'Seeing is believing' - gender disparities in otolaryngology-head and neck surgery in Africa: a narrative review

PURPOSE OF REVIEW

Various factors affect otolaryngology - head and neck surgery (OHNS) services in low- and middle-income countries (LMICs); including inadequate infrastructure, limited academic positions, unfavorable hospital research policies, and traditional misconceptions about gender and surgery, among others. Although gender inequalities exist globally, they are particularly pronounced in LMICs, especially in Africa.

RECENT FINDINGS

A comparative narrative literature review for relevant manuscripts from January 1, 2017 to through January 10th, 2024, using PubMed, Embase and Google Scholar for articles from the United States/Canada and Africa was done. 195 relevant articles were from the United States/Canada, while only 5 were from Africa and only 1 manuscript was relevant to OHNS. The reviewed articles reported that gender disparities exist in medical training, authorship, and career advancement. We highlight possible solutions to some of these disparities to promote a more gender-diversified workforce in OHNS in Africa as well as all over the world.

SUMMARY

Additional studies on gender disparities in Africa, are needed. These studies will highlight need for inclusive policies, structured and accessible mentorship programs; through which these disparities can be highlighted and addressed. This will in the long run ensure sustainability of OHNS care in LMICs.

Impact of the COVID-19 epidemic on ENT surgical volume

Purpose

The purpose of this study was to assess the impact of the COVID-19 pandemic on the surgical volume of three ENT departments in Ile-de-France, a region severely affected by the epidemic.

Materials and methods

The number and nature of surgeries was collected from three university hospital ENT departments from 17/03/2020 to 17/04/2020 and from 18/03/2019 to 18/04/2019. Centre 1 is a general adult ENT department specialized in otology, centre 2 is a general adult ENT department specialized in cancer and centre 3 is a paediatric ENT department. Comparative analysis of the decreased surgical volume was conducted between 2019 and 2020.

Objective

To analyse the reduction of ENT surgical volume.

Results

The three centres operated on 540 patients in 2019, versus 89 in 2020, i.e. an 84% decrease: 89% in Centre 1, 61% in Centre 2, and 95% in the paediatric centre. Otological surgery decreased by 97%, endonasal surgery decreased by 91%, head and neck surgery decreased by 54%, plastic surgery decreased by 82%, and transoral surgery decreased by 85%. The number of surgical operations for skin cancer decreased (24 vs. 9), while the total number of head and neck cancer surgeries remained stable (18 vs. 22). The number of planned tracheostomies increased from 8 to 22.

Conclusion

The number of ENT surgeries decreased by 84% during the first month of the COVID-19 epidemic. This decreased surgical volume mainly concerned functional surgery, while the level of cancer surgery remained stable. Hospital units will need to absorb a marked excess surgical volume after the epidemic.

Restructuring ENT out-patient services during the coronavirus disease 2019 pandemic - an iterative approach

BACKGROUND

Coronavirus disease 2019 has demanded enormous adjustments to National Health Service provisions. Non-urgent out-patient work was initially postponed or performed virtually, but is now being re-established. In ENT surgery, aerosol-generating procedures pose a particular challenge in out-patient settings.

OBJECTIVE

A rapid restructuring of ENT out-patient services is required, to safely accommodate aerosol-generating procedures and increase in-person attendances, whilst coronavirus disease 2019 persists.

METHODS

Data were collected prospectively over four consecutive cycles. Two surveys were conducted. Results were analysed and disseminated, with recommendations for service restructuring implemented at cycle end-points.

RESULTS

Out-patient activity increased four-fold, associated with a significant rise in aerosol-generating procedures during the study period. Mean aerosol-generating procedure duration dropped weekly, implying a learning curve. Service restructuring occurred at cycle end-points.

CONCLUSION

Iterative data gathering, results analysis and outcome dissemination enabled a swift, data-driven approach to the restructuring of ENT out-patient services. Patient and staff safety was ensured, whilst out-patient capacity was optimised.

Head and neck cancer surgery in COVID-19 pandemic in Northern Italy

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COVID-2019 pandemic represents a great challenge both in itself and for time-sensitive diseases.

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Head and neck cancer surgery is a high risk procedure for COVID-19.

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Possibility of SARS-CoV-2 false negative at pre-operative evaluation in asymptomatic subjects should not let guard down in the post-operative time.

Comparison of Referral Pathways in Otolaryngology at a Public Versus Private Academic Center

OBJECTIVE

Delayed medical care may be costly and dangerous. Examining referral pathways may provide insight into ways to reduce delays in care. We sought to compare time between initial referral and first clinic visit and referral and surgical intervention for index otolaryngologic procedures between a public safety net hospital (PSNH) and tertiary-care academic center (TAC).

METHODS

Retrospective cohort study of eligible adult patients undergoing one of several general otolaryngologic procedures at a PSNH (n = 216) and a TAC (n = 161) over a 2-year time period.

RESULTS

PSNH patients were younger, less likely to have comorbidities and more likely to be female, Hispanic or Asian, and to lack insurance. Time between referral and first clinic visit was shorter at the PSNH than the TAC (Mean 35.8 ± 47.7 vs 48.3 ± 60.3 days; P = .03). Time between referral and surgical intervention did not differ between groups (129 ± 90 for PSNH vs 141 ± 130 days for TAC, P = .30). On multivariate analysis, the TAC had more patient-related delays in care than the PSNH (OR: 3.75, P < .001). Time from referral to surgery at a PSNH was associated with age, source of referral, type of surgery, diagnostic workup and comorbidities, and at a TAC was associated with gender and type of surgery and comorbidities.

CONCLUSIONS

Sociodemographic differences between PSNH and TAC patients, as well as differences in referral pathways between the types of institutions, influence progression of surgical care in otolaryngology. These differences may be targets for interventions to streamline care.

LEVEL OF EVIDENCE

2c.

United States-based global otolaryngology surgery: A call to more horizontal sustainable efforts

OBJECTIVE

To examine global surgery involvement among general members of the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) and characterize international otolaryngology surgical interventions.

METHODS

Data on global surgery involvement were derived from responses provided by voluntary online survey respondent members of the AAO-HNS, obtained in October 2017. These data were compared against World Bank metrics of national health expenditure and surgical specialists per capita as benchmarks for need.

RESULTS

There were 362 responses (response rate of 3.7%). A large proportion of respondents reported being involved in global surgery (61.3%). Locations where respondents worked included: South America (13.3%), Central America (17.7%), Caribbean (10.2%), Europe (4.1%), Africa (16.3%), Asia (16.6%), the Middle East (4.1%), and Oceania (3.6%). A greater proportion of respondents reported traveling to locations that have lower health care expenditure per capita and lower mean number of surgical specialists per 100,000 people, according to data from the World Bank. The primary purpose of trips was most commonly surgical mission (60.3%), followed by education (37.8%), and research (1.9%).

CONCLUSION

Members of the AAO-HNS are active in global surgery efforts around the world. Collaboration among members of the AAO-HNS may serve to improve long-term sustainability of these efforts.

Readmissions After Day Care Surgery In Ent: A Tertiary Care Experience

BACKGROUND

Re-admission following day care surgery in ENT (Ear, Nose & Throat) results in significant morbidity to patient & massive load to hospital & also raises the question on the safety of day care surgery. Only a small number of published studies emphases on return to hospital within 30 days following day care surgery in otorhinolaryngology especially from our region. This study was carried out to determine the frequency of re-admission after day care surgery in ENT.

METHODS

We prospectively studied consecutive patients who underwent ENT procedures [i.e., septoplasty, tympanoplasty type I & functional endoscopic sinus surgery (FESS) for deviated nasal septum (DNS), chronic suppurative otitis media tubotympanic (CSOM TT) variety & ethmoidal nasal polyposis (ENP) respectively] as day care surgery case under general anaesthesia at the Section of Otorhinolaryngology and Head & Neck Surgery, Aga Khan University Hospital & Liaquat National Hospital, Karachi from January 2015 to December 2016. All patients aged 20- 60 years of both genders were included in the study. SPSS software version 20 was used for data compilation and analysis. p-value less than or equal to 0.05 was taken as significant.

