Association Between Hearing Loss and Cardiovascular Disease: A Meta-analysis

OBJECTIVE

Hearing loss (HL) has been postulated to be linked to cardiovascular diseases (CVDs) via vascular mechanisms, but epidemiological associations remain unclear. The study aims to clarify the association between HL and stroke, coronary artery disease (CAD), and any CVD.

DATA SOURCES

PubMed, Embase, and SCOPUS from inception until April 27, 2022.

REVIEW METHODS

Three blinded reviewers selected observational studies reporting stroke, CAD, and any CVD in patients with HL, compared to individuals without HL. We extracted data, evaluated study bias using the Newcastle-Ottawa scale, following Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines and a PROSPERO-registered protocol (CRD42022348648). We used random-effects inverse variance meta-analyses to pool the odds ratios (ORs) for the association of HL with stroke, CAD, and any CVD.

RESULTS

We included 4 cohort studies (N = 940,771) and 6 cross-sectional studies (N = 680,349). Stroke, CAD, and any CVD were all strongly associated with HL. The overall pooled OR of the association between HL and stroke was 1.26 (95% confidence interval [CI] = 1.16-1.37, I2  = 78%), and was 1.33 (95% CI = 1.12-1.58) and 1.29 (95% CI = 1.14-1.45) for low- and high-frequency HL, respectively. Minimal publication bias was observed, with minimal change to pooled effect size following trim and fill. Similarly, the pooled OR of the association between HL and CAD was 1.36 (95% CI = 1.13-1.64, I2  = 96%), while that between HL and any CVD was 1.38 (95% CI = 1.07-1.77, I2  = 99%).

CONCLUSION

Our findings suggest that HL and CVD are closely related. Physicians treating patients with HL should be cognizant of this association and view HL in the broader context of general health and aging.

Non-Tuberculous Mycobacterial Cervicofacial Lymphadenitis in Children-10-Year Experience in a Tertiary Pediatric Center

BACKGROUND

Lymphadenitis is the most common manifestation of non-tuberculous mycobacteria (NTM) infection in children. We describe the epidemiology and clinical characteristics of NTM lymphadenitis, determine diagnostic yield from tissue sampling, and review management and outcomes.

METHODS

This was a 10-year retrospective review of children aged 0-16 years diagnosed with NTM cervicofacial lymphadenitis who were seen in a pediatric infectious disease clinic in a tertiary public hospital. Data relating to patient demographics, clinical features, surgical and antimicrobial treatment, complications, and outcomes were retrieved from patients' electronic medical records and analyzed.

RESULTS

There were 48 episodes of NTM cervicofacial lymphadenitis in 45 children (17 males and 28 females). Of these episodes, 43.7% manifested as a unilateral single node, mostly parotid (39.6%) and submandibular (29.2%). All patients underwent diagnostic fine-needle aspiration or surgery. Surgical excision more frequently yielded positive histological findings (P = .016). NTM was identified in 22/48 episodes (45.8%) via culture or molecular sequencing. Mycobacterium abscessus was most commonly found (47.8%). Thirty-eight children (79.2%) received antibiotics. Outcomes in 43 episodes revealed full resolution in 69.8%, while 25.6% had de novo disease and 4.6% experienced recurrence at the same site. Overlying skin changes and multiple or bilateral nodal diseases were significantly associated with de novo disease or recurrence (P = .034 and .084, respectively). Complications occurred in 11/70 (15.7%) procedures. Antibiotic-associated adverse effects occurred in 14/38 (36.8%) episodes.

CONCLUSIONS

NTM lymphadenitis remains a challenging condition. More aggressive management with surgical excision and antibiotics is recommended for those with overlying skin changes and extensive nodal disease.

