Outcomes of in-office versus operating room insertion of tympanostomy tubes in children

OBJECTIVE

Tympanostomy tube insertion in children is commonly performed under general anesthesia, but there has been increasing interest in office-based alternatives. Although initial research comparing in-office versus operating room (OR) insertion of tubes looks promising, there are scant data available on long-term outcomes. The objective of this study is to compare long-term outcomes of tympanostomy tubes placed in-office versus the OR, with emphasis on the duration of tube function.

METHODS

We reviewed electronic medical records in an academic pediatric otolaryngology practice of children under age 13 years who had tubes placed in-office or the OR between 2010 and 2021. Differences in time to unilateral and bilateral tube occlusion/extrusion were compared by Kaplan-Meier survival analysis with log rank comparison. Cox regression modeling was performed to identify predictors of tube occlusion/extrusion.

RESULTS

817 children were included (473 office tubes, 344 OR tubes). Tube placement was equally successful for both groups (98.3% for office and 98.9% for OR). Comparison of Kaplan-Meier plots for time to unilateral and bilateral tube occlusion/extrusion by location showed no significant difference (P = .842 for unilateral and P = .714 for bilateral). However, regression analysis indicated a strong interaction of location with operator status (resident vs attending). Median time to unilateral occlusion/extrusion and bilateral occlusion/extrusion was shorter for OR residents compared to OR attendings (15.0 vs 19.5 months, P = .002, and 22.1 vs 32.0 months, P = .030, respectively). There was no difference in the time to unilateral or bilateral tube occlusion/extrusion between the office attending and OR attending groups (16.8 vs 19.5 months, P = .057 for unilateral, and 23.0 vs 32.0 months, P = .320 for bilateral). There was no significant difference between groups in the need for tube removal, repeat tubes, tube medialization, or post-extrusion tympanic membrane perforation.

CONCLUSION

The comparable long-term outcomes found for tubes inserted in-office versus the OR, including time to occlusion/extrusion, suggest that both settings are acceptable for the procedure, with choice based primarily on parental preference, clinician experience, and shared decision making with families.

Could the use of a new novel bipolar radiofrequency device (Aerin) improve nasal valve collapse? A systematic review and meta-analysis

BACKGROUND

Surgical treatment for nasal obstruction caused by nasal valve collapse requires a significant recovery period and risks of complications, while nasal dilators are uncomfortable. Recently, radiofrequency treatment of lateral walls has been used under local anesthesia as an office base surgery. This work aims to assess the efficacy of a new radiofrequency device, the Vivaer™ System (Aerin Medical, Sunnyvale, CA), to treat nasal obstruction through a systematic review and meta-analysis.

METHODS

Two researchers independently reviewed the literature up to December 2021. Studies on patients seeking treatment for nasal obstruction due to nasal valve collapse were included in the analysis.

RESULTS

Four studies (218 patients) met the inclusion criteria and treated the nasal valve regions bilaterally with the Aerin Medical Vivaer™ System. After the treatment, the NOSE score was reduced at three months postoperatively. Minor adverse events were reported in the included studies, and two showed no complications. None of the studies reported changes in the external appearance of the nose.

CONCLUSION

The radiofrequency treatment using the Vivaer device can be useful for treating nasal valve collapse, improving significantly subjective breathing symptom scores. Further studies on a large scale are needed to confirm these results.

Tolerance of Patients Using Different Approaches in Laryngeal Office-Based Procedures

OBJECTIVE

To evaluate the tolerance, overall experience, procedure discomfort, and patient anxiety using different routes in office-based laryngeal procedures.

SUBJECTS AND METHODS

We performed a retrospective analysis of patients undergoing office-based laryngeal procedures for the treatment or diagnosis of laryngeal lesions via transnasal, transoral, or percutaneous routes. Tolerability, overall experience, procedure discomfort, and patient's anxiety were evaluated and reported on a custom scale over 5.

RESULTS

A total 178 procedures performed on 154 patients were reviewed. The video-recordings and data on 15 procedures were missing. A total of 163 procedures were included in this study. These were stratified as follows; 128 procedures via the transnasal fiberoptic approach, 16 procedures via the transoral fiberoptic approach, and 19 procedures via the percutaneous approach. There was no significant difference in the mean score of overall experience across the three different approaches (P= 0.926). The mean overall experience score for the transnasal approach was 1.85, vs 1.93 and 1.94 for the transoral and percutaneous approach, respectively. Similarly, there was no significant difference in the mean score of tolerability across the three different approaches. The mean tolerability score was 1.68 using the transnasal approach, compared to 1.6 using the transoral approach, and 1.84 using the percutaneous approach (P= 0.77). Anxiety scores, and procedure discomfort scores did not differ either among the three groups (P= 0.138 and P= 0.656, respectively).