RESULTS

In the phase of 24 months, total 317 cases met the inclusion criteria & were included in the study. There were 205 males & 112 females in the study population. One hundred & twenty-two patients having DNS, 128 having CSOM TT & 67 suffering from ENP & underwent septoplasty, tympanoplasty type I & FESS respectively. Complications were observed in a total of 7 (2.2%) patients in our study group & required re-admission within 1 month of surgery. Stratification was done between re-admission & all effect modifiers, with all showing insignificant results.

CONCLUSIONS

Our results demonstrate that ENT surgeries (septoplasty, tympanoplasty type I & FESS) are safe procedures which can be performed as a day care case with acceptably low readmission rates.

Perioperative safety, feasibility, and oncologic utility of transoral robotic surgery with da Vinci Xi platform

Transoral robotic surgery (TORS) is a common modality for treatment of oropharyngeal and laryngeal cancer. Current FDA approval extends to the da Vinci S and Si platforms. Many hospitals are adopting the da Vinci Xi platform. Reports of head and neck surgical outcomes with this platform are scant. This study reports outcomes of TORS procedures performed with the da Vinci Xi platform including perioperative adverse events, functional outcomes, and short-term local control. A retrospective review of TORS performed with the da Vinci Xi platform is undertaken. Twenty-two consecutive TORS cases with the Xi platform are reviewed. Procedures performed include radical tonsillectomy, base of tongue resection, and lingual tonsillectomy. Two bleeding events occurred (9% of cases), both of intermediate severity as per Mayo criteria. Three procedures resulted in positive margin status, early in the case series, and two were cleared with revision resection. One-year local control rate, where available, is 100%. There were no perioperative deaths, long-term gastrostomy dependence, or performance of tracheostomy. Advantages of this platform include ease of robot deployment and setup. Disadvantages include increased width of instrumentation compared with previous platforms with crowding of access. The availability of a specific robotic platform may be dictated by hospital-wide policy across service lines. This report suggests that the da Vinci Xi permits performance of TORS with safety and oncologic outcomes similar to previous platforms; however, long-term follow-up is needed.

Perioperative Risk Factors Associated With Morbidity and Mortality Following Pediatric Inpatient Sinus Surgery

OBJECTIVES:

Pediatric sinus surgery is indicated for a wide range of sinonasal and skull base pathologies, but it is most commonly performed for recalcitrant chronic rhinosinusitis or complicated acute sinusitis. The authors aim to report medical risk factors of morbidity and mortality following inpatient sinus surgery in the pediatric population.

METHODS:

Using data from the Kids' Inpatient Database from 2003 to 2012, patients with International Classification of Diseases, Ninth Revision, procedure codes for primary sinus surgery were identified. Mixed-effect multivariable logistic regression was used to identify risk factors of inpatient postoperative morbidity and mortality.

RESULTS:

The final sample included a weighted estimate of 4965 pediatric patients. The rates of inpatient morbidity and mortality were 6% and 1%, respectively. Respiratory complications (2.5%) were the most prevalent postoperative adverse events. The most prevalent comorbidities were chronic sinusitis (59.8%), acute sinusitis (27.8%), and cystic fibrosis (26.4%). Compared with patients who did not experience any morbidity, patients with inpatient morbidity had higher rates of pneumonia, mycoses, and nasal or paranasal benign neoplasm ( P < .05). The odds of inpatient morbidity and mortality were highest for patients with leukemia (odds ratio, 2.74; 95% confidence interval, 1.59-4.72; P < .001) and mycoses (odds ratio, 15.84; 95% confidence interval, 6.45-38.89; P < .001), respectively.

CONCLUSIONS:

This study is the first to report the national comorbidity burden and risk factors for postoperative adverse events following inpatient sinus surgery. Knowledge of the comorbidities and independent factors associated with morbidity and mortality will help in directing preoperative optimization and counseling.

LEVEL OF EVIDENCE:

2c.

Treatment outcomes in HPV-negative oropharyngeal cancer: Surgery plus radiotherapy vs. definitive chemoradiotherapy

We performed a retrospective study to compare clinical outcomes among 51 consecutively presenting patients-38 men and 13 women, aged 46 to 74 years (median: 57)-with locally advanced human papillomavirus (HPV)-negative oropharyngeal cancer who were treated with either primary surgery followed by postoperative radiotherapy (S/RT group; n = 22) or definitive chemoradiotherapy alone (CRT group; n = 29). Within the cohort, 45 patients reported a history of tobacco use, with a median intensity of 40 pack-years. In addition, 39 patients (76%) reported moderate to heavy alcohol use. At baseline, there were no statistically significant differences between the two cohorts in sex, median age, cancer stage, intensity of smoking history, and alcohol use (p > 0.05 for all). Radiation doses ranged from 40 to 70 Gy (median: 70). Follow-up ranged from 2 to 93 months (median: 29). After treatment, we found no difference between the S/RT group and the CRT group in the incidence of locoregional recurrence (36 vs. 24%; p = 0.43) or distant metastases (14 vs. 21%; p = 0.56). Likewise, the difference in 2-year estimates of progression-free survival in the two groups was not significant (66 vs. 62%; p = 0.64), nor was the difference in 2-year overall survival (75 vs. 76%; p = 0.83). We conclude that treatment with either (1) primary surgery followed by postoperative radiotherapy or (2) CRT for locally advanced HPV-negative oropharyngeal cancer results in similar outcomes. In view of the relatively poor prognosis for patients with HPV-negative disease compared with their HPV-positive counterparts, clinical trials to investigate intensifying treatment may be warranted.

Down Syndrome as an indicator for pediatric otolaryngologic procedures

OBJECTIVE

Down Syndrome (DS) is the most common chromosome abnormality in humans. Due to the phenotype associated with DS, there are many disease states that require otolaryngologic procedures. Our goal is to use national data to study otolaryngologic procedures, their association with DS, and the degree of difference in risk profiles encountered with DS.

METHODS

Data was obtained from the 2012-2015 American College of Surgeons' National Surgical Quality Improvement Program-Pediatric public use files. ENT procedure CPT codes were used to query the database and DS patients were identified using ICD-9 code 758.0. The ENT procedures were grouped into 18 categories and their frequency in DS patients as well as outcomes were analyzed. Postoperative outcomes were measured by complication rates, readmission rates, operation time, anesthesia time, and total length of stay.

RESULTS

Results showed that DS patients are significantly (p < 0.05) over-represented in the following categories: Tracheostomy, Endoscopy, Laryngoscopy, Tracheoplasty, Myringoplasty, Tympanoplasty with Mastoidectomy, and Tympanoplasty without Mastoidectomy. DS patients are under-represented in the following categories: Abscess, Palatoplasty, Excision of Congenital Neck Cyst, and Cochlear Implantation. Logistic regression analysis showed that DS patients were significantly (p < 0.05) more likely to undergo procedures in the over-represented categories and were significantly (p < 0.05) less likely to undergo procedures in the under-represented categories as listed above. Outcomes analysis yielded no pattern of significance.

CONCLUSION

Our data showed that DS may predispose patients to require certain procedures over others.

[Surgical quality registries: large room for improvement if they should be used for analyses of life style risk factors and the effect of preoperative initiatives on postoperative complications]

Surgical quality registries: large room for improvement if they should be used for analyses of life style risk factors and the effect of preoperative initiatives on postoperative complications Tobacco, alcohol, malnutrition, overweight and physical inactivity increase postoperative morbidity. Preoperative intervention has been shown to improve the outcome significantly. The aim was to investigate if these lifestyle risk factors were reported in the Swedish national surgical quality registries together with preoperative interventions and postoperative complications. Altogether, 44 registers reporting on surgical procedures were identified. Preoperative documentation existed in about half of the registries, but relevant health promoting intervention was not documented. Postoperative complications were reported with varying degrees. No registry had complete reporting of preoperative lifestyle risk factors, related intervention and postoperative complications. For most registries, there is a large room for improvement if they should be used for analyses of risk factors and the effect of implementation of preoperative initiatives on postoperative complications.