Deconstructive versus reconstructive approach to internal carotid artery blowout in radiated nasopharyngeal carcinoma: A tertiary center experience and systematic review

The objective of this study was to compare the outcomes of parent artery occlusion (PAO) versus stent-assisted reconstruction in radiated nasopharyngeal carcinoma (NPC) patients with internal carotid artery (ICA) blowouts. A retrospective review from our institution (2011-2021) and systematic review of Pubmed and Embase (1995-2022) was performed. Twenty-eight eligible studies were identified. Eighty-six PAOs and 37 stent-assisted reconstructions were analyzed, including 11 PAOs and 5 stents from our institution. Stents were associated with significantly higher incidence of overall re-bleeding (16.2% [95% CI 7.4-31.9] vs. 4.6% [95% CI 1.3-13.5], p = 0.047), delayed stroke (5.4% [95% CI 1.3-19.4] vs. 0%, p = 0.034) and reduced median survival (7.1 [95% CI 3.8-14.0] months vs. 29.0 [95% CI 9.4-63.4] months, p = 0.017) compared to PAO. There were no significant differences in terms of overall stroke, infection, extruded/migrated foreign body, and peri-procedure death. PAO is preferred over reconstructive treatment in patients with adequate collateral circulation.

Association of Hearing Aids and Cochlear Implants With Cognitive Decline and Dementia: A Systematic Review and Meta-analysis

Importance

Hearing loss is associated with cognitive decline. However, it is unclear if hearing restorative devices may have a beneficial effect on cognition.

Objective

To evaluate the associations of hearing aids and cochlear implants with cognitive decline and dementia.

Data Sources

PubMed, Embase, and Cochrane databases for studies published from inception to July 23, 2021.

Study Selection

Randomized clinical trials or observational studies published as full-length articles in peer-reviewed journals relating to the effect of hearing interventions on cognitive function, cognitive decline, cognitive impairment, and dementia in patients with hearing loss.

Data Extraction and Synthesis

The review was conducted in accordance with Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) reporting guidelines. Two authors independently searched the PubMed, Embase, and Cochrane databases for studies relating to the effect of hearing interventions on cognitive decline and dementia in patients with hearing loss.

Main Outcomes and Measures

Maximally adjusted hazard ratios (HRs) were used for dichotomous outcomes and ratio of means for continuous outcomes. Sources of heterogeneity were investigated using sensitivity and subgroup analyses, and publication bias was assessed using visual inspection, the Egger test, and trim and fill.

Results

A total of 3243 studies were screened; 31 studies (25 observational studies, 6 trials) with 137 484 participants were included, of which 19 (15 observational studies, 4 trials) were included in quantitative analyses. Meta-analysis of 8 studies, which had 126 903 participants, had a follow-up duration ranging from 2 to 25 years, and studied long-term associations between hearing aid use and cognitive decline, showed significantly lower hazards of any cognitive decline among hearing aid users compared with participants with uncorrected hearing loss (HR, 0.81; 95% CI, 0.76-0.87; I2 = 0%). Additionally, meta-analysis of 11 studies with 568 participants studying the association between hearing restoration and short-term cognitive test score changes revealed a 3% improvement in short-term cognitive test scores after the use of hearing aids (ratio of means, 1.03; 95% CI, 1.02-1.04, I2 = 0%).

Conclusions and Relevance

In this meta-analysis, the usage of hearing restorative devices by participants with hearing loss was associated with a 19% decrease in hazards of long-term cognitive decline. Furthermore, usage of these devices was significantly associated with a 3% improvement in cognitive test scores that assessed general cognition in the short term. A cognitive benefit of hearing restorative devices should be further investigated in randomized trials.

Pathophysiology of SARS-CoV-2 Infection of Nasal Respiratory and Olfactory Epithelia and Its Clinical Impact

PURPOSE OF REVIEW

While the predominant cause for morbidity and mortality with SARS-CoV-2 infection is the lower respiratory tract manifestations of the disease, the effects of SARS-CoV-2 infection on the sinonasal tract have also come to the forefront especially with the increased recognition of olfactory symptom. This review presents a comprehensive summary of the mechanisms of action of the SARS-CoV-2 virus, sinonasal pathophysiology of COVID-19, and the correlation with the clinical and epidemiological impact on olfactory dysfunction.

