Opioid Prescriptions Following Otologic Surgery: A Population-Based Study

OBJECTIVE

To examine postoperative opioid-prescribing patterns following otologic surgery.

STUDY DESIGN

Retrospective population-based descriptive study.

SETTING

All hospitals in the Canadian province of Ontario.

METHODS

Of all patients with advanced ear surgery between July 1, 2012, and March 31, 2019, 7 cohorts were constructed: tympanoplasty with or without ossiculoplasty (n = 7812), atticotomy/limited mastoidectomy (n = 1371), mastoidectomy (n = 3717), semicircular canal occlusion (SCO; n = 179), stapedectomy (n = 2735), bone-implanted hearing aid insertion (n = 280), and cochlear implant (n = 2169). Prescriptions filled for narcotics postoperatively were calculated per morphine milligram equivalent (MME) opioid dose. Multivariable regression was used to determine predictors of higher opioid doses.

RESULTS

The mean ± SD MMEs prescribed were as follows: tympanoplasty with or without ossiculoplasty, 246.77 ± 1380.78; atticotomy/limited mastoidectomy, 283.32 ± 956.10; mastoidectomy, 280.56 ± 1018.50; SCO, 328.61 ± 1090.86; stapedectomy, 164.64 ± 657.18; bone-implanted hearing aid insertion, 326.11 ± 1054.66; and cochlear implant, 200.87 ± 639.93. SCO (odds ratio [OR], 1.69 [95% CI, 1.16-2.48]) and mastoidectomy (OR, 1.50 [95% CI, 1.36-1.66]) were associated with higher opioid doses than tympanoplasty-ossiculoplasty. Asthma (OR, 1.24 [95% CI, 1.12-1.38]), chronic obstructive pulmonary disease (OR, 1.29 [95% CI, 1.12-1.47]), myocardial infarction (OR, 1.33 [95% CI, 1.05-1.68]), diabetes (OR, 1.22 [95% CI, 1.08-1.39]), and substance-related and addictive disorders (OR, 2.59 [95% CI, 1.67-4.00]) were associated with higher opioid doses prescribed. Overall MME prescribed by year demonstrates a sharp drop from 2017-2018 to 2018-2019.

CONCLUSION

This large comprehensive population study provides insight into the prescribing patterns following otologic surgery. The large amounts prescribed and substantial variation require further study to determine barriers that limit good opioid-prescribing stewardship in the postoperative period.

The benefits and risks of non-steroidal anti-inflammatory drugs for postoperative analgesia in sinonasal surgery: a systematic review and meta-analysis

BACKGROUND

Non-steroidal anti-inflammatory drugs (NSAIDs) have emerged as an alternative to opioids for optimal postoperative pain management. However, the adoption of NSAIDs in sinonasal surgery has been impeded by a theoretical concern for postoperative bleeding. Our objective is to systematically review the efficacy and safety of NSAIDs for patients undergoing sinonasal surgery.

METHODS

MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, CINAHL, and the WHO International Clinical Trials Registry Platform were searched from inception to January 27, 2022. Randomized controlled trials (RCTs) and comparative observational studies in any language were considered. Screening, data extraction, and risk of bias assessment were performed in duplicate. Our outcomes were postoperative pain scores, requirement for rescue analgesia, and postoperative adverse events (epistaxis, nausea/vomiting).

RESULTS

Out of 4661 records, 15 RCTs (enrolling 1210 patients) and two observational studies were included. Following endoscopic sinus surgery, there was no difference in pain scores between NSAIDs and non-NSAIDs groups (standardized mean differences [SMD] 0.44 units better, 95% CI -0.18 to 1.05). Following septorhinoplasty, NSAIDs decreased pain scores compared to non-NSAID regimens (SMD 1.14 units better, 95% CI 0.61 to 1.67 units better). Overall, NSAIDs reduced the need for rescue medication with a relative risk (RR) of 0.45 (95% CI 0.24 to 0.84). In addition, NSAIDs decreased the risk of nausea with an RR of 0.62 (95% CI 0.42 to 0.91) and did not increase the risk of epistaxis (RR 0.72, 95% CI 0.23-2.22).

CONCLUSION

Among patients undergoing sinonasal surgery, NSAIDs are beneficial in postoperative pain management and avoidance of postoperative nausea without increasing the risk of postoperative epistaxis.

Cost-effectiveness Analysis of Inferior Turbinate Reduction and Immunotherapy in Allergic Rhinitis

BACKGROUND

Allergic rhinitis (AR) is a common condition that is frequently associated with atopic inferior turbinate hypertrophy (ITH) resulting in nasal obstruction. Current guidelines support the use of subcutaneous allergen immunotherapy (SCIT) when patients fail pharmacologic management. However, there is a lack of consensus regarding the role of inferior turbinate reduction (ITR), a treatment that we hypothesize is cost-effective compared with other available treatments.