Experience of First Deployed Otolaryngology Team in Operation Iraqi Freedom: The Changing Face of Combat Injuries

OBJECTIVES: In September, 2004, an Air Force otolaryngology team was deployed to Iraq as a member of the multispecialty head and neck team, which had historically consisted of neurosurgery, ophthalmology, and oral surgery. We examined our operative and outpatient experience to determine if otolaryngology would be a critical component of this new head and neck team.

STUDY DESIGN AND SETTING: Between September 7, 2004, and January 22, 2005, we collected data on all otolaryngology operative procedures and outpatient visits at the Air Force Theater Hospital at Balad Air Base, Iraq.

RESULTS: One hundred fifty-nine patients underwent 257 operative procedures with the 3 most common procedures being complex facial laceration repair, tracheostomy, and neck exploration for penetrating neck trauma. In the otolaryngology clinic, we examined and treated 529 patients from throughout the Middle East.

CONCLUSIONS: The otolaryngology team proved to be a critical component of the Air Force multispecialty head and neck team.

EBM rating: C-4

Long-term follow-up after ESS and balloon sinuplasty: Comparison of symptom reduction and patient satisfaction

CONCLUSION

This is the first controlled study of balloon sinuplasty's long-term efficacy with the follow-up time over 5 years. The results are in accordance with a previous 2-year-follow-up study. Both techniques retained the efficacy and patient satisfaction on average 6 years after the surgery.

BACKGROUND

Endoscopic sinus surgery (ESS) and balloon sinuplasty are considered as a treatment for chronic rhinosinusitis (CRS) after a failure of conservative therapy. High cost and lack of long-term follow-up studies restrain the use of balloon sinuplasty.

OBJECTIVE

The aim of this study was to compare long-term efficacy and satisfaction in CRS patients who had undergone maxillary sinus operation with either balloon sinuplasty or ESS technique. Previous or additional sinonasal operations were exclusion criteria.

MATERIALS AND METHODS

Study patients were recruited from 208 CRS-patients who underwent either ESS or balloon sinuplasty. Patients with nasal polyposis (gradus ≥ 2), previous sinonasal surgery, unilateral disease, or immune deficiency were excluded. Altogether 45 patients in the ESS group and 40 patients in the balloon group were included. Of these, 30 and 28, respectively, answered to a phone interview held on average 6 years after primary surgery. Symptom reduction and long-term satisfaction were evaluated by using symptom scores of 19 parameters altogether.

RESULTS

Both groups experienced improvement in symptoms and were equally satisfied with the operation. The number of patient-reported acute exacerbations was higher among the balloon dilated patients. Also, the reduction of thick nasal discharge was less evident in the balloon sinuplasty group. Four patients in the balloon sinuplasty group underwent revision surgery. There were no revisions in the ESS group.

Flap Necrosis after Palatoplasty in Patients with Cleft Palate

Palatal necrosis after palatoplasty in patients with cleft palate is a rare but significant problem encountered by any cleft surgeon. Few studies have addressed this disastrous complication and the prevalence of this problem remains unknown. Failure of a palatal flap may be attributed to different factors like kinking or section of the pedicle, anatomical variations, tension, vascular thrombosis, type of cleft, used surgical technique, surgeon's experience, infection, and malnutrition. Palatal flap necrosis can be prevented through identification of the risk factors and a careful surgical planning should be done before any palatoplasty. Management of severe fistulas observed as a consequence of palatal flap necrosis is a big challenge for any cleft surgeon. Different techniques as facial artery flaps, tongue flaps, and microvascular flaps have been described with this purpose. This review article discusses the current status of this serious complication in patients with cleft palate.

The burden of revision sinonasal surgery in the UK-data from the Chronic Rhinosinusitis Epidemiology Study (CRES): a cross-sectional study

OBJECTIVES

The aim of this study was to investigate the surgical revision rate in patients with chronic rhinosinusitis (CRS) in the UK CRS Epidemiology Study (CRES). Previous evidence from National Sinonasal Audit showed that 1459 patients with CRS demonstrated a surgical revision rate 19.1% at 5 years, with highest rates seen in those with polyps (20.6%).

SETTING

Thirty secondary care centres around the UK.

PARTICIPANTS

A total of 221 controls and 1249 patients with CRS were recruited to the study including those with polyps (CRSwNPs), without polyps (CRSsNPs) and with allergic fungal rhinosinusitis (AFRS).

INTERVENTIONS

Self-administered questionnaire.

PRIMARY OUTCOME MEASURE

The need for previous sinonasal surgery.

RESULTS

A total of 651 patients with CRSwNPs, 553 with CRSsNPs and 45 with AFRS were included. A total of 396 (57%) patients with CRSwNPs/AFRS reported having undergone previous endoscopic nasal polypectomy (ENP), of which 182 of the 396 (46%) reported having received more than one operation. The mean number of previous surgeries per patient in the revision group was 3.3 (range 2-30) and a mean duration of time of 10 years since the last procedure. The average length of time since their first operation up to inclusion in the study was 15.5 years (range 0-74). Only 27.9% of all patients reporting a prior ENP had received concurrent endoscopic sinus surgery (ESS; n=102). For comparison, surgical rates in patients with CRSsNPs were significantly lower; 13% of cases specifically reported ESS, and of those only 30% reported multiple procedures (χ(2) p<0.001).

CONCLUSIONS

This study demonstrated that there is a high burden of both primary and revision surgery in patients with CRS, worst in those with AFRS and least in those with CRSsNPs. The burden of revision surgery appears unchanged in the decade since the Sinonasal Audit.

Hospital volume and failure to rescue after head and neck cancer surgery

OBJECTIVE

To investigate the relationship between hospital volume and mortality, complications, and failure-to-rescue rates among patients undergoing head and neck cancer (HNCA) surgery.

STUDY DESIGN

Cross-sectional analysis.

SETTING

Nationwide Inpatient Sample.

SUBJECTS AND METHODS

Discharge data for 159,301 patients who underwent an ablative procedure for a malignant oral cavity, laryngeal, hypopharyngeal, or oropharyngeal neoplasm from 2001 to 2010 were analyzed using cross-tabulations and multivariate regression modeling. Failure to rescue was defined as death after a major complication, including acute myocardial infarction, acute renal failure, venous thromboembolism, pneumonia, gastrointestinal bleed, pulmonary failure, hemorrhage, or surgical site infection. We compared the incidence of mortality, major complications, and failure-to-rescue rates across hospital volume tertiles.

RESULTS

The majority of hospitals performing HNCA surgery were low-volume hospitals, which performed a mean of 6 HNCA cases per year (n = 7635). Intermediate-volume hospitals performed a mean of 37 cases per year (n = 729), and high-volume hospitals performed a mean of 131 cases (n = 207). High-volume hospital care was associated with significantly decreased odds of death (odds ratio, 0.56; 95% confidence interval, 0.46-0.86) and failure to rescue (odds ratio, 0.56; 95% confidence interval, 0.33-0.97) compared to low-volume hospital care. However, there was no significant difference in major complication rates between patients undergoing HNCA surgery at high-volume hospitals and those at low-volume hospitals.

CONCLUSION

Patients with HNCA who receive care at high-volume hospitals compared with low-volume hospitals have a 44% lower odds of mortality, which appears to be associated with differences in the response to and management of complications rather than differences in complication rates.

Cervical branch of the facial nerve approach for retrograde parotidectomy compared with anterograde parotidectomy

CONCLUSION

The cervical branch of the facial nerve approach for parotidectomy is an excellent surgical technique that can reduce the incidence of facial nerve paralysis, surgical time, and surgical blood loss.

