay S Dhall
- Department of Neurological Surgery, University of California-San Francisco, San Francisco, California, USA
| | - Bobby K Tay
- Department of Orthopedic Surgery, University of California-San Francisco, San Francisco, California, USA
| | - Patricia A Loftus
- Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, San Francisco, California, USA
| | - Ivan H El-Sayed
- Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, San Francisco, California, USA
| | - Matthew S Russell
- Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, San Francisco, California, USA
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Juszczak H, Aubin‐Pouliot A, Sharon JD, Loftus PA. Sinonasal risk factors for eustachian tube dysfunction: Cross‐sectional findings from NHANES 2011‐2012. Int Forum Allergy Rhinol 2019; 9:466-472. [DOI: 10.1002/alr.22275] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 12/02/2018] [Accepted: 12/04/2018] [Indexed: 12/29/2022]
Affiliation(s)
| | - Annick Aubin‐Pouliot
- Department of Otolaryngology–Head and Neck SurgeryUniversity of California San Francisco CA
| | - Jeffrey D. Sharon
- Department of Otolaryngology–Head and Neck SurgeryUniversity of California San Francisco CA
| | - Patricia A. Loftus
- Department of Otolaryngology–Head and Neck SurgeryUniversity of California San Francisco CA
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12
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Locketz GD, Brant JD, Adappa ND, Palmer JN, Goldberg AN, Loftus PA, Chandra RK, Bleier BS, Mueller SK, Orlandi RR, Becker M, Dorminy CA, Becker SD, Blasetti M, Becker DG. Postoperative Opioid Use in Sinonasal Surgery. Otolaryngol Head Neck Surg 2018; 160:402-408. [DOI: 10.1177/0194599818803343] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Objective To survey patients following sinonasal surgery regarding postoperative pain and opioid use. Study Design Patients were surveyed for 4 days following sinus and/or nasal surgery regarding their pain level and use of prescribed opioids. Setting Four academic medical centers and 1 private practice institution. Subjects Consecutive adult patients undergoing sinonasal surgery. Results A total of 219 subjects met criteria and were included for analysis; 134 patients (61%) took 5 or fewer combination oxycodone (5-mg) and acetaminophen (325-mg) tablets in the first 3 postoperative days, and 196 patients (89.5%) took fewer than 15. Fifty-one patients (23%) consumed no opioid pain medication. Opioid consumption was positively correlated with postoperative pain ( R2 = 0.2, P < .01) but was not correlated with the use of acetaminophen ( R2 = 0.002, P = .48). No significant difference in postoperative pain or opioid consumption was seen with respect to age, sex, specific procedures performed, postoperative steroids, or smoking history. Current smokers reported higher average pain than nonsmokers ( P < .001) and also required more postoperative opioids ( P = .02). Conclusions An evidence-based approach to postoperative pain control following sinonasal surgery that reduces the number of unused and potentially diverted opioids is needed. The current study suggests that 15 combination oxycodone (5-mg) and acetaminophen (325-mg) tablets provide sufficient pain control for 90% of patients in the immediate postoperative period following sinonasal surgery, irrespective of the specific procedures performed, use of acetaminophen, or use of systemic steroids. Smoking status may help surgeons predict which patients will require larger opioid prescriptions.