METHODS

We conducted a cost-effectiveness analysis comparing the following treatment combinations over a 5-year time horizon for AR patients presenting with atopic nasal obstruction who fail initial pharmacotherapy: (1) continued pharmacotherapy alone, (2) allergy testing and SCIT, (3) allergy testing and SCIT and then ITR for SCIT nonresponders, and (4) ITR and then allergy testing and SCIT for ITR nonresponders. Results were reported as incremental cost-effectiveness ratios (ICERs).

RESULTS

For patients who fail initial pharmacotherapy, prioritizing ITR, either by microdebrider-assisting submucous resection or radiofrequency ablation, before SCIT was the most cost-effective strategy. Probabilistic sensitivity analysis demonstrated that prioritizing ITR before SCIT was the most cost-effective option in 95.4% of scenarios. ITR remained cost-effective even with the addition of concurrent septoplasty.

CONCLUSION

For many AR patients who present with nasal obstruction secondary to atopic inferior turbinate hypertrophy that is persistent despite pharmacotherapy, ITR is a cost-effective treatment that should be considered prior to immunotherapy.

LEVEL OF EVIDENCE

NA - Laryngoscope, 2023 Laryngoscope, 134:1572-1580, 2024.

Hearing Loss and Dementia: A Population-Based Cohort Study

INTRODUCTION

Hearing loss (HL) is considered a potentially modifiable risk factor for dementia. We aimed to examine the relationship between HL and incident dementia diagnosis in a province-wide population-based cohort study with matched controls.

METHODS

Administrative healthcare databases were linked to generate a cohort of patients who were aged ≥40 years at their first claimed hearing amplification devices (HAD) between April 2007 and March 2016 through the Assistive Devices Program (ADP) (257,285 with claims and 1,005,010 controls). The main outcome was incident dementia diagnosis, ascertained using validated algorithms. Dementia incidence was compared between cases and controls using Cox regression. Patient, disease and other risk factors were examined.

RESULTS

Dementia incidence rates (per 1,000 person-years) were 19.51 (95% Confidence Interval [CI] 19.26-19.77) and 14.15 (95% CI 14.04-14.26) for the ADP-claimants and matched controls, respectively. In adjusted analyses, risk of dementia was higher in ADP-claimants compared with controls (Hazard Ratio [HR] 1.10 [95% CI 1.09-1.12, p<0.001]). Subgroup analyses showed a dose-response gradient, with risk of dementia higher amongst patients with bilateral HADs (HR 1.12 [95% CI 1.10-1.14, p<0.001]), and an exposure-response gradient, with increasing risk over time from April 2007-March 2010 (HR 1.03 [95% CI 1.01-1.06, p=0.014]), April 2010-March 2013 (HR 1.12 [95% CI 1.09-1.15, p<0.001]) and April 2013-March 2016 (HR 1.19 [95% CI 1.16-1.23, p<0.001]).

CONCLUSION

In this population-based study, adults with HL had an increased risk of being diagnosed with dementia. Given the implications of HL on dementia risk, understanding the effect of hearing interventions merits further investigation.

Cost-effectiveness analysis of biologics for the treatment of chronic rhinosinusitis with nasal polyps in Canada

BACKGROUND

Dupilumab, omalizumab, and mepolizumab are the three biologics currently approved for use in CRSwNP in Canada. Despite evidence of efficacy, their cost-effectiveness, which is a key factor influencing prescribing patterns, has not yet been compared to each other.

METHODS

A cost-effectiveness model using quality-adjusted life years (QALYs) was constructed using a Decision Tree Markov analysis. A third-party healthcare payer perspective and a 10-year time horizon was used. A willingness-to-pay (WTP) threshold of 50,000 Canadian dollars (CAD) per QALY was used to determine cost-effectiveness. Dupilumab, omalizumab, and mepolizumab were each compared to each other.

RESULTS

Omalizumab was the most cost-effective biologic using current estimates of cost and efficacy in CRSwNP. Using omalizumab as a baseline, dupilumab had an ICER of $235,305/QALY. Mepolizumab was dominated by omalizumab and dupilumab at the current drug prices and estimates of efficacy. Sensitivity analyses determined that when increasing the WTP threshold to $150,000/QALY, dupilumab became cost-effective compared to omalizumab in 22.5% of simulation scenarios. Additionally, altering dosing frequency had a significant effect on cost-effectiveness.