OBJECTIVE

To develop and evaluate a surgical technique for parotidectomy that can reduce the incidence of facial nerve paralysis.

METHODS

Retrograde parotidectomy following identification of the cervical branch of the facial nerve in 90 subjects was compared with standard anterograde parotidectomy in 100 subjects.

RESULTS

Retrograde parotidectomy with a cervical branch approach was associated with significant decreases in the incidence of facial nerve paralysis, surgical time, and surgical blood loss, compared with anterograde parotidectomy.

Epidemiology and pathology of parotid tumors five-year retrospective study

AIM

To retrospectively analyze the epidemiological, clinical and pathological data of parotid tumors.

MATERIAL AND METHODS

Reassessment of the histologic diagnosis of parotid tumor in the patients admitted to the Oral and Maxillofacial Surgery Unit of the Iasi "Sf. Spiridon" University Emergency Hospital during 2009-2013. Data on gender, age, place of residence, location, size, surgical procedure type and histopatological type were recorded.

RESULTS

The risk of developing pleomorphic adenonma is 7.40 times higher in women and 4.08 times higher before the age of 50 years. The risk of Warthin tumor is 16.47 times higher in male patients and 3.58 times higher in urban patients. People older than 50 years have a 7.14 times higher risk of developing malignancy and rural people have a 2.41 times higher risk of developing cancer. Diabetes, obesity and systemic hypertension were not important risk factors in our study.

CONCLUSIONS

According to this study age and the place of residence could be important predictors for parotid gland tumors. Since in Romania there are few epidemiological data regarding the parotid gland pathology, further cohort studies are needed for a better understanding of their clinical and pathological behavior.

A cross-specialty survey to assess the application of risk stratified surgery for differentiated thyroid cancer in the UK

INTRODUCTION

This study describes variability of treatment for differentiated thyroid cancer among thyroid surgeons, in the context of changing patterns of thyroid surgery in the UK.

METHODS

Hospital Episodes Statistics on thyroid operations between 1997 and 2012 were obtained for England. A survey comprising six scenarios of varying 'risk' was developed. Patient/tumour information was provided, with five risk stratified or non-risk stratified treatment options. The survey was distributed to UK surgical associations. Respondent demographics were categorised and responses analysed by assigned risk stratified preference.

RESULTS

From 1997 to 2012, the Hospital Episode Statistics data indicated there was a 55% increase in the annual number of thyroidectomies with a fivefold increase in otolaryngology procedures and a tripling of cancer operations. Of the surgical association members surveyed, 264 respondents reported a thyroid surgery practice. Management varied across and within the six scenarios, and was not related consistently to the level of risk. Associations were demonstrated between overall risk stratified preference and higher volume practice (>25 thyroidectomies per year) (p=0.011), fewer years of consultant practice (p=0.017) and multidisciplinary team participation (p=0.037). Logistic regression revealed fewer years of consultant practice (odds ratio [OR]: 0.96/year in practice, 95% confidence interval [CI]: 0.922-0.997, p=0.036) and caseload of >25/year (OR 1.92, 95% CI: 1.044-3.522, p=0.036) as independent predictors of risk stratified preference.

CONCLUSIONS

There is a substantial contribution to thyroid surgery in the UK by otolaryngology surgeons. Adjusting management according to established case-based risk stratification is not widely applied. Higher caseload was associated with a preference for management tailored to individual risk.

Effectiveness of setting numerical targets in the surgical training of residents: a trial to achieve an optimal balance

During the past 10 years, residency training in otorhinolaryngology-head and neck surgery (ORL-HNS) in Japan, especially at university hospitals, has emphasized subspecialization, resulting in insufficiencies in basic surgical techniques with an extreme bias toward acquiring subspecialty surgical case experience. To address this problem, we developed a target-oriented program intended to achieve a more balanced approach to surgical training and performed a 1-year trial of the program at the Jikei University School of Medicine. Fourteen residents with 1 to 4 years of ORL-HNS experience completed the trial. Each resident's competencies in six basic surgical procedures were assessed on the basis of the number of cases handled by the resident, and each resident's case selection bias after implementation of the target-oriented training was examined. The case selection bias in the trial group residents was reduced and their balance in case experience was shown to be improved in comparison with that in control group residents who were trained in the conventional way. In addition, opinion surveys of the participants and supervising otorhinolaryngologists (trainers) indicated that they felt that the new training system had been effective in improving the balance in case experience and improving motivation, and creating greater awareness of training goals and progress.

Determining legal responsibility in otolaryngology: a review of 44 trials since 2008

PURPOSE

Medicolegal factors contribute to increasing healthcare costs through the direct costs of malpractice litigation, malpractice insurance premiums, and defensive medicine. Malpractice litigation trends are constantly changing as a result of technological innovations and changes in laws. In this study, we examine the most recent legal decisions related to Otolaryngology and characterize the factors responsible for determining legal responsibility.

METHODS

The Westlaw legal database (Thomson Reuters, New York, NY) was used to search for jury verdicts since 2008 in Otolaryngology malpractice cases. The 44 cases included in this analysis were studied to determine the procedures most commonly litigated and progressing to trial, as well as the year, location, alleged cause of malpractice, specialty of co-defendants, and case outcomes.

RESULTS

Out of the 44 cases included in this analysis, physicians were not found liable in 36 (81.8%) cases. Rhinologic procedures comprised 38.6% of cases litigated, and rulings were in physicians' favor in 66.7% of endoscopic sinus surgery (ESS) cases and all non-ESS rhinologic cases. A perceived lack of informed consent was noted in 34.1% of cases. The 8 jury awards averaged $940,000 (range, $148,000-$3,600,000).

CONCLUSION

Otolaryngologists were not found liable in the majority of cases reviewed. Rhinologic surgeries were the most common procedures resulting in litigation. Adenotonsillectomies, thyroidectomies, and airway management are also well-represented. Perceived deficits in informed consent and misdiagnosis were noted in a considerable proportion of otolaryngologic malpractice cases resulting in jury decisions.

[Nasal polyposis and olfactory function: results of the surgical treatment]

INTRODUCTION

Hyposmia is a common cause of functional complaint in patients with nasal polyposis. The aim of the current study was to report the olfactory functional results after sinus surgery.

MATERIALS AND METHODS

A systematic review of the scientific literature was achieved in the Pubmed database.

RESULTS

Overall, 10 series published between 1989 and 2013, involving 959 patients, were selected. The surgery for nasal polyposis, adjuvant medical treatment, may allow olfactory improvement. The results are even better than surgery is as wide as possible and the evolutionary stage is low.

Evidence-based practice: management of glottic cancer

The main issue in the management of glottic squamous cell carcinoma, as for all cancers, is adequate disease control while optimizing functional outcomes and minimizing morbidity. This is true for early-stage disease as for advanced tumors. This article evaluates the current evidence for the diagnostic and pretherapeutic workup for glottic squamous cell carcinoma and the evidence concerning different treatment options for glottic carcinoma, from early-stage to advanced-stage disease.

The European positional paper on rhinosinusitis and nasal polyps: has the introduction of guidance on the management of sinus disease affected uptake of surgery and acute admissions for sinusitis?

