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Kaffenberger TM, Plawecki A, Kaki P, Boon M, Huntley C. Troubleshooting Upper Airway Stimulation Therapy Using Drug-Induced Sleep Endoscopy. Otolaryngol Head Neck Surg 2024. [PMID: 38643409 DOI: 10.1002/ohn.785] [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: 10/06/2023] [Revised: 01/17/2024] [Accepted: 02/17/2024] [Indexed: 04/22/2024]
Abstract
OBJECTIVE This study assesses the utility of drug-induced sleep endoscopy (DISE) in guiding further treatment for patients with obstructive sleep apnea (OSA) who have difficulty tolerating upper airway stimulation (UAS) or have inadequate response to therapy. STUDY DESIGN We conducted a retrospective analysis of UAS patients at our institution who underwent DISE, post-UAS, and evaluated the efficacy of different electrode configurations and maneuvers. SETTING A tertiary care hospital. METHODS Out of 379 patients who received UAS therapy, 34 patients who underwent DISE post-UAS (DISE-UAS) were included. Palatal coupling (PC) was assessed with UAS stimulation alone, jaw thrust alone, and both simultaneously during DISE. RESULTS Among 34 patients, 5 had suboptimal adherence to UAS therapy, 19 had suboptimal therapy efficacy with residual OSA burden, and 10 had both. During DISE-UAS, PC was observed in 7 patients (21%) with UAS stimulation alone, 9 patients (26%) with jaw thrust alone, and 8 patients (24%) with both maneuvers combined. Notably, 10 patients (29%) did not exhibit PC with any maneuver. Based on DISE-UAS findings, 13 patients were recommended oral appliance therapy (OAT), and 8 patients underwent further surgical interventions. CONCLUSION DISE-UAS is a valuable adjunct in troubleshooting UAS therapy for patients intolerant to CPAP or with suboptimal therapy efficacy. This study provides an algorithm for targeted multimodality therapy based on DISE findings, facilitating personalized management approaches.
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Affiliation(s)
- Thomas M Kaffenberger
- Department of Otolaryngology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Andrea Plawecki
- Henry Ford Department of Otolaryngology, Detroit, Michigan, USA
| | - Praneet Kaki
- Department of Otolaryngology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Maurits Boon
- Department of Otolaryngology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Colin Huntley
- Department of Otolaryngology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Eichar BW, Kaffenberger TM, McCoy JL, Padia RK, Muzumdar H, Tobey ABJ. Effect of Speaking Valves on Tracheostomy Decannulation. Int Arch Otorhinolaryngol 2024; 28:e157-e164. [PMID: 38322435 PMCID: PMC10843928 DOI: 10.1055/s-0043-1767797] [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: 04/12/2022] [Accepted: 12/05/2022] [Indexed: 02/08/2024] Open
Abstract
Introduction Despite several pediatric tracheostomy decannulation protocols there remains tremendous variability in practice. The effect of tracheostomy capping on decannulation has been studied but the role of speaking valves (SVs) is unknown. Objective Given the positive benefits SVs have on rehabilitation, we hypothesized that SVs would decrease time to tracheostomy decannulation. The purpose of the present study was to evaluate this in a subset of patients with chronic lung disease of prematurity (CLD). Methods A retrospective chart review was performed at a tertiary care children's hospital. A total of 105 patients with tracheostomies and CLD were identified. Data collected included demographics, gestational age, congenital cardiac disease, airway surgeries, granulation tissue excisions, SV and capping trials, tracheitis episodes, and clinic visits. Statistics were performed with logistic and linear regression. Results A total of 75 patients were included. The mean gestational age was 27 weeks (standard deviation [SD] = 3.6) and the average birthweight was 1.1 kg (SD = 0.6). The average age at tracheostomy was 122 days (SD = 63). A total of 70.7% of the patients underwent decannulation and the mean time to decannulation (TTD) was 37 months (SD = 19). A total of 77.3% of the patients had SVs. Those with an SV had a longer TTD compared to those without (52 versus 35 months; p = 0.008). Decannulation was increased by 2 months for every increase in the number of hospital presentations for tracheitis ( p = 0.011). Conclusion The present study is the first, to our knowledge, to assess the effect of SVs on tracheostomy decannulation in patients with CLD showing a longer TTD when SVs are used.
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Affiliation(s)
- Bradley W. Eichar
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Thomas M. Kaffenberger
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Jennifer L. McCoy
- Office of Research and Development, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, United States
| | - Reema K. Padia
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
- Office of Research and Development, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, United States
| | - Hiren Muzumdar
- Division of Pulmonary Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, United States
| | - Allison B. J. Tobey
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
- Office of Research and Development, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, United States
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Kaffenberger TM, Chandna M, Kaki P, Corr AM, Plawecki A, Doghramji K, Boon M, Huntley C. Reduced usage of upper airway stimulation therapy in patients with comorbid insomnia and obstructive sleep apnea. J Clin Sleep Med 2023; 19:1997-2004. [PMID: 37589148 PMCID: PMC10692932 DOI: 10.5664/jcsm.10752] [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: 03/16/2023] [Revised: 08/03/2023] [Accepted: 08/03/2023] [Indexed: 08/18/2023]
Abstract
STUDY OBJECTIVES Upper airway stimulation (UAS) is a hybrid surgical-medical device used to treat moderate-to-severe obstructive sleep apnea (OSA). Comorbid insomnia and OSA (COMISA) is present in ∼50% of these patients. Our aim was to study UAS outcomes and adherence in patients with COMISA. METHODS A retrospective review of 379 patients with OSA who underwent UAS implantation at a single institution between 2014 and 2021. Demographics, OSA severity metrics, and insomnia data were collected. Patients were categorized into OSA alone (OSAa) or COMISA. Objective adherence data were collected from device downloads during follow-up. Data were analyzed with using R Studio (R Foundation for Statistical Computing, Vienna, Austria) and Prism (Boston, MA, USA). RESULTS Of the 274 patients included, 148 had COMISA (54.0%) and 126 OSAa (46.0%). Average follow-up time was 2.5 years and OSAa had more males than COMISA (P < .001). Patients with COMISA had higher insomnia severity index scores than OSAa preoperatively (16 vs 8.7; P = .003). All groups showed significant decreases in objective and self-reported OSA outcomes postoperatively, but there was no difference between COMISA and OSAa. Patient with COMISA had decreased device usage (4.9 vs 5.8 h/night; P = .015) and paused therapy more often than patients with OSAa (1.4 vs 0.4 pauses/night; P < .001). Multivariate linear regression, when controlling for sex as a covariate, showed insomnia to be an independent predictor of lower UAS hours/night and more pauses/night (P < .01). CONCLUSIONS Patients with COMISA use UAS therapy for shorter durations and require more breaks from therapy when compared with those with OSAa. Future research is needed to explore the underlying mechanism and improve UAS treatment adherence in patients with COMISA. CITATION Kaffenberger TM, Chandna M, Kaki P, et al. Reduced usage of upper airway stimulation therapy in patients with comorbid insomnia and obstructive sleep apnea. J Clin Sleep Med. 2023;19(12):1997-2004.
