Endotype evaluation of Hispanic/Latinx-American patients with chronic rhinosinusitis with nasal polyps

KEY POINTS

Hispanic-American patients with chronic rhinosinusitis with nasal polyps have a comparable level of tissue eosinophilia compared to their Caucasian counterparts in the United States. Mixed inflammation involving both neutrophils and eosinophils is more common in this population compared to Caucasians. Findings from this study may indicate that Hispanic-American patients have a unique endotype or endotypes that deserves further investigation.

Gender-Specific Differences in Preoperative Concerns in Patients Undergoing Endoscopic Sinus Surgery for Chronic Rhinosinusitis

OBJECTIVES

Among patients with chronic rhinosinusitis (CRS), gender differences in epidemiology as well as quality of life have been reported. However, whether gender differences in endoscopic sinus surgery (ESS) preoperative concerns exist is unclear.

METHODS

CRS patients undergoing ESS at 3 tertiary care centers in Los Angeles completed the validated Western Surgical Concern Inventory - ESS assessing ESS preoperative concerns.

RESULTS

Of the 75 patients included, female patients expressed greater concern than male patients in regard to nasal packing, undergoing anesthesia, impact of surgery on daily activities, and pain and discomfort following surgery.

CONCLUSION

This study suggests there are gender differences in ESS preoperative concerns and otolaryngologists should be aware of these possible concerns during preoperative discussions.

Effect of Hormone Replacement Therapy on Chronic Rhinosinusitis Management

OBJECTIVES

To investigate whether hormone replacement therapy (HRT) impacts health care resource utilization in the management of chronic rhinosinusitis (CRS) in older women.

METHODS

Using the TriNetX US health record database, women 55 years or older with a diagnosis of CRS were included and followed for 3 years. The cohort was stratified into two groups: women who received HRT at the beginning of the study were compared to women who did not receive HRT. The groups were matched by age, race, ethnicity, history of asthma, and history of nasal polyps. Outcomes included whether the patient underwent endoscopic sinus surgery (ESS) and frequency of antibiotic use. Measures of association, Kaplan-Meier analysis, and cohort descriptive statistics were calculated.

RESULTS

Of the 65,400 women included, the mean age was 66.9 years. 27.0% and 3.6% of patients had a history of asthma or nasal polyps, respectively. Overall, 2.0% of CRS patients underwent ESS, with the HRT group less likely to undergo ESS [OR: 0.28; 95% CI: (0.25-0.32)] compared to patients who did not receive HRT. When stratified by polyp status, HRT patients with nasal polyps had a greater decrease in ESS rates compared to control than HRT patients without nasal polyps. The HRT group had a higher mean number of antibiotic prescriptions compared to the non-HRT group.

CONCLUSION

HRT is associated with decreased utilization of ESS to treat CRS, with a greater effect size for ESS among CRSwNP patients. However, HRT was associated with higher antibiotic utilization.

LEVEL OF EVIDENCE

Level 3 Laryngoscope, 2024.

Radiofrequency Neurolysis of the Posterior Nasal Nerve: A Systematic Review and Meta-Analysis

OBJECTIVE

Temperature-controlled radiofrequency neurolysis of the posterior nasal nerve (PNN) has been approved for use since 2020. This review synthesized the published data to assess its efficacy for treatment of chronic rhinitis.

DATA SOURCES

Pubmed/Medline, Embase, Scopus, Web of Science.

REVIEW METHODS

A systematic search was conducted with no restrictions on publication years in April 2023. RCTs and prospective investigations that reported the reflective Total Nasal Symptom Score (rTNSS) outcome of radiofrequency neurolysis as a single procedure in chronic rhinitis patients were included. Pooled estimates for change in rTNSS from baseline at 3 months and responder rates (≥30% reduction in baseline rTNSS) at 3 and 6 months were obtained. Other outcomes, such as postnasal drip and cough scores, quality of life (QoL) measures, and adverse events were included for qualitative review.

RESULTS

Five studies were included in the systematic review, of which four were included in the meta-analysis. A total of 284 participants underwent treatment. The pooled change in rTNSS score at 3 months was -4.28 (95% CI, -5.10 to -3.46). The pooled responder rate at 3 months was 77.11% (95% CI, 68.21%-86.01%) and at 6 months 80.80% (95% CI, 70.85%-90.76%). Postnasal drip and cough scores and QoL also improved significantly at follow up. A total of 36 adverse events were reported in 21 (7.4%) patients.

CONCLUSIONS

The findings from this review suggest that temperature-controlled radiofrequency neurolysis of the PNN is effective at treating chronic rhinitis symptoms and that it has an overall favorable safety profile. Laryngoscope, 134:507-516, 2024.

Evaluation of the quality of thyroidectomy-related posts on a video-based social media platform

Objective

To evaluate the quality of thyroidectomy-related posts on TikTok, the fastest-growing social media platform worldwide.

Methods

Videos posted from April 2020 to September 2022 were queried on TikTok using the search terms "thyroidsurgery," "thyroidectomy," and "thyroidremoval." Two reviewers recorded thematic, demographic, and performance data of these posts. The DISCERN instrument was used to evaluate the quality and reliability of the information contained in the videos. Descriptive statistics were used to characterize post-submitter demographics and video content. Simple and multiple linear regression analyses were used to evaluate the association between DISCERN scores and video characteristics. Univariate analysis of variance was performed to compare DISCERN scores between author types.

Results

In this study, 228 TikTok videos were included which totaled over 23 million views. On average, each video accumulated more than 6000 "likes," 300 comments, and 70 shares. The average total DISCERN score was 27.46, which is deemed to be of poor overall quality. Upon multiple linear regression, video duration (β = 4.66, p < .001) and educational subject type (β = 3.97, p < .001) significantly positively predicted aggregate DISCERN scores, while journey subject type (β = -3.19, p = .006), and reassurance subject type (β = -2.52, p = .035) significantly negatively predicted aggregate DISCERN scores. Aggregate DISCERN scores varied significantly (p < .05) between author types.

Conclusion

Social media posts on TikTok about thyroidectomy are mostly of poor quality and reliability but vary by authorship, subject type, and video characteristics. Given its widespread popularity, TikTok videos may have an increasing role in shaping patient perception of thyroidectomy and may represent an opportunity to provide education.

Lay summary

TikTok posts about thyroidectomy are mostly of poor quality but vary by authorship, subject, and video characteristics. Given its popularity, TikTok videos may have a role in shaping the patient perception of thyroidectomy and may represent an opportunity to provide education.

Level of evidence

Level 4.

Association of ethnicity and time to surgery among patients with chronic rhinosinusitis

Objectives

Determine factors associated with delayed endoscopic sinus surgery (ESS) in patients with chronic rhinosinusitis (CRS).

Methods

This is a retrospective cohort study conducted at a tertiary care academic center. Patients were included in the study if they were at least 18 years old and underwent surgery for CRS. Electronic medical records were retrospectively reviewed to collect demographic and clinical data. Patients with CRS secondary to another pathology such as malignancy were excluded. Multiple linear regression was performed to determine factors associated with the number of days between a patient's preoperative consultation and the date of surgery.

Results

A total of 103 patients with a mean age of 46.6 ± 16.8 years were included in the analysis; 51.5% of patients were females, 46.6% identified as White, and 29.1% identified as Hispanic. The majority of patients (67.0%) had preferred provider organization health insurance; 43.7% of patients had nasal polyps, 70.9% had a deviated nasal septum, and the mean preoperative Sinonasal Outcomes Test-22 (SNOT-22) score was 41.0 ± 23.8. The mean time to surgery after the final preoperative visit was 71.7 days ± 65.6 days. Hispanic ethnicity was associated with increased time to surgery (p < .05) when controlling for other variables. No other variables were associated with time to surgery on multivariate analysis.

Conclusion

Hispanic ethnicity may be an independent predictor of increased time to sinus surgery independent of disease severity and other demographic variables.

Level of Evidence

2b.