Rhinosinusitis is a common condition with adults experiencing 2-5 episodes per year. The European Positional Paper on Rhinosinusitis and Nasal Polyps (EP3OS) published in 2005 and updated in 2007 provided evidence-based guidelines on the management of sinus disease promoting a conservative approach to treatment. This study examines the effect of EP3OS on sinus surgery uptake and acute admissions for sinusitis in England and Wales. A retrospective study using the national electronic health databases of England (Hospital Episodes Statistics, HES online) and Wales (Patient Episodes Database of Wales, PEDW) was undertaken from 2000 to 2010 using the OPCS-4 codes E12-E17 (sinus surgery) and ICD10 code J01 (acute admission for sinusitis). Data were analysed for effect following the introduction of the EP3OS in 2005 using linear regression and Chi squared analysis. 116,370 sinus procedures and 10,916 acute admissions for sinusitis were made during the study period. No significant decrease in sinus surgery procedures occurred following the introduction of the EP3OS as may have been expected (p > 0.05), although subgroup analysis suggested a significant increase in Wales (p < 0.05). In addition, significant increases in acute admissions for sinusitis were observed following the introduction of EP3OS (p < 0.05). However, subgroup analysis suggested this was not the case in Wales (p > 0.05). The EP3OS appears to have had little impact on the rates of sinus surgery but more conservative approaches to managing of sinus disease may have led to an increase in acute admissions. Further research is required to investigate whether changes in practice were adopted.

Three-year follow-up of palatal implants for the treatment of snoring

CONCLUSIONS

The safety of treatment with palatal implants remains high 3 years after the procedure. The implant extrusion rate decreases over time. Additional surgery to the palate is safe. The presence of the implants seems important in sustaining efficacy past 1 year.

OBJECTIVES

To investigate long-term safety and treatment results of palatal implants for treatment of snoring.

METHODS

A prospective clinical non-randomized trial of 55 patients with primary snoring followed over a period of 3 years.

RESULTS

No major adverse events were observed. Eleven of the 55 patients (20%) experienced implant extrusions, 8 during the first year, 3 in the second, and none in the third year. Twenty-six patients (47.3%) had additional procedures past 1 year. Only one post-implant surgery caused an extrusion. The success defined as no additional surgery followed by endpoint satisfaction rate was 34.6%. For patients with implants intact it was 41.5% (17/41) at 3 years, significantly better than for those who experienced loss of implants.

The management of vocal fold nodules in children: a national survey of speech-language pathologists

The purpose of this study was to determine the management options and voice therapy techniques currently being used by practicing speech-language pathologists (SLPs) to treat vocal fold nodules (VFNs) in children. The sources used by SLPs to inform and guide their clinical decisions when managing VFNs in children were also explored. Sixty-two SLPs completed a 23-item web-based survey. Data was analysed using frequency counts, content analyses, and supplementary analyses. SLPs reported using a range of management options and voice therapy techniques to treat VFNs in children. Voice therapy was reportedly the most frequently used management option across all respondents, with the majority of SLPs using a combination of indirect and direct voice therapy techniques. When selecting voice therapy techniques, the majority of SLPs reported that they did not use the limited external evidence available to guide their clinical decisions. Additionally, the majority of SLPs reported that they frequently relied on lower levels of evidence or non-evidence-based sources to guide clinical practice both in the presence and absence of higher quality evidence. Further research needs to investigate strategies to remove the barriers that impede SLPs use of external evidence when managing VFNs in children.

Treatment outcomes of sinonasal inverted papillomas according to surgical approaches

CONCLUSIONS

The midfacial degloving approach is a favorable option for advanced sinonasal inverted papilloma with a fair recurrence rate, and can replace the lateral rhinotomy approach, which is considered too invasive for benign tumor due to its facial scar.

OBJECTIVE

This study aimed to assess the treatment outcomes of advanced sinonasal inverted papillomas according to surgical approaches over a 20-year period.

MATERIAL AND METHODS

We retrospectively reviewed clinic, operative, radiologic, and pathologic records of patients with surgically treated sinonasal inverted papilloma, and compared recurrence rates of patients treated with the endoscopic approach, midfacial degloving approach, and lateral rhinotomy approach in each Krouse stage of inverted papilloma.

RESULTS

A total of 114 patients were diagnosed and treated surgically for the sinonasal inverted papilloma. The follow-up period ranged from 10 months to 12 years (mean 2.8 years). The overall recurrence rate was 23.7% (27/114). Among the patients classified as Krouse stage III, 33.3% (9/27) of the endoscopic approach group, 11.1% (2/18) of the midfacial degloving approach group, and 25.0% (2/8) of the lateral rhinotomy approach group had recurrences.

Single dose of preoperative analgesia with gabapentin (600 mg) is safe and effective in monitored anesthesia care for nasal surgery

This study was aimed to compare the intraoperative sedative and perioperative analgesic drug requirements and the incidences of postoperative side effects on the patients who received preoperative gabapentin or placebo. Sixty patients undergoing nasal septal or nasal sinus surgery were included. The patients received either 600 mg gabapentin (Group G) or placebo (Group P) orally, 1 h before surgery. The scores for sedation and pain were recorded at 5, 15, 30, 45 and 60 min, intraoperatively and at 30 min, 1, 2, 4, 6, 9, 12, 16, 20, 24 h, postoperatively. Sedation was achieved with an IV bolus of propofol and continuous infusion of remifentanil. There were significant differences between gabapentin and placebo groups with regard to total consumptions of remifentanil (171.42 + or - 68 vs. 219.17 + or - 95 microg, respectively; P = 0.033) and propofol (59.45 + or - 36.08 vs. 104.14 + or - 54.98 mg, respectively; P = 0.001). Group G patients had significantly lower intraoperative VAS scores at all time points (P < 0.05). The anxiety score of Group G was better at all times (P < 0.05). All postoperative pain scores were lower in the Group G (P < 0.05). Time to first request for analgesic was 12.7 + or - 2.3 h in Group G, and 7.8 2.1 h in Group P (P < 0.0001). Total consumption of lornoxicam was lower in Group G (P < 0.004). We concluded that monitored anesthesia care combined with preoperative analgesia with a low dose of (600 mg) oral gabapentin is an efficient option with tolerable side effects for patients undergoing ear, nose and throat ambulatory surgery.

A betrayal of our handiwork: postoperative hemorrhage and the need for reoperation

Postoperative hemorrhage (PH) that requires reoperation to control bleeding represents a potentially life-threatening and avoidable complication that could have serious implications for recovery. All surgical patients were reviewed who developed PH and required reoperation for control of hemorrhage over a 12-year period, to examine contributing factors possibly related to surgeon misadventure. Of 89,663 operations during this period, there were 1,031 patients (1.2%) who developed PH. Of these, 36 patients required reoperation for control of PH (0.04%), including, general surgery (17), otolaryngologic (9), cardiovascular (9), and gynecologic (1) patients. In 27 general, cardiovascular, and gynecologic patients (29 reoperations), the age ranged from 6 to 91 years. Almost one-half of patients (56%) developing PH were on preoperative anticoagulation. Estimated operative blood loss (EBL) was moderate (EBL = 100-500 mL, 48%). Most patients were normothermic (80%) and normotensive (93%) intraoperatively. The decision to reoperate was not made for at least 8 hours in 55 per cent of patients. At reoperation 10/29 patients were hypotensive. In 20/36 patients (56%) the reoperation note did not identify a single source of bleeding. PH is a distinctly uncommon complication of surgery and often not due to obvious surgeon misadventure. Reoperation for PH is even rarer and embarked upon with reluctance, frequently not yielding a discernible cause for hemorrhage.

Surgical emergencies in pediatric otolaryngology

OBJECTIVE

To obtain baseline data on the most common surgical emergencies in pediatric otolaryngology in Saudi Arabia.

METHODS

This report is a retrospective study of all children presenting to the pediatric otolaryngology emergency service at King Abdulaziz University Hospital in Riyadh, Kingdom of Saudi Arabia. Between January 2001 to January 2006 data were carefully collected and then analyzed for patients requiring emergent surgical intervention by the pediatric otolaryngology service.

RESULTS

A total of 15,850 children presented to our pediatric otolaryngology emergency service. Surgical intervention was indicated in 183 children (1.2%). The larynx/head & neck was the most common site involved. Foreign body related emergencies were the most common presentation requiring surgical interventions (42%). The aero-digestive tract was the most common site for foreign body retrieval (54%).

