An examination of antibiotic administration in septorhinoplasty: A systematic review and meta-analysis

PURPOSE

Septoplasty and rhinoplasty are common otolaryngological procedures, often combined as septorhinoplasty (SRP), offering aesthetic and functional benefits. These surgeries are believed to potentially risk postoperative infections due to natural bacterial flora in the nares. This study evaluates the effectiveness of prophylactic antibiotics in reducing post-surgical infection complications.

MATERIALS AND METHODS

A systematic review was conducted using PubMed, Cochrane, and Web of Science, adhering to PRISMA guidelines, focusing on antibiotic use in septoplasty, rhinoplasty, and SRP. The study included randomized control trials, single/double-blind studies, retrospective chart reviews, and prospective cohort studies, excluding pediatric, non-human research, or studies with inaccessible data. Postoperative infection rates were analyzed utilizing R software as a form of Statistic.

RESULTS

From 697 articles, 15 studies were chosen for meta-analysis, involving 2225 patients, with 1274 receiving prophylactic antibiotics and 951 as controls. The meta-analysis indicated an odds ratio of 0.65 (95 % CI: [0.23, 1.89]), showing no significant protective effect of prophylactic antibiotics.

DISCUSSION

The study found no significant infection rate reduction with prophylactic antibiotic use. Notable were inconsistencies in study designs, antibiotic administration timing, and varied surgical practices. Antibiotic use risks were considered. Study limitations include potential biases and the retrospective nature of many studies.

CONCLUSIONS

This review and meta-analysis found no substantial evidence supporting prophylactic antibiotics' effectiveness in reducing postoperative infection rates in septoplasty, rhinoplasty, and SRP, indicating a need to reevaluate practices and develop evidence-based guidelines. Future research should focus on comprehensive, randomized control studies, covering both preoperative and postoperative stages.

Letter to the Editor of Journal of Otolaryngology regarding "Risk of diabetes in patients with sleep apnea: comparison of surgery versus CPAP in a long-term follow-up study"

Obstructive sleep apnea (OSA) is associated with multiple chronic comorbidities with treatments including continuous positive airway pressure (CPAP), upper airway surgery (UAS), and hypoglossal nerve stimulation (HNS). Given the complexity of the condition and multiple treatment options, there is an ongoing debate to determine the best management. O'Connor-Reina et al. recently published a paper titled "Risk of diabetes in patients with sleep apnea: comparison of surgery versus CPAP in a long-term follow-up study." In their study, the authors stated that OSA patients who received surgery had a 50% less chance of developing diabetes compared to patients who only received CPAP treatment. However, we would like to point out some limitations that warrant attention and caution interpretation of the findings by physicians and patients.

Benralizumab as an Adjuvant Therapy for Recurrent Laryngeal Papillomatosis

Recurrent respiratory (RRP) or laryngeal papillomatosis is the result of human papillomavirus-mediated benign tumor growth on the larynx and is challenging to manage. Benralizumab is a monoclonal antibody targeted against the alpha subunit of the IL-5 receptor on eosinophils. A 61-year-old male patient presented with refractory RRP following multiple surgical excisions. His disease course improved substantially when benralizumab was added to his asthma regimen. There is no clear mechanistic role suggested for benralizumab directly treating RRP. This case may represent a novel application of benralizumab as an adjuvant treatment for patients with RRP and comorbid asthma. Laryngoscope, 133:863-865, 2023.

The need for systematic quality controls in implementing N95 reprocessing and sterilization

BACKGROUND

Due to increased requirement for personal protective equipment during the coronavirus disease 2019 pandemic, many medical centres utilized sterilization systems approved under Food and Drug Administration Emergency Use Authorization for single-use N95 mask re-use. However, few studies have examined the real-world clinical challenges and the role of ongoing quality control measures in successful implementation.

AIMS

To demonstrate successful implementation of quality control measures in mask reprocessing, and the importance of continued quality assurance.