RECENT FINDINGS

ACE2 and TMPRSS2 receptors are key players in the mechanism of infection of SARS-CoV-2. They are present within both the nasal respiratory as well as olfactory epithelia. There are however differences in susceptibility between different groups of individuals, as well as between the different SARS-CoV-2 variants. The sinonasal cavity is an important route for SARS-CoV-2 infection. While the mechanism of infection of SARS-CoV-2 in nasal respiratory and olfactory epithelia is similar, there exist small but significant differences in the susceptibility of these epithelia and consequently clinical manifestations of the disease. Understanding the differences and nuances in sinonasal pathophysiology in COVID-19 would allow the clinician to predict and counsel patients suffering from COVID-19. Future research into molecular pathways and cytokine responses at different stages of infection and different variants of SARS-CoV-2 would evaluate the individual clinical phenotype, prognosis, and possibly response to vaccines and therapeutics.

Associations of Hearing Loss and Dual Sensory Loss With Mortality: A Systematic Review, Meta-analysis, and Meta-regression of 26 Observational Studies With 1 213 756 Participants

IMPORTANCE

Hearing loss (HL) and dual sensory loss (DSL) are prevalent, disabling, and associated with numerous age-related health conditions, including dementia and frailty. To date, no evidence-based summary of their mortality risk is available.

OBJECTIVE

To clarify the epidemiological associations between HL/DSL and mortality.

DATA SOURCES

PubMed, Embase, and Cochrane Library, from inception until June 18, 2021.

STUDY SELECTION

Two blinded reviewers selected observational or interventional studies, published as full-length English articles in peer-reviewed journals, that reported the presence or severity of HL or DSL (ie, comorbid HL and vision loss), whether objectively measured or self-reported, in association with any mortality estimate, among adults 18 years and older.

DATA EXTRACTION AND SYNTHESIS

Two reviewers extracted data and evaluated study bias using the Newcastle-Ottawa Scale, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)/Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines and a PROSPERO-registered protocol. The analysis pooled maximally adjusted estimates using mixed-effects models, measured heterogeneity using I2, investigated sources of heterogeneity using meta-regression and subgroup meta-analyses, examined and adjusted for publication bias, performed influence and cumulative meta-analyses, and assessed evidence quality using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) framework.

MAIN OUTCOMES AND MEASURES

Hazard ratios (HRs) for all-cause, cardiovascular, or other mortality estimates.

RESULTS

This review included 14 retrospective and 12 prospective observational studies (1 213 756 participants) from 3220 records. Risk of bias was low to moderate; exclusion of 3 high-risk studies did not alter conclusions. Hearing loss was associated with excess all-cause mortality (HR, 1.13; 95% CI, 1.07-1.19; I2 = 77%; n = 21; 95% prediction interval [PI], 0.93-1.37) and cardiovascular mortality (HR, 1.28; 95% CI, 1.10-1.50; I2 = 60%; n = 6; 95% PI, 0.84-1.96), while DSL was associated with larger excess risks (all-cause: HR, 1.40; 95% CI, 1.30-1.51; I2 = 34%; n = 10; 95% PI, 1.18-1.66; cardiovascular: HR, 1.86; 95% CI, 1.31-2.65; I2 = 0%; n = 2), after adjustment for demographics and comorbidities. Prespecified meta-regression sufficiently explained heterogeneity, with longer follow-up duration weakening the pooled association, leaving low (29%) residual heterogeneity. Meta-regression among audiometric studies showed a dose-response association (doubling of HR per 30-dB increase in HL). Self-reported and audiometric effect sizes were similar, with lower heterogeneity in the latter. Associations were robust to trim-and-fill adjustment for publication bias and single-study influence and cumulative meta-analyses. Associations with accident/injury, cancer, and stroke mortality were inconclusive, with only 1 to 3 studies. Overall evidence quality was moderate.

CONCLUSIONS AND RELEVANCE

In this systematic review and meta-analysis, HL and DSL were associated with excess all-cause and cardiovascular mortality. Physicians caring for patients with HL should consider its relevance to general health and longevity.

Diabetes is a risk factor for hearing loss in older adults: Results of a community screening programme

OBJECTIVES

To investigate the association between diabetes mellitus (DM) and the prevalence and severity of hearing loss in a population of community-dwelling older adults in Singapore.