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Affiliation(s)
- Thomas M. Kaffenberger
- Thomas Jefferson University Sleep Disorders Center, Philadelphia, Pennsylvania
- Department of Otolaryngology, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Megha Chandna
- Department of Otolaryngology, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Praneet Kaki
- Department of Otolaryngology, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Andrew M. Corr
- Department of Otolaryngology, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Andrea Plawecki
- Thomas Jefferson University Sleep Disorders Center, Philadelphia, Pennsylvania
- Department of Otolaryngology, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Karl Doghramji
- Thomas Jefferson University Sleep Disorders Center, Philadelphia, Pennsylvania
| | - Maurits Boon
- Thomas Jefferson University Sleep Disorders Center, Philadelphia, Pennsylvania
- Department of Otolaryngology, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Colin Huntley
- Thomas Jefferson University Sleep Disorders Center, Philadelphia, Pennsylvania
- Department of Otolaryngology, Thomas Jefferson University, Philadelphia, Pennsylvania
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Chang JL, Goldberg AN, Alt JA, Alzoubaidi M, Ashbrook L, Auckley D, Ayappa I, Bakhtiar H, Barrera JE, Bartley BL, Billings ME, Boon MS, Bosschieter P, Braverman I, Brodie K, Cabrera-Muffly C, Caesar R, Cahali MB, Cai Y, Cao M, Capasso R, Caples SM, Chahine LM, Chang CP, Chang KW, Chaudhary N, Cheong CSJ, Chowdhuri S, Cistulli PA, Claman D, Collen J, Coughlin KC, Creamer J, Davis EM, Dupuy-McCauley KL, Durr ML, Dutt M, Ali ME, Elkassabany NM, Epstein LJ, Fiala JA, Freedman N, Gill K, Boyd Gillespie M, Golisch L, Gooneratne N, Gottlieb DJ, Green KK, Gulati A, Gurubhagavatula I, Hayward N, Hoff PT, Hoffmann OM, Holfinger SJ, Hsia J, Huntley C, Huoh KC, Huyett P, Inala S, Ishman SL, Jella TK, Jobanputra AM, Johnson AP, Junna MR, Kado JT, Kaffenberger TM, Kapur VK, Kezirian EJ, Khan M, Kirsch DB, Kominsky A, Kryger M, Krystal AD, Kushida CA, Kuzniar TJ, Lam DJ, Lettieri CJ, Lim DC, Lin HC, Liu SY, MacKay SG, Magalang UJ, Malhotra A, Mansukhani MP, Maurer JT, May AM, Mitchell RB, Mokhlesi B, Mullins AE, Nada EM, Naik S, Nokes B, Olson MD, Pack AI, Pang EB, Pang KP, Patil SP, Van de Perck E, Piccirillo JF, Pien GW, Piper AJ, Plawecki A, Quigg M, Ravesloot MJ, Redline S, Rotenberg BW, Ryden A, Sarmiento KF, Sbeih F, Schell AE, Schmickl CN, Schotland HM, Schwab RJ, Seo J, Shah N, Shelgikar AV, Shochat I, Soose RJ, Steele TO, Stephens E, Stepnowsky C, Strohl KP, Sutherland K, Suurna MV, Thaler E, Thapa S, Vanderveken OM, de Vries N, Weaver EM, Weir ID, Wolfe LF, Tucker Woodson B, Won CH, Xu J, Yalamanchi P, Yaremchuk K, Yeghiazarians Y, Yu JL, Zeidler M, Rosen IM. International Consensus Statement on Obstructive Sleep Apnea. Int Forum Allergy Rhinol 2023; 13:1061-1482. [PMID: 36068685 PMCID: PMC10359192 DOI: 10.1002/alr.23079] [Citation(s) in RCA: 34] [Impact Index Per Article: 34.0] [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: 08/12/2022] [Revised: 08/12/2022] [Accepted: 08/18/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND Evaluation and interpretation of the literature on obstructive sleep apnea (OSA) allows for consolidation and determination of the key factors important for clinical management of the adult OSA patient. Toward this goal, an international collaborative of multidisciplinary experts in sleep apnea evaluation and treatment have produced the International Consensus statement on Obstructive Sleep Apnea (ICS:OSA). METHODS Using previously defined methodology, focal topics in OSA were assigned as literature review (LR), evidence-based review (EBR), or evidence-based review with recommendations (EBR-R) formats. Each topic incorporated the available and relevant evidence which was summarized and graded on study quality. Each topic and section underwent iterative review and the ICS:OSA was created and reviewed by all authors for consensus. RESULTS The ICS:OSA addresses OSA syndrome definitions, pathophysiology, epidemiology, risk factors for disease, screening methods, diagnostic testing types, multiple treatment modalities, and effects of OSA treatment on multiple OSA-associated comorbidities. Specific focus on outcomes with positive airway pressure (PAP) and surgical treatments were evaluated. CONCLUSION This review of the literature consolidates the available knowledge and identifies the limitations of the current evidence on OSA. This effort aims to create a resource for OSA evidence-based practice and identify future research needs. Knowledge gaps and research opportunities include improving the metrics of OSA disease, determining the optimal OSA screening paradigms, developing strategies for PAP adherence and longitudinal care, enhancing selection of PAP alternatives and surgery, understanding health risk outcomes, and translating evidence into individualized approaches to therapy.
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Affiliation(s)
- Jolie L. Chang
- University of California, San Francisco, California, USA
| | | | | | | | - Liza Ashbrook
- University of California, San Francisco, California, USA
| | | | - Indu Ayappa
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | | | | | | | - Maurits S. Boon
- Sidney Kimmel Medical Center at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Pien Bosschieter
- Academic Centre for Dentistry Amsterdam, Amsterdam, The Netherlands
| | - Itzhak Braverman
- Hillel Yaffe Medical Center, Hadera Technion, Faculty of Medicine, Hadera, Israel
| | - Kara Brodie
- University of California, San Francisco, California, USA
| | | | - Ray Caesar
- Stone Oak Orthodontics, San Antonio, Texas, USA
| | | | - Yi Cai
- University of California, San Francisco, California, USA
| | | | | | | | | | | | | | | | | | - Susmita Chowdhuri
- Wayne State University and John D. Dingell VA Medical Center, Detroit, Michigan, USA
| | - Peter A. Cistulli
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - David Claman
- University of California, San Francisco, California, USA
| | - Jacob Collen
- Uniformed Services University, Bethesda, Maryland, USA
| | | | | | - Eric M. Davis
- University of Virginia, Charlottesville, Virginia, USA
| | | | | | - Mohan Dutt
- University of Michigan, Ann Arbor, Michigan, USA
| | - Mazen El Ali
- University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | | | | | | | - Kirat Gill
- Stanford University, Palo Alto, California, USA
| | | | - Lea Golisch
- University Hospital Mannheim, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
| | | | | | | | - Arushi Gulati
- University of California, San Francisco, California, USA
| | | | | | - Paul T. Hoff
- University of Michigan, Ann Arbor, Michigan, USA
| | - Oliver M.G. Hoffmann
- University Hospital Mannheim, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
| | | | - Jennifer Hsia
- University of Minnesota, Minneapolis, Minnesota, USA
| | - Colin Huntley
- Sidney Kimmel Medical Center at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | | | | | - Sanjana Inala
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | | | | | | | | | | | | | | | | | - Meena Khan
- Ohio State University, Columbus, Ohio, USA
| | | | - Alan Kominsky
- Cleveland Clinic Head and Neck Institute, Cleveland, Ohio, USA
| | - Meir Kryger
- Yale School of Medicine, New Haven, Connecticut, USA
| | | | | | | | - Derek J. Lam
- Oregon Health and Science University, Portland, Oregon, USA
| | | | | | | | | | | | | | - Atul Malhotra
- University of California, San Diego, California, USA
| | | | - Joachim T. Maurer
- University Hospital Mannheim, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
| | - Anna M. May
- Case Western Reserve University, Cleveland, Ohio, USA
| | - Ron B. Mitchell
- University of Texas, Southwestern and Children’s Medical Center Dallas, Texas, USA
| | | | | | | | | | - Brandon Nokes
- University of California, San Diego, California, USA
| | | | - Allan I. Pack
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | | | | | | | | | | | | | | | - Mark Quigg
- University of Virginia, Charlottesville, Virginia, USA
| | | | - Susan Redline
- Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Armand Ryden
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | | | - Firas Sbeih
- Cleveland Clinic Head and Neck Institute, Cleveland, Ohio, USA
| | | | | | | | | | - Jiyeon Seo
- University of California, Los Angeles, California, USA
| | - Neomi Shah
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | | | - Ryan J. Soose
- University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Erika Stephens
- University of California, San Francisco, California, USA
| | | | | | | | | | - Erica Thaler
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sritika Thapa
- Yale School of Medicine, New Haven, Connecticut, USA
| | | | - Nico de Vries
- Academic Centre for Dentistry Amsterdam, Amsterdam, The Netherlands
| | | | - Ian D. Weir
- Yale School of Medicine, New Haven, Connecticut, USA
| | | | | | | | - Josie Xu
- University of Toronto, Ontario, Canada
| | | | | | | | | | | | - Ilene M. Rosen
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
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5
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Kaffenberger TM, Soose RJ. Hypoglossal Nerve Stimulation Therapy for Obstructive Sleep Apnea. Compend Contin Educ Dent 2023; 44:332-339. [PMID: 37418470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 07/09/2023]
Abstract
Obstructive sleep apnea (OSA) is characterized by repetitive episodes of disrupted breathing during sleep. The most effective treatment for OSA is positive pressure ventilation; however, this treatment can be complicated by adherence difficulties. An array of alternative OSA therapies have emerged, including positional therapy, nasal exhalation devices, oral appliances, and various nasal, pharyngeal, and skeletal surgical treatments. One of the newest options, hypoglossal nerve stimulation (HNS) therapy, represents a hybrid medical and surgical treatment. This therapy involves an FDA-approved surgically implanted neuromodulation system that is activated by the patient each night to augment upper airway dilator muscle activity and improve airflow. The implanted components comprise a pulse generator, an electrode on the distal portion of the hypoglossal nerve, and a respiratory sensing lead that allows for synchronization of electrical impulses with the patient's respiratory cycle. Using a representative patient case, the authors describe HNS therapy, including its indications, patient selection, surgical procedure, long-term outpatient management, and outcomes data.