METHODS

A prospective quality improvement study was conducted at a tertiary care medical centre. In total, 982 3M 1860 masks and Kimberly-Clark Tecnol PFR95 masks worn by healthcare workers underwent sterilization using a vaporized hydrogen peroxide gas plasma-based reprocessing system. Post-processing qualitative fit testing (QFT) was performed on 265 masks. Mannequin testing at the National Institute for Occupational Safety and Health (NIOSH) laboratory was used to evaluate the impact of repeated sterilization on mask filtration efficacy and fit. A locally designed platform evaluated the filtration efficiency of clinically used and reprocessed masks.

FINDINGS

In total, 255 N95 masks underwent QFT. Of these, 240 masks underwent post-processing analysis: 205 were 3M 1860 masks and 35 were PFR95 masks. Twenty-five (12.2%) of the 3M masks and 10 (28.5%) of the PFR95 masks failed post-processing QFT. Characteristics of the failed masks included mask deformation (N=3, all 3M masks), soiled masks (N=3), weakened elastic bands (N=5, three PFR95 masks), and concern about mask shrinkage (N=3, two 3M masks). NIOSH testing demonstrated that while filter efficiency remained >98% after two cycles, mask strap elasticity decreased by 5.6% after reprocessing.

CONCLUSIONS

This study demonstrated successful quality control implementation for N95 mask disinfection, and highlights the importance of real-world clinical testing beyond laboratory conditions.

Human Papillomavirus Integration Strictly Correlates with Global Genome Instability in Head and Neck Cancer

Human papillomavirus (HPV)-positive head and neck cancers, predominantly oropharyngeal squamous cell carcinoma (OPSCC), exhibit epidemiologic, clinical, and molecular characteristics distinct from those OPSCCs lacking HPV. We applied a combination of whole-genome sequencing and optical genome mapping to interrogate the genome structure of HPV-positive OPSCCs. We found that the virus had integrated in the host genome in two thirds of the tumors examined but resided solely extrachromosomally in the other third. Integration of the virus occurred at essentially random sites within the genome. Focal amplification of the virus and the genomic sequences surrounding it often occurred subsequent to integration, with the number of tandem repeats in the chromosome accounting for the increased copy number of the genome sequences flanking the site of integration. In all cases, viral integration correlated with pervasive genome-wide somatic alterations at sites distinct from that of viral integration and comprised multiple insertions, deletions, translocations, inversions, and point mutations. Few or no somatic mutations were present in tumors with only episomal HPV. Our data could be interpreted by positing that episomal HPV is captured in the host genome following an episode of global genome instability during tumor development. Viral integration correlated with higher grade tumors, which may be explained by the associated extensive mutation of the genome and suggests that HPV integration status may inform prognosis.

IMPLICATIONS

Our results indicate that HPV integration in head and neck cancer correlates with extensive pangenomic structural variation, which may have prognostic implications.

In Vivo Transfection of Rat Salivary Glands With Fluorescently Tagged Aquaporin-5 Channel DNA

Background 

The acinar cells of salivary glands are responsible for most saliva production and are, unfortunately, h­­ighly radiosensitive. As such, dry mouth or xerostomia is an adverse effect experienced by half of head and neck cancer patients treated with radiation. We evaluate a novel method of gene transfection of aquaporin channels to rat salivary glands.

Materials and methods

A green fluorescent protein (GFP)-tagged human Aquaporin-5 (AQP5) cDNA sequence cloned into a pCMV6-AC-GFP vector was complexed with lipofectamine 2000. One submandibular gland of the anesthetized rats was injected with the complexed cDNA and lipid solution under ultrasound guidance, while the opposite gland was injected with the vehicle control. The animals were sacrificed between 24 to 48 hours post-injection. The salivary glands were removed and evaluated via fluorescence imaging. Western blot assays were also performed to determine AQP5 cDNA expression.

Results 

In the experiments, the submandibular glands were identified and injected under ultrasound guidance. Four control glands and eight experimental glands were evaluated. The cDNA was expressed successfully and variably within the experimental glands, noting greater intensity along the cell surface consistent with appropriate trafficking of the AQP5 channel. Western blot analysis demonstrated variable expression in the experimental sample with no expression in the control sample. Several glands across the groups showed mild to moderate interstitial edema or inflammation.