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Affiliation(s)
- Garrett D. Locketz
- Department of Otolaryngology–Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jason D. Brant
- Department of Otolaryngology–Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nithin D. Adappa
- Department of Otolaryngology–Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - James N. Palmer
- Department of Otolaryngology–Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Andrew N. Goldberg
- Department of Otolaryngology–Head and Neck Surgery, University of California, San Francisco, California, USA
| | - Patricia A. Loftus
- Department of Otolaryngology–Head and Neck Surgery, University of California, San Francisco, California, USA
| | - Rakesh K. Chandra
- Department of Otolaryngology–Head and Neck Surgery, Vanderbilt University, Nashville, Tennessee, USA
| | - Benjamin S. Bleier
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA
| | - Sarina K. Mueller
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA
| | - Richard R. Orlandi
- Division of Otolaryngology–Head and Neck Surgery, University of Utah, Salt Lake City, Utah, USA
| | - Madeleine Becker
- Deptartment of Psychiatry and Human Behavior, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Cindy A. Dorminy
- Department of Otolaryngology–Head and Neck Surgery, Vanderbilt University, Nashville, Tennessee, USA
| | | | - Mariel Blasetti
- Department of Otolaryngology–Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Daniel G. Becker
- Department of Otolaryngology–Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Abstract
BACKGROUND Isolated polypoid changes of the middle turbinate were recently reported as having a high association with inhalant allergy. A more advanced manifestation of this association may present as polypoid changes of the entire central sinonasal compartment (i.e., the middle and superior turbinates, and the posterosuperior nasal septum), while the lateral sinus mucosa remains relatively normal. OBJECTIVE To introduce and describe this newly recognized variant of chronic rhinosinusitis (CRS), termed central compartment atopic disease (CCAD). METHODS A case series of 15 patients from two institutions who presented with sinonasal symptoms and demonstrated central compartment polypoid mucosal changes on computed tomography (CT). The endoscopic appearance of central compartment edema was assessed. Allergy status was determined by skin or serum in vitro testing. RESULTS The mean ± standard deviation patient age was 42.4 ± 14.8 years, and 47% of the patients were women. All 15 patients had a diagnosis of allergic rhinitis symptomatically, and those who underwent allergy assessment (14/15) tested positive. All the patients had central compartment polypoid edema on endoscopy and central nasal soft-tissue thickening with peripheral clearing on CT. Even with more severe sinus disease, a central focus of inflammatory change existed. CONCLUSION CCAD may represent a local inhalant allergy process that affects the central nasal structures of ethmoid origin. Although inhalant allergy changes mainly appear within the nasal cavity, medial-to-lateral progression to involve the sinuses can occur as a simple obstructive phenomenon. This is a pattern of CRS distinct from the more diffuse sinonasal inflammatory disease and likely requires allergy management as a core component.
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Affiliation(s)
- John M DelGaudio
- Department of Otolaryngology-Head and Neck Surgery, Emory University, Atlanta, Georgia, USA
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14
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Hamizan AW, Loftus PA, Alvarado R, Ho J, Kalish L, Sacks R, DelGaudio JM, Harvey RJ. Allergic phenotype of chronic rhinosinusitis based on radiologic pattern of disease. Laryngoscope 2018; 128:2015-2021. [PMID: 29602169 DOI: 10.1002/lary.27180] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Revised: 02/04/2018] [Accepted: 02/21/2018] [Indexed: 11/10/2022]
Abstract
OBJECTIVES/HYPOTHESIS Polypoid edema of the middle turbinate is a marker of inhalant allergy. Extensive edematous changes may result in limited central nasal and sinus disease, which has been called central compartment atopic disease (CCAD). Radiologically, this is seen as soft tissue thickening in the central portion of the sinonasal cavity with or without paranasal sinus involvement. When the sinuses are involved, the soft tissue thickening spares the sinus roof or lateral wall (centrally limited). This centrally limited radiological pattern was assessed among chronic rhinosinusitis (CRS) patients and compared to allergy status. STUDY DESIGN Diagnostic cross-sectional study. METHODS This study included consecutive CRS patients without prior sinus surgery. Computed tomography (CT) scans of the paranasal sinuses were blindly assessed and allergy status was confirmed by serum or skin testing. Individual sinus cavities were defined as either centrally limited or diffuse disease. The radiological pattern that may predict allergy was determined, and its diagnostic accuracy was calculated. RESULTS One hundred twelve patients diagnosed to have CRS, representing 224 sides, were assessed (age 46.31 ± 13.57 years, 38.39% female, 41.07% asthma, Lund-Mackay CT score 15.88 ± 4.35, 56.25% atopic). The radiological pattern defined by centrally limited changes in all of the paranasal sinuses was associated with allergy status (73.53% vs. 53.16%, P = .03). This predicted atopy with 90.82% specificity, 73.53% positive predictive value, likelihood positive ratios of 2.16, and diagnostic odds ratio of 4.59. CONCLUSIONS A central radiological pattern of mucosal disease is associated with inhalant allergen sensitization. This group may represent a CCAD subgroup of patients with mainly allergic etiology. LEVEL OF EVIDENCE 3b Laryngoscope, 128:2015-2021, 2018.