CONCLUSION

When comparing the relative cost-effectiveness of biologics in recalcitrant CRSwNP, omalizumab currently appears to be the most cost-effective option. Future reductions in drug prices, adjustments to currently approved dosing regimens, better patient selection, and improvements in sinus surgery outcomes will challenge the current cost-effectiveness models and necessitate reassessment as treatments for CRSwNP continue to evolve.

Parents' Perceptions of the Factors Influencing the Uptake of Remote Pediatric Hearing Aid Support: Development of a Conceptual Framework

BACKGROUND

To achieve effective integration of virtual care into family-centered audiology practices, participatory research methods, including parents as vital participants in the delivery of pediatric audiology care, should be considered. A better understanding of the barriers and facilitators influencing the adoption of virtual care for families is warranted.

OBJECTIVE

This study aimed to develop a conceptual framework of the factors perceived to influence the adoption of remote pediatric hearing aid support among the parents of children with hearing loss.

METHODS

A total of 12 parents of children who wear hearing aids, between the ages of 0-17 years, were recruited to participate in group or individual interviews as part of the 6-step participatory-based concept mapping (CM) process. Data collection was specific to parents in a Canadian context. Analyses included multidimensional scaling and hierarchical cluster analysis.

RESULTS

The CM process resulted in 6 main themes, displayed in a cluster map according to their order of importance. These themes include access to timely, consistent care; technology considerations; convenience; child engagement; cost; and partnership considerations. Key underlying statements and subthemes are highlighted per theme.

CONCLUSIONS

Findings from this study demonstrate the use of CM in participatory research with parents and as part of a family-centered care model. Future research should aim to investigate the factors that influence the uptake of remote hearing aid support in different contexts, for example, in low- to middle-income countries versus those in high-income countries.

Olfactory Dysfunction in Children: A Scoping Review

OBJECTIVE

Olfactory disorders are well-studied in the adult population, however, there is a paucity of literature characterizing olfactory dysfunction in pediatric patients. The purpose of this scoping review was to identify known causes of olfactory loss in pediatric populations, clarify the extent of use and validity of smell tests, and summarize current therapies for olfactory loss.

DATA SOURCES

PubMed, Ovid MEDLINE, and Web of Science.

REVIEW METHODS

Databases were systematically searched in September 2020. Two independent reviewers conducted the title and abstract screen, followed by review of full-texts for inclusion based on preset inclusion and exclusion criteria. Extracted data included study type, age/age-range of participants, gender, radiological evidence of olfactory dysfunction, types and results of smell tests used, etiology of olfactory loss, and therapies employed for olfactory loss.

RESULTS

A total of 103 articles (n = 1654) were eligible for final data extraction. The University of Pennsylvania Smell Identification Test was used most frequently for smell testing (21% of studies). In total, 45 causes of olfactory dysfunction have been elucidated by this study: 22 congenital and 23 acquired. Few therapies were described, and all were specific to the etiology of olfactory loss.

CONCLUSION

Olfactory dysfunction has a wide range of etiologies in the pediatric population, and clinicians should have a diagnostic algorithm for how to identify a cause should they encounter it in practice. If no etiology can be identified, education around safety should be provided to both the patient and their caregivers.

Trends in otolaryngology publications: a 9-year bibliometric analysis of articles published in Journal of Otolaryngology-Head and Neck Surgery

BACKGROUND

The advancement of Otolaryngology-Head and Neck Surgery (OHNS) as a specialty relies on excellence in research. The Journal of Otolaryngology-Head and Neck Surgery is an open access, peer-reviewed journal publishing on all aspects and subspecialities of OHNS. It is the official journal of the Canadian Society of Otolaryngology-Head and Neck Surgery. This study aims to analyze bibliometric trends in authorships and institutional contributions within the Journal of Otolaryngology-Head and Neck Surgery over a 9-year period.

METHODS

All research articles published online in the journal were analyzed from 2013 to the end of 2021. The professional designation of all authors was recorded along with the article type, article category, institutional affiliations and international collaborations. Cochran-Armitage trend tests were used to assess the change in proportion over time between years and groups.