Conclusion 

In this study, we demonstrate an alternative in vivo transfection method via lipofection and demonstrate the successful expression of the AQP5 channel in rat salivary gland tissue.

Virtual reality surgical planning for endoscopic endonasal approaches to the craniovertebral junction

PURPOSE

To demonstrate the utility of virtual reality (VR) for preoperative surgical planning of endoscopic endonasal craniovertebral junction (CVJ) surgery.

MATERIALS AND METHODS

Five patients who had undergone endoscopic endonasal surgery of the craniovertebral junction with preoperative virtual reality surgical planning were identified and described.

RESULTS

The anterior approach to the CVJ has been traditionally accomplished transorally. However, recently the transnasal endoscopic approach to this location has been described. Multiple anatomical studies have been conducted using the nasopalatine, nasoaxial, and rhinopalatine lines (NPL, NAxL, RPL) in an attempt to preoperatively delineate the inferior limits of endoscopic dissection. The use of advanced surgical simulation using immersive virtual reality is an innovative approach for analyzing CVJ anatomy and developing a surgical plan. VR simulation through the use of interactive and highly accurate patient specific models allows for the creation of three-dimensional (3D) digital reconstructions via the fusion of CT and MRI studies. Incorporation of simulation technology has been shown to increase surgeon proficiency while simultaneously decreasing complication rates. The described case series demonstrates the novel utility of VR planning for designing the endoscopic surgical approach to the CVJ.

CONCLUSIONS

VR technology allows for the creation of anatomically accurate 3D models that can be used for preoperative planning of endoscopic endonasal surgery. Such models help in the development of safe surgical plans by predicting inferior and lateral planes of dissection and assisting in the identification of critical structures.

The Role of Advanced Endoscopic Resection of Diverse Skull Base Malignancies: Technological Analysis during an 8-Year Single Institutional Experience

Background Resection of skull base malignancies poses complex pathological and treatment-related morbidities. Recent technological advancements of endoscopic endonasal surgery (EES) offer the ability to reexamine traditional treatment paradigms with endoscopic procedures. The utility of EES was quantitatively examined in a longitudinal series with attention to morbidities and postoperative outcomes.

Methods A single-center retrospective review was performed of all malignant sinonasal tumors from 2010 to 2018. Patients with purely EES were selected for analysis. Disease features, resection extent, complications, adjuvant treatment, recurrence, and survivability were assessed. Despite the mixed pathological cohort, analysis was performed to identify technical aspects of resection.

Results A total of 68 patients (47.6% males and 52.4% females, average age: 60.3 years) were included. A diversity of histotypes included clival chordoma (22.1%), olfactory neuroblastoma (14.7%), squamous cell carcinoma (11.8%), and adenoid cystic carcinoma (11.8%). Gross total resection (GTR) was achieved in 83.8% of cases. Infection (4.4%) and cerebrospinal fluid leak (1.5%) were the most common postoperative complications. Total 46 patients (67.6%) underwent adjuvant treatment. The average time between surgery and initiation of adjunctive surgery was 55.7 days.

Conclusion In our 8-year experience, we found that entirely endoscopic resection of mixed pathology of malignant skull base tumors is oncologically feasible and can be accomplished with high GTR rates. There may be a role for EES to reduce operative morbidity and attenuate time in between surgery and adjuvant treatment, which can be augmented through recent mixed reality platforms. Future studies are required to systematically compare the outcomes with those of open surgical approaches.

The Affordable Care Act: Implications for underserved populations with head & neck cancer

PURPOSE

This study was done to determine the direct impact implementation of the Affordable Care Act (ACA) on patients with Head and Neck Cancer (HNCA) in states that chose to expand Medicaid compared to in states that did not, as well as assess whether this impact varied among different demographic groups.

MATERIALS AND METHODS

The Surveillance, Epidemiology, and End Results (SEER) database was queried for cases of HNCA diagnosed from 2011 to 2014. Rates of uninsured status were compared before and after Medicaid expansion and contrasted between states that did and did not expand coverage, stratified by patient and tumor characteristics, and assessed via multivariate regression.