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Affiliation(s)
- Aneeza W Hamizan
- Rhinology and Skull Base Research Group, St. Vincent's Centre for Applied Medical Research, University of New South Wales, Sydney, Australia.,Department of Otorhinolaryngology-Head and Neck Surgery, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Patricia A Loftus
- Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine, Atlanta, Georgia, U.S.A
| | - Raquel Alvarado
- Rhinology and Skull Base Research Group, St. Vincent's Centre for Applied Medical Research, University of New South Wales, Sydney, Australia
| | - Jacqueline Ho
- Rhinology and Skull Base Research Group, St. Vincent's Centre for Applied Medical Research, University of New South Wales, Sydney, Australia
| | - Larry Kalish
- Sydney Medical School, University of Sydney, Sydney, Australia.,Department of Otolaryngology-Head and Neck Surgery, Concord General Hospital, University of Sydney, Sydney, Australia
| | - Raymond Sacks
- Sydney Medical School, University of Sydney, Sydney, Australia.,Faculty of medicine and Health Sciences, Macquarie University, Sydney, Australia.,Department of Otolaryngology-Head and Neck Surgery, Concord General Hospital, University of Sydney, Sydney, Australia
| | - John M DelGaudio
- Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine, Atlanta, Georgia, U.S.A
| | - Richard J Harvey
- Rhinology and Skull Base Research Group, St. Vincent's Centre for Applied Medical Research, University of New South Wales, Sydney, Australia.,Faculty of medicine and Health Sciences, Macquarie University, Sydney, Australia
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15
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Yen AJ, Conrad MB, Loftus PA, Kumar V, Nanavati SM, Wilson MW, Cooke DL. Internal Jugular Vein Embolization to Control Life-Threatening Hemorrhage after Penetrating Neck Trauma. J Vasc Interv Radiol 2018; 29:435-437. [PMID: 29455882 DOI: 10.1016/j.jvir.2017.09.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Revised: 09/21/2017] [Accepted: 09/21/2017] [Indexed: 11/25/2022] Open
Affiliation(s)
- Adam J Yen
- School of Medicine, 505 Parnassus Avenue, San Francisco, CA 94143
| | - Miles B Conrad
- Department of Interventional Radiology, 505 Parnassus Avenue, San Francisco, CA 94143
| | - Patricia A Loftus
- Department of Otolaryngology - Head and Neck Surgery, 505 Parnassus Avenue, San Francisco, CA 94143
| | - Vishal Kumar
- Department of Interventional Radiology, 505 Parnassus Avenue, San Francisco, CA 94143
| | - Sujal M Nanavati
- Department of Interventional Radiology, 505 Parnassus Avenue, San Francisco, CA 94143
| | - Mark W Wilson
- Department of Interventional Radiology, 505 Parnassus Avenue, San Francisco, CA 94143
| | - Daniel L Cooke
- Department of Neurointerventional Radiology, 505 Parnassus Avenue, San Francisco, CA 94143
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16
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Loftus PA. Book Review: Endoscopic Approaches to the Paranasal Sinuses and Skull Base. Ann Otol Rhinol Laryngol 2017. [DOI: 10.1177/0003489417727522] [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: 11/16/2022]
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17
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Abstract
Background Spontaneous cerebrospinal fluid (CSF) leaks are largely attributed to idiopathic intracranial hypertension and typically present as skull base defects with or without prolapse of intracranial contents. However, in our practice, we have encountered a distinct type of spontaneous CSF leak that presents in a different manner. Objective To discuss a newly-classified, difficult to treat, subset of spontaneous CSF leaks that present as excavation of the bone of the skull base in a tunnel- or canal-like fashion by a meningocele or meningoencephalocele instead of as a localized area of bony dehiscence. Methods A retrospective review was performed at a tertiary care rhinology practice to identify a subset of CSF leak patients with an excavating/canal-like skull base defect visualized radiographically on computed tomography (CT) scan or magnetic resonance imaging and/or endoscopically in the operating room. Results The cohort of patients consisted of 7 females and 1 male with an average age of 53.6 years and a self-reported race of 4:3:1 African-American: Caucasian-Indian. All patients presented with CSF rhinorrhea. The most common leak site was the cribriform and upper septum. Six of the 8 patients had multiple defects and/or progression of their skull base defects, and 5 patients required multiple and/or repeat repairs in the operating room. Seven of the 8 patients underwent a cisternogram because the excavating nature of the leaks made it difficult to identify the specific leak site on high-resolution CT scan alone. Conclusion In spontaneous CSF leaks that are difficult to identify or recur soon after a proper repair, an excavating pattern should be considered. Failure to recognize this type of leak and all of its tributaries, to fully unroof the excavated bone to completely resect the meningocele, and to visualize and close the site of origin will likely result in failure and recurrence of CSF leak.