MATERIALS AND METHODS

This is a retrospective, cross-sectional study of 1787 adults aged 60-100 who had undergone a comprehensive audiological assessment in a community-based audiology clinic. Data extracted included their age, hearing profile, medical history, and comorbidities collected through verbal interview at the point of audiologic assessment. Multivariate linear regression and multivariate logistic regression were performed to investigate the relationship between DM and hearing loss.

RESULTS

The prevalence of DM in our studied population is 17.9%. After controlling for age, gender, race, hypertension, and hyperlipidaemia status, DM was found to be independently associated with at least moderate hearing loss (adjusted OR 1.3 [95% CI 1.06-1.59], p = .012). This was especially so in the younger (<70) age group (adjusted OR 1.7 [95% CI 1.18-2.44], p = .004).

CONCLUSION

DM is an independent risk factor for the presence of at least moderate hearing in community-dwelling seniors. Individuals aged <70 with DM should be screened for hearing loss to enable early intervention.

Clinical predictors of internal carotid artery blowout in patients with radiated nasopharyngeal carcinoma

BACKGROUND

The primary objective is to identify clinical predictors of internal carotid artery (ICA) blowout in radiated nasopharyngeal carcinoma (NPC).

METHODS

Seventeen ICA blowouts, 14 external carotid artery (ECA) bleeds, and 60 controls were identified from January 1, 2007 to July 31, 2020. Multinomial logistic regression was performed to identify features predictive of ICA blowouts.

RESULTS

Headache was significantly more common among ICA blowouts than ECA bleeds and controls (58.8% vs. 7.1% vs. 6.7%, p < 0.001). The petrous skull base and sphenoid sinus lateral wall was eroded in all petrous and cavernous segment blowouts, respectively. Nasoendoscopy showing exposed clivus (OR 20.5, 95%CI 1.3-324.2) and computed tomography demonstrating skull base erosion (OR 17.8, 95%CI 1.0-311.0) were significantly associated with ICA blowouts compared to controls.

CONCLUSIONS

Findings of headache and skull base erosion on nasoendoscopy or imaging during NPC surveillance warrants prophylactic intervention to avoid an ICA blowout.

Clinical-Pathological Correlation of the Pathophysiology and Mechanism of Action of COVID-19 - a Primer for Clinicians

PURPOSE OF REVIEW

Increasing knowledge of the pathogenesis of the SARS-CoV-2 infection and the complex interaction between host and viral factors have allowed clinicians to stratify the severity of COVID-19 infection. Epidemiological data has also helped to model viral carriage and infectivity. This review presents a comprehensive summary of the pathophysiology of COVID-19, the mechanisms of action of the SARS-CoV-2 virus, and the correlation with the clinical and biochemical characteristics of the disease.

RECENT FINDINGS

ACE2 and TMPRSS2 receptors have emerged as a key player in the mechanism of infection of SARS-CoV-2. Their distribution throughout the body has been shown to impact the organ-specific manifestations of COVID-19. The immune-evasive and subsequently immunoregulative properties of SARS-CoV-2 are also shown to be implicated in disease proliferation and progression. Information gleaned from the virological properties of SARS-CoV-2 is consistent with and reflects the clinical behavior of the COVID-19 infection. Further study of specific clinical phenotypes and severity classes of COVID-19 may assist in the development of targeted therapeutics to halt progression of disease from mild to moderate-severe. As the understanding of the pathophysiology and mechanism of action of SARS-CoV-2 continues to grow, it is our hope that better and more effective treatment options continue to emerge.

Design and Multicenter Clinical Validation of a 3-Dimensionally Printed Nasopharyngeal Swab for SARS-CoV-2 Testing

Importance

Three-dimensionally printed nasopharyngeal swabs (3DP swabs) have been used to mitigate swab shortages during the coronavirus disease 2019 (COVID-19) pandemic. Clinical validation for diagnostic accuracy and consistency, as well as patient acceptability, is crucial to evaluate the swab's performance.

Objective

To determine the accuracy and acceptability of the 3DP swab for identifying severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).