CONCLUSION

Pediatric patients have always constituted a significant portion of the general otolaryngology service. Most pediatric otolaryngology emergencies are relatively benign. Aero-digestive tract foreign bodies are the most common indication for surgical intervention in ped iatric otolaryngology.

One-day surgery in pediatric otolaryngology--10 years' experience

OBJECTIVE

Based on long-term results, to evaluate the safety and efficacy of 1-day surgery in pediatric otolaryngology.

METHODS

Clinical records in our surgical day care unit during 10 years of its operation were retrospectively evaluated.

RESULTS

From 12,331 children treated on day care unit, for 356 children (2.9%) it was necessary to stay in hospital overnight due to complications.

CONCLUSIONS

Based on our results, 1-day surgery is safe and effective and has several advantages including patients' satisfaction, a short hospital stay and therefore cost reduction and shorter waiting time for elective surgery.

An estimate of the number of mastoidectomy procedures performed annually in the United States

We conducted a study to estimate the number of mastoidectomy procedures performed annually in the United States. Our results are based on state-specific healthcare utilization data and Medicare-funded procedural data from 2002. The utilization data were obtained from the State Ambulatory Surgery Database, which is made available through the Healthcare Cost and Utilization Project. Statistical Package for the Social Sciences (SPSS) statistical software was used to quantify the number of mastoidectomy procedures performed during 2002 in Maryland, New Jersey, New York, and Florida. Information was also obtained from the Federated Ambulatory Surgery Association on the number of Medicare-funded mastoidectomy procedures performed in 2002. State and U.S. population statistics were obtained from the U.S. Census Bureau. These data were extrapolated to obtain a nationwide estimate of the number of mastoidectomies performed annually in the U.S. With 99% confidence, we determined that 0.73 to 0.94 mastoidectomy procedures were performed per 10,000 population in Maryland and 2.55 to 2.74/10,000 in New York. Estimates for both New Jersey and Florida fell in between. Medicare patients underwent between 1.68 and 1.79 procedures per 10,000 population. Based on these data, we estimate that between 30,000 and 60,000 mastoidectomies are performed each year in the U.S., although we suspect that our range may be an underestimation of the actual number because of some limitations inherent in the data collection process. Although mastoidectomy is a common outpatient procedure, to the best of our knowledge, no report on the annual frequency of mastoidectomy procedures in the U.S. has ever been published in the English-language literature. We hope that our report will serve to motivate further research into technological and surgical advancements surrounding this procedure.

Tracheolaryngeal Complications of Inherited Epidermolysis Bullosa: Cumulative Experience of the National Epidermolysis Bullosa Registry

OBJECTIVES/HYPOTHESIS

To accurately determine the frequency with which complications arise in the ears, noses, and throats of patients with inherited epidermolysis bullosa (EB) as well as the cumulative risk of tracheolaryngeal stenosis or stricture.

STUDY DESIGN

Cross-sectional study (3,280 patients) with a nested, randomly sampled longitudinal subcohort (n=450), representing data collection, stratified by major EB subtype, of the National EB Registry, an epidemiologic project focused on enrolling all EB patients within the continental United States from 1986 to 2002, to permit generalization of findings to the entire American EB population.

METHODS

Systematic epidemiologic case finding and data collection were performed throughout the continental United States, followed by subclassification of patients by EB subtype. ENT complications were quantified via contingency tables (as frequencies) and lifetable analyses. Frequencies of surgical procedures were also determined.

RESULTS

The most important clinical ENT complication in inherited EB was tracheolaryngeal stenosis or stricture, arising during early childhood and primarily within infants and children with junctional EB (JEB) (cumulative risk of 39.8% and 12.8% in Herlitz and non-Herlitz JEB, respectively, by ages 6 and 9). Other uncommon complications included chronic otitis media, chronic otitis externa, and hearing loss.

CONCLUSIONS

Given the potential risk for sudden airway occlusion and death, meticulous surveillance by a pediatric otolaryngologist is a critical part of the overall management of infants and children with EB, especially those with JEB and two rare subtypes of generalized EB simplex. Elective tracheostomy should be considered in EB infants and children with evidence of airway embarrassment.

[Case allocation of extensive operations on head and neck within the German DRG system 2004-2007: what is the net result of the continued developments in case allocation?]

BACKGROUND

When the German DRG system was implemented there was some doubt about whether patients with extensive head and neck surgery would be properly accounted for. Significant efforts have therefore been invested in analysis and case allocation of those in this group. The object of this study was to investigate whether the changes within the German DRG system have led to improved case allocation.

METHODS

Cost data received from 25 ENT departments on 518 prospective documented cases of extensive head and neck surgery were compared with data from the German institute dealing with remuneration in hospitals (InEK). Statistical measures used by InEK were used to analyse the quality of the overall system and the homogeneity of the individual case groups.

RESULTS

The reduction of variance of inlier costs improved by about 107.3% from the 2004 version to the 2007 version of the German DRG system. The average coefficient of cost homogeneity rose by about 9.7% in the same period. Case mix index and DRG revenues were redistributed from less extensive to the more complex operations. Hospitals with large numbers of extensive operations and university hospitals will gain most benefit from this development.

CONCLUSION

Appropriate case allocation of extensive operations on the head and neck has been improved by the continued development of the German DRG system culminating in the 2007 version. Further adjustments will be needed in the future.

Chronisch polypöse Rhinosinusitis

BACKGROUND

The prevalence of chronic polypous rhinosinusitis is high at 1-2%. In the present study, the predisposing factors for this condition, the clinical symptomatology, results of surgical interventions, significance of computed tomography diagnosis, as well as histology and post-operative therapy with steroids were investigated.

METHODS AND RESULTS

A 15% stratified sample, made up of 194 post-paranasal sinus surgery patients of 5 surgical years was investigated. Above all, the eosinophil dominated type led to the formation of polyps. In the diagnosis of chronic polypous rhinosinusitis computed tomography is only sufficiently sensitive for the ethmoid bone. The complication rate was, with 4.6%, in the lower range of comparable pre-examinations. In addition, the 18% relapse rate in the patient population, of whom 49% had already been operated on once or several times, corresponds to a good result when compared at an international level.

CONCLUSIONS

These data confirm that surgical experience and a consistent post-surgical treatment can reduce the relapse frequency of chronic polypous rhinosinusitis. This is indicated by the on average late occurrence of a relapse.

Adverse Patient Occurrences in Otorhinolaryngology: Results of a Systematic Registry in a Tertiary Referral Hospital

OBJECTIVE

To identify patient groups at risk for Adverse Patient Occurrences (APOs) to improve the quality of care.

STUDY DESIGN

This study was conducted using retrospective analysis.

METHODS

APOs have been systematically registered from 1997 to 2006 in all patients (6,932) admitted to the otorhinolaryngology-head and neck surgery department of the University Hospital Maastricht, the Netherlands. Several characteristics such as length of stay, age, gender, season, and diagnosis were related to the incidence and type of APOs.

RESULTS

Increasing age and length of stay are related to an increasing incidence of APOs. Children are found to be at high risk too and outpatient treatment (<24 h) is a risk factor for APOs. Of all APOs, 67% were organizational and 33% medical. The three diagnosis-related groups (DRGs), in which APOs occurred most, were the inner ear/cerebellopontine angle (CPA), esophagus, and head and neck oncology group. No seasonal influences on APO occurrences existed.

CONCLUSIONS

Male and female patients >60 or <10 years old are at the highest risk for APOs. Their risk increases with their length of stay and is high when admitted less than 24 hours. When patients are among the three most prevalent DRGs, their risk is even higher.

Variation in day-case nasal surgery - why cannot we improve our day-case rates?

OBJECTIVES

The NHS plan states that 75% of all elective operations should be performed as day-cases. We set out to evaluate day surgery rates in sinonasal surgery and to identify factors limiting current practice.

STUDY DESIGN AND SETTING

Prospective multicentre cohort study.

PARTICIPANTS

3128 patients undergoing sinonasal surgery during 2000 and 2001.