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Affiliation(s)
- Patricia A. Loftus
- Department of Otolaryngology—Head and Neck Surgery, Emory University, Atlanta, Georgia
| | - Sarah K. Wise
- Department of Otolaryngology—Head and Neck Surgery, Emory University, Atlanta, Georgia
| | - Pedram Daraei
- Department of Otolaryngology—Head and Neck Surgery, Emory University, Atlanta, Georgia
| | - Kristen Baugnon
- Department of Head and Neck Radiology, Emory University, Atlanta, Georgia
| | - John M. DelGaudio
- Department of Otolaryngology—Head and Neck Surgery, Emory University, Atlanta, Georgia
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18
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Abstract
Allergic fungal rhinosinusitis (AFRS) is the most common form of fungal sinusitis in the United States. Its pathophysiological basis is associated with a predisposed person's type I IgE-mediated allergic response to inhaled mold spores that are ubiquitous in the environment. AFRS is a well-recognized type of chronic, recurrent, and non-invasive hypertrophic sinus disease that affects immunocompetent hosts, most commonly young African American males. There are 5 main criteria used for the diagnosis of AFRS, one being the presence of nasal polyposis. A review of the current literature was performed in order to provide the most up-to-date knowledge regarding the background, diagnosis, management, recent research, and controversies surrounding AFRS. Although much is known about the pathophysiology and etiology of this disease, controversy exists regarding the importance of type I hypersensitivity in AFRS, as humoral immunity and immunoglobulin-independent pathways may also contribute. The potential role of local sinonasal IgE production in the pathophysiology of AFRS is an area of discussion, as is the role of preoperative antifungal medication in improving postoperative patient outcomes. Recent advancements in the diagnosis of AFRS include identification of genes and proteins unique to or over-expressed in AFRS patients. Although AFRS is a well-known and well-described cause of nasal polyposis, controversy still exists regarding this diagnosis. Advances in research may eventually resolve any diagnostic controversies in AFRS.
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19
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Siegel B, Ow TJ, Abraham SS, Loftus PA, Tassler AB, Smith RV, Schiff BA. How radiologic/clinicopathologic features relate to compressive symptoms in benign thyroid disease. Laryngoscope 2016; 127:993-997. [PMID: 27438354 DOI: 10.1002/lary.26124] [Citation(s) in RCA: 2] [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: 11/25/2015] [Revised: 04/05/2016] [Accepted: 05/09/2016] [Indexed: 11/06/2022]
Abstract
OBJECTIVES/HYPOTHESIS To identify compressive symptomatology in a patient cohort with benign thyroid disease who underwent thyroidectomy. To determine radiographic/clinicopathologic features related to and predictive of a compressive outcome. STUDY DESIGN Retrospective cohort study. METHODS Medical records of 232 patients with benign thyroid disease on fine needle aspiration who underwent thyroidectomy from 2009 to 2012 at an academic medical center were reviewed. Data collection and analyses involved subjects' demographics, compressive symptoms, preoperative airway encroachment, intubation complications, specimen weight, and final pathologic diagnosis. RESULTS Subjects were ages 14 to 86 years (mean: 52.4 years). Ninety-six subjects (41.4%) reported compressive symptomatology of dysphagia (n =74; 32%), dyspnea (n = 39; 17%), and hoarseness (n = 24; 10%). Ninety-seven (42.2%) had preoperative airway encroachment. Dyspnea was significantly related to tracheal compression, tracheal deviation, and substernal extension. Dysphagia was related to tracheal compression and tracheal deviation. Compressive symptoms and preoperative airway encroachment were not related to intubation complications. Final pathologic diagnosis was not related to compressive symptoms, whereas specimen weight was significantly related to dyspnea and dysphagia. Final pathology revealed 74 subjects (32%) with malignant lesions. Malignant and benign nodular subject groups differed significantly in substernal extension, gland weight, tracheal deviation, and dyspnea. Logit modeling for dyspnea was significant for tracheal compression as a predictor for the likelihood of dyspnea. CONCLUSION Dyspnea was closely related to preoperative airway encroachment and most indicative of a clinically relevant thyroid in our cohort with benign thyroid disease. Tracheal compression was found to have predictive value for the likelihood of a dyspneic outcome. LEVEL OF EVIDENCE 4. Laryngoscope, 127:993-997, 2017.