Optical Coherence Tomography as a Tool for Imaging the Sinonasal Mucosa in Patients: A Systematic Review

Objectives: To summarize the current applications and potential uses of optical coherence tomography (OCT), a noninvasive imaging modality that uses near-infrared light to produce cross-sectional, high-resolution images of biologic tissues, for evaluating the sinonasal mucosa in patients. Methods: Original articles utilizing OCT to image the sinonasal mucosa in patients were identified from the PubMed, Embase, Cochrane Library, Web of Science, and Scopus databases using the search phrase: "Optical Coherence Tomography" AND (sinonasal OR intranasal OR sinus OR nose OR sinusitis OR rhinitis OR olfactory). Strength of evidence, quality of evidence, and risk of bias were measured using validated scales. Study results were qualitatively assessed. Results: Out of 1662 original records identified through database searching, 9 studies were included in the systematic review. Levels of evidence ranged from III to IV and quality of evidence ranged from moderate to very low. Endoscopic OCT systems as well as OCT systems integrated with surgical microscopes were described in the literature. Applications of OCT for imaging the sinonasal mucosa included identifying morphological patterns unique to individual diseases, detecting mucosal structural changes after medical therapies and procedures, and evaluating mucociliary clearance. Conclusions: Most studies investigating OCT imaging of the sinonasal mucosa featured small sample sizes and lacked control groups. While OCT imaging could be a useful adjunct for diagnosing sinonasal disorders and monitoring response to treatment in the future, additional high-quality studies are necessary to determine if the use of OCT imaging can lead to improved diagnostic accuracy and health outcomes for patients with sinonasal pathologies.

The Differential Experience of COVID-19 on Asian American Subgroups: The Los Angeles Pandemic Surveillance Cohort Study

Data from Asian Americans (AsA) are commonly aggregated in research studies and reporting, obscuring the significant differences across AsA subgroups. We investigated the differential experience of AsA subgroups in COVID-19 testing, vaccination, engagement in risky and protective behaviors and mental health status against this infectious disease. We surveyed a representative sample of the Los Angeles County population (N = 5500) in April 2021 as part of the Los Angeles Pandemic Surveillance Cohort Study and focused on participants who self-identified as AsA (N = 756). There were significant differences across the AsA subgroups, with Koreans, Asian Indians, and Other Asians living in areas with higher COVID-19 mortality rates, and Asian Indians demonstrating the lowest proportion of COVID-19 vaccination. Vietnamese and Koreans had a higher proportion of becoming unemployed during the pandemic. Although the AsA sample on average demonstrated better outcomes than other racial and ethnic groups, the apparent advantages were heterogenous and due to specific subgroups of AsAs rather than AsAs as a whole. The observed differences in COVID-19 measures across AsA subgroups underscore the need to disaggregate AsA data to identify and reduce existing disparities.

Head and Neck Cancer Online Support Groups: Disparities in Participation and Impact on Patients

Objective

To characterize the users of the head and neck cancer (HNC) online support group (OSG) and describe the perceived benefits of membership.

Study Design

Cross-sectional.

Setting

Online.

Methods

An administered survey with questions asking about demographics, cancer history, treatment choices, and feelings about OSGs was posted on the 5 largest HNC OSGs on Facebook.

Results

A total of 97 participants completed the survey. Mean age was 57.8 years old (standard deviation = 10.7 years). Most participants were female (50.5%) and Caucasian (92.8%). This cohort was well educated with 65.5% holding at least a college degree. Annual income was high with 41.8% reporting annual income of $100,000 or greater. The most common treatment modality was radiation (88.7%). The most common surgery was neck dissection (46.4%). Most participants preferred OSGs (70.8%) over other support group types. OSGs were heavily utilized with our cohort reporting using the OSG at least several times a week (80.0%). The top reasons for joining the OSG were sharing one's experience of HNC (76.3%) and gaining support from others with HNC (85.6%). OSGs were ranked as the #3 source of medical information for HNC behind otolaryngologists and oncologists. Membership in a HNC OSG had a minimal impact on decision-making.

Conclusion

HNC OSGs appear to provide a beneficial community for HNC patients. Otolaryngologists should consider incorporating HNC OSG as a possible supplemental resource for their HNC patients.

An Exploratory Analysis of the Chronic Rhinosinusitis Online Support Community

Objective

To characterize the users of the largest chronic rhinosinusitis (CRS) online support communities (OSCs), describe the perceived benefits of OSCs for their users, and understand how patient medical decision making is affected by membership in OSCs.

Study Design

Cross-sectional online survey.

Setting

Online.

Methods

A cross-sectional online survey was adapted from the existing literature on patient support groups and modified for CRS patients. The survey was posted on multiple Facebook/Reddit groups aimed at providing support toward patients with CRS. Survey data was collected over 3 months and analyzed thereafter.

Results

There were 127 total participants. The majority were female (65.35%), white (76.98%), and the median age was 38 years. Just under half of patients had nasal polyps (48.67%) and 54.54% had undergone surgery. Many participants (69.42%) reported engaging in the OSC at least multiple times per month. The most common reason for joining an OSC was to learn tips on how to manage CRS (89.7%) and the most achieved goal from membership was hearing from others undergoing a similar experience (79.5%). Involvement in an OSC impacted knowledge of CRS in 87.41% of participants. Most users (81.1%) would recommend membership in an OSC and 54.33% reported the OSC influenced their medical decision-making.

Conclusion

A majority of patients with CRS who frequently engage in an OSC for CRS have a positive experience. OSCs are a resource that CRS patients utilize to manage their disease.

Opioid-limiting legislation and prescribing habits of otolaryngologists among Medicare beneficiaries

Objectives

To identify changes in otolaryngologists' opioid prescribing trends for Medicare beneficiaries associated with the enactment of state laws that limit the duration of prescriptions to 3-7 days in the years 2016 and 2017 in the United States.

Methods

Through the Centers for Medicare and Medicaid Services (CMS) database, we retrieved data on Medicare enrollment and on the total days prescribed and total number of beneficiaries for the drugs codeine/acetaminophen, hydrocodone/acetaminophen, oxycodone HCl, oxycodone/acetaminophen, and tramadol HCl, by each otolaryngologist prescriber in 13 states from January 2013 to December 2019. We modeled trends using linear spline regression models that controlled for Medicare beneficiaries' state-level socio-demographic characteristics' fixed effects.

Results

Across the 13 states, the number of days of all five opioids prescribed per beneficiary declined by 8.35 (SD = 12.61). The most commonly prescribed opioid type by otolaryngologists during the 5-year study period was tramadol HCl (28.72 days/beneficiary) followed by oxycodone HCl (19.99 days/beneficiary). All opioids had declines in prescription days over this time window and higher rates of decline in the years following law passage. Four states experienced statistically significant declines in the prescriptions of all opioids after the year of legislation passage (p < .05). Some states that had the greatest inclines in opioid prescriptions in the years prior to law enactment also experienced the greatest reductions in the time after legislation enactment.

Conclusions

Opioid prescribing practices of otolaryngologists may have been affected by opioid prescription duration limiting laws passed in 13 states in 2016 and 2017.

Level of Evidence

Level 4.

Anatomic Considerations Guiding Single Versus Multiportal Endoscopic Approaches for Resection of Juvenile Nasopharyngeal Angiofibroma: Cases Series With Graded Multicorridor Resections

BACKGROUND

Juvenile nasopharyngeal angiofibromas (JNAs) are characterized by expansive and destructive growth, often invading the midline/paranasal sinuses, pterygopalatine fossa, and infratemporal fossa and can extend into the orbit, cavernous sinus, or intracranially.

OBJECTIVE

To evaluete the major benefits of the extended endoscopic endonasal approach (EEA) for JNA resection as compared with more traditional and invasive transpalatal and transfacial approaches. When JNAs extend into lateral anatomic compartments, the optimal operative trajectory often requires additional approach strategies or surgical staging.

METHODS

We retrospectively reviewed 8 cases of large JNAs arising in symptomatic adolescent boys (University of Pittsburgh Medical Center Stages II, III, and V) and discuss anatomic and tumor considerations guiding the decision of a pure EEA vs combined EEA and sublabial transmaxillary approach (Caldwell-Luc).

RESULTS

A pure extended EEA was used in 6 JNA cases (UPMC Stages II-III); a multiportal EEA + Caldwell-Luc maxillotomy was used in 2 cases. One of the 2 patients (UPMC Stage V) previously treated with multiportal EEA + Caldwell-Luc maxillotomy underwent staged left temporal/transzygomatic craniotomy, obtaining gross total resection. Seven patients ultimately underwent complete removal without recurrence. One patient with a small residual JNA (UPMC II) underwent stereotactic radiosurgery without progression to date.

CONCLUSION

JNAs with lateral extension into the infratemporal fossa often benefited from additional lateral exposure using a Caldwell-Luc maxillotomy. Cases with significant skull base and/or dural involvement may undergo staged surgical treatment; temporalis + transzygomatic craniotomy is often useful for second-stage approaches for residual tumor in these lateral infratemporal or intracranial regions. SRS should be considered for residual tumor if additional surgery is not warranted.

Impact of Age and Gender on Quality of Life Among General Otolaryngology Patients

OBJECTIVES

The combined effects of age and gender on health-related quality of life (HRQoL) in otolaryngology patients are unclear. This study tested the hypothesis that the effect of age on HRQoL differs by gender in otolaryngology patients.