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Affiliation(s)
- Thomas M Kaffenberger
- Sleep Medicine and Sleep Surgery Fellow Physician, Department of Otolaryngology, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Ryan J Soose
- Director, Sleep Division, Associate Professor, Department of Otolaryngology, University of Pittsburgh, Pittsburgh, Pennsylvania
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Harris AL, Kaffenberger TM, Green KJ, Kolich B, Khan N, Solari MG, Sridharan SS, Kubik MW. Functional outcomes of hyoid suspension in anterior oromandibular reconstruction. Am J Otolaryngol 2023; 44:103812. [PMID: 36963234 DOI: 10.1016/j.amjoto.2023.103812] [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: 12/28/2022] [Accepted: 02/19/2023] [Indexed: 03/13/2023]
Abstract
BACKGROUND Hyoid suspension can be considered in major oromandibular reconstruction. The impact of hyoid suspension on flap viability, swallowing outcomes, airway, and long term radiographic hyoid position is unknown. The objective of this study is to describe outcomes after hyoid suspension in anterior mandibular reconstruction with fibular free flaps. We hypothesized hyoid suspension would not affect flap viability and would benefit functional outcomes. METHODS A retrospective cohort study was conducted in an academic tertiary medical center. The study consisted of 84 adults who underwent anterior mandibular reconstruction from February 2014 to September 2020. The primary outcome studied was the post-suspension flap viability. Secondary outcomes include pre/post-operative hyomental distance on computed-tomography, duration of perioperative tracheostomy, postoperative feeding tube dependence, and post-operative aspiration pneumonia. RESULTS A total of 84, predominantly male (66.5 %), patients with an average age of 58.9 ± 11.5 were included in the study. Of those that met inclusion criteria, 25 (29.4 %) underwent intraoperative hyoid suspension. Univariable analysis showed no significant association between resuspension and post-operative total flap loss (p = 0.864) or partial flap loss (p = 0.318). There was no association between hyoid suspension and any of the studied postoperative functional outcomes or radiographic measures. CONCLUSIONS Hyoid suspension is an option during oromandibular reconstruction and does not impact flap viability. The impact on functional outcomes and long-term hyoid position in this patient subset remains unclear.
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Affiliation(s)
- Alexandria L Harris
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Thomas M Kaffenberger
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Katerina J Green
- Department of Plastic and Reconstructive Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Brian Kolich
- University of Pittsburgh, School of Medicine, Pittsburgh, PA, United States
| | - Nayel Khan
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Mario G Solari
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States; University of Pittsburgh, School of Medicine, Pittsburgh, PA, United States
| | - Shaum S Sridharan
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States; University of Pittsburgh, School of Medicine, Pittsburgh, PA, United States
| | - Mark W Kubik
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States; University of Pittsburgh, School of Medicine, Pittsburgh, PA, United States.
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Mady LJ, Kaffenberger TM, Baddour K, Melder K, Godse NR, Gardner P, Snyderman CH, Solari MG, Kubik MW, Wang EW, Sridharan S. Anatomic Considerations of Microvascular Free Tissue Transfer in Endoscopic Endonasal Skull Base Surgery. Skull Base Surg 2022; 83:e143-e151. [DOI: 10.1055/s-0041-1722935] [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: 04/30/2020] [Accepted: 12/03/2020] [Indexed: 10/22/2022]
Abstract
Abstract
Objective Though microvascular free tissue transfer is well established for open skull base reconstruction, normative data regarding flap design and inset after endoscopic endonasal skull base surgery (ESBS) is lacking. We aim to describe anatomical considerations of endoscopic endonasal inset of free tissue transfer of transclival (TC) and anterior cranial base resection (ACBR) defects.
Design and Setting Radial forearm free tissue transfer (RFFTT) model.
Participants Six cadaveric specimens.
Main Outcome Measures Pedicle orientation, pedicle length, and recipient vessel intraluminal diameter.
Results TC and ACBR defects averaged 17.2 and 11.7 cm2, respectively. Anterior and lateral maxillotomies and endoscopic medial maxillectomies were prepared as corridors for flap and pedicle passage. Premasseteric space tunnels were created for pedicle tunneling to recipient facial vessels. For TC defects, the RFFTT pedicle was oriented cranially with the flap placed against the clival defect (mean pedicle length 13.1 ± 0.6 cm). For ACBR defects, the RFFTT pedicle was examined in three orientations with respect to anterior–posterior axis of the RFFTT: anteriorly, posteriorly, and laterally. Lateral orientation offered the shortest average pedicle length required for anastomosis in the neck (11.6 ± 1.29 cm), followed by posterior (13.4 ± 0.7cm) and anterior orientations (14.4 ± 1.1cm) (p < 0.00001, analysis of variance).
Conclusions In ACBR reconstruction using RFFTT, our data suggests lateral pedicle orientation shortens the length required to safely anastomose facial vessels and protects the frontal sinus outflow anteriorly while limiting pedicle exposure through a maxillary corridor within the nasal cavity. With greater understanding of anatomical factors related to successful preoperative flap planning, free tissue transfer may be added to the ESBS reconstruction ladder.