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Affiliation(s)
- Bianca Siegel
- Department of Otorhinolaryngology-Head Neck Surgery, Montefiore Medical Center, Bronx, U.S.A
| | - Thomas J Ow
- Department of Otorhinolaryngology-Head Neck Surgery, Montefiore Medical Center, Bronx, U.S.A
| | - Suzanne S Abraham
- Department of Communication Sciences and Disorders, New York University, New York, New York, U.S.A
| | - Patricia A Loftus
- Department of Otorhinolaryngology-Head Neck Surgery, Montefiore Medical Center, Bronx, U.S.A
| | - Andrew B Tassler
- Department of Otorhinolaryngology-Head Neck Surgery, Montefiore Medical Center, Bronx, U.S.A
| | - Richard V Smith
- Department of Otorhinolaryngology-Head Neck Surgery, Montefiore Medical Center, Bronx, U.S.A
| | - Bradley A Schiff
- Department of Otorhinolaryngology-Head Neck Surgery, Montefiore Medical Center, Bronx, U.S.A
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20
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Loftus PA, Wise SK, Nieto D, Panella N, Aiken A, DelGaudio JM. Intranasal volume increases with age: Computed tomography volumetric analysis in adults. Laryngoscope 2016; 126:2212-5. [DOI: 10.1002/lary.26064] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 03/24/2016] [Accepted: 04/01/2016] [Indexed: 11/06/2022]
Affiliation(s)
- Patricia A. Loftus
- Department of Otolaryngology-Head and Neck Surgery; Emory University; Atlanta Georgia U.S.A
| | - Sarah K. Wise
- Department of Otolaryngology-Head and Neck Surgery; Emory University; Atlanta Georgia U.S.A
| | - Daniel Nieto
- Department of Otolaryngology-Head and Neck Surgery; Emory University; Atlanta Georgia U.S.A
| | - Nicholas Panella
- Department of Otolaryngology-Head and Neck Surgery; Emory University; Atlanta Georgia U.S.A
| | - Ashley Aiken
- Department of Otolaryngology-Head and Neck Surgery; Emory University; Atlanta Georgia U.S.A
| | - John M. DelGaudio
- Department of Otolaryngology-Head and Neck Surgery; Emory University; Atlanta Georgia U.S.A
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21
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Kamil RJ, Jerschow E, Loftus PA, Tan M, Fried MP, Smith RV, Foster D, Ow TJ. Case-control study evaluating competing risk factors for angioedema in a high-risk population. Laryngoscope 2016; 126:1823-30. [PMID: 27426939 DOI: 10.1002/lary.25821] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [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: 03/10/2015] [Revised: 10/10/2015] [Accepted: 11/13/2015] [Indexed: 01/13/2023]
Abstract
OBJECTIVES/HYPOTHESIS Black race is a risk factor for angioedema. The primary aim was to examine the relationship between race-ethnicity and risk factors for angioedema. STUDY DESIGN Using a retrospective case-control study design, data was extracted with the Clinical Looking Glass utility, a data collection and management tool that captures data from electronic medical record systems within the Montefiore Healthcare System. Cases were emergency department (ED) visits with primary or secondary International Classification of Diseases, Ninth Revision, code diagnoses of angioedema in adults aged ≥ 18 years from January 2008 to December 2013 at three Montefiore centers in Bronx, New York. Controls were a random sampling of adult ED visits during the same period. METHODS In primary analyses, angiotensin-converting enzyme inhibitor (ACE-I) and black race were evaluated for synergy. The influence of different risk factors in the development of angioedema was evaluated using logistic regression models. Finally, race-ethnicity was further explored by evaluating for effect modification by stratification of models by race-ethnicity categories. RESULTS There were 1,247 cases and 6,500 controls randomly selected from a larger control pool. ACE-I use (odds ratio [OR] 3.70, 95% confidence interval [CI] 2.98, 4.60), hypertension (OR 1.88, 95% CI 1.55, 2.29), and black race (OR 2.25, 95% CI 1.86, 2.72) were the strongest risk factors. ACE-I use and black race were not synergistic (OR 1.10, 95% CI 0.80, 1.51). Race-ethnicity was an effect modifier for certain risk factors. CONCLUSION Race-ethnicity acts as an effect modifier for particular angioedema risk factors. The two strongest risk factors, ACE-I use and black race, were not synergistic. LEVEL OF EVIDENCE 3b. Laryngoscope, 126:1823-1830, 2016.