Design, Setting, and Participants

A diagnostic study was conducted from May to July 2020 at 2 tertiary care centers in Singapore with different reference swabs (FLOQSwab [COPAN Diagnostics] or Dacron swab [Deltalab]) and swab processing techniques (wet or dry) to evaluate the performance of the 3DP swab compared with traditional, standard-of-care nasopharyngeal swabs used in health care institutions. The participants were patients with COVID-19 in the first 2 weeks of illness and controls with acute respiratory illness with negative test results for SARS-CoV-2. Paired nasopharyngeal swabs were obtained from the same nostril and tested for SARS-CoV-2 by reverse-transcriptase polymerase chain reaction. The sequence of swabs was randomized based on odd and even participant numbers.

Main Outcomes and Measures

Primary outcome measures were overall agreement (OA), positive percentage agreement (PPA), and negative percentage agreement of the 3DP swab compared with reference swabs. Secondary outcome measures were the correlation of cycle threshold (Ct) values of both swabs.

Results

The mean (SD) age of participants was 45.4 (13.1) years, and most participants were men (87 of 89 [97.8%]), in keeping with the epidemiology of the COVID-19 pandemic in Singapore. A total of 79 patients with COVID-19 and 10 controls were recruited. Among the patients with COVID-19, the overall agreement and PPA of the 3DP swab was 91.1% and 93.5%, respectively, compared with reference swabs. The PPA was 100% for patients with COVID-19 who were tested within the first week of illness. All controls tested negative. The reverse-transcriptase polymerase chain reaction Ct values for the ORF1ab and E-gene targets showed a strong correlation (intraclass correlations coefficient, 0.869-0.920) between the 3DP and reference swab on independent testing at each institution despite differences in sample processing. Discordant results for both gene targets were observed only at high Ct values.

Conclusions and Relevance

In this diagnostic study of 79 patients with COVID-19 and 10 controls, the 3DP swab performed accurately and consistently across health care institutions and could help mitigate strained resources in the escalating COVID-19 pandemic.

Clinical Diagnostic Study of a Novel Injection Molded Swab for SARS-Cov-2 Testing

Introduction

The gold standard for COVID-19 diagnosis is currently a real-time reverse transcriptase polymerase chain reaction (RT-PCR) to detect SARS-CoV-2. This is most commonly performed on respiratory secretions obtained via a nasopharyngeal swab. Due to supply chain limitations and high demand worldwide because of the COVID-19 pandemic, access to commercial nasopharyngeal swabs has not been assured. 3D printing methods have been used to meet the shortfall. For longer-term considerations, 3D printing may not compare well with injection molding as a production method due to the challenging scalability and greater production costs of 3D printing.

Methods

To secure sufficient nasopharyngeal swab availability for our national healthcare system, we designed a novel injection molded nasopharyngeal swab (the IM2 swab). We performed a clinical diagnostic study comparing the IM2 swab to the Copan FLOQSwab. Forty patients with a known diagnosis of COVID-19 and 10 healthy controls were recruited. Paired nasopharyngeal swabs were obtained from the same nostril of each participant and tested for SARS-CoV-2 by RT-PCR.

Results

When compared to the Copan FLOQswab, results from the IM2 swab displayed excellent overall agreement and positive percent agreement of 96.0% and 94.9%, respectively. There was no significant difference in mean RT-PCR cycle threshold values for the ORF1ab (28.05 vs. 28.03, p = 0.97) and E-gene (29.72 vs. 29.37, p = 0.64) targets, respectively. We did not observe any significant adverse events and there was no significant difference in patient-reported pain.

Conclusion

In summary, the IM2 nasopharyngeal swab is a clinically safe, highly accurate option to commercial nasopharyngeal swabs.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40121-020-00391-6.