METHODS

Patients seen in a general otolaryngology clinic were included in this retrospective chart review. HRQoL was measured by the SF-6D score. Patient characteristics, including demographics and category of chief otolaryngology complaint, were extracted from medical records. A multivariable linear regression analysis was used to analyze the combined effect of age and gender on HRQoL. The model was adjusted for race, ethnicity, number of complaint categories, and number of medications.

RESULTS

The study included 728 patients (age mean = 52, SD = 18; 48% male). Multivariable linear regression models found a significant interaction effect between age and gender (β = 0.213, p < 0.05). For younger patients, female gender was protective; however, at age greater than 35 years, female gender was a risk factor for decreased HRQoL. Compared to Black patients, Asian and other race patients reported significantly greater HRQoL (β = 0.207, p < 0.05 for Asian; β = 0.126, p < 0.05 for other races). Additionally, an antagonistic interaction effect was found between age and number of category of otolaryngology complaints in moderating HRQoL (β = 0.468, p < 0.001).

CONCLUSION

Age affects HRQoL differently in men than in women. Among otolaryngology patients, women experience a greater decrease in HRQoL as they age.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:801-806, 2023.

Effects of Language, Age, and Hearing Loss on Health-Related Quality of Life

Objective

To understand the effect of age on health-related quality of life (HRQoL) in patients with hearing loss and determine how primary language mediates this relationship.

Study Design

Cross-sectional study.

Setting

General otolaryngology clinic in Los Angeles.

Methods

Demographics, medical records, and HRQoL data of adult patients presenting with otology symptoms were reviewed. HRQoL was measured using the Short-Form 6-Dimension utility index. All patients underwent audiological testing. A path analysis was performed to generate a moderated path analysis with HRQoL as the primary outcome.

Results

This study included 255 patients (mean age = 54 years; 55% female; 27.8% did not speak English as a primary language). Age had a positive direct association with HRQoL (p < .001). However, the direction of this association was reversed by hearing loss. Older patients exhibited significantly worse hearing (p < .001), which was negatively associated with HRQoL (p < .05). Primary language moderated the relationship between age and hearing loss. Specifically, patients who did not speak English as a primary language had significantly worse hearing (p < .001) and therefore worse HRQoL (p < .01) than patients who spoke English as a primary language with hearing loss. Increasing age was associated with bilateral hearing loss compared to unilateral hearing loss (p < .001) and subsequently lower HRQoL (p < .001). Polypharmacy (p < .01) and female gender (p < .01) were significantly associated with lower HRQoL.

Conclusion

Among otolaryngology patients with otology symptoms, older age and not speaking English as a primary language were associated with worse hearing and subsequently lower HRQoL.

Disparities in the prevalence of self-reported dysphagia and treatment among U.S. adults

OBJECTIVE

To assess sociodemographic differences in the prevalence of self-reported dysphagia and treatment and to identify barriers in access to care.

STUDY DESIGN

Cross-sectional analysis.

SETTING

National healthcare survey database.

METHODS

The 2012 National Health Interview Survey was used to analyze adults who reported a swallowing problem in the prior 12 months. Associations of sociodemographic variables with dysphagia prevalence and treatment as well as access to care were determined by multivariate logistic regression.

RESULTS

Among 235 million adults in the United States, 9.4 ± 0.3 million (4.0 % ± 0.1 %) adults (mean age 52.1 ± 0.6 years; 60.2 % female) reported swallowing problems, only 19.2 % ± 2.0 % of whom reported receiving treatment or therapy for their swallowing problem. In a multivariate model controlling for sociodemographic factors, female gender, older age, lower income level, public insurance status and unemployment were independently associated with increased odds of reporting dysphagia, while also associated with decreased odds of receiving treatment. Conversely, Black, Hispanic and other racial/ethnic minorities were less likely to report swallowing problems, but among those who did report dysphagia, non-white adults were more likely to receive treatment. Barriers leading to delayed care for women, low-income adults and adults with public or no health insurance included cost, not being able to get an appointment soon enough, limited office hours, inability to get through to an office by phone, lack of transportation, and long office wait times.

CONCLUSION

Sociodemographic groups at higher risk for dysphagia are less likely to receive treatment. Targeted interventions are needed to address barriers to care.

LEVEL OF EVIDENCE

IV.

Adverse Events Associated With Image-Guided Sinus Navigation in Endoscopic Sinus Surgery: A MAUDE Database Analysis

OBJECTIVE

The utilization of image-guided navigation during endoscopic sinus surgery (ESS) has increased significantly since its introduction. However, the most common associated complications are still unknown. This study describes and analyzes adverse events related to image-guided ESS.

STUDY DESIGN

Cross-sectional analysis.

SETTING

The Food and Drug Administration's 2018-2022 MAUDE database (Manufacturer and User Facility Device Experience).

METHODS

The MAUDE database was searched for all reports on adverse events involving sinus navigation systems used in ESS from 2018 to 2022. Reported events were reviewed and categorized.

RESULTS

During the study period, there were 1857 adverse events from 1565 reports, which were divided into device-related (n = 1834, 98.8%) and patient-related (n = 23, 1.2%) complications. The most common device-related complications were nonfunctionality of the system (n = 512, 27.9%), device imprecision (n = 427, 23.3%), and device sensing problems (n = 277, 15.1%). The most common patient-related complications were cerebrospinal fluid (CSF) leak (n = 14, 60.9%), intracranial injury (n = 4, 17.4%), and bleeding/hemorrhage (n = 3, 13.1%). Imprecision was associated with increased risk of navigation abortion by the surgeon (odds ratio, 1.50 [95% CI, 1.38-1.65]; P < .001) and increased risk of CSF leak (odds ratio, 16.5 [95% CI, 3.66-74.0]; P < .001) as compared with other device-related complications.

CONCLUSIONS

The most commonly reported device- and patient-related adverse events associated with image-guided sinus navigation systems were device nonfunction, imprecision, device sensing difficulties, and CSF leak. When imprecise navigation occurred, there was an increased likelihood of CSF leak and navigation abortion by the surgeon. Health care providers should be mindful of these possible complications when electing to use image-guided sinus navigation during ESS.

Geographic Variation in Otolaryngologist Intranasal Steroid Prescribing Patterns Among Medicare Beneficiaries

BACKGROUND

Intranasal corticosteroids (INCS) are a commonly prescribed medication to treat various rhinological conditions. However, no prior studies have looked at factors and patterns that influence the rates of INCS prescriptions among Medicare beneficiaries in the United States.

OBJECTIVE

This study aims to describe the patterns of INCS prescriptions by otolaryngologists for Medicare beneficiaries in the United States between 2013 and 2017.

METHODS

Data on the most common INCS prescriptions by otolaryngologists for Medicare beneficiaries were obtained from the 2013 to 2017 Medicare Provider Utilization and Payment Data: Physician and Other Supplier Public Use File (PUF) and the Part D Public Use Files from the Centers for Medicare and Medicaid Services (CMS). INCS prescriptions were analyzed by cost, state, provider, and regional temperature. State temperature data was collected through the National Centers for Environmental Information.

RESULTS

From 2013 to 2017, the total claims per beneficiary for fluticasone, mometasone, and triamcinolone combined increased from 2.31 to 2.39. Combined cost/beneficiary was similar for mometasone and triamcinolone at 102.47 and 103.60 respectively, while it was much lower for fluticasone at 39.12. There was a strong correlation between otolaryngology providers per beneficiary in each state and total claims per state with a correlation coefficient of .79. Additionally, comparing the average state temperature to the claims/beneficiary yielded a moderately strong correlation coefficient of .44, suggesting that temperature was a possible factor for INCS prescription patterns.

CONCLUSIONS

INCS prescriptions by otolaryngologists and the number of INCS beneficiaries have increased between 2013 and 2017. Over the same time period, the costs of fluticasone and triamcinolone have decreased while the cost of mometasone increased. Total providers by state correlated with claims per state. Additionally, average annual temperature was positively correlated with INCS claims per beneficiary in each state.

Racial, Ethnic, and Gender Variations in Sinonasal Anatomy

BACKGROUND

Complications during endoscopic sinus surgery often result from unfavorable anatomy. The prevalence rates of such anatomic findings vary tremendously in the literature, in part due to the small, homogenous populations previously studied.

OBJECTIVE

To characterize the prevalence of sinonasal anatomic variants among ethnic groups and genders seen at an academic medical center.

METHODS

This is a retrospective cross-sectional study of adult subjects who underwent CT imaging of the sinuses from January 2019 to November 2020 at a tertiary academic setting. CT scans were analyzed systematically by 3 trained study personnel for the presence of critical sinus anatomic variants that endoscopic sinus surgeons typically evaluate for preoperatively. Chi-squared tests and analyses of variance were conducted to detect differences in the prevalence of structural findings between genders and races/ethnicities.