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Affiliation(s)
- Rebecca J Kamil
- Department of Otorhinolaryngology-Head and Neck Surgery, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, U.S.A
| | - Elina Jerschow
- Division of Allergy and Immunology, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, U.S.A
| | - Patricia A Loftus
- Department of Otorhinolaryngology-Head and Neck Surgery, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, U.S.A
| | - Melin Tan
- Department of Otorhinolaryngology-Head and Neck Surgery, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, U.S.A
| | - Marvin P Fried
- Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center, Bronx, NY
| | - Richard V Smith
- Department of Otorhinolaryngology-Head and Neck Surgery, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, U.S.A
| | | | - Thomas J Ow
- Department of Otorhinolaryngology-Head and Neck Surgery, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, U.S.A.,Department of Pathology, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, U.S.A
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22
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Loftus PA, Stegnjajic A, Tibbetts KM, Badhey AK, Glicksman J. Elongated Uvula Causing Chronic Cough: Role of the Modified Uvulopalatoplasty Procedure. Ann Otol Rhinol Laryngol 2015; 125:325-30. [PMID: 26543075 DOI: 10.1177/0003489415613800] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [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: 11/15/2022]
Abstract
OBJECTIVE A subset of patients previously diagnosed with idiopathic chronic cough were found to have an elongated uvula contacting the laryngeal surface of the epiglottis and inducing a cough reflex. These patients were successfully treated with an in-office modified uvulopalatoplasty procedure (mUPP) at our institution. We aim to further categorize this subset of patients and describe the mUPP that can potentially offer this group of patients cure for their chronic cough. STUDY DESIGN Institutional Review Board-approved retrospective chart review. METHODS Patient demographics, medical history, associated symptoms, prior treatment remedies, and response to mUPP were recorded and analyzed for 30 patients who underwent an in-office mUPP. RESULTS The majority of patients were middle-aged, nonsmoking females with symptoms of globus sensation and a gag reflex when lying supine. 96.7% of patients reported complete resolution or noticeable improvement of their cough following mUPP. There were no complications from this in-office procedure in our study. CONCLUSIONS The authors' main goals are to make other physicians aware of this under-recognized subset of patients with chronic cough who have an identifiable and treatable cause for their symptoms and to provide the steps of a simple and effective surgical solution to chronic cough in this group of patients.
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Affiliation(s)
- Patricia A Loftus
- Department of Otolaryngology-Head and Neck Surgery, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA
| | - Arsen Stegnjajic
- Department of Otolaryngology-Head and Neck Surgery, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA
| | - Kathleen M Tibbetts
- Department of Otolaryngology-Head and Neck Surgery, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA
| | - Arvind K Badhey
- Department of Otolaryngology-Head and Neck Surgery, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA
| | - Jeffrey Glicksman
- Department of Otolaryngology-Head and Neck Surgery, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA
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23
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Loftus PA, Wise SK. Epidemiology and economic burden of asthma. Int Forum Allergy Rhinol 2015; 5 Suppl 1:S7-10. [PMID: 26010063 DOI: 10.1002/alr.21547] [Citation(s) in RCA: 85] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Revised: 03/31/2015] [Accepted: 04/01/2015] [Indexed: 11/09/2022]
Abstract
BACKGROUND The "asthma epidemic" is on the rise, with the Center for Disease Control (CDC) epidemiological studies reporting a 3.0% asthma prevalence in the United States in 1970, 5.5% in 1996, and 7.8% in 2006 to 2008. This results in an immense economic burden, with asthma costing an estimated $56 billion in the United States in 2007, which is a 6% increase from the $53 billion that was spent in 2002. METHODS A review of the current literature and CDC reports were used to thoroughly examine and summarize the epidemiology and economic burden of asthma domestically and globally. RESULTS Asthma shows a male predominance before puberty, and a female predominance in adulthood. Studies show Puerto Ricans to be the most commonly affected ethnicity, and a higher prevalence of asthma is found in lower income populations. Asthma is related to some of the more common otolaryngologic diseases such as allergy and obstructive sleep apnea. The condition results in significant morbidity, such as an increase in emergency department visits and a decrease in productivity due to missed school and works days. CONCLUSION Epidemiological statistics report an undisputable increase of asthma both domestically and worldwide, which means the economic burden of this disease is also on the rise. Better access to healthcare, improved asthma education, and bridging the gap between ethnic and racial disparities in the treatment and management of asthma may help to control this epidemic, promote better outcomes, and prevent continued rising costs related to the management of this widespread disease.