Epithelioid Sarcoma of the External Auditory Canal: An Uncommon Tumor at an Unusual Site and a Brief Overview of the Literature

We present a case (41 years old pregnant female) with epithelioid sarcoma arising in the left external auditory canal. On immunohistochemistry, the tumor cell diffusely expressed cytokeratins and showed patchy expression of ERG and CD34. The neoplastic cells demonstrated uniform loss of INI1-expression. Epithelioid sarcoma arising in the external auditory canal is rare. Awareness that ES may rarely arise at unusual sites is of critical importance in order to apply a broad enough panel in the immunohistochemical study, so a misdiagnosis of carcinoma can be avoided.

Tracheostomy During the COVID-19 Pandemic: Comparison of International Perioperative Care Protocols and Practices in 26 Countries

OBJECTIVE

The coronavirus disease 2019 (COVID-19) pandemic has led to a global surge in critically ill patients requiring invasive mechanical ventilation, some of whom may benefit from tracheostomy. Decisions on if, when, and how to perform tracheostomy in patients with COVID-19 have major implications for patients, clinicians, and hospitals. We investigated the tracheostomy protocols and practices that institutions around the world have put into place in response to the COVID-19 pandemic.

DATA SOURCES

Protocols for tracheostomy in patients with severe acute respiratory syndrome coronavirus 2 infection from individual institutions (n = 59) were obtained from the United States and 25 other countries, including data from several low- and middle-income countries, 23 published or society-endorsed protocols, and 36 institutional protocols.

REVIEW METHODS

The comparative document analysis involved cross-sectional review of institutional protocols and practices. Data sources were analyzed for timing of tracheostomy, contraindications, preoperative testing, personal protective equipment (PPE), surgical technique, and postoperative management.

CONCLUSIONS

Timing of tracheostomy varied from 3 to >21 days, with over 90% of protocols recommending 14 days of intubation prior to tracheostomy. Most protocols advocate delaying tracheostomy until COVID-19 testing was negative. All protocols involved use of N95 or higher PPE. Both open and percutaneous techniques were reported. Timing of tracheostomy changes ranged from 5 to >30 days postoperatively, sometimes contingent on negative COVID-19 test results.

IMPLICATIONS FOR PRACTICE

Wide variation exists in tracheostomy protocols, reflecting geographical variation, different resource constraints, and limited data to drive evidence-based care standards. Findings presented herein may provide reference points and a framework for evolving care standards.

Using 3D-printed nose models in nasopharyngeal swab training

Background

The COVID-19 pandemic has swept across the globe with massive effects on health care systems as well as global economies. Enhanced testing has been put forward as a means to reduce transmission while awaiting the development of targeted therapy or effective vaccination. However, achieving accurate testing necessitates proper nasopharyngeal swab techniques.

Methods and results

We aimed to design and investigate the utility of an anatomically accurate three-dimensional (3D) printed model of the nose in the training for nasopharyngeal swabs. These models were implemented during training sessions for healthcare workers. All participants surveyed felt that the 3D printed models were useful and beneficial in the training of nasopharyngeal swab techniques.

Conclusions

3D printed nose models are a useful tool in nasopharyngeal swab training. Their usage may help to facilitate the training of potential swabbing manpower in the upscaling of testing capabilities and volumes in this COVID-19 era.

Integration of Antiangiogenic Therapy with Cisplatin and Gemcitabine Chemotherapy in Patients with Nasopharyngeal Carcinoma

PURPOSE

Induction cisplatin and gemcitabine chemotherapy is a standard treatment for locally advanced nasopharyngeal carcinoma (NPC). Inhibition of VEGF axis has been shown to promote maturation of microvasculature and improve perfusion. We conducted a four-arm study to assess the effect of two doses of either sunitinib or bevacizumab with chemotherapy in NPC.

PATIENTS AND METHODS

Patients with treatment-naïve locally advanced NPC were treated with three cycles of 3-weekly cisplatin and gemcitabine preceded by 1 week of anti-VEGF therapy for each cycle, followed by standard concurrent chemoradiation: arm A patients received 7 days of 12.5 mg/day sunitinib; arm B 7 days of 25 mg/day sunitinib; arm C bevacizumab 7.5 mg/kg infusion; arm D bevacizumab 2.5 mg/kg infusion. Patients with metastatic NPC were treated with up to six cycles of similar treatment without concurrent chemoradiation.

