Factors associated with eosinophilic esophagitis in an urban, tertiary care pediatric aerodigestive population undergoing triple endoscopy.

BACKGROUND: Children with aerodigestive dysfunction often undergo triple endoscopy (flexible bronchoscopy, rigid direct laryngoscopy and bronchoscopy, and esophagogastroduodenoscopy) for diagnostic evaluation as well as screening prior to airway reconstruction. Prevalence and risk factors for eosinophilic esophagitis (EoE) in this population are poorly understood. METHODS: A retrospective chart review was performed for pediatric patients, aged 0-21 years, who received a triple endoscopy with biopsy from January 1, 2015, to December 31, 2019, at the Children's Hospital at Montefiore (CHAM). Bivariate and multivariable analyses were used to compare the baseline characteristics between patients with and without EoE to assess for potential predictors of EoE. RESULTS: Of the 119 cases included in the analysis, 16.0 % (19) received a histopathologic diagnosis of EoE following triple endoscopy. Patients with EoE were more likely to have a family history of eczema (p = 0.02) and a dairy-free diet (p = 0.02). Age, sex, history of environmental allergies, and recency of initiating oral diet were not significantly associated with increased odds of an EoE diagnosis. CONCLUSIONS: A family history of eczema and a diet lacking allergenic foods, such as milk, may be associated with an increased risk of a future diagnosis of EoE in patients with aerodigestive dysfunction. Larger, multi-institutional studies are needed to identify early predictors of EoE.

The Efficacy of Human Papillomavirus Vaccination as an Adjuvant Therapy in Recurrent Respiratory Papillomatosis.

OBJECTIVE: To characterize the efficacy of human papillomavirus (HPV) vaccination as an adjuvant therapy in recurrent respiratory papillomatosis (RRP). DATA SOURCES: PubMed, Embase, Cochrane, Google Scholar, ClinicalTrials.gov, and Web of Science databases were queried for articles published before April 2021. REVIEW METHODS: All retrieved studies (n = 870) were independently analyzed by two reviewers according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement using predefined inclusion and exclusion criteria. 13 studies met inclusion criteria. A random-effects meta-analysis was performed to study intersurgical interval (ISI) and number of surgical procedures per year before and after vaccination. RESULTS: The systematic review included 13 studies, comprising 243 patients. All studies utilized the Gardasil® quadrivalent vaccine, and one study (Yiu et al. 2019) utilized both the quadrivalent and Gardasil® 9-valent vaccines. Our meta-analysis included 62 patients with ISI data across 4 studies, and 111 patients with data on the number of surgical procedures per month across 7 studies. The mean number of surgical procedures decreased by 4.43 per year after vaccination (95% CI, -7.48 to -1.37). Mean ISI increased after vaccination, with a mean difference of 15.73 months (95% CI, 1.46-29.99). Two studies reported on HPV sero-conversion, with HPV seropositivity of 100% prior to vaccination and 25.93% after vaccination. CONCLUSION: The addition of HPV vaccination was associated with an increase in time between surgeries and reduction in the number of surgical procedures required. HPV vaccination may be a beneficial adjuvant treatment for RRP. LEVEL OF EVIDENCE: NA Laryngoscope, 133:2046-2054, 2023.

The surgical airway in the COVID-19 era.

The aim is to summarize the guidelines for tracheostomy management during the COVID-19 pandemic. This is a comparative study analysis and literature review using articles found in the PubMed/MEDLINE database. Here we summarize published work on tracheostomy timing, technique, outcomes, mortality, and decannulation rates during the COVID-19 pandemic, with a focus on expertise from our own institution. Among 12 studies, 2,692 tracheostomies were performed at an average of 17.5 days from intubation. 66.4% were performed open, and 33.6% percutaneously. A total of 85.6% were performed bedside, and 14.4% in the operating room. 19.5% experienced all-cause mortality, and 43.4% were decannulated. In these studies, only 1 proceduralist became infected with COVID-19. Early COVID-19 recommendations advocated for tracheostomy a minimum of 14 days from intubation. Currently, tracheostomy is performed more closely to prepandemic criteria. Bedside tracheostomy comprised most procedures during the pandemic. Tracheostomy in COVID-19 patients, when performed with techniques to minimize aerosolization, is safe and poses minimal risk of infection to providers performing the procedure.

Comparison of Open and Endoscopic Approaches in the Resection of Esthesioneuroblastoma.