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Affiliation(s)
- Patricia A Loftus
- Department of Otolaryngology-Head and Neck Surgery, Emory University, Atlanta, GA
| | - Sarah K Wise
- Department of Otolaryngology-Head and Neck Surgery, Emory University, Atlanta, GA
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Abstract
Objectives: Patients with angioedema present to the emergency department (ED) with myriad signs and symptoms with a wide range of severity, from mild discomfort to severe airway compromise. Initial estimation of angioedema course and patient airway safety can be challenging. Base of tongue (BOT) and laryngeal involvement are recognized to correlate with need for intubation; however, there are few clear indicators of potential future airway compromise. We evaluated the relationship between presenting signs and symptoms with fiberoptic laryngoscopic findings to help in the immediate stratification of angioedema patients. Methods: Retrospective chart review of patients presenting with angioedema to the ED of a tertiary care center from January 2005 to July 2013. Results: Of 1987 patients treated by the ED for angioedema, 401 generated an otolaryngology consult; of these, 79 (19.7%) and 128 (31.9%) had base of tongue (BOT) and laryngeal involvement, respectively. Dysphagia and voice change correlated with both BOT and laryngeal edema ( P < .01). Sensation of throat closure correlated with laryngeal edema alone ( P < .01). Tongue, floor of mouth (FOM), and neck swelling correlated with BOT edema while FOM, uvular, and neck swelling were correlated with laryngeal edema ( P < .01). Lip edema had strong negative correlations to both BOT and laryngeal edema ( P < .0001). Conclusions: Patient report of dysphagia, voice change, sensation of throat closure along with tongue, floor of mouth, uvular, or neck swelling on initial presentation should raise suspicion of compromising BOT or laryngeal involvement. This cohort of patients requires a higher index of suspicion for potential airway intervention.
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Loftus PA, Tan M, Patel G, Lin J, Helman S, Badhey A, Du E, Smith RV, Fried MP, Ow TJ. Risk factors associated with severe and recurrent angioedema: an epidemic linked to ACE-inhibitors. Laryngoscope 2014; 124:2502-7. [PMID: 24938823 DOI: 10.1002/lary.24777] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [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: 03/14/2014] [Revised: 04/27/2014] [Accepted: 05/20/2014] [Indexed: 11/09/2022]
Abstract
OBJECTIVES/HYPOTHESIS To evaluate the etiology and risk factors for severe manifestation and recurrent episodes of angioedema; to evaluate efficacy of short-term and long-term management strategies for angioedema among a high-risk population. STUDY DESIGN Institutional review board-approved retrospective review of a large, urban population. METHODS Data from 875 adult patients treated from January 2008 to December 2013 with the diagnosis of angioedema were obtained using the Clinical Looking Glass utility and review of medical records. Demographic and clinicopathologic risk factors were recorded. The major outcomes evaluated were hospital admission, need for airway intervention, and recurrent episodes of angioedema following the first presentation. Initial treatment strategy and follow-up recommendations were also recorded. RESULTS The most common cause of angioedema was angiotensin converting enzyme inhibitor (ACEi)-induced (496 [56.6%]). Significant risk factors for severe cases of angioedema included older age, Hispanic race, ACEi-induced angioedema type, American Society of Anesthesiologists class III or above, coexistent cardiopulmonary disease, and a positive smoking history. A total of 17.2% of patients experienced recurrent attacks of angioedema; of those patients, 25.9% were still taking an ACEi at subsequent presentation. Risk factors for recurrent episodes included older age, idiopathic angioedema type, and coexistent cardiopulmonary disease. Only 54.1% of patients who experienced ACEi-induced angioedema had electronic medical record documentation of these allergies. CONCLUSIONS Knowledge of risk factors for severe and recurrent episodes of angioedema and improved education for both healthcare providers and patients, specifically related to ACEi use and allergy documentation, may significantly decrease the burden and morbidity of angioedema among high risk populations. LEVEL OF EVIDENCE 2b.