RESULTS

A total of 489 subjects (57% female) were included: 44 Asian, 14 Black/African American, 101 Hispanic/Latino, 203 White, 127 Other. The prevalence of the following anatomical variants differed by race/ethnicity: Haller cells, Type 3 optic nerve, Onodi cells, maxillary septations, sphenoid lateral recess, anterior clinoid process pneumatization, and carotid artery dehiscence. Asian subjects had higher rates of Haller cells (48% vs 16%, P < .001) and Type 3 optic nerve (18% vs 4%, P = .022) compared to Hispanic subjects, as well as a higher prevalence of Onodi cells (39% vs 17%, P = .003) compared to White subjects. Males had a higher prevalence of mesenteric anterior ethmoid arteries (62% vs 45%, P < .001) and dehiscent carotid arteries (30% vs 21%, P = .024).

CONCLUSION

Certain sinonasal anatomic variants, which have direct implications for complications during endoscopic sinus surgery, were found to be significantly more prevalent in some demographic groups. Surgeons should be aware of these differences in their review of preoperative imaging for safe surgical planning.

Contralateral Sinonasal Symptoms Following Unilateral Endoscopic Sinus Surgery

OBJECTIVES

To explore the degree to which patients undergoing unilateral endoscopic sinus surgery (ESS) experience post-operative contralateral sinonasal symptoms and determine risk factors for contralateral symptomatology following unilateral ESS.

METHODS

Patients who underwent unilateral surgery for chronic rhinosinusitis (CRS) were contacted and asked if they felt symptomatic on the contralateral side at that point in time. Nasal Obstruction Symptom Evaluation (NOSE) scores were obtained based on contralateral symptomatology they recalled at the following time points: pre-ESS, 1 month post-ESS, and 3 months post-ESS. Demographics, contralateral symptomatology, and NOSE scores were compared between those with 2 or fewer sinusotomies versus 3 or more sinusotomies.

RESULTS

Of the 97 patients included in this study, 24% of patients reported contralateral congestion, a median of 24 months post-ESS, and more than 10% of patients reported other contralateral symptoms including swelling, rhinorrhea, difficulty breathing, and hyposmia post-ESS. Those with 2 or fewer sinusotomies were more likely to feel that they had developed worsened sensation of contralateral sinus swelling (P = .008). The median amount of time from the participants' index surgery until the time they were interviewed was 24 months. There were no differences in long-term contralateral symptomatology between those who did and did not have septoplasty (27%).

CONCLUSION

Patients who have unilateral ESS for CRS may experience long-term contralateral symptoms. Having a septoplasty did not affect contralateral symptoms.

Cannabis Use and Sinonasal Symptoms in US Adults

Importance

Cannabis is the most commonly used illicit substance in the US and worldwide. Understanding the association between cannabis use and sinonasal symptoms may help clinicians and patients better understand the symptomatology associated with cannabis use.

Objective

To assess the association between frequency of cannabis use and presence of sinonasal symptoms in a nationally representative sample of US adults.

Design, Setting, and Participants

This population-based, retrospective cross-sectional study included adults aged 20 to 69 years who had completed data on sinonasal symptoms and substance use for the 2013 to 2014 National Health and Nutrition Examination Survey. The data were analyzed in February 2022.

Exposures

Cannabis use frequency.

Main Outcomes and Measures

Presence of sinonasal symptoms, demographic information, and medical history were obtained from National Health and Nutrition Examination Survey questionnaires. Presence of any sinonasal symptoms was defined as responding yes to any of a series of questions assessing rhinologic symptoms. Regular cannabis users were defined as using cannabis 15 or more times within the last 30 days. Nonregular users were defined as using cannabis fewer than 15 times within the last 30 days. Multivariable models were used to examine the association between frequency of cannabis use and presence of sinonasal symptoms while adjusting for demographic characteristics and medical comorbidities.

Results

The study included 2269 adults with a mean (SD) age of 36.5 (12.4) years (1207 women [53.2%]; 330 Asian [14.5%], 739 Black [32.6%], 461 Hispanic [20.3%], and 656 White [28.9%] individuals). The prevalence of sinonasal symptoms among regular cannabis users (45.0%; 95% Cl, 38.9%-51.1%) was lower than the prevalence among never users (64.5%; 95% Cl, 58.3%-68.8%). Compared with adults who had never used cannabis, regular cannabis users were less likely to have sinonasal symptoms (odds ratio, 0.22, 95% CI, 0.10-0.50). Current tobacco smokers were more likely to have sinonasal symptoms (odds ratio, 1.96; 95% CI, 1.17-3.28). The most common sinonasal symptoms reported were nasal congestion (62.8%; 95% Cl, 60.2%-65.4%) and change in smell (17.8%; 95% Cl, 15.2%-20.9%).

Conclusions and Relevance

This cross-sectional study found that the prevalence of sinonasal symptoms was lower among regular cannabis users. Further research is needed to elucidate the mechanisms underlying the association between cannabis use and sinonasal symptoms.

Association Between Limited English Proficiency and Healthcare Access and Utilization in California

In this study, we aimed to investigate healthcare access and utilization among patients with limited English proficiency (LEP). We analyzed aggregated data from the 2018 California Health Interview Survey, a large population-based survey. Survey weighted univariate and multivariable logistic regression analyses were conducted. A total of 21,177 participants were included with 8.2% having LEP. Compared to participants with proficient English, LEP participants were less likely to have a usual place to go to when sick other than the ER or have a preventive care visit in the past year after adjusting for sociodemographic characteristics. However, LEP participants were also less likely to need to see a medical specialist and less likely to delay necessary medical care compared to English proficient participants. While patients with LEP were less likely to have access to preventative care, they were also less likely to delay necessary care.

Trends in Nasal Spray Prescribing Patterns by Otolaryngologists in the US Medicare Population

OBJECTIVES

To quantify national and state-level prescribing and cost trends for the 3 most prescribed nasal sprays by otolaryngologists in the Medicare population.

METHODS

Through the Centers for Medicare and Medicaid Services (CMS) database and the Kaiser Family Foundation, we retrieved data on Medicare enrollment and on claims and costs of fluticasone propionate, azelastine HCl, and ipratropium bromide prescribed by otolaryngologists from January 1, 2013 to December 31, 2017.

RESULTS

From 2013 to 2017, CMS reimbursed $128.8 million for 5.2 million claims of fluticasone propionate, azelastine HCl, and ipratropium bromide prescribed by otolaryngologists. The national claim rate for fluticasone propionate increased 6.5% per year from 2013 to 2015 and then decreased 4.3% per year from 2015 to 2017 while azelastine HCl and ipratropium bromide consistently increased annually (19.0% and 12.2% respectively) from 2013 to 2017. The cost for fluticasone propionate decreased 33.0% a year from 2013 to 2015 and then increased 5.4% annually to $13.60 per claim in 2017. Azelastine HCl decreased 14.8% annually from $91.30 to $50.23 per claim and ipratropium bromide increased 5.2% annually to $34.78 in 2017. Variations in the claim rate and cost for all 3 nasal sprays were observed in some states.

CONCLUSIONS

Otolaryngologists are prescribing azelastine HCl and ipratropium at an increasingly higher rate in the Medicare population, while the rate for fluticasone propionate has been decreasing nationally. Utilization and costs of nasal sprays also vary geographically across the United States.

Radiographic disease severity in chronic rhinosinusitis patients and health care utilization

OBJECTIVES

Chronic rhinosinusitis (CRS) affects approximately 12% of the population and leads to increased health care utilization and indirect costs exceeding $20 billion annually in the United States. The Lund-Mackay score (LMS) measures radiographic disease severity for CRS but poorly correlates with symptom scores. The association between LMS and health care utilization in CRS patients has not yet been investigated. The study aimed to assess the association between health care utilization and CRS radiographic severity using LMS.

METHODS

CRS patients enrolled in a clinical registry were evaluated. Nasal endoscopy findings and LMS were recorded for patients with sinus CT imaging. Patient symptom scores, demographic characteristics, and health care utilization measures were collected. The relationship between these factors and LMS was examined.

RESULTS

A total of 556 patients met inclusion criteria. Mean age was 45.3 years, 53.4% were male, and 41.7% had nasal polyps. There was no difference in sex, smoking history, 22-item Sino-nasal Outcome Test scores, or past medical history factors between patients with high (≥8, n = 410) and low (<8, n = 146) LMS. Among high LMS patients, 73.7% underwent endoscopic sinus surgery (ESS) compared to 55.5% with low LMS (P < .01), and a greater percentage of patients had nasal polyps (49.3% vs 20.5%, P < .01). On multivariable logistic regression, high LMS patients used fewer antibiotic courses (OR: 0.68 [0.51-0.91]), but were more likely to be managed with ESS (OR: 2.28 [1.41-3.73]), and have nasal polyps (OR: 2.11 [1.16-3.93]) compared to low LMS patients. There was no significant difference in the number of steroid courses, over the counter pill use, provider visits, work/school days missed, or symptom duration between the two LMS groups.