RESULTS

Complete metabolic response (mCR) by whole body ¹⁸FDG PET was highest in arm C (significant difference in four groups Fisher exact test P = 0.001; type 1 error = 0.05), with 42% mCR (95% confidence interval, 18-67) and 3-year relapse-free survival of 88% in patients with locally advanced NPC. Significant increase in pericyte coverage signifying microvascular maturation and increased immune cell infiltration was observed in posttreatment tumor biopsies in Arm C. Myelosuppression was more profound in sunitinib containing arms, and tolerability was established in arm C where hypertension was the most significant toxicity.

CONCLUSIONS

Bevacizumab 7.5 mg/kg with cisplatin and gemcitabine was well tolerated. Promising tumor response was observed and supported mechanistically by positive effects on tumor perfusion and immune cell trafficking into the tumor.

Sustaining Otolaryngology Services for the Long Haul during the COVID-19 Pandemic: Experience from a Tertiary Health System

The impact of the COVID-19 pandemic has been far-reaching and has profoundly affected the practice of otolaryngology in an unprecedented way. In this commentary, we draw from our experience in the first 90 days of the pandemic and discuss a set of workflow measures, personal protection equipment protocols, and strategic goals that can provide a safe environment for patients and staff to continue managing a significant proportion of patients in the otolaryngology service during the pandemic.

Efficacy of Sialendoscopy in the Management of Noncalculi-Related Sialadenitis

PURPOSE

Sialendoscopy has effectively changed the paradigm for the treatment of sialolithiasis. Its effect on noncalculi-related recurrent sialadenitis is, however, unclear, especially regarding the long-term outcomes. The objectives of the present study were to evaluate the long-term efficacy of sialendoscopy for noncalculi-related recurrent sialadenitis and determine the clinical and intraoperative features that might be prognosticate outcomes.

PATIENTS AND METHODS

We performed a prospective cohort study of 33 consecutive patients who had undergone sialendoscopy for recurrent noncalculi-related sialadenitis by a single surgeon in a tertiary institution from January 2010 to December 2016. The patient-reported outcome measures were used as the primary determinant of treatment efficacy. The clinical features and endoscopic findings were evaluated as variables that might predict the treatment outcomes. The Fischer exact test was used to analyze the descriptive data, and a P value of < .05 was considered to indicate statistical significance.

RESULTS

Of the 33 patients with recurrent noncalculi-related sialadenitis, 1 was lost to follow-up and thus excluded from the analysis. The mean and median follow-up period for the 32 patients was 27 and 21.5 months, respectively. Of the 33 patients, 28 (87.5%) reported symptom improvement, and 19 patients (59.4%) were symptom free after a single sialendoscopic treatment. The chronicity of symptoms, younger patient age, and concurrent autoimmune disease were predictive of recurrent symptoms despite sialendoscopy.

CONCLUSIONS

The use of sialendoscopy achieved sustained long-term improvements or resolution of symptoms for most patients with recurrent noncalculi-related sialadenitis. The data from our study support the benefits of sialendoscopy for patients with recurrent noncalculi-related sialadenitis.

Extensive subcutaneous emphysema, pneumomediastinum, and pneumorrhachis following third molar surgery

Third molar extraction is a common procedure in dental surgery. Common complications that may occur post procedure include pain, trismus, bleeding, dry socket, and nerve injuries. Subcutaneous emphysema is an uncommon complication. A rare case of extensive cervicofacial subcutaneous emphysema, pneumomediastinum, and pneumorrhachis following third molar extraction is reported here. Issues relating to the diagnosis, aetiology, and management of these complications are discussed.

A Case Report of Absent Epiglottis in Children With Nager Syndrome: Its Impact on Swallowing

OBJECTIVE

This clinical report is the first literature report exploring the issues of an absent epiglottis in children diagnosed with Nager syndrome. Absent epiglottis has previously been described in children with Pierre Robin sequence and other syndromes.

CONCLUSION

The function of the epiglottis and its contribution to swallowing has always been debated. In this article and from our literature review, we felt that absent epiglottis possibly contributed to the aspiration risk and may partly explain the long-term feeding issues in these children despite corrective surgeries.