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Affiliation(s)
- Patricia A Loftus
- Department of Otorhinolaryngology-Head and Neck Surgery, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, U.S.A
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Loftus PA, Ow TJ, Siegel B, Tassler AB, Smith RV, Cohen HW, Schiff BA. Risk Factors for Perioperative Airway Difficulty and Evaluation of Intubation Approaches Among Patients With Benign Goiter. Ann Otol Rhinol Laryngol 2014; 123:279-85. [DOI: 10.1177/0003489414524171] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: The objective was to determine patient and gland characteristics associated with difficult intubation in patients undergoing thyroidectomy for goiter and to assess different methods of intubation in these patients. Methods: This study was an IRB-approved, retrospective chart review of 112 consecutive patients undergoing hemithyroidectomy or total thyroidectomy for thyroid goiter from 2009-2012 at an academic tertiary care facility in Bronx, New York. Patient demographics, thyroid gland characteristics (gland weight and nodule size), presence of preoperative symptoms (dyspnea, dysphagia, and hoarseness), and radiographical findings (tracheal compression, tracheal deviation, and substernal extension of the thyroid gland) were recorded. Anesthesia records were reviewed for method of intubation, as well as success or failure of intubation attempts. Results: Nineteen patients (17.0%) were men and 93 (83.0%) were women. The age of the patients included in the study ranged from 14 to 86 years with a mean ± SD age of 53.5 ± 14.7 years. Difficult intubation was noted with 13 (11.6%) patients. Only patient age was significantly associated with difficult intubation. The mean age of patients with airway difficulty was 60.7 ± 3.7 years compared to 52.1 ± 1.5 years in those who did not experience airway difficulty ( P = .04). No other reviewed risk factors were found to be significantly associated with difficult intubation. Fiberoptic intubation (FOI) was used in 38 patients and difficult intubation occurred in 18.4% (7/38). Direct laryngoscopy with transoral intubation (LTOI) was used in 58 patients, in whom 3.4% (2/58) experienced a difficult intubation. FOI was aborted 6 times and LTOI was subsequently successful in each of these cases. Conclusions: Our results suggest that benign nodular goiter disease does not pose significant challenges to intubation in our patient cohort. The technique of intubation deviated from the initial plan several times in the FOI group, whereas LTOI was ultimately successful in every case. Our data suggest that the role of fiberoptic intubation for patients with large goiters should be further refined.
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Affiliation(s)
- Patricia A. Loftus
- Department of Otorhinolaryngology–Head and Neck Surgery, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA
| | - Thomas J. Ow
- Department of Otorhinolaryngology–Head and Neck Surgery, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA
| | - Bianca Siegel
- Department of Otorhinolaryngology–Head and Neck Surgery, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA
| | - Andrew B. Tassler
- Department of Otorhinolaryngology–Head and Neck Surgery, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA
| | - Richard V. Smith
- Department of Otorhinolaryngology–Head and Neck Surgery, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA
| | - Hillel W. Cohen
- Department of Otorhinolaryngology–Head and Neck Surgery, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA
| | - Bradley A. Schiff
- Department of Otorhinolaryngology–Head and Neck Surgery, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA
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Loftus PA, Fried MP. Office-Based Rhinology: Principles and Techniques. Zara M.Patel, Sarah K.Wise, and John M.DelGaudio. San Diego, CA: Plural Publishing, 2013; 151 pp., hardcover, illustrated, indexed, $175, includes DVD. Laryngoscope 2013. [DOI: 10.1002/lary.24389] [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: 11/07/2022]
Affiliation(s)
- Patricia A. Loftus
- Department of Otorhinolaryngology-Head and Neck Surgery; Albert Einstein College of Medicine/Montefiore Medical Center; Bronx New York U.S.A
| | - Marvin P. Fried
- Department of Otorhinolaryngology-Head and Neck Surgery; Albert Einstein College of Medicine/Montefiore Medical Center; Bronx New York U.S.A
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