CONCLUSIONS

There was no significant difference in tolerability, anxiety, procedure discomfort, and overall experience regarding the different approaches employed.

Unsedated Office-Based Thulium Laser Therapy in Patients With Reinke's Edema

OBJECTIVE

To report the outcome of unsedated office based Thulium laser therapy for Reinke's edema.

MATERIALS AND METHODS

A retrospective chart review of patients operated between March 2017 and November 2018 was conducted. Twelve patients were included, two of whom had two procedures performed. Demographic data included age, gender, smoking status, and grade of Reinke's edema. Outcome measures included Voice Handicap Index-10 (VHI), perceptual evaluation, extent of disease regression, acoustic analysis, and maximal phonation time.

RESULTS

Twelve patients were enrolled in this study, one of whom was lost for follow-up. There were eight females and three males. The mean age was 51.27 ± 9.12 years. Endoscopic evaluation 6-12 weeks after surgery revealed complete and partial regression of disease in three and eight patients, respectively. There was a significant improvement in the mean score of VHI-10 (15.00 ± 9.45 vs 3.07 ± 3.81) and the mean score of GRABS parameters following surgery (P < 0.05). The mean habitual pitch increased from 125.11 ± 28.48 Hz to 155.86 ± 55.14 Hz (P = 0.070). There was improvement in the mean jitter and shimmer but none reached a statistical significance. There was no significant change in the mean Maximum phonation time (MPT) scores before and after surgery.

CONCLUSION

Unsedated office-based Thulium laser therapy can be considered as an alternative therapy to patients with Reinke's edema who are not willing to undergo conventional microlaryngeal surgery.

Office-based inferior turbinate reduction using bipolar cautery: Technique and results

OBJECTIVES

Several methods have been reported for inferior turbinate (IT) reduction. We describe office-based interstitial IT reduction using bipolar cautery and evaluate long-term efficacy.

METHODS

Sixty patients with allergic and nonallergic rhinitis unresponsive to medical treatment underwent office IT reduction between January 2012 and December 2014. Bipolar cautery was used at 15 to 20 W. Mean procedure time was 12 min for unilateral and 16 min for bilateral IT reduction. Patients followed up at 2, 6, and 12 weeks and 1 year. Mean follow-up was 22 months. The Sinonasal Outcome Test was completed before and after at 6 weeks and 1 year.

RESULTS

SNOT-22 scores were 35.7 ± 5.4 and 18.5 ± 4.2 preoperatively and at 1 year respectively. Symptoms improved at 6 weeks, nasal obstruction and rhinorrhea improving most. Complications included vaso-vagal reactions in 6 requiring rescheduling the procedure in 2 patients. One patient had bleeding controlled conservatively.

CONCLUSION

Bipolar IT cautery is safe, effective, well-tolerated and doesn't require expensive equipments. It can be incorporated into general otolaryngology practice.

In-Office Evaluation and Management of Dysphagia

Dysphagia is a common complaint encountered in otolaryngology clinics. Approaching the patient with dysphagia starts with a comprehensive symptomatic analysis and thorough physical examination. The recent rapid revolution in office-based procedures has a great impact in the evaluation and management of dysphagia. Currently, diagnostic and therapeutic procedures can be performed safely and effectively in the office setting with the advantage of avoidance of sedation or general anesthesia.

Topical Anesthesia for Endoscopic Office-based Procedures of the Upper Aerodigestive Tract

OBJECTIVE

Over the last two decades, an increase in office-based procedures under topical anesthesia in laryngology and head and neck oncology has occurred. Adequate anesthesia in the nasal cavity, pharynx, and larynx is essential for successful performance of these procedures. Our goal is to provide an objective summary on the available local anesthetics, methods of application, local secondary effects, efficacy, and complications.

MATERIAL AND METHODS

A descriptive review of literature on topical anesthesia for office-based procedures in laryngology and head and neck oncology was performed.

RESULTS

Lidocaine is the most applied and investigated topical anesthetic. Topical anesthesia results in decreased sensory function without impairing motor function of the pharynx and larynx. For the nasal cavity, cotton pledgets soaked in anesthetic spray and decongestant, or anesthetic gel, are effective. For the pharynx, anesthetic spray is the most frequently used and effective method. For the larynx, applying local anesthesia through a catheter through the working channel of the endoscope or anesthetic injection through the cricothyroid membrane is effective. Studies comparing the most effective application methods for each anatomical site are lacking. Complications of topical lidocaine administration are rare.

CONCLUSIONS

By properly applying topical anesthesia to the upper aerodigestive tract, several surgical procedures in laryngology and head and neck oncology can be performed in the outpatient clinic under topical anesthesia instead of the operating room under general anesthesia. Lidocaine is the most investigated anesthetic, with adequate efficacy and few complications. Studies that determine the most effective application methods are still wanting.