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Affiliation(s)
- Leila J. Mady
- Department of Otorhinolaryngology – Head and Neck Surgery, University of Pennsylvania, Philadelphia, United States
| | | | - Khalil Baddour
- University of Pittsburgh, Pittsburgh, Pennsylvania, United States
| | - Katie Melder
- University of Pittsburgh, Pittsburgh, Pennsylvania, United States
| | - Neal R. Godse
- University of Pittsburgh, Pittsburgh, Pennsylvania, United States
| | - Paul Gardner
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
| | - Carl H. Snyderman
- Department of Otolaryngology, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
| | - Mario G. Solari
- University of Pittsburgh, Pittsburgh, Pennsylvania, United States
| | - Mark W. Kubik
- University of Pittsburgh, Pittsburgh, Pennsylvania, United States
| | - Eric W. Wang
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
| | - Shaum Sridharan
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
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8
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Kaffenberger TM, Eichar BW, McCoy JL, Yang TS, Shaffer AD, Dohar JE. Cystic fibrosis mutation classes in pediatric otitis media - Fickle or faulty? Am J Otolaryngol 2021; 42:103067. [PMID: 33957545 DOI: 10.1016/j.amjoto.2021.103067] [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: 04/09/2021] [Accepted: 04/13/2021] [Indexed: 11/17/2022]
Abstract
PURPOSE Recent data have challenged the historical paradigm that cystic fibrosis (CF) protects against otitis media (OM). These findings raised questions about the pathogenesis of this ostensible change. In this study our aim is to characterize acute OM (AOM) risk based on CF genotype. METHODS A retrospective chart review was completed at a tertiary care pediatric hospital. Charts of 159 CF patients seen at our facility from 2010 to 2019 were reviewed. Data collected included demographics, AOM infections, cystic fibrosis transmembrane conductance regulator (CFTR) allele mutations, pulmonary exacerbations (PE), and pancreatic insufficiency (PI) status. Mutation alleles were divided into five classes based on CF guidelines, which were further classified as severe (classes I-III) or mild (classes IV-V). RESULTS 54% of patients had at least one episode of AOM with a mean of 1.5 episodes of AOM (standard deviation = 2.3). 86% of patients had severe/severe (S/S) alleles and 14% had severe/mild (S/M). S/S patients had significantly more PE (p = .004) and increased rates of PI (p < .001). Of the 131 patients with S/S mutations, 57% had an episode of AOM while only 46% the 22 S/M patients had an AOM episode (p = .357). CONCLUSIONS To our knowledge this is the first report showing a clinical trend towards increased middle ear disease in patients with severe CFTR mutations. Future prospective studies will be powered to demonstrate whether this trend is statistically significant. Patients with S/S mutations not only have more severe clinical phenotypes but may have additional unexpected complications such as middle ear disease.
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Affiliation(s)
- Thomas M Kaffenberger
- Department of Otolaryngology, University of Pittsburgh School of Medicine, 203 Lothrop St. Suite 500, Pittsburgh, PA 15213, USA
| | - Bradley W Eichar
- Department of Otolaryngology, University of Pittsburgh School of Medicine, 203 Lothrop St. Suite 500, Pittsburgh, PA 15213, USA.
| | - Jennifer L McCoy
- Division of Pediatric Otolaryngology, UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA 15224, USA.
| | - Tiffany S Yang
- Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA 15224, USA.
| | - Amber D Shaffer
- Division of Pediatric Otolaryngology, UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA 15224, USA.
| | - Joseph E Dohar
- Department of Otolaryngology, University of Pittsburgh School of Medicine, 203 Lothrop St. Suite 500, Pittsburgh, PA 15213, USA; Division of Pediatric Otolaryngology, UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA 15224, USA; Department of Communication Science and Disorders, University of Pittsburgh School of Health & Rehabilitation, Forbes Tower, 3600 Forbes Ave., Pittsburgh, PA 15260, USA.
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9
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Kaffenberger TM, Patel AK, Lyu L, Li J, Wasserman‐Wincko T, Zandberg DP, Clump DA, Johnson JT, Nilsen ML. Quality of life after radiation and transoral robotic surgery in advanced oropharyngeal cancer. Laryngoscope Investig Otolaryngol 2021; 6:983-990. [PMID: 34667840 PMCID: PMC8513430 DOI: 10.1002/lio2.628] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 06/08/2021] [Accepted: 07/09/2021] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES Oropharyngeal squamous cell carcinoma (OPSCC) treatment results in impaired swallowing and quality of life (QOL). We analyzed a cross-section of advanced stage OPSCC patients treated with multimodal therapies at our Survivorship Clinic to investigate treatment factors associated with QOL. METHODS Retrospective analysis of patient-reported outcomes (PROMs) after primary OPSCC treatment using AJCC seventh edition staging. RESULTS A total of 73 patients were included (90.1% human papillomavirus positive [HPV+]). There were no QOL differences between robotic surgery with radiation ± chemotherapy patients (n = 29) and those treated by radiation ± chemotherapy (n = 44). Radiation field analysis demonstrated significant correlations between increasing doses to larynx and contralateral parotid and submandibular gland and worse swallowing as measured by the Eating Assessment Tool-10 (P = .02; P = .01; P = .01). CONCLUSIONS In advanced, mostly HPV+, OPSCC, we did not find clinically significant differences between QOL PROMs between surgical and radiation ± chemotherapy treatment groups. This highlights the need for continued therapy de-escalation along with improved interventions for treatment related toxicities. LEVEL OF EVIDENCE 4.
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Affiliation(s)
- Thomas M. Kaffenberger
- Department of Otolaryngology—Head and Neck SurgeryUniversity of Pittsburgh School of MedicinePittsburghPennsylvaniaUSA
| | - Ankur K. Patel
- Department of Radiation OncologyUPMC Hillman Cancer Center, University of Pittsburgh School of MedicinePittsburghPennsylvaniaUSA
| | - Lingyun Lyu
- Department of BiostatisticsUniversity of Pittsburgh School of Public HealthPittsburghPennsylvaniaUSA
| | - Jinhong Li
- Department of BiostatisticsUniversity of Pittsburgh School of Public HealthPittsburghPennsylvaniaUSA
| | - Tamara Wasserman‐Wincko
- Department of Otolaryngology—Head and Neck SurgeryUniversity of Pittsburgh School of MedicinePittsburghPennsylvaniaUSA
| | - Dan P. Zandberg
- Department of Hematology/OncologyUPMC Hillman Cancer Center, University of Pittsburgh School of MedicinePittsburghPennsylvaniaUSA
| | - David A. Clump
- Department of Radiation OncologyUPMC Hillman Cancer Center, University of Pittsburgh School of MedicinePittsburghPennsylvaniaUSA
| | - Jonas T. Johnson
- Department of Otolaryngology—Head and Neck SurgeryUniversity of Pittsburgh School of MedicinePittsburghPennsylvaniaUSA
| | - Marci L. Nilsen
- Department of Otolaryngology—Head and Neck SurgeryUniversity of Pittsburgh School of MedicinePittsburghPennsylvaniaUSA
- Department of Acute and Tertiary CareUniversity of Pittsburgh School of NursingPittsburghPennsylvaniaUSA
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10
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McCoy JL, Kaffenberger TM, Yang TS, Dohar JE. Otitis media prone children with cystic fibrosis: A new normal. Am J Otolaryngol 2021; 42:103137. [PMID: 34174638 DOI: 10.1016/j.amjoto.2021.103137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 06/13/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES To determine if children with cystic fibrosis (CF) who are otitis media prone and treated with tympanostomy tube placement (TTP) follow the natural course of non-CF children regarding the incidence of tympanostomy tube otorrhea (TTO) (21-34%). METHODS All CF patients seen at a large tertiary pediatric hospital were retrospectively reviewed from 2010 to 2019. A total of 483 patients were identified and seventeen met the inclusion criteria and were included in the analysis. Data collected included demographics, CF diagnosis history including date of diagnosis and genotype, TTP notes, and otorrhea found in otolaryngology clinic and pediatrician clinic notes for up to 18 months post-TTP. RESULTS CF was diagnosed at a median age of 13 days (0 days to 6 years). In terms of surgical frequency, 14/17 (82.4%) patients had one TTP, 2/17 (11.8%) had two TTPs, and 1/17 (5.9%) had five TTPs. The median (range) age at first TTP was 2 years (3 months to 13 years). After the first TTP, TTO occurred in 5 (29.4%) patients at 3 months, 6 (35.3%) at 6 and 9 months, and 7 (41.2%) at 12 and 18 months at median (range) = 1 (0-5) otolaryngology appointments and median (range) = 0 (0-8) pediatrician appointments. CONCLUSION To our knowledge this is the first study to report that CF children are more likely to be severely affected with recurrent acute otitis media (RAOM), to require TTP, and to exhibit a natural history of TTO commensurate with the non-CF population.