RESULTS

Of the 603 articles, 20 were excluded as they represented correspondence or corrections, or author identity could not be determined. 583 articles with 3409 total authors were included. Number of first authors with a Doctor of Medicine (MD) degree decreased from 90.2 to 85.3% (P = 0.165). Sub-group analysis of non-MD first authors demonstrated a significant increase in medical students as first authors from 1.6 to 11.8% (P = 0.008). Senior author degree demonstrated a significant increase in MD degree from 96.7 to 98.5% (P = 0.002). Analysis of article categories demonstrated a significant decrease in education and head and neck surgery related articles from 8.2 to 2.9% (P = 0.032) and 44.3 to 29.4% (P = 0.028) respectively. Pediatric otolaryngology articles increased significantly from 0 to 5.9% (P < 0.0001). Systematic and scoping reviews significantly increased, from 3.3 to 10.3% (P = 0.015) and original research significantly decreased from 83.6 to 82.4% (P < 0.0001). There was a significant decrease in Canadian/international collaborations from 14.3 to 4.7% (P = 0.037). There was a significant increase in international first and senior authors, from 23.0 to 36.8% (P = 0.008) and 19.7 to 38.2% (P = 0.002) respectively.

CONCLUSION

The landscape of the journal is evolving with increased representation of non-MDs and international authors along with content that reflects higher level of scientific evidence. Future studies should characterize trends in other Otolaryngology journals to understand the research trajectory within the field.

Mechanics of Total Drum Replacement Tympanoplasty Studied With Wideband Acoustic Immittance

OBJECTIVE

Poor hearing outcomes often persist following total drum replacement tympanoplasty. To understand the mechanics of the reconstructed eardrum, we measured wideband acoustic immittance and compared the mechanical characteristics of fascia-grafted ears with the normal tympanic membrane.

STUDY DESIGN

Prospective comparison study.

SETTING

Tertiary care center.

METHODS

Patients who underwent uncomplicated total drum replacement with temporalis fascia grafts were identified. Ears with healed grafts, an aerated middle ear, and no other conductive abnormalities were included. All patients underwent pre- and postoperative audiometry. Wideband acoustic immittance was measured with absorbance and impedance computed. Fascia-grafted ears were compared with normal unoperated ears.

RESULTS

Eleven fascia-grafted ears without complications were included. Postoperatively, the median air-bone gap was 15 dB (250-4000 Hz), with variation across frequency and between ears. Fifty-six control ears were included. Absorbance of fascia-grafted ears was significantly lower than that of normal ears at 1 to 4 kHz (P < .05) but similar below 1 kHz. Impedance magnitude demonstrated deeper and sharper resonant notches in fascia-grafted ears than normal ears (P < .05), suggesting lower mechanical resistance of the fascia graft.

CONCLUSION

The mechanics of fascia-grafted ears differ from the normal tympanic membrane by having lower absorbance at mid- to high frequencies and thus poor sound transmission. The lower resistance in fascia-grafted ears may be due to poor coupling of the graft to the malleus. To improve sound transmission, grafts for tympanic membrane reconstructions would benefit from refined mechanical properties.

Implantable Hearing Devices in Ontario: A Population-Based Study of Access to Care and Access to Devices

INTRODUCTION

The prevalence of hearing loss in Canada is high, with many patients requiring implantable hearing devices (IHDs) as treatment for their disease severity. Despite this need, many eligible patients do not pursue these interventions. The objective of this study was to examine rates of IHD based on geographic location to understand locoregional variation in access to care.

STUDY DESIGN

This was a retrospective population-based cohort study.

SETTING

All hospitals in the Canadian province of Ontario.

METHODS

Of all patients with IHD between April 1, 1992, and March 31, 2021, cochlear implants (CIs) (4,720) and bone-anchored hearing aids (BAHA) (1,125) cohorts were constructed. Place of residence was categorized based on Local Health Integrated Network (LHIN). Summary statistics for place of surgical institution based on LHIN at first surgery, name of institution of first surgery and "as the crow flies" distance (in km) between place of residence and surgical institution were calculated. Rate of implantations was calculated for LHIN regions based on number of surgeries per 1,000,000 persons/years.

RESULTS

Toronto Central, Central, Central East, and Champlain regions had >10% of patients undergoing BAHA and CI. 1,019 (90.6%) and 4,232 (89.7%) of patients receiving BAHA and CI, respectively, resided in urban/suburban regions and 94 patients (8.4%) and 436 (9.2%) resided in rural regions. The median distance between residential location and the institution was 46.4 km (interquartile range [IQR], 18.9-103.6) and 44.7 km (IQR, 15.7-96.9) for BAHA and CI, respectively. From 1992 to 2021, the number of CI and BAHA performed across Ontario increased by 17 folds and 6 folds, respectively.

CONCLUSION

This large comprehensive population study provides longitudinal insight into the access to care of IHD based on geographic factors. Our findings of the present population-based study indicate an overall increase in access to devices with disproportionate access to care based on geographic locations. Further work is needed to characterize barriers to IHD access to align with demands.