CONCLUSION

CRS patients with severe radiographic disease are more likely to have nasal polyps, undergo ESS, and take fewer antibiotic courses. However, there is no association between radiographic disease severity and other measures of health care utilization.

LEVEL OF EVIDENCE

2b, individual retrospective cohort study.

Aerosol Generation During Laryngology Procedures in the Operating Room

OBJECTIVE

Severe acute respiratory syndrome coronavirus-2 spreads through respiratory fluids. We aim to quantify aerosolized particles during laryngology procedures to understand their potential for transmission of infectious aerosol-based diseases.

STUDY DESIGN

Prospective quantification of aerosol generation.

METHODS

Airborne particles (0.3-25 μm in diameter) were measured during live-patient laryngology surgeries using an optical particle counter positioned 60 cm from the oral cavity to the surgeon's left. Measurements taken during the procedures were compared to baseline concentrations recorded immediately before each procedure. Procedures included direct laryngoscopy with general endotracheal anesthesia (GETA), direct laryngoscopy with jet ventilation, and carbon dioxide (CO₂ ) laser use with or without jet ventilation, all utilizing intermittent suction.

RESULTS

Greater than 99% of measured particles were 0.3 to 1.0 μm in diameter. Compared to baseline, direct laryngoscopy was associated with a significant 6.71% increase in cumulative particles, primarily 0.3 to 1.0 μm particles (P < .0001). 1.0 to 25 μm particles significantly decreased (P < .001). Jet ventilation was not associated with a significant change in cumulative particles; when analyzing differential particle sizes, only 10 to 25 μm particles exhibited a significant increase compared to baseline (+42.40%, P = .002). Significant increases in cumulative particles were recorded during CO₂ laser use (+14.70%, P < .0001), specifically in 0.3 to 2.5 μm particles. Overall, there was no difference when comparing CO₂ laser use during jet ventilation versus GETA.

CONCLUSIONS

CO₂ laser use during laryngology surgery is associated with significant increases in airborne particles. Although direct laryngoscopy with GETA is associated with slight increases in particles, jet ventilation overall does not increase particle aerosolization.

LEVEL OF EVIDENCE

III Laryngoscope, 2021.

Association Between Olfactory Dysfunction and Mortality in US Adults

Importance

A study of olfactory dysfunction and mortality in a large national cohort will aid in better understanding their association when accounting for multiple relevant factors and possible underlying mechanisms.

Objective

To investigate the association of olfactory dysfunction with all-cause 5-year mortality in US adults.

Design, Setting, and Participants

This cohort study included participants 40 years or older from the 2013-2014 National Health and Nutritional Examination Survey who had data on olfaction and mortality (n = 3503). Olfaction was assessed by self-report and objective test (8-odor Pocket Smell Test). Mortality was determined by linking with the National Death Index through February 24, 2019. Data were analyzed from July 1 to September 30, 2019.

Main Outcomes and Measures

Olfaction and 5-year mortality. Cox proportional regression models were used to examine the associations between olfaction and mortality while adjusting for demographics and medical comorbidities. Multivariate models were further adjusted for depression and cognitive assessments.

Results

Among the 3503 participants (1831 women [52.3%]; mean [SD] age, 59.0 [12.0] years), the prevalence of olfactory dysfunction was 13.5% (95% CI, 11.0%-16.0%) based on results of an objective smell test and 21.6% (95% CI, 18.9%-24.2%) based on self-report. Risk of mortality increased by 18% (95% CI, 7%-29%) per 1-point decrease in smell test score in a multivariate model. The association was significant among adults 65 years or older in association with binary (hazard ratio [HR], 1.95; 95% CI, 1.19-3.21) and linear (HR, 1.19; 95% CI, 1.08-1.31) measures of objective olfactory dysfunction, but not among adults aged 40 to 64 years. There was no association between self-reported olfactory dysfunction and mortality. The association between objective olfactory dysfunction and mortality remained after further adjusting for cognitive assessment battery and depression among older adults (HR, 1.18; 95% CI, 1.01-1.37).

Conclusions and Relevance

These findings suggest that objective olfactory dysfunction is associated with increased mortality among older adults. In addition to its effect on quality of life, the association of olfactory dysfunction with mortality has implications for physical and cognitive health.

COX-2 Overexpression in Schneiderian Papillomas

Background

Schneiderian papillomas (SP) are aggressive sinonasal tumors that occasionally extend into areas that are surgically unresectable.

Objective

evaluate the signifcance of cyclo-oxygenase-2 (COX-2) expression in SP.

Methods

Immunohistochemistry for COX-2 was performed on SP samples and middle turbinates from chronic rhinosinusitis without nasal polyps controls obtained during surgical resection between 2009–2017. A positive stain was defined as having 10% or more cells exhibiting diffuse immunoreactivity. Comparisons were performed using Fisher Exact tests, t-tests, and ANOVA.

Results

The study included 67 tumor samples and 9 controls from two academic institutions. The mean age of the SP group was 55.4 years and 53.2 years in the control group (p = 0.71). Thirty-nine (58.2%) SP patients had previous surgery compared to 1 (11.1%) in the control group (p = 0.01). The most common tumor attachment sites were the maxillary (47.8%) and ethmoid (25.4%) sinuses. Fifteen (22.4%) SP samples stained strongly positive for COX-2 and 24 (35.8%) stained weakly positive compared to no positive stains in the control group (p < 0.01). When stratified by COX-2 intensity, there were no statistically significant differences in gender, smoking history, history of previous sinus surgery, site of attachment, papilloma subtype, or future recurrence between SP samples.

Conclusion

COX-2 was overexpressed in 58.2% of SP cases, and strongly positive in 22.4% of cases, compared to no positive staining among controls. No significant differences in COX-2 expression were observed between SP subtypes or recurrent tumors. Further studies are warranted to evaluate COX-2 as a possible therapeutic target in tumors that overexpress the enzyme.

Developing a predictive model for distinguishing invasive nail unit melanoma from nail unit melanoma in situ

BACKGROUND

Clinical information that distinguishes invasive nail unit melanoma from nail unit melanoma in situ before surgery would aid physicians in the decision-making process and estimating prognosis. However, limited information is available on the detailed demographic and dermoscopic features of invasive nail unit melanoma and nail unit melanoma in situ for differential diagnosis.

OBJECTIVE

This study aimed to investigate the demographic data and dermoscopic features of invasive nail unit melanoma and nail unit melanoma in situ and establish a predictive model for differentiating these two forms of nail unit melanoma.

METHODS

A retrospective observational study of ninety-seven patients diagnosed with nail unit melanoma (59 in situ and 38 invasive cases) in four healthcare centres in South Korea (three tertiary referral hospitals and one second referral hospital) from March 2014 to December 2019.

RESULTS

A multivariable analysis revealed that ulcer (odds ratio = 21.6, confidence interval = 2.1-219.8, P = 0.009), total melanonychia (odds ratio = 17.6, confidence interval = 3.0-104.0, P = 0.002), nail plate destruction (odds ratio = 10.9, confidence interval = 2.0-59.4, P = 0.006) and polychromia (odds ratio = 5.3, confidence interval = 1.36-20.57, P = 0.016) were distinctive dermoscopic features of invasive nail unit melanoma. A predictive model with scores ranging from 0 to 6 points demonstrated a reliable diagnostic value (C-statistic = 0.902) in differentiating invasive nail unit melanoma from nail unit melanoma in situ.

CONCLUSIONS

Invasive nail unit melanoma and nail unit melanoma in situ have different dermoscopic features. A predictive model based on morphologic dermoscopic features could aid in differentiating invasive nail unit melanoma from nail unit melanoma in situ.

Enhanced Recovery After Surgery-Based Perioperative Protocol for Head and Neck Free Flap Reconstruction

Objectives

Evaluate an enhanced recovery after surgery (ERAS)–based free flap management protocol implemented at our center.

Study Design

Prospective cohort study of patients after implementation of an ERAS-based perioperative care protocol for patients undergoing free flap reconstruction of the head and neck as compared with a historical control group.

Setting

Tertiary care academic medical center.

Participants and Methods

All patients undergoing free flap reconstruction were prospectively enrolled in the ERAS protocol group. A retrospective control group was identified by randomly selecting an equivalent number of patients from a records search of those undergoing free flap surgery between 2009 and 2015. Blood transfusion, complications, 30-day readmission rates, intensive care unit (ICU) and hospital length of stay, and costs of hospitalization were compared.

