Opioid versus non-opioid postoperative pain management in otolaryngology.

BACKGROUND: The opioid epidemic in the United States has had devastating consequences, with many opioid-related deaths and a significant economic toll. Opioids have a significant role in postoperative pain management. Here we aim to analyze differences in postoperative opioid and non-opioid pain medications regimens following common otolaryngological surgeries between two large tertiary care medical centers: the Milton S. Hershey Medical Center, USA (HMC) and The Chaim Sheba Medical center, Israel (SMC). METHODS: A retrospective chart review of patients undergoing common otolaryngological procedures during the years 2017-2019 was conducted at two tertiary care centers, one in the U.S. and the other in Israel. Types and doses of postoperative pain medications ordered and administered during admission were analyzed. Average doses ordered and administered in 24 h were calculated. Opioid medications were converted to a standardized unit of morphine milliequivalents (MME). Chi-square test and Wilcoxon rank-sum test were used to compare the groups. RESULTS: The study included 204 patients (103 U.S., 101 Israel). Patient demographics were similar except for a longer length of stay in Israel (p < 0.01). In the U.S., 95% of patients were ordered opioids compared to 70% in Israel (P < 0.01). In the U.S., 68.9% of patients ordered opioids received the medications compared to 29.7% in Israel. The median opioid dose ordered in the U.S. was 45MME/24 h compared to 30MME/24 h in Israel (P < 0.01), while median dose received in the U.S. was 15MME/24 h compared to 3.8MME/24 h in Israel (P < 0.01). Opioid prescriptions at discharge were given to 92% of patients in the U.S. compared to 4% of patients in Israel (p < 0.01). A significantly higher number of patients in the U.S. were prescribed acetaminophen and ibuprofen (p < 0.0001). Dipyrone was prescribed to 78% of patients in Israel. CONCLUSIONS: HMC demonstrated a significantly more permissive approach to both prescribing and consuming opioid medications for postoperative pain management than SMC for similar, common otolaryngological surgeries. Non-opioid alternatives and examining the cultural and medical practice-based differences contributing to the opioid epidemic should be discussed and reevaluated.

Adult tonsillectomy: An evaluation of indications and complications.

OBJECTIVE: This study aimed to evaluate current adult tonsillectomy indications along with risk factors associated with postoperative complications. METHODS: In this retrospective chart review, demographic, clinical, and surgical data were collected from 2004 to 2020 of adult patients who underwent tonsillectomy. Indications for surgery were categorized as infectious etiology, biopsy, obstructive sleep apnea (OSA), and tonsillar stones. Data regarding postoperative hemorrhage, emergency department (ED) visits, and readmissions were collected. Multivariable logistic regression models were used to evaluate factors associated with postoperative complications. RESULTS: 574 adults (mean age 32 years, 69.9% F vs. 30.1% M) were included. The most common indication was infections (62.2%), followed by biopsy (26.5%), tonsillar stones (6.8%), and OSA (4.5%). The highest frequency of postoperative bleeds (17.9%) occurred in the tonsillar stones cohort; however, the indication for surgery was not a significant predictor on multivariate analysis. Male sex and younger age were independent predictors of postoperative bleeding, while younger age was a significant predictor of postoperative ED visits. There was a significant linear trend of an increasing proportion of tonsillectomies performed for tonsillar stones compared to other indications for 2011-2019. CONCLUSION: Infectious etiology was the most common indication for tonsillectomy. Indication for surgery was not a significant predictor of postoperative bleeding; however, male sex and younger age had higher odds of postoperative bleeding. The proportion of tonsillectomies performed for tonsillar stones was steadily increasing.

Transoral floor of mouth lipoma resection: A technical multimedia analysis.

Lipomas are common benign mesenchymal tumors that originate from mature adipocytes throughout the body, with 13-20% occurring in the head and neck region, however only 1-4.4% affect the oral cavity, where they are found predominately in the cheek, followed by the tongue, lips, palatal mucosa, gingiva, and floor of the mouth. Herein, we present a multimedia analysis of transoral floor of mouth lipoma resection in a 58-year-old female. Learning points include (1) Identification and stenting of Wharton's ducts in order to facilitate their functional preservation and to minimize risk of postoperative sialocele; (2) postoperative observation with airway monitoring due to expected floor of mouth edema; (3) utilization of a midline incision to minimize injury to Wharton's ducts and maximize bilateral access to the floor of mouth.

Warthin tumor within the superficial lobe of the parotid gland: a suggested criterion for diagnosis.

The location of Warthin tumor (WT) in the parotid gland impacts the surgical approach and may be indicative of the elusive origin of this intriguing entity. Location in the deep versus superficial lobe of the gland is not directly addressed when defining WT characteristics. Our observation, of rare occurrence of deep lobe WT, if at all, led to the current investigation. The study design is cohort study. This is a retrospective chart review of all patients undergoing parotidectomy for WT in two tertiary academic referral centers: the Sheba Medical Center (SMC), Israel, and the Christiana Care (CC), Newark, Delaware, USA. 122 consecutive adult patients underwent parotidectomy for WT (72 from SMC and 50 from CC). Seventy percent were males, with a mean age of 60.6 years. Bilateral WT or multi-centric WT were found in 9.8 and 17.2% of the cases, respectively. In one case, the tumor was described as originating in the deep lobe. In all other cases, the tumor originated and was limited to the superficial lobe. 99.2% of WT originated in the superficial lobe, corresponding with the few reports directly addressing its location in the gland. The reason for the tumor to be limited almost uniformly to the superficial lobe is unknown, and could be related to the etiopathogenesis of this elusive entity. We suggest adding tumor location within the superficial lobe to the common characteristics of WT (male, smoking, and lower pole) that serve as "common criterion" while evaluating a parotid lesion.

Type I-II laryngeal cleft: clinical course and outcome.

BACKGROUND: Laryngeal cleft (LC) is a rare congenital anomaly manifesting in a variety of symptoms, including swallowing disorders and aspirations, dyspnea, stridor and hoarseness. The mild forms (types I-II) may be underdiagnosed, leading to protracted symptomatology and morbidity. OBJECTIVES: To evaluate the diagnostic process, clinical course, management and outcome in children with type I-II laryngeal clefts. METHODS: We conducted a retrospective case analysis for the years 2005-2012 in a tertiary referral center. RESULTS: Seven children were reviewed: five boys and two girls ranging in age from birth to 5 years. The most common presenting symptoms were cough, aspirations and pneumonia. Evaluation procedures included fiber-optic laryngoscopy (FOL), direct laryngoscopy (DL) and videofluoroscopy. Other pathologies were seen in three children. Six children underwent successful endoscopic surgery and one child was treated conservatively. The postoperative clinical course was uneventful in most of the cases. CONCLUSIONS: Types I-II LC should be considered in the differential diagnosis of children presenting with protracted cough and aspirations. DL is crucial for establishing the diagnosis. Endoscopic surgery is safe and should be applied promptly when conservative measures fail.

Efficacy of myringoplasty in older people.

The aim of current investigation was to analyze the efficacy of myringoplasty in an elderly population. The medical records of 12 males and 9 females, aged 65-90 years (mean 70.7 years), who underwent myringoplasty between 2007