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11
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Branstetter BF, Kaffenberger TM, Eichar B, Traylor KS, Kubik MW. In Response to Utility of Esophagrams to Detect Prevertebral Invasion in Hypopharyngeal Carcinomas. Laryngoscope 2021; 131:E2791. [PMID: 34318935 DOI: 10.1002/lary.29774] [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: 07/07/2021] [Accepted: 07/08/2021] [Indexed: 11/07/2022]
Affiliation(s)
- Barton F Branstetter
- Departments of Otolaryngology, UPMC, Pittsburgh, Pennsylvania, U.S.A.,Radiology, UPMC, Pittsburgh, Pennsylvania, U.S.A
| | | | - Bradley Eichar
- School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
| | | | - Mark W Kubik
- Departments of Otolaryngology, UPMC, Pittsburgh, Pennsylvania, U.S.A
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12
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Huyett P, Kent DT, D'Agostino MA, Green KK, Soose RJ, Kaffenberger TM, Woodson BT, Huntley C, Boon MS, Heiser C, Birk A, Suurna MV, Lin HS, Waxman JA, Kezirian EJ. Drug-Induced Sleep Endoscopy and Hypoglossal Nerve Stimulation Outcomes: A Multicenter Cohort Study. Laryngoscope 2021; 131:1676-1682. [PMID: 33443811 DOI: 10.1002/lary.29396] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [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: 07/16/2020] [Revised: 12/03/2020] [Accepted: 12/29/2020] [Indexed: 02/04/2023]
Abstract
OBJECTIVES/HYPOTHESIS To determine the association between findings of blinded reviews of preoperative drug-induced sleep endoscopy (DISE) and outcomes of hypoglossal nerve stimulation (HNS) for obstructive sleep apnea (OSA). STUDY DESIGN Cohort study. METHODS A retrospective, multicenter cohort study of 343 adults who underwent treatment of OSA with HNS from 10 academic medical centers was performed. Preoperative DISE videos were scored by four blinded reviewers using the VOTE Classification and evaluation of a possible primary structure contributing to airway obstruction. Consensus DISE findings were examined for an association with surgical outcomes based on therapy titration polysomnogram (tPSG). Treatment response was defined by a decrease of ≥50% in the apnea-hypopnea index (AHI) to <15 events/hour. RESULTS Study participants (76% male, 60.4 ± 11.0 years old) had a body mass index of 29.2 ± 3.6 kg/m2 . AHI decreased (35.6 ± 15.2 to 11.0 ± 14.1 events/hour; P < .001) on the tPSG, with a 72.6% response rate. Complete palate obstruction (vs. none) was associated with the greatest difference in AHI improvement (-26.8 ± 14.9 vs. -19.2 ± 12.8, P = .02). Complete (vs. partial/none) tongue-related obstruction was associated with increased odds of treatment response (78% vs. 68%, P = .043). Complete (vs. partial/none) oropharyngeal lateral wall-related obstruction was associated with lower odds of surgical response (58% vs. 74%, P = .042). CONCLUSIONS The DISE finding of primary tongue contribution to airway obstruction was associated with better outcomes, whereas the opposite was true for the oropharyngeal lateral walls. This study suggests that the role for DISE in counseling candidates for HNS extends beyond solely for excluding complete concentric collapse related to the velum. LEVEL OF EVIDENCE 3 Laryngoscope, 131:1676-1682, 2021.
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Affiliation(s)
- Phillip Huyett
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - David T Kent
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, U.S.A
| | - Mark A D'Agostino
- Southern New England Ear, Nose and Throat Group, Middlesex Hospital, Middlesex, Connecticut, U.S.A.,Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, U.S.A
| | - Katherine K Green
- Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine, Aurora, Colorado, U.S.A
| | - Ryan J Soose
- UPMC Department of Otolaryngology Head and Neck Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, U.S.A
| | - Thomas M Kaffenberger
- UPMC Department of Otolaryngology Head and Neck Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, U.S.A
| | - B Tucker Woodson
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, U.S.A
| | - Colin Huntley
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, U.S.A
| | - Maurits S Boon
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, U.S.A
| | - Clemens Heiser
- Department of Otorhinolaryngology, Head and Neck Surgery, Technische Universität München, Munich, Germany
| | - Amelie Birk
- Department of Otorhinolaryngology, Head and Neck Surgery, Technische Universität München, Munich, Germany
| | - Maria V Suurna
- Department of Otolaryngology-Head and Neck Surgery, Weill Cornell Medicine/New York Presbyterian Hospital, New York, New York, U.S.A
| | - Ho-Sheng Lin
- Department of Otolaryngology-Head and Neck Surgery, Wayne State University School of Medicine, Detroit, Michigan, U.S.A
| | - Jonathan A Waxman
- Department of Otolaryngology-Head and Neck Surgery, Wayne State University School of Medicine, Detroit, Michigan, U.S.A
| | - Eric J Kezirian
- USC Caruso Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine of the University of Southern California, California, Los Angeles, U.S.A
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13
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Kaffenberger TM, Eichar B, Traylor KS, Kubik MW, Branstetter BF. Utility of Esophagrams to Detect Prevertebral Invasion in Hypopharyngeal Squamous Cell Carcinoma. Laryngoscope 2020; 131:800-805. [PMID: 33270244 DOI: 10.1002/lary.29011] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 07/12/2020] [Accepted: 07/20/2020] [Indexed: 11/08/2022]
Abstract
OBJECTIVES/HYPOTHESIS Prevertebral fascia invasion is a feature of advanced hypopharyngeal squamous cell carcinoma (HPSCC) that predicts surgical futility. Magnetic resonance and computed topography imaging are used to identify prevertebral involvement, but reliable prediction remains a challenge. Our aims were to describe a new indication for esophagrams and assess its ability to detect prevertebral invasion preoperatively. STUDY DESIGN Retrospective Review. METHODS A retrospective review of advanced HPSCC patients from 2001 to 2019. Thirty-one patients underwent curative treatment (21 surgically, 10 with chemoradiation) with a preoperative esophagram. Operative and pathology reports, and fluoroscopic images were collected from the medical record. Esophagrams were read independently by two blinded radiologists. Excursion of the laryngeal complex was quantified relative to the height of vertebral bodies; <0.5 bodies was considered positive for fixation. Surgery or comparative imaging modalities were the gold-standard comparisons. RESULTS Mean age at diagnosis was 63 years. Twenty-one patients underwent surgical treatment with laryngopharyngectomies. One patient had prevertebral invasion during surgical exploration. Ten patients underwent chemoradiation therapy, and three of these had prevertebral invasion. The average hyolaryngeal elevation was 1.05 vertebral bodies (standard deviation = 0.5). There was a strong correlation between radiologists (R = 0.80, P < .0001). Compared to the gold standard, esophagrams had sensitivity of 75%, specificity of 93%, positive predictive value of 60%, and a negative predictive value (NPV) of 96%. CONCLUSIONS This study highlights the utility of a common radiologic modality in assessing prevertebral fascia invasion in an advanced-stage HPSCC cohort undergoing surgical treatment. With a high NPV and specificity, the esophagram's potential to rule out prevertebral fascia invasion is a useful predictor of resectability. LEVEL OF EVIDENCE 4 Laryngoscope, 131:800-805, 2021.