Intralaryngeal Thyroglossal Duct Cyst: Implications for the Migratory Pathway of the Thyroglossal Duct

An atypically located thyroglossal duct cyst in a 42-year-old man is described. A purely intralaryngeal thyroglossal duct cyst is extremely rare and can mimic other laryngeal lesions. This case demonstrates that thyroglossal duct cyst is a possible cause of intralaryngeal swellings and would have significant implications for the manner in which they are managed.

Surgical Intervention for Congenital Absent Oval Window

Objectives:

Congenital absent oval window is an uncommon condition that results in significant conductive hearing loss in the pediatric population. Treatment outcomes and results following surgery are still not well established in light of the limited cases that have been published in the literature. This study aims to evaluate the outcomes following surgical intervention of patients with congenital absent oval window in a single institution.

Methods:

This is a retrospective review of patients who underwent surgical exploration and treatment for congenital absent oval window from 2000 to 2013 in a single institution.

Results:

Twelve patients were diagnosed with congenital absent oval window. Six of these patients were affected bilaterally. Of the 19 ears affected, 13 were operated on. Eight ears were successfully treated following stapedotomy and insertion of prosthesis. The average pure-tone audiogram for these patients was 62.6 prior to the operation. Following surgery, the average pure-tone level was 22.4. Five of the ears that were operated on showed minimal improvement. Of these 5 ears, 3 were unsuitable for insertion of prosthesis due to unfavorable position of the incus. Two patients underwent stapedotomy with Teflon wire prosthesis insertion. However, this failed to improve hearing levels.

Conclusions:

Congenital absence of oval window is an uncommon condition that can lead to significant disruption to hearing. Surgical intervention by means of stapedotomy and prosthesis insertion may lead to significant improvement in hearing levels selected patients. However, it may be technically unsuitable for others.

Malignant Otitis Externa

Objective

Malignant otitis externa (MOE) is a severe disease with varying outcomes. Despite advances in antibiotic treatment, a significant proportion still succumbs to this disease. We aimed to analyze the effect of clinical factors on prognosis and to review treatment outcomes in our institution.

Study Design

Case series with retrospective chart review of MOE cases from 2006 to 2011.

Setting

Department of Otolaryngology–Head and Neck Surgery, National University Hospital, Singapore, a tertiary referral center.

Subjects and Methods

Patients with MOE admitted for treatment were studied and divided into 2 outcome groups depending on response to a 6-week course of intravenous antibiotics. Demographic and disease factors were analyzed with regard to outcome.

Results

Nineteen cases were analyzed. Disease resolved in 63.2% after 6 weeks of antibiotics. Mortality was 21.1%. Age, diabetic control, duration of diagnostic delay, cranial nerve involvement, and inflammatory markers were not found to predict prognosis. Erythrocyte sedimentation rate and C-reactive protein levels correlated with disease activity and can be used to monitor progress. Clival involvement was associated with persistent disease ( P = .002). Only 63.2% of cases had positive cultures. Pseudomonas aeruginosa was the main organism, and 33.3% of isolates were multidrug resistant. Outcome was not different in cases where culture-directed therapy was employed vs those where empirical ceftazidime and fluoroquinolone were used ( P = .650).

Conclusion

Malignant otitis externa remains an insidious disease with significant mortality. Involvement of the clivus portends a poorer prognosis. Combination therapy with intravenous ceftazidime and oral fluoroquinolone remains relevant despite concerns of culture-negative cases and multidrug-resistant Pseudomonas.

Hazardous foreign bodies: complications and management of button batteries in nose

Miniature batteries are easily available in our domestic environment, powering many electronic devices and toys. Despite improvement in the safety standards, children are able to remove the batteries from these devices. These batteries pose a hazard to children, as they are small and easily inserted into the nose or ears or even swallowed. We describe 6 children who inserted button batteries into their noses. Four of these insertions resulted in septal perforations. The mechanisms and management of button battery injury are discussed. We emphasize the need for urgent removal of a battery from the nose to prevent long-term complications.