BACKGROUND: Olfactory neuroblastoma, or esthesioneuroblastoma (ENB), is an uncommon sinonasal malignancy arising from olfactory neuroepithelium that is optimally treated with surgical resection. The objective of this study is to determine preoperative predictors of undergoing open versus endoscopic approach for ENB and to investigate significant postoperative survival outcomes between the two surgical approaches. METHODS: The National Cancer Database (NCDB) was queried for cases of ENB histology that were treated surgically from 2010 to 2015. Groups were stratified into open or endoscopic approach cohorts. Patient demographics, tumor characteristics, treatment modality, and 5-year overall survival were compared between the two groups using Chi-Square analysis and Kaplan-Meier survival analysis. Cases were classified as Kadish stage A, B, C, or D based on the "Collaborative Stage-Extension" codes in NCDB. RESULTS: Of 533 patients meeting inclusion criteria, 276 (51.8%) patients underwent open, and 257 (48.2%) patients underwent endoscopic surgical approaches. Patients undergoing endoscopic surgery were more likely to be Kadish stages A and B and less likely to be stages C and D (P = .020). Those undergoing endoscopic approach overall had a shorter mean hospital stay postoperatively (3.8 vs. 7.0 days, P < .001). Endoscopic cases had a greater 5-year overall survival (81.9% vs. 75.6%, P = .030); after multivariate regression, there was a trend toward survival benefit to endoscopic surgery that did not reach clinical significance (HR 0.644, [0.392-1.058], P = .083). CONCLUSION: Although not statistically significant, there is a trend toward increased overall survival with an endoscopic approach in patients undergoing surgery for ENB as compared to an open approach, regardless of Kadish stage. An endoscopic approach is an adequate alternative to an open approach for the surgical treatment of ENB.

Morbidity and mortality associated with ventral skull base surgery: analysis of the National Surgical Quality Improvement Program.

BACKGROUND: Ventral skull base (VSB) surgery has associated morbidity and mortality that is poorly defined. In this study we aim to identify factors associated with adverse events in VSB surgery. METHODS: We queried the database of the American College of Surgeons National Surgical Quality Improvement Program for cases of VSB surgery during the period 2005-2014. Patients with complications, readmissions, reoperations, or mortality were compared to those without adverse events. RESULTS: Nine hundred patients were included; 253 (28.1%) had complications, underwent reoperation, were readmitted, or died. These patients were older (42.6% vs 32.8, p = 0.032) and had higher rates of congestive heart failure (CHF) (3.2% vs 0.2%, p < 0.0001), disseminated cancer (8.3% vs 4.6%, p = 0.032), and preoperative sepsis (8.7% vs 2.2%, p < 0.0001). Other comorbidities included long-term steroid use (13.4% vs 9.0%, p = 0.046) and higher rates of preoperative transfusion (2.4% vs 0%, p < 0.0001). The most common complication was bleeding (13.7%). Preoperative systemic sepsis (odds ratio [OR], 2.6; 95% confidence interval [CI], 1.0-6.6) and lower hematocrit (OR, 2.1; 95% CI, 1.4-3.4) were more likely to be associated with a complication. Those with disseminated cancer (OR, 12.0; 95% CI, 2.9-50.5) were more likely to experience 30-day mortality. Black patients had lower rates of reoperation (OR, 0.3; 95% CI, 0.1-0.8), whereas patients with CHF (OR, 12.6; 95% CI, 1.7-94.4) and hypertension (OR, 2.1; 95% CI, 1.1-4.0) had higher rates of reoperation. Predictors of extended length of stay were Hispanic ethnicity (OR, 2.2; 95% CI, 1.2-4.1) and lower hematocrit (OR, 2.3; 95% CI, 1.5-3.6). CONCLUSION: VSB surgery can involve significant morbidity and mortality, and thus identifying risk factors allows for better prognostication and delivery of care in these patients.

Risk Factors for Blood Transfusion with Neck Dissection.