RESULTS

Overall rates of uninsured status (UR) were decreased by 63.08% in states that expanded coverage (ES) but only by 2.6% in states that did not (NS). In NS, there was an increase in proportion of black patients who were uninsured over the study period (13.7%, p = 0.077) whereas in ES, this proportion decreased by 73.3%. When stratified by primary site, patients with laryngeal cancer had the highest UR with an increase by 16.7% in NS and a decrease by 70.5% in ES. Multivariate analysis yielded predictors of uninsured status including residence in a NS, Hispanic ethnicity, and black race.

CONCLUSIONS

Implementation of the ACA resulted in expanded insurance coverage for patients diagnosed with HNCA concentrated mainly in states that expanded Medicaid coverage and for patients derived from vulnerable populations, including black and Hispanic patients. In states that did not expand Medicaid, vulnerable populations were disproportionately affected.

Surgical outcomes in patients with endoscopic versus transcranial approach for skull base malignancies: a 10-year institutional experience

Object: The authors performed an extensive comparison between patients treated with open versus an endoscopic approach for skull base malignancy with emphasis on surgical outcomes.Methods: A single-institution retrospective review of 60 patients who underwent surgery for skull base malignancy between 2009 and 2018 was performed. Disease features, surgical resection, post-operative morbidities, adjuvant treatment, recurrence, and survival rates were compared between 30 patients who received purely open surgery and 30 patients who underwent purely endoscopic resection for a skull base malignancy.Results: Of the 60 patients with skull base malignancy, 30 underwent open resection and 30 underwent endoscopic resection. The most common hisotype for endoscopic resection was squamous cell carcinoma (26.7%), olfactory neuroblastoma (16.7%), and sarcoma (10.0%), and 43.3%, 13.3%, and 10.0% for the open resection cohort, respectively. There were no statistical differences in gross total resection, surgical-associated cranial neuropathy, or ability to achieve negative margins between the groups (p > 0.1, all comparisons). Patients who underwent endoscopic resection had shorter surgeries (320.3 ± 158.5 minutes vs. 495.3 ± 187.6 minutes (p = 0.0003), less intraoperative blood loss (282.2 ± 333.6 ml vs. 696.7 ± 500.2 ml (p < 0.0001), and shorter length of stay (3.5 ± 3.7 days vs. 8.8 ± 6.0 days (p < 0.0001). Additionally, patients treated endoscopically initiated adjuvant radiation treatment more quickly (48.0 ± 20.3 days vs. 72.0 ± 20.5 days (p = 0.01).Conclusions: An endoscopic endonasal approach facilitates a clinically meaningful improvement in surgical outcomes for skull base malignancies.

Intravascular Papillary Endothelial Hyperplasia of the Maxillary Sinus in Patient with Tricuspid Atresia

Intravascular papillary endothelial hyperplasia (IPEH) is a benign, highly vascularized, endothelial growth that can be mischaracterized as a malignancy. While hundreds of IPEH cases are reported, only four occurred in the maxillary sinus. We present the case of a 28-year-old male who underwent surgical resection of IPEH of the right maxillary sinus. An additional consideration was the patient's condition of univentricular tricuspid atresia which contributed to chronic hypoxemia and polycythemia. After complete resection from the maxillary sinus, post-operational workup determined the lesion to be IPEH. Given the potential for misdiagnosis of IPEH, careful histopathologic evaluation is required in order to avoid improper treatment.

Aspirin misuse: a case report

Aspirin-use disorder is an underreported condition. Identification of the signs and symptoms of aspirin misuse are important in light of prevalent non-prescribed medicine/over-the-counter medication (NPM/OTC) misuse. We discuss here the case of a patient with a history of chronic aspirin misuse who presented to the emergency department with salicylate intoxication and described elation secondary to deliberate aspirin consumption. This case highlights the importance of screening for NPM/OTC medication misuse in at-risk populations.