Results

Sixty-one patients were included in each group. Patients in the ERAS group underwent less frequent flap monitoring by physicians and had lower rates of intraoperative (70.5% vs 86.8%, P = .04) and postoperative (49.2% vs 27.2%, P = .026) blood transfusion, were more likely to be off vasopressors (98.3% vs 50.8%, P < .01) and ventilator support (63.9% vs 9.8%, P < .01) at the conclusion of surgery, and had shorter ICU stays (2.11 vs 3.39 days, P = .017). Length of stay, readmissions, and complication rates did not significantly differ between groups.

Conclusion

ERAS-based perioperative practices for head and neck free flap reconstruction can reduce time on the ventilator and in the ICU and the need for vasopressors, blood transfusions, and labor-intensive flap monitoring, without adverse effects on outcomes.

THU0078 EXPRESSION PROFILE ANALYSIS OF LONG NONCODING RNAS INDUCED BY IL-1ß IN RHEUMATOID ARTHRITIS FIBROBLAST-LIKE SYNOVIOCYTES

Background:

Long noncoding RNAs (lncRNAs) have recently emerged as important biological regulators and the aberrant expression of lncRNAs has been reported in various diseases including cancer, cardiovascular disease, and diabetes mellitus. However, the role of lncRNAs in the pathogenesis of rheumatoid arthritis (RA) remains unknown.

Objectives:

Thus, we studied lncRNAs influenced by IL-1, which is one of the key mediators in the pathogenesis of RA, and also investigated whether regulation of NF-κB activation, which is known to be induced by IL-1, could lead to the changes of expression of those lncRNAs.

Methods:

Fibroblast-like synoviocytes (FLS) were obtained from the knee joints of the patients with RA. The next-generation sequencing (NGS) data were analyzed to identify differentially expressed lncRNAs between unstimulated RA FLS and IL-1-stimulated RA FLS. The expression levels of the top 5 candidates in NGS data were validated by RT-qPCR using extended number of unstimulated RA FLS and IL-1-stimulated RA FLS. IMD-0560, an inhibitor of IκB kinase (IKK) was used for the regulation of NF-κB activation. Activation and inhibition of NF-κB were confirmed by Western blotting. Changed expressions of the lncRNAs were identified by RT-qPCR.

Results:

NGS analysis revealed up-regulated 30 lncRNAs and down-regulated 15 lncRNAs in IL-1-treated RA FLS compared with unstimulated RA FLS. Top 5 lncRNAs were selected among 30 lncRNAs up-regulated by IL-1 in RA FLS based on fold-change with P-value cutoff. The up-regulated lncRNAs including NR_046035, NR_027783, NR_033422, NR_003133, and NR_049759 were validated by RT-qPCR. IMD-0560 inhibited phosphorylation of IκBα induced by IL-1 in RA FLS. Overexpression of lncRNAs induced by IL-1 was also inhibited by IMD-0560 in RA FLS.

Conclusion:

Our study revealed that IL-1 increased the expression of NR_046035, NR_027783, NR_033422, NR_003133, and NR_049759 in RA FLS. In addition, the expression of these lncRNAs was regulated by inhibition of NF-κB activation. Thus, our data suggest that the lncRNAs might be involved in the pathogenesis of RA through NF-κB signaling pathway.

References:

[1]Long noncoding RNAs and human disease. Trends Cell Biol. 2011 Jun;21(6):354-61.

[2]A long noncoding RNA mediates both activation and repression of immune response genes. Science. 2013 Aug 16;341(6147):789-92.

[3]Long noncoding RNA expression profile in fibroblast-like synoviocytes from patients with rheumatoid arthritis. Arthritis Res Ther. 2016 Oct 6;18(1):227.

Disclosure of Interests:

None declared

Factors Associated With Intubation and Prolonged Intubation in Hospitalized Patients With COVID-19

Objective

To identify risk factors associated with intubation and time to extubation in hospitalized patients with coronavirus disease 2019 (COVID-19).

Study Design

Retrospective observational study.

Setting

Ten hospitals in the Chicago metropolitan area.

Subjects and Methods

Patients with laboratory-confirmed COVID-19 admitted between March 1 and April 8, 2020, were included. We evaluated sociodemographic and clinical characteristics associated with intubation and prolonged intubation for acute respiratory failure secondary to COVID-19 infection.

Results

Of the 486 hospitalized patients included in the study, the median age was 59 years (interquartile range, 47-69); 271 (55.8%) were male; and the median body mass index was 30.6 (interquartile range, 26.5-35.6). During the hospitalization, 138 (28.4%) patients were intubated; 78 (56.5%) were eventually extubated; 21 (15.2%) died; and 39 (28.3%) remained intubated at a mean ± SD follow-up of 19.6 ± 6.7 days. Intubated patients had a significantly higher median age (65 vs 57 years, P < .001) and rate of diabetes (56 [40.6%] vs 104 [29.9%], P = .031) as compared with nonintubated patients. Multivariable logistic regression analysis identified age, sex, respiratory rate, oxygen saturation, history of diabetes, and shortness of breath as factors predictive of intubation. Age and body mass index were the only factors independently associated with time to extubation.

Conclusion

In addition to clinical signs of respiratory distress, patients with COVID-19 who are older, male, or diabetic are at higher risk of requiring intubation. Among intubated patients, older and more obese patients are at higher risk for prolonged intubation. Otolaryngologists consulted for airway management should consider these factors in their decision making.

Geographic Variation in Epistaxis Interventions Among Medicare Beneficiaries

OBJECTIVES

To quantify the utilization of epistaxis procedures in the elderly population and assess whether the geographic variability of these procedures is associated with hypertension and direct oral anticoagulant (DOAC) use.

METHODS

A cross-sectional study was performed on publicly available Medicare procedure and beneficiary data from 2013 to 2016 for all epistaxis procedures categorized by Common Procedural Terminology (CPT). Epistaxis procedures were analyzed by state, complexity, and provider type. Pearson's correlation coefficient was calculated.

RESULTS

Over 4 years, 2 19 827 epistaxis procedures were performed on Medicare patients, 44.3% of which were categorized as simple (control of nasal hemorrhage: anterior simple or posterior primary). Otolaryngologists performed 92.6% of all epistaxis procedures. The frequency of epistaxis procedures performed by state ranged from 0.99 procedures per 10 000 Medicare beneficiaries (PP10K) in Hawaii to 25.7 PP10K in New Jersey. The percentage of epistaxis interventions categorized as complex (anterior complex, posterior subsequent, with nasal endoscopy, or open procedures) in each state varied from 0% in North Dakota to 72.6% in Hawaii. Epistaxis procedure utilization was weakly correlated with the prevalence of hypertension (R² = 0.08, P = .04) and higher percentage of DOAC among all anticoagulants prescribed (R² = 0.08, P = .04) in a state's Medicare population. Utilization of complex epistaxis interventions was not correlated with the prevalence of hypertension or DOAC use.

CONCLUSIONS

Otolaryngologists perform the vast majority of epistaxis procedures in the Medicare population. However, practice patterns vary across the United States. Hypertension and DOAC use are weakly associated with the utilization of epistaxis interventions.

Geographic Heterogeneity in Otolaryngology Medicare New Patient Visits

Objective

To analyze the spatial variation of sociodemographic factors associated with the geographic distribution of new patient visits to otolaryngologists.

Study Design

Retrospective cross-sectional analysis.

Setting

United States.

Subject and Methods

Medicare new patient visits pooled from 2012 to 2016 to otolaryngology providers were obtained from the Centers for Medicare and Medicaid Services, and county-level sociodemographic data were obtained from the 2012-2016 American Community Survey. The mean number of new patient visits per otolaryngology provider by county was calculated. The spatial variation was analyzed with negative binomial and geographically weighted regression. Predictors included various neighborhood characteristics.

Results

There were 7,199,129 Medicare new patient visits to otolaryngology providers from 2012 to 2016. A 41.7-fold difference in new patient evaluation rates was observed across US counties (range, 11-458.8 per otolaryngology provider). On multivariable regression analysis, median age, sex, work commute time, percentage insured, and the advantage index of a county were predictors for the rate of new patient visits to otolaryngology providers. However, geographically weighted regression demonstrated that the association of a county’s disadvantage index, advantage index, percentage insured, and work commute times with new patient visits per provider varied across space.

Conclusions

There are wide geographic differences in the number of new Medicare patients seen by otolaryngologists, and the influence of county sociodemographic factors varied regionally. Further research to analyze the variations in practice patterns of otolaryngologists is warranted to predict future public health needs.