OBJECTIVES: To identify risk factors of perioperative blood transfusions (PBTs) for neck dissection and identify the association of PBTs with other postoperative outcomes. METHODS: This is a retrospective study of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. The database was queried for neck dissection procedures performed by otolaryngologists from 2006 to 2014. Multivariable logistic regression was used to determine associations between demographic and preoperative factors, mortality, unplanned reoperation, and unplanned readmission with PBTs. RESULTS: Of the 3090 patients included in our study, 346 (11.2%) received a PBT, 249 patients (72.0%) received blood intraoperatively or on postoperative day (POD) 0, and 97 patients (28.0%) received blood within 5 PODs. American Society of Anesthesiologists (ASA) class ≥3 (odds ratio [OR], 2.1; 95% confidence interval [CI], 1.4-3.2), preoperative weight loss (OR, 2.2; 95% CI, 1.5-3.2), and anemia (OR, 5.5; 95% CI, 4.1-7.6) were independently associated with PBTs. Free flaps were also significantly associated with PBTs. PBTs were significantly associated with unplanned return to the operating room within 30 days (OR, 4.31; 95% CI, 3.01-6.18) but not with 30-day unplanned readmission or 30-day mortality. DISCUSSION: Eleven percent of patients undergoing neck dissection receive a PBT. Identifying associated risk factors may reduce PBT among patients with cancer. Comorbid data, such as weight loss, anemia, and ASA class, may be useful in determining risk for transfusion during these procedures. IMPLICATIONS FOR PRACTICE: Awareness of preoperative risk factors for PBT may lead surgeons to reduce the risk of PBT, anticipate the need for transfusion, and manage these patients carefully to prevent unplanned reoperation.

Pediatric Human Immunodeficiency Virus and Otolaryngologic Manifestations: An Analysis of Hospital Admissions From 1997 to 2012.

OBJECTIVES/HYPOTHESIS: Many human immunodeficiency virus (HIV)-infected pediatric patients develop otolaryngologic disease. We aimed to characterize their otolaryngologic manifestations by type and demographic variation, and model temporal trends. STUDY DESIGN: Retrospective cohort review. METHODS: A retrospective review utilizing the Kids' Inpatient Database (KID) was conducted. International Classification of Diseases, Ninth Revision, Clinical Modification codes for HIV and otolaryngologic diagnoses were used to query data from the triennially published KID files from 1997 to 2012. A subset analysis of infectious versus non-infectious admitting otolaryngologic diagnoses was conducted. RESULTS: A total of 11,150 cases met the inclusion criteria. Of these cases, 21.8% were admitted for otolaryngologic manifestations, with 18.0% presenting with infectious symptomatology, 4.8% with noninfectious disease, and 1.0% with both. On average, patients presenting with infectious disease were younger (8.17 years vs. 9.65 years, P < .001). Patients in the South were significantly more likely to be admitted for infection (54.8% vs. 42.0%, P < .001), with non-infectious predominance in the Northeast and West. HIV-infected children in 1997 were more likely to present with infectious otolaryngologic disease (56.3% vs. 45.8%, P < .001); however, there has been a decrease in the prevalence of infectious head and neck presentations (46.5%, 19.9%, 11.5%, 6.7%, 3.7%, and 1.9% from 1997 to 2012), and a gradual shift toward noninfectious manifestation with notable differences in 2000 and 2012 (19.9% vs. 25.2%; P = .017; and 1.9% vs. 4.8%, P < .001, respectively). CONCLUSIONS: Otolaryngologic disease accounts for nearly one-fifth of hospitalizations in HIV-infected children; however, rates of hospitalization as well as otolaryngologic manifestations have progressively decreased over time. HIV-infected children nowadays are more likely to present with noninfectious rather than infectious disease. LEVEL OF EVIDENCE: NA Laryngoscope, 129:E377-E382, 2019.

Is quicker better? A NSQIP analysis of anesthesia time and complications following tracheostomy placement.

BACKGROUND: Increased anesthesia time may lead to respiratory complications in patients receiving tracheostomy, which contributes to patient morbidity. METHODS: The American College of Surgeon's National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for cases of planned tracheostomy (CPT 31600) from 2005 to 2012. Patients were stratified into quintiles based on anesthesia duration. Pearson's chi square, Fischer's exact test, one-way ANOVA, and multivariate regression were used to determine the association between patient characteristics with pneumonia and ventilator dependence. RESULTS: Out of 752 patients, 83 patients experienced post-operative pneumonia, and 166 experienced ventilator dependence. Following multivariate regression analysis, anesthesia quintiles were not significantly associated with pneumonia or ventilator dependence. Age (OR 1.03, 95% CI 1.00-1.05, P = .032), dyspnea (OR 2.21, 95% CI 1.18-4.13; P = .013), pre-operative ventilator dependence (OR 3.08, 95% CI 1.19-7.98; P = .020), and sepsis (OR 6.68, 95% CI 3.19-14.0; P < .001) remained as significant predictors of post-operative ventilator dependence. CONCLUSIONS: Faster may not be better-- prolonged anesthesia time does not increase the risk of post-operative pneumonia or ventilator dependence in patients receiving a planned tracheostomy in the operating room.