OUTCOME MEASURES

Same day discharge, complication and readmission rates.

RESULTS

There is potential selection bias due to the non-random selection of NHS Trusts and patients in this study. However, as results are similar to Hospital Episode Statistics data such bias is probably small. Only 15.5% of all procedures are performed as day surgery. We are achieving day-case rates of 18, 20 and 6% for nasal polypectomy, intranasal antrostomy and extensive FESS respectively, compared with recently published targets of 90%, 80% and 50%. Factors significantly associated with overnight admission were use of packs, extensive surgery, excess post-operative bleeding and high ASA grade. There was considerable unexplained variation in day-case rates and the use of packs between different surgeons. A third of consultants pack all patients post-operatively. More than 51% of consultants admit all patients, while 5% discharge all patients on the day of surgery. There were no excess adverse events or readmissions amongst the day surgery patients. However, only 17% of in-patients would have liked to be discharged on the day of surgery. Both patient and surgeon must overcome resistance to day case surgery before targets can be reached.

CONCLUSIONS

Strategies for improving day-case rates in sinonasal surgery. All ASA grade 1 and 2 patients could be considered for day-case surgery, but particularly those with less extensive disease on radiography, and those planned to undergo less extensive procedures. Excess peri-operative bleeding was reported in 6% of patients. There must therefore be provision for overnight admission if required. Greater utilisation of day-case units, selective use of packs, and earlier removal may increase the proportion of patients managed as day-cases. There remains considerable variation in practice at both consultant and trust levels. Units should continue to audit their own figures and compare them against national rates in order to reduce nationwide variation in practice.

A national audit of paediatric service provision in otolaryngology in England and Wales

INTRODUCTION

Otolaryngology is the surgical speciality with the highest paediatric workload, accounting for 29% of the total. Children are not miniature adults and require specially trained staff, equipment, facilities and an environment appropriate to their needs. Documents from the Department of Health and the Royal Colleges of Surgeons and Anaesthetists have been published outlining national standards and recommendations for paediatric surgical service provision. We undertook an audit to assess the current state of paediatric services in ENT in England and Wales and how they conform to these guidelines.

METHOD

A database of ENT departments in England and Wales was constructed and a postal questionnaire sent to a named consultant in each unit. The questionnaire encompassed the areas of recommendation outlined in the aforementioned reports. Respondents were also asked to state the kind of hospital in which they worked so a further breakdown of the results could be made.

RESULTS

One hundred and eighty-nine units were included in the audit with a response rate of 56%. Structurally the documents recommend that each unit has a dedicated named paediatric ENT consultant and a designated clinical lead for children's surgery. This is being met in 54.7% and 56.6%, respectively. Omitting the specialist stand alone group the paediatric facilities in theatre were of a lower standard and overall only 30% met the requirements set by the reports. This theme continues when analysing the data of the provision of anaesthetic services with only 50% of the small district general hospitals having the appropriate level of supervision and expertise. One of the worst met targets is that of acute pain service being provided in only 26% of the hospitals that responded. Overall there is a common theme with the specialist stand alone units scoring the highest and the small district general hospitals scoring the lowest.

CONCLUSION

This audit reveals that we are not meeting the guidelines in nearly 50% of the targeted areas. Paediatric care should be "child centred" and if we are not able to provide this specialised care then paediatric surgical services could be forced into centralisation.

Influence of ethnicity on the frequency of nasal surgery

OBJECTIVE

To determine whether surgery for nasal obstruction differs in frequency between ethnic groups.

METHOD

Ethnicity data was collected from all patients attending otolaryngology clinic appointments and compared to census data. Odds ratios with confidence intervals were calculated for attendance at otolaryngology clinics, rhinology clinics, undergoing septoplasty, septorhinoplasty and/ or turbinate surgery for each ethnic group over a 3-year period.

RESULTS

The ethnic groups of the 39493 outpatient attendees closely mirrored demographic data from the 2001 Census. Non-Chinese Asian ethnic groups were more likely to undergo septal surgery than the general (mainly white) population (odds ratio 1.44, 95% CI 1.25 to 1.66, p < 0.00001), whereas Black groups (odds ratio 0.31 [0.23 - 0.41], p < 0.00001) and Chinese (odds ratio 0.28 [0.11 - 0.70], p = 0.00311) were much less likely. Similar results were found for rhinoplasty and turbinate surgery.

CONCLUSIONS

There is strong statistical evidence for large differences in the frequency of surgery for nasal obstruction between ethnic groups. Asian groups were more likely to undergo surgery, whereas Chinese and Blacks were less likely than the general population, which was predominantly white in this study. This may be due to anatomical variations, differences cultural views towards surgery, or inequalities in clinician's attitudes.

Otolaryngologists' responses to errors and adverse events

OBJECTIVES

The objectives of this study were to describe otolaryngologists' emotional reactions to errors and adverse events, their efforts to take responsibility, and their attempts to implement improvements.

STUDY DESIGN AND METHODS

A retrospective, anonymous survey of 2,500 U.S. otolaryngologists who were members of the American Academy of Otolaryngology-Head and Neck Surgery about errors in their practice was conducted. Respondents were asked whether an error had occurred in their practice in the past 6 months and, if so, to describe the error, its consequences, and any corrective actions taken. Two aspects of these reports stood out, which were beyond the scope of the original study: the respondents' emotional responses and their corrective actions.

RESULTS

The response rate was 18.6%. Two hundred ten (45%) respondents reported a total of 212 analyzable error reports and 230 corrective actions. Corrective actions included disclosure to the patient (20 [9%]), ameliorating the consequences of the event to the patient (107 [50%]), personal practice changes (14 [7%]), improvements in the respondent's practice or department (60 [28%]), and hospitalwide or broader corrective actions (19 [9%]). Emotional reactions to errors and adverse events were reported by 22 (10%) otolaryngologists, including regret, embarrassment, guilt, anxiety, loss of temper, and irritation. Legal action was mentioned by five physicians (2%).

CONCLUSIONS

Otolaryngologists took actions not only to treat their patients, but also to improve patient care in their practice, department, hospital, or community. Emotional reactions to errors and adverse events are common and need to be addressed in medical training and practice.

Patients undergoing sinus surgery: constructing a demographic profile

OBJECTIVES

The objective of this study is to construct an accurate and representative demographic profile of patients undergoing sinus surgery for chronic rhinosinusitis (CRS). This will enable future studies to enroll representative samples so that results can be more easily compared across studies and generalized to the U.S. population.

METHODS

The investigators interrogated the databases of the National Survey of Ambulatory Surgery to gather demographic data. Whenever the NSAS provided incomplete characterization, deficiencies were corrected using state-level data provided by the Health care Cost and Utilization Project. The constructed profile was compared with available profiles of patients with CRS and demographic data provided by the U.S. Census Bureau.

RESULTS

The demographic profile of patients undergoing sinus surgery is 52.7% female with a mean age of 38.5 years. A total of 93.5% of surgery is performed on an outpatient basis with 78.8% of patients having private insurance sources. No significant difference in occurrence of surgery was found between months of the year or between regions of the country. The constructed race profile is 85.7% white, 5% black, 1.2% Asian/Pacific Islander, 0.2% Native American, and 7.8% other.

CONCLUSIONS

A novel integration of national and state databases can be used to create a demographic profile of patients undergoing surgery for CRS. The creation of this profile enables further study of representative populations of patients with CRS and enables thoughtful analysis of the existing literature. The difficulty in creating the profile highlights the need for complete and accurate healthcare information collection by national and state agencies.

Nationwide survey on the use of image-guided functional endoscopic sinus surgery

OBJECTIVE

To evaluate impressions and usage of sinus surgery image-guided surgical (IGS) systems by ENT surgeons in the United States.

STUDY DESIGN AND SETTING

A survey was mailed to selected practicing ENT physicians, investigating regional information, practice type, IGS usage patterns, perceived benefits and limitations, and usage of the 61795 surgery code.