Characterization of Chronic Sinonasal Disease Symptoms in an Urban Homeless Population

BACKGROUND

The urban homeless population has increased exposure to risk factors associated with chronic rhinosinusitis (CRS). However, a gap in knowledge of the prevalence of sinonasal symptoms in these demographic limits complete understanding of CRS epidemiology. There is a need to elucidate sinonasal disease burden in this vulnerable patient population to bring awareness to any existing disparities.

OBJECTIVE

To assess the prevalence, severity, and associated factors of CRS clinical symptoms and health-care barriers in an urban homeless population.

METHODS

Homeless adults completed a sociodemographic questionnaire and the 22-item Sinonasal Outcome Test (SNOT-22) and EuroQol-5 Dimension-3 Level-Visual Analog Scale surveys. Responses were categorized by potential CRS symptoms defined as reporting at least 2 CRS cardinal symptoms. Risk factors associated with potential CRS symptoms were analyzed with multivariate regression models.

RESULTS

Fifty-six (16%) out of 341 total subjects reported potential CRS symptoms. Those with potential CRS symptoms had a higher median SNOT-22 score (53 vs 22, P < .001) than those without. Logistic regression models identified history of smoking (odds ratio [OR], 6.54; 95% confidence interval [CI], 2.04-21.04) and duration of homelessness over 3 months (OR, 3.46; CI, 1.51-7.94) as factors associated with potential CRS symptoms. Duration of homelessness over 3 months was associated with higher SNOT-22 scores (standardized beta coefficient [β], 0.48; CI, 0.39-0.57). Among those reporting 2 or more CRS cardinal symptoms, 18% had ever been seen by any physician for their symptoms.

CONCLUSIONS

Our study estimates a high prevalence of potential CRS symptoms in the urban homeless population. Longer duration of homelessness was associated with potential CRS symptoms and poor CRS-specific quality of life scores. Disparities in access to care emphasize the need for increased preventive efforts designed for this unique patient group.

Assessment of Trends in Utilization of Nasal Endoscopy in the Medicare Population, 2000-2016

Importance

Nasal endoscopy is the most highly reimbursed routine clinical procedure in otolaryngology by Medicare. To our knowledge, the economic and demographic characteristics of nasal endoscopy have not been characterized at a population level.

Objective

To quantify trends in use of nasal endoscopy among Medicare recipients at a national and state level.

Design, Setting, and Participants

Cross-sectional study of procedure and beneficiary data from January 1, 2000, to December 31, 2016, and available health care provider data from 2015 obtained from the Centers for Medicare & Medicaid Services for all diagnostic nasal endoscopies categorized as Current Procedural Terminology code 31231.

Exposures

Diagnostic nasal endoscopy.

Main Outcomes and Measures

Nasal endoscopies were analyzed by state, medical or surgical specialty, mean reimbursement, health care provider density, and type of health care practitioner performing the procedure.

Results

The Centers for Medicare & Medicaid Services reimbursed $86.3 million for 559 547 nasal endoscopies in 2016. The total number of nasal endoscopies increased 313%, from 135 494 in 2000 to 559 547 in 2016 (9.3% average annual rate of increase). The mean reimbursement rate per nasal endoscopy varied by state, from $114.25 in Puerto Rico to $189.53 in New York. The percentage of Medicare beneficiaries receiving nasal endoscopy per state ranged from 0.1% in Alaska to 1.7% in New York. Almost all nasal endoscopies were performed by physicians (97.3%), with otolaryngologists (97.2%) being the most common specialty. Reimbursement rates (r = 0.60) and density of health care providers (r = -0.56) were correlated with higher utilization in a state's Medicare population.

Conclusions and Relevance

Utilization of nasal endoscopy by otolaryngologists in the Medicare population appears to have increased substantially over the past 2 decades. Practice patterns and reimbursement appeared to vary across the United States.

Endoscopic Endonasal Repair of Spontaneous Cerebrospinal Fluid Leaks Using Multilayer Composite Graft and Vascularized Pedicled Nasoseptal Flap Technique

Background

Endoscopic repair of cerebrospinal fluid (CSF) fistulas is a fundamental practice in anterior skull base surgery due to high success rates and low morbidity profile. However, spontaneous CSF (sCSF) leaks have the highest recurrence rate compared to other etiologies. The most effective management is undetermined due to variations in graft materials and limited evidence.

Objective

We present the largest study of a standardized endoscopic repair technique for sCSF leaks.

Methods

Single-institution retrospective review of patients who underwent endoscopic sCSF leak repair between October 2011 and January 2018. All patients underwent repair using a temporary lumbar drain, intrathecal fluorescein, and multilayer reconstruction using bilayered fascia lata autograft and vascularized nasoseptal flap.

Results

Twenty patients (100% female, mean age: 53.2 years) with 25 separate sCSF leak sites were included. Obesity was present in 15 of 20 patients (mean body mass index [BMI] = 35.3). No patients had previous sinus surgery. Locations of skull base defects included: cribriform plate (44%), ethmoid (32%), lateral sphenoid (12%), and planum sphenoidale (12%). The mean follow-up was 22.8 months and 92% of the leak sites (23/25) were successfully repaired primarily. There were no neurological complications or cases of meningitis. Two patients (mean BMI = 52) with persistent postoperative CSF leaks and elevated intracranial pressure were successfully managed with ventriculoperitoneal shunt placement. BMI was associated with likelihood of repair failure (P = .003).

Conclusions

At our institution, endoscopic repair of sCSF leaks using a composite autograft of fascia and a nasoseptal flap demonstrates high success rates. Elevated BMI was a statistically significant risk factor for revision.

Adverse Events Associated with Balloon Sinuplasty: A MAUDE Database Analysis

Objective

Balloon sinuplasty utilization has increased significantly since its introduction over a decade ago. However, the most common associated complications are still unknown. The objective of this study was to analyze adverse events related to balloon sinuplasty.

Study Design

Retrospective cross-sectional analysis.

Setting

Food and Drug Administration’s MAUDE database (Manufacturer and User Facility Device Experience; 2008-2018).

Subjects and Methods

The MAUDE database was searched for all reports on adverse events involving balloon sinuplasty devices from the 3 leading manufacturers: Acclarent, Entellus, and Medtronic. Reported events were reviewed and categorized.

Results

During the study period, there were 211 adverse events from 208 reports divided into the following categories: patient related (n = 102, 48.3%), device related (n = 101, 47.9%), and packaging related (n = 8, 3.8%). Four periprocedural deaths were reported but were not clearly associated with technical complications. The most common device-related complications were guide catheter malfunction (39.6%), balloon malfunction (38.6%), and imprecise navigation (17.8%). The most common patient-related complications were cerebrospinal fluid leak (36.3%), eye swelling (29.4%), and epistaxis (11.8%). A lateral canthotomy was performed in 30.0% of eye-swelling complications. Sixty percent of eye complications occurred during balloon dilation of the maxillary sinus. The years 2014 (n = 48) and 2012 (n = 32) had the highest number of adverse events reported as compared with all other years.

Conclusion

The most common adverse events associated with balloon sinuplasty include balloon malfunction, guide catheter malfunction, cerebrospinal fluid leak, and significant eye swelling. Health care providers should discuss these possible complications when consenting patients for balloon sinuplasty.

Trends in Diagnostic Flexible Laryngoscopy and Videolaryngostroboscopy Utilization in the US Medicare Population

Importance

Diagnostic flexible laryngoscopy (DFL) is the second-most reimbursed procedure by Medicare in otolaryngology. However, the economic trends of this procedure on a population level are unknown.

Objective

To describe national- and state-level DFL and videolaryngostroboscopy (VLS) utilization and payment trends from 2000 to 2016 in the Medicare population.

Design, Setting, and Participants

This population-based, cross-sectional study of all Medicare beneficiaries from 2000 through 2016 found that at the national level the total absolute number of DFLs performed in the US Medicare population increased by 87% from 344 183 to 645 172 services, whereas total absolute payments for DFLs made by Medicare concurrently increased by 41% from $38 720 243 to $54 499 071. Rates of DLS and VLS categorized as Current Procedural Terminology (CPT) code 31575 and 31579, respectively. Analysis was carried out between November 18, 2018 and December 18, 2018.

Exposures

Diagnostic flexible laryngoscopy and VLS.

Main Outcomes and Measures

The DFL and VLS utilization rates, payments, and reimbursement rate trends were analyzed by year and state. Utilization was assessed for physician characteristics, including specialty and credentials.