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Affiliation(s)
- Thomas M Kaffenberger
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, U.S.A
| | - Bradley Eichar
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, U.S.A
| | - Katie S Traylor
- Department of Radiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, U.S.A
| | - Mark W Kubik
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, U.S.A
| | - Barton F Branstetter
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, U.S.A.,Department of Radiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, U.S.A
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14
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Kaffenberger TM, Belsky MA, Oberlies NR, Kumar A, Donohue JP, Yang TS, Shaffer AD, Chi DH. Long-term Impact of Middle Ear Effusion in Pediatric Tympanostomy Tubes. Laryngoscope 2020; 131:E993-E997. [PMID: 32621539 DOI: 10.1002/lary.28860] [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: 01/14/2020] [Revised: 05/12/2020] [Accepted: 05/20/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVES/HYPOTHESIS Bilateral myringotomy and tympanostomy tube placement (BMT) is the most common pediatric surgery in the United States. Intraoperative middle ear effusion (MEE) is a risk factor for future BMTs in children with recurrent acute otitis media (RAOM). However, the impact of the type of MEE is unknown. Here, we assess otologic outcomes based on intraoperative MEE type and indication for surgery. STUDY DESIGN Case series chart review. METHODS After institutional review board approval, we performed a review of children undergoing BMTs between 2008 and 2009. Included patients had their first BMT, preoperative visit, and an operative report. Patients with cleft palate or Down syndrome were excluded. Indications for surgery included RAOM and chronic otitis media with effusion (COME). Other variables evaluated were future BMT, acquired cholesteatoma, and otorrhea. Logistic regression was used for statistical analysis. RESULTS Out of 1,045 patients reviewed, 680 were included and underwent their first BMT. There were 619 patients who had RAOM. Serous effusions were present in 22.2%, mucoid in 31.3%, purulent in 12.9%, undocumented or bloody in 2.3% of patients, and 31.2% of patients had dry middle ears. Moreover, 22.7% of patients underwent future BMTs. In RAOM patients, serous effusions decreased odds of perforation (odds ratio [OR]: 0.195, 95% confidence interval [CI]: 0.0438-0.867, P = .032), and purulent effusions increased the odds of in-office otorrhea suctioning (OR: 2.13, 95% CI: 1.20-3.77, P = .010) compared to dry. Mucoid effusions had no significant effect on outcomes in COME or RAOM patients. CONCLUSIONS Intraoperative MEEs were noted in 68.7% of cases; purulent effusions increase the odds of in-office suctioning in RAOM patients. LEVEL OF EVIDENCE 4 Laryngoscope, 131:E993-E997, 2021.
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Affiliation(s)
- Thomas M Kaffenberger
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, U.S.A
| | - Michael A Belsky
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, U.S.A
| | - Nicholas R Oberlies
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, U.S.A
| | - Aarti Kumar
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, U.S.A
| | - Joseph P Donohue
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, U.S.A
| | - Tiffany S Yang
- University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
| | - Amber D Shaffer
- University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
| | - David H Chi
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, U.S.A.,University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
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15
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McCoy JL, Kaffenberger TM, Yang TS, Shaffer AD, Dohar JE. Middle ear disease in CF? It's not just about the sinuses anymore! Int J Pediatr Otorhinolaryngol 2020; 134:110032. [PMID: 32259649 DOI: 10.1016/j.ijporl.2020.110032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 03/25/2020] [Accepted: 03/28/2020] [Indexed: 01/14/2023]
Abstract
INTRODUCTION Historically cystic fibrosis (CF), in contrast to primary ciliary dyskinesia (PCD), has been considered protective of the middle ear from otitis media and rarely were such patients "severely affected" to require tympanostomy tube placement (BMT). Previously the Pittsburgh Otitis Media Research group reported a 10% prevalence of otitis media in the pediatric CF population which is significantly lower than age matched non-CF children. We studied the prevalence of OM in pediatric CF patients to assess if the otologic phenotype has changed in parallel with changes in the diagnosis itself. METHODS The medical records of 133 CF patients seen either inpatient or outpatient from one of the largest tertiary pediatric CF centers in the world from 2010 to 2019 were reviewed for demographics, acute otitis media (AOM) episodes, risk factors for AOM, placement of myringotomy tubes, genotype, BMI, pancreatic status, respiratory culture results, and pulmonary exacerbations. RESULTS Just over half (52.6%) the patients were male. A median age for CF diagnosis was 11 days old (range 0 days-16 years). The most common genotype (49.6%) was homozygous for ΔF508 mutation. Fifty-five (41.4%) patients had 1-2 episodes of AOM, and 15 (11.3%) were severely affected (i.e. ≥3 episodes/6 months or ≥4 episodes/year). COME was diagnosed in 4 (3.0%) of the patients. Twelve (9.0%) patients had tympanostomy tubes at least once, including 3 patients with multiple sets of tubes. Having at least one AOM episode was not predicted by genetic mutation groups, BMI, age at diagnosis, or comorbidities, p > .05. CONCLUSIONS The time-honored adage of CF protecting against otitis media is no longer true and pediatric otolaryngologists must now prioritize the management of middle ear disease as highly as sino-nasal and pulmonary disease. Future study into mechanisms explaining the change is needed.
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Affiliation(s)
- Jennifer L McCoy
- Division of Pediatric Otolaryngology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Thomas M Kaffenberger
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Tiffany S Yang
- Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Amber D Shaffer
- Division of Pediatric Otolaryngology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Joseph E Dohar
- Division of Pediatric Otolaryngology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA; Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
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16
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Schwarzbach HL, Mady LJ, Kaffenberger TM, Duvvuri U, Jabbour N. Quality and Readability Assessment of Websites on Human Papillomavirus and Oropharyngeal Cancer. Laryngoscope 2020; 131:87-94. [PMID: 32282087 DOI: 10.1002/lary.28670] [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] [Received: 11/30/2019] [Revised: 02/13/2020] [Accepted: 03/23/2020] [Indexed: 12/18/2022]
Abstract
OBJECTIVES/HYPOTHESIS The incidence of human papillomavirus-positive (HPV+) oropharyngeal cancer is rising, but public knowledge about this diagnosis remains low. This study aimed to investigate the quality and readability of online information about HPV+ oropharyngeal cancer. STUDY DESIGN Cross-sectional website analysis. METHODS This study conducted a total of 12 web searches across Google, Yahoo, and Bing to identify websites related to HPV+ oropharyngeal cancer. The QUality Evaluation Scoring Tool (QUEST) was used to measure quality based on seven website criteria. The Flesch Reading Ease Score (FRES) and Flesch-Kincaid Grade Level (FKGL) were used to measure readability, with scores estimating the education level a reader would require to understand a piece of text. Readability improves as FRES increases and FKGL decreases. RESULTS Twenty-seven unique web pages were evaluated. The mean USA reading grade level as measured by FKGL was 10.42 (standard deviation = 1.54). There was an inverse relationship between quality and readability, with a significant positive correlation between QUEST score and FKGL (r = 0.343, P = .040) and a significant negative correlation between QUEST score and FRES (r = -0.537, P = .002). CONCLUSIONS With a mean USA reading grade level more than four grades above the American Medical Association's recommendation and results indicating that readability suffers as quality improves, these findings suggest that the currently available online information about HPV+ oropharyngeal cancer is insufficient. Improved patient education practices and resources about this diagnosis are needed. LEVEL OF EVIDENCE NA Laryngoscope, 131:87-94, 2021.
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Affiliation(s)
| | - Leila J Mady
- Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, U.S.A
| | - Thomas M Kaffenberger
- Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, U.S.A
| | - Umamaheswar Duvvuri
- Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, U.S.A
| | - Noel Jabbour
- Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, U.S.A
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Lumley CJ, Kaffenberger TM, Desale S, Tefera E, Han CJ, Rafei H, Maxwell JH. Post-diagnosis aspirin use and survival in veterans with head and neck cancer. Head Neck 2018; 41:1220-1226. [PMID: 30537085 DOI: 10.1002/hed.25518] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [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: 05/31/2018] [Revised: 08/26/2018] [Accepted: 10/06/2018] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Our objective was to determine the effect of post-diagnosis aspirin use on survival in veterans with head and neck squamous cell carcinoma. METHODS Retrospective cohort study of 584 veterans with head and neck squamous cell carcinoma treated at the Washington DC VA Medical Center between 1995 and 2015. Charts were queried for clinical-pathologic data, aspirin prescriptions, and outcome. The Kaplan-Meier method was used to determine overall survival (OS) and disease-specific survival (DSS) among aspirin users and nonusers. RESULTS A total of 329 patients met inclusion criteria. Primary subsites included oropharynx (n = 143), larynx (n = 105), oral cavity (n = 62), and hypopharynx (n = 19). Eighty-four patients were aspirin users (25.5%). Aspirin users demonstrated significantly better 3-year OS and DSS (78.6% and 88.1%) compared to nonaspirin users (OS: 55.9% and DSS: 70.2%; P = .0003 and P = .0019, respectively). On multivariate analysis, aspirin use remained independently associated with improved survival. CONCLUSION Aspirin use following diagnosis and curative treatment of head and neck squamous cell carcinoma is associated with improved OS and DSS.
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Affiliation(s)
- Catherine J Lumley
- Department of Otolaryngology-Head and Neck Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
| | - Thomas M Kaffenberger
- Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Sameer Desale
- Department of Biostatistics and Biomedical informatics, MedStar Health Research Institute, Washington, District of Columbia
| | - Eshetu Tefera
- Department of Biostatistics and Biomedical informatics, MedStar Health Research Institute, Washington, District of Columbia
| | - Chihun Jim Han
- Department of Otolaryngology-Head and Neck Surgery, Georgetown University School of Medicine, Washington, District of Columbia
| | - Hind Rafei
- Department of Medicine, George Washington University School of Medicine, Washington, District of Columbia
| | - Jessica H Maxwell
- Department of Otolaryngology-Head and Neck Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia.,Department of Surgery, Washington DC Veterans Affairs Medical Center, Washington, District of Columbia
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18
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Kaffenberger TM, Dedhia RC, Schwarzbach HL, Mady LJ, Lee SE. Comparative effectiveness of allergy testing method in driving immunotherapy outcomes. Int Forum Allergy Rhinol 2017; 8:563-570. [PMID: 29266815 DOI: 10.1002/alr.22061] [Citation(s) in RCA: 7] [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] [Received: 08/26/2017] [Revised: 11/11/2017] [Accepted: 11/16/2017] [Indexed: 12/30/2022]
Abstract
BACKGROUND Skin-prick testing (SPT), in vitro testing (IVT), and intradermal-dilutional testing (IDT) are methods to detect patient sensitivities to specific allergens and direct immunotherapy dosing. We used objective and subjective measures of improvement to compare outcomes based on test method. METHODS Patients underwent 1 of 3 protocols: SPT, screening SPT followed by IDT, or IVT. We used institution billing data to do a cost analysis of these tests. The time to maintenance (TTM) therapy was analyzed and patients were stratified into high and low reactors. The Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ) was used to quantify symptoms pre-maintenance and post-maintenance. RESULTS Of 177 patients (SPT, n = 40; IVT, n = 91; IDT, n = 46), 115 (SPT, n = 35; IVT, n = 39; IDT, n = 41) were high reactors. Out of 90 patients (SPT, n = 17; IVT, n = 37; IDT, n = 36) reaching maintenance, 58 were high reactors (SPT, n = 15; IVT, n = 12; IDT, n = 31). Overall, SPT, IVT, and IDT median TTM were 542, 329, and 578.5 days, respectively. IDT TTM was shorter compared to IVT overall and in high reactors (hazard ratio [HR] = 1.91, p = 0.02; HR = 2.12, p = 0.03), but was not significant compared to SPT high reactors (p = 0.33). The IDT cost was $62.66, translating to an incremental cost-effectiveness ratio of $0.23 per day of shortened TTM. Median RQLQ change for the SPT, IVT, and IDT groups was 6.5, 1, and 1.5, respectively, but was not significant (p = 0.60). CONCLUSION IDT reached maintenance immunotherapy quicker than IVT but there was no difference compared to SPT. TTM did not correlate with improvements in patient symptoms between testing methods. This study represents a novel comparison of outcomes based on initial allergy testing method.
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Affiliation(s)
- Thomas M Kaffenberger
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Raj C Dedhia
- Department of Otolaryngology, Emory University School of Medicine, Atlanta, GA
| | | | - Leila J Mady
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Stella E Lee
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, PA
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Mady LJ, Schwarzbach HL, Moore JA, Boudreau RM, Kaffenberger TM, Willson TJ, Lee SE. The association of air pollutants and allergic and nonallergic rhinitis in chronic rhinosinusitis. Int Forum Allergy Rhinol 2017; 8:369-376. [DOI: 10.1002/alr.22060] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Revised: 10/23/2017] [Accepted: 11/16/2017] [Indexed: 02/05/2023]
Affiliation(s)
- Leila J. Mady
- Department of Otolaryngology; University of Pittsburgh; Pittsburgh PA
| | | | - John A. Moore
- Department of Otolaryngology; University of Pittsburgh; Pittsburgh PA
| | - Robert M. Boudreau
- Department of Epidemiology; University of Pittsburgh Graduate School of Public Health; Pittsburgh PA
| | | | - Thomas J. Willson
- Department of Otolaryngology; San Antonio Military Medical Center; Uniformed Services University of the Health Sciences; San Antonio TX
| | - Stella E. Lee
- Department of Otolaryngology; University of Pittsburgh; Pittsburgh PA
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Kaffenberger TM, Maxwell JH, Kim S. Prophylactic central neck dissection in 68 patients with lateral compartment metastases from well-differentiated thyroid cancer. Clin Otolaryngol 2017; 43:365-369. [PMID: 28834229 DOI: 10.1111/coa.12957] [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] [Accepted: 08/13/2017] [Indexed: 11/30/2022]
Affiliation(s)
- T M Kaffenberger
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - J H Maxwell
- Georgetown University School of Medicine, Washington, DC, USA
| | - S Kim
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Govil N, Kaffenberger TM, Shaffer AD, Chi DH. Factors influencing hearing outcomes in pediatric patients undergoing ossicular chain reconstruction. Int J Pediatr Otorhinolaryngol 2017; 99:60-65. [PMID: 28688567 DOI: 10.1016/j.ijporl.2017.05.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Revised: 05/16/2017] [Accepted: 05/27/2017] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Ossicular chain disruption in children leads to conductive hearing loss. Few studies have focused on factors influencing successful results in pediatric ossicular chain reconstruction (OCR). We aim to determine whether demographic or surgical factors affect hearing outcomes in pediatric OCR. METHODS We conducted a retrospective chart review of 120 patients undergoing OCR at our institution, a tertiary care hospital, between 2003 and 2014, with median length of follow-up of 2.2 years (range 0.1-9.3 years). Pediatric patients (<18 years old at time of surgical procedure) who had current procedural terminology (CPT) codes of OCR, and available pre- and post-operative audiograms were included in the study. Demographic information, surgical details, and pre- and post-operative pure-tone averages (PTA), speech reception thresholds (SRT), and air-bone gaps (ABG) were recorded from clinic notes, audiograms and operative reports. Differences between PTA, SRT and ABG pre- and post-operatively, as well as demographic and surgical factors, were evaluated using Wilcoxon rank-sum tests. Factors influencing revision were evaluated using Log-rank tests. RESULTS A total of 120 patients (123 ears) were included. 35.8% of cases were revised, most commonly due to displaced prostheses. 28.5% of surgeries resulted in normal hearing (PTA ≤25 dB) post-operatively. Post-operative SRT and ABG were significantly better in patients with partial ossicular replacement prosthesis (PORP) compared with those with total ossicular replacement prosthesis (TORP) (p = 0.016, 0.027). Titanium prostheses resulted in better post-operative PTA and larger changes in PTA compared with all other materials (p = 0.034, p = 0.038). CONCLUSIONS In our experience, children with titanium prostheses had better hearing outcomes than those with other materials, and children with PORP had better hearing outcomes than those with TORP.
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Affiliation(s)
- Nandini Govil
- Department of Otolaryngology, University of Pittsburgh Medical Center, Eye and Ear Institute, Suite 519, 203 Lothrop St, Pittsburgh, PA 15213, USA
| | - Thomas M Kaffenberger
- University of Pittsburgh School of Medicine, M240 Scaife Hall, 3550 Terrace St, Pittsburgh, PA 15261, USA
| | - Amber D Shaffer
- Division of Pediatric Otolaryngology, Children's Hospital of Pittsburgh of UPMC, 4401 Penn Ave, Pittsburgh, PA 15224, USA
| | - David H Chi
- Department of Otolaryngology, University of Pittsburgh Medical Center, Eye and Ear Institute, Suite 519, 203 Lothrop St, Pittsburgh, PA 15213, USA; Division of Pediatric Otolaryngology, Children's Hospital of Pittsburgh of UPMC, 4401 Penn Ave, Pittsburgh, PA 15224, USA.
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22
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Abstract
6042 Background: The phosphatidylinositol-3-kinase (PI3K) signaling pathway is the most common genetic alteration in HNC, particularly in oropharynx cancers (OPC). Up-regulation of the PI3K pathway enhances the production of prostaglandins inhibiting apoptosis in cancer cells. We hypothesized that aspirin (ASA) improves survival in HNC patients (pts) by counteracting the effects of prostaglandins. Methods: This is an IRB-approved retrospective cohort study of 584 veterans with HNC treated at the Washington DC Veterans Affairs Medical Center between 1995 and 2015. Charts were reviewed for clinical-pathologic and treatment data; recurrence/distant metastases; cause of death; and for the number, date and dose of ASA prescriptions. Pts who filled more than one prescription, excluding refills, after diagnosis of HNC were considered ASA users. All others were considered non-ASA users. The Kaplan-Meier method and log-rank test were used to compare disease-free survival (DFS) and disease-specific survival (DSS) between users and non-users. Results: 332 pts met inclusion criteria. Primary subsites included oropharynx (n = 146), larynx (n = 105), oral cavity (n = 62), and hypopharynx (n = 19). 86 pts were ASA users after diagnosis (25.9%) and more likely to be older (p = 0.002), African American (p = 0.03), never-alcohol users (p = 0.044), and have early stage cancer (I/II; p < 0.0005) compared to non-ASA users. Among all HNC pts, ASA users demonstrated significantly better 5-year (y) DSS (82%) compared to non users (43%; p = 0.009). 5-y DFS was also significantly higher among users (72%) vs non users (39%; p < 0.001). Among the OPC pts, 5-y DSS was higher for ASA users (74%) vs non users (41%; p = 0.024). 5-y DFS was also better for users (72%) vs non users (39%; p = 0.004). For stages III and IV, 5-y DFS was significantly higher among ASA users (64%) vs non users (44%; p = 0.035). 5-y DSS was higher as well in users (69%) vs non users (44%) but p = 0.098. On multivariate analysis, aspirin use remained an independent prognostic factor associated with improved DSS and DFS when accounting for age, race, gender, subsite, stage, tobacco and alcohol use. Conclusions: Aspirin use following diagnosis and curative treatment of HNC is associated with improved DSS and DFS.
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Affiliation(s)
- Hind Rafei
- Department of Medicine, the George Washington University School of Medicine and Health Sciences, Washington, DC
| | | | - Jim Han
- Georgetown University School of Medicine, Washington, DC
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23
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Kaffenberger TM, Mandal R, Schaitkin BM, Hirsch BE. Palatal botulinum toxin as a novel therapy for objective tinnitus in forced eyelid closure syndrome. Laryngoscope 2016; 127:1199-1201. [PMID: 27717035 DOI: 10.1002/lary.26191] [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] [Accepted: 06/23/2016] [Indexed: 11/10/2022]
Abstract
Objective tinnitus associated with eyelid closure is a rare clinical entity with only a few reported cases. This association previously was identified as forced eyelid closure syndrome (FECS) and involves an aberrant neural reflex between cranial nerve VII (activating the orbicularis oculi muscle) and cranial nerve V (activating the tensor tympani muscle). We present a 52-year-old Caucasian female with a 2-month history of FECS who was successfully treated with intrapalatal botulinum toxin, with full resolution of her objective tinnitus symptoms. This is the first reported use of botulinum toxin in FECS. Laryngoscope, 127:1199-1201, 2017.
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Affiliation(s)
| | - Rajarsi Mandal
- Head and Neck Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, U.S.A
| | - Barry M Schaitkin
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, U.S.A
| | - Barry E Hirsch
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, U.S.A
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Mandal R, Duvvuri U, Ferris RL, Kaffenberger TM, Choby GW, Kim S. Analysis of post-transoral robotic-assisted surgery hemorrhage: Frequency, outcomes, and prevention. Head Neck 2015; 38 Suppl 1:E776-82. [PMID: 25916790 DOI: 10.1002/hed.24101] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/16/2015] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Transoral robotic-assisted surgery (TORS) carries a small, but not insignificant, risk of life-threatening postsurgical hemorrhage. The purpose of this study was to analyze all post-TORS hemorrhagic events at our institution to establish preventative recommendations. METHODS We conducted a retrospective review of 224 consecutive patients who underwent TORS for any indication at a single tertiary care institution. RESULTS Twenty-two patients (n = 22; 9.82%) had varying degrees of postoperative bleeding. An impaired ability to protect the airway at the time of hemorrhage increased the rate of severe complications. Prophylactic transcervical arterial ligation did not significantly decrease overall postoperative bleeding rates (9.1% vs 9.9%; p = 1.00); however, there was a trend toward decreased hemorrhage severity in prophylactically ligated patients (3.0% vs 7.3%; p = .7040). CONCLUSION Prophylactic transcervical arterial ligation may reduce the incidence of severe bleeding following TORS. Post-TORS patients displaying an inability to protect the airway should be strongly considered for prophylactic tracheostomy to assist airway protection. © 2015 Wiley Periodicals, Inc. Head Neck 38: E776-E782, 2016.
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Affiliation(s)
- Rajarsi Mandal
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Umamaheswar Duvvuri
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.,Veterans Affairs Pittsburgh Health System, Pittsburgh, Pennsylvania
| | - Robert L Ferris
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | - Garret W Choby
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Seungwon Kim
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Abstract
The treatment of psoriasis has been revolutionized since the introduction of biologic therapies. Prior to their introduction, it was unclear if psoriasis was primarily a keratinocyte signaling dysfunction or an autoimmune T-cell mediated pathway. Nonspecific T-cell targeting treatments had been used with some success, but they were limited by a narrow therapeutic index. The nonspecific nature of these agents was fraught with side effects, and the efficacy of these treatments pales in comparison to current treatments. The initial biologic molecules, alefacept and efalizumab, were not specific for any T-cell driven pathway, and neither are currently available in the USA. The successors to these early therapies have shown high efficacy and low side effects in psoriasis and other autoimmune diseases through the specific targeting of tumor necrosis factor-alpha (TNF-α). Since the initial use of antitumor necrosis factor agents, a renaissance in our understanding of psoriasis has been underway, leading to the elucidation of the T-helper 17 (Th17) from the Th1 pathway. With each new treatment, the pathogenesis for psoriasis continues to be more defined, allowing for improved targeted therapies and the ability to achieve new milestones in efficacy.
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Affiliation(s)
| | | | - Henry K Wong
- College of Medicine, Ohio State University, Columbus, OH, USA
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