RESULTS

Seventy-three percent of respondents use IGS. Nonusers respond that it provides no benefit or is too expensive. Eighty percent of respondents replied that IGS may allow for increased safety in certain procedures. Most users attempt reimbursement with the 61795 code.

CONCLUSION

IGS usage is increasing but appears to be perceived as expensive and nonbeneficial in certain situations. Most respondents, however, felt that IGS may lead to safer surgery in certain situations, including revision and frontal procedures. Several factors appear to limit routine use including ease of use, technical setup, code reimbursement, and initial purchase costs.

SIGNIFICANCE

IGS use appears to be increasing. The most frequent users appear to agree with the previously issued AAO-HNS guidelines regarding appropriate indications. Expanded use may depend on ease of use, reimbursement, and affordability.

EBM RATING

D-5.

Profile of hospitalizations due to otorhinolaryngologic morbidity requiring surgical treatment. Brazil, 2003

Aim

To analyze the profile of the surgical procedures related to otorhinolaryngology in Brazil in the year 2003.

Study Design

This was an observational, descriptive, cross-sectional study.

Methods

We analyzed 80,030 surgical procedures performed in 27 Brazilian States during the period from January to December 2003. The data were obtained from the Hospital Information System of the Ministry of Health. The inclusion factor was a surgical procedure in otorhinolaryngology (ORL). All files were processed with the TABWIN software.

Results

In 2003, 80,030 ORL-related surgical procedures were performed in Brazil. The Southeast region had the largest number of procedures (53.08%), followed by the South and Northeast regions (19.6% and 15.6%, respectively). Regarding the group of procedures, surgeries of the pharynx represented 45% of ORL procedures. Procedures of high complexity were more numerous in the ear surgery group. Regarding the distribution of the type of attending institution, the highest concentration of surgical procedures occurred in philanthropic hospitals, followed by state and university public hospitals. The table adopted by SUS for payment of ORL surgical procedures has not been updated for the procedures currently performed, with the consequent inappropriate notification of some types of surgery.

Conclusion

Knowledge about the profile of surgical hospitalizations related to ORL permits the identification of the peculiarities of the different regions that can help health-managing authorities to make decisions in order to guarantee the principles recommended by SUS regarding access to health services.

Operative workload of a paediatric otolaryngology department over a five-year period

INTRODUCTION

The KK Women's and Children's Hospital (KKWCH) is Singapore's only tertiary institution dedicated wholly to the provision of healthcare for women and children. Since its opening in 1997, the clinical caseloads and the complexity of medical conditions managed by the various departments has increased considerably. This review aims to analyse the operative caseloads in the Department of Otolaryngology over five years from 2000 to 2004.

METHODS

This is a retrospective review of the KKWCH Department of Otolaryngology operative records from year 2000 to 2004. The data on the type of operation and their frequency were collated, and the data are presented in a descriptive format.

RESULTS

There was an increase in the number of operations performed from 656 in year 2000 to 1,148 in 2004, an increase of 75 percent. The increase in the staffing and operating clinical hours (in 2003 and 2004) plus the significant demand for paediatric otolaryngology service probably contributed to this increase. Tonsillectomy, with or without adenoidectomy, continues to be the most common procedure being performed in children, with myringotomy and tympanostomy tube insertion being the second commonest. Together, the ten most common operative procedures constitute 78.2 percent of all paediatric otolaryngological operative workload in the department over a five-year period.

CONCLUSION

The data provided a review of the current pattern of otolaryngological surgical disease in the Singapore paediatric population, which may require operative intervention. Understanding and monitoring of this trend is important, as it allows the proper allocation of appropriate resources for the prevention and treatment of common paediatric surgical otolaryngological conditions.

Audit of the use of antimicrobial prophylaxis in nasal surgery at a specialist Australian hospital

BACKGROUND

In 2002-03 a retrospective audit of the use of surgical antimicrobial prophylaxis (AMP) for elective nasal surgery was undertaken at the Royal Victorian Eye and Ear Hospital (RVEEH). The RVEEH is a publicly funded teaching hospital that provides specialist eye, nose and throat medicine in Victoria, Australia. The aim of the audit was to determine the extent to which the use of antimicrobial prophylaxis in the hospital was consistent with Australian and international evidence-based guidelines and if there was a need for the hospital to develop internal guidelines for the use of AMP.

METHODS

The histories of 500 consecutive patients who had undergone nasal surgery within the study period of August 2001 and July 2002 were examined. The data collected from these histories included information such as the patients' age, gender, diagnosis, surgical procedure performed, antimicrobial agents used, and the length of follow up and a range of factors shown in previous studies to increase the risk of surgical site infection.

RESULTS

A total of 306 (72.86%) patients were found to have received antimicrobial agents either prior to admission, during admission or on discharge. Only 24 patients (5.71%) were administered antimicrobials immediately prior to surgery and at no other time.

CONCLUSIONS

The findings of this study support the need for further research to examine the appropriateness of the use of AMP at the RVEEH and the need for internal guidelines for its use.

Rhino-bronchial syndrome in children: pathogenic correlations and clinical-experimental aspects

OBJECTIVE

This study aims at defining the incidence of rhino-bronchial syndrome (RBS) in children in order both to verify the influence of nasal obstructions on the disease and to determine therapeutic strategies which may cure the syndrome effectively at its early stage.

METHODS

The investigation includes 128 non-allergic children with obstructive disorders (adenoid hypertrophy, septal deviation, etc.) and rhino-sinus inflammations associated with bronchopulmonary diseases (asthma, chronic cough, bronchopulmonary infections). Medical and/or surgical treatment was chosen in consideration of the type and entity of the patients' main nasal pathology. At least 1 year follow-up was provided for each case to establish the improvement in the disorders affecting both the lower and upper airways. The results were statistically assessed.

RESULTS

Medical and mainly surgical treatment always cured the upper airways disorders in patients with chronic nasal obstruction and rhino-sinus inflammation. Improvement of bronchopulmonary disease was reported in about half of the patients (49.4%). Statistically significant results were obtained only in the group with recurrent bronchopulmonary infections (80.9%, p<0.05).

CONCLUSIONS

The study confirms that RBS may be quite frequent in childhood. This disorder has a multifactorial pathogenesis prevalently due to nasal obstruction and rhino-sinus infections. In the population studied, among the lower airways disorders, only infective bronchopulmonary inflammation showed a significant correlation in the assessment between lower and upper airways disorders. In order to prevent the progression of the syndrome to serious pathologic events of the lower airways, a prompt and effective treatment of children's nasal disorders is thus recommended.

[Prolonged healing process after endonasal nasal sinus surgery. Gastroesophageal reflux as a cause?]

BACKGROUND

The healing process after functional endoscopic sinus surgery (FESS) normally takes weeks to months under an intensive therapy regime. Occasionally, symptomatic failures and local problems occur despite extensive follow-up treatment.

PATIENTS AND METHODS

Over a 3-year period 900 patients underwent FESS in our department. Of these patients, 79 were found with no tendency toward improvement of symptoms and signs more than 3 weeks after the operation. Nasal obstruction, frontal headache, and postnasal drainage were evaluated to be the frequent postoperative complaints. Scarring of the middle meatal antrotomy and the ethmoid, inflammatory granulation, and early recurrence of polyps occurred as the local problems. Historical factors and clinical signs of gastroesophageal or laryngopharyngeal reflux were examined in this group. Afterwards, proton pump inhibitors were prescribed on a trial basis.

RESULTS

Historical clues of reflux were reported by 30 patients only. However, clinical signs of a reflux were found in 66 cases. Rhinological symptoms and signs were improved in 60 patients following the application of proton pump inhibitors over 2 weeks.

CONCLUSION

Our results support earlier experiences reported in the literature. Laryngopharyngeal reflux could be a factor altering the healing process after FESS.