Results

Nationally from 2000 to 2016 in the Medicare population, DFL utilization per Medicare enrollee increased 30% from 0.0087 to 0.0110 and payment per enrollee decreased 2% from $0.98 to $0.96, whereas VLS utilization and payment per enrollee both increased at least 300% during the same time period, with VLS procedure per enrollee and payment per enrollee increasing by 382% from 0.00028 to 0.0013 and 301% from $0.05 to $0.22, respectively. There was a weak correlation between reimbursement and utilization per enrollee for both DFL (r = 0.23; 95% CI, 0.12-0.34) and VLS (r = 0.26; 95% CI, 0.14-0.37) performed from 2012 to 2016. In 2016, the mean (SD) payment per DFL was $85.14 ($7.95), ranging from $65.45 in Puerto Rico to $104.82 in Washington, DC, a 1.6-fold difference. For VLS, there was a 2-fold difference between the lowest-reimbursing state, Maine ($92.20) and the highest, New York ($182.96). All US dollar values were uniformly adjusted for inflation to 2018 dollar values. Most DFLs in 2016 were performed by otolaryngologists (93.6%).

Conclusions and Relevance

The DFL utilization rates remained stable compared with VLS in the Medicare population from 2000 to 2016. There was a decrease in both DFL and VLS payments per procedure in the same time period and also weak correlations between reimbursement and utilization. Practice patterns and reimbursement varied geographically across the United States, though VLS exhibited significantly higher variation than DFL at the state level.

Open Versus Endoscopic Approach for Sinonasal Melanoma: A Systematic Review and Meta-analysis

Background

Open resection (OR) of sinonasal mucosal melanoma (SNM) traditionally has been the gold standard for treatment. However, endoscopic resection (ER) has recently become a surgical alternative. The aim of this study was to compare survival outcomes between OR and ER of SNM.

Methods

A literature search encompassing PubMed, Embase, Cochrane Library, Web of Science, ClinicalTrials.gov, and Google Scholar was performed. Two reviewers independently screened for original studies comparing survival outcomes between OR and ER for SNM. Data were systematically collected on study design, patient demographics, outcomes, and level of evidence. Quality assessment was performed using the Newcastle-Ottawa scale (NOS). Meta-analysis of overall survival and disease-free survival was performed using random-effects models.

Results

The initial search yielded 2078 abstracts, of which 9 cohort studies were included for a total of 510 patients from 6 different countries. The average quality of all included studies using the NOS was 7.7 stars. Six out of 7 studies reported no differences in the stages of SNM between patients receiving ER versus OR. Overall survival was longer in the ER group versus OR group (hazard ratio [HR]: 0.68, 95% confidence interval [CI]: 0.49–0.95). There was no significant difference in disease-free survival between groups (HR: 0.59, 95% CI: 0.28–1.25).

Conclusion

Based on the available literature, an endoscopic approach for SNM resection has survival outcomes that are similar or greater compared to an open approach.

Geographic health disparities in the Los Angeles pediatric neck abscess population

OBJECTIVE

To assess geographical sociodemographic differences in neck abscesses that require surgical drainage in Los Angeles.

STUDY DESIGN

retrospective review.

METHODS

We reviewed the medical records of 119 consecutive pediatric patients at Children's Hospital Los Angeles (CHLA) from 2014 to 2017 with a diagnosis of a neck abscess requiring incision and drainage. Sociodemographic information including zip code of residence was extracted and analyzed with Chi-square, Fisher's exact test, and multivariate logistic regression.

RESULTS

The average age of patients with a neck abscess in this study was 3.4 years old, 53.8% were female, 54.6% were Hispanic, and 82.5% had public health insurance. 79% of patients had an abscess located in the superficial neck, and 10.1% had an abscess located in the retropharyngeal space. There were no significant differences in gender, race, type of health insurance, or income between patients that lived within 10 miles of CHLA versus those that lived farther than 10 miles. On multivariate analysis, zip codes with a high volume of neck abscesses were more likely to be lower income neighborhoods. Gender, race, type of health insurance, and distance from CHLA were not associated with zip codes with a high volume of neck abscesses.

CONCLUSION

Geographic areas in the greater Los Angeles community with a high volume of neck abscesses requiring incision and drainage at our institution were associated with lower income neighborhoods.

LEVEL OF EVIDENCE

IV.

Geographic health disparities in the Los Angeles pediatric esophageal foreign body population

OBJECTIVE

To assess geographical sociodemographic differences in the pediatric esophageal foreign body population of Los Angeles.

METHODS

We retrospectively reviewed the medical records of 128 consecutive pediatric patients at Children's Hospital Los Angeles (CHLA) from 2014 to 2017 with a diagnosis of a retained foreign body in the esophagus removed by rigid or flexible esophagoscopy. Sociodemographic information including zip code of residence was extracted and analyzed with Chi-square, Fisher's exact test, and multivariable logistic regression.

RESULTS

The average age of patients with a retained esophageal foreign body in this study was 2.5 years old, 52.3% were male, 91.4% had no past medical history, 53.1% were Hispanic, 82.0% had public health insurance, and 63.3% were transfers from an outside hospital. The most common foreign body removed was a coin. There were no significant differences in gender, race, type of health insurance, or income between patients that lived within 10 miles of CHLA versus farther than 10 miles. On multivariable analysis, zip codes with a high volume of esophageal foreign bodies were more likely to be lower income neighborhoods. Gender, race, type of health insurance, and distance from CHLA were not risk factors for zip codes with a high volume of esophageal foreign bodies.

CONCLUSION

Geographic areas in the greater Los Angeles community with a high volume of retained esophageal foreign bodies requiring endoscopic removal at our institution are associated with lower income neighborhoods. Further studies should be performed to better understand health disparities within the U.S. pediatric esophageal foreign body population.

Association of alterations in smell and taste with depression in older adults

Objective

Examine the relationship between depression and changes in smell or taste.

Study Design

Cross‐sectional analysis of 2011–2012 and 2013–2014 National Health and Nutrition Examination Survey (NHANES).

Methods

We examined 5,275 adults ≥40 years old who completed smell and taste questionnaires as well as a validated depression assessment instrument, the Patient Health Questionnaire (PHQ‐9). Analyses incorporated sampling weights to account for the complex sampling design and associations were analyzed using multivariate logistic regression adjusted for related demographics and socioeconomic data.

Results

The prevalence of altered smell and taste was 23.0% (95% CI: 20.7–25.3%) and 11.9% (95% CI: 10.7–13.1%), respectively. Among those who met criteria for major depressive disorder, the prevalence of altered smell and taste was higher at 39.8% (95% CI: 33.4–46.1%) and 23.7% (95% CI: 18.7–28.7%), respectively. In a multivariate model adjusting for age, gender, education, major comorbidities, smoking history, heavy alcohol use, sinus disease, cold symptoms, and trauma history, adults ≥40 and <65 years old who reported alterations in smell (OR: 1.64, p = 0.004) and adults ≥40 years old who reported alterations in taste (OR: 1.77, p = 0.001) were more likely to meet criteria for major depressive disorder.

Conclusion

There is a strong association between major depression and alterations in smell and taste among certain age groups in the general U.S. population. Primary care providers should screen for depression when patients report changes in smell or taste.

Level of Evidence

4.

Objective Validation of Perfusion-Based Human Cadaveric Simulation Training Model for Management of Internal Carotid Artery Injury in Endoscopic Endonasal Sinus and Skull Base Surgery

BACKGROUND

The emergence of minimally invasive endoscopic endonasal skull base surgery has necessitated reproducible and realistic simulators of rare vascular injuries.

OBJECTIVE

To assess the face and content validity of an innovative perfusion-based cadaveric model developed to simulate internal carotid artery (ICA) injury during endoscopic surgery.

METHODS

Otolaryngology and neurosurgery trainees attempted 3 consecutive trials of endoscopic control of a parasellar ICA injury, with standardized technical feedback. Time to hemostasis (TTH) and blood loss were trended. All participants completed validated questionnaires using a 5-point Likert scale to assess the domains of confidence gain, face validity, content validity, and curriculum applicability.

RESULTS

Among all participants (n = 35), TTH and mean blood loss significantly decreased between first vs second attempt (P = .005), and first vs third attempt (P = .03). Following the first attempt, trainees experienced an average 63% reduction in blood loss and 59% reduction in TTH. In the quartile of most improved participants, average blood loss reduction was 1115 mL (84% reduction) and TTH of 259 s (84% reduction). There were no significant differences between trainees of varying postgraduate year or specialty. Average pre and postprocedural confidence scores were 1.38 and 3.16, respectively (P &lt; .0001). All trainees reported model realism, which achieved mean face validity 4.82 ± 0.41 and content validity 4.88 ± 0.33.

CONCLUSION

The perfusion-based human cadaveric ICA injury model achieves high ratings of face and content validity across all levels of surgical trainees, and enables safe, realistic simulation for standardized skull base simulation and future curriculum development. Objective improvements in performance metrics may translate to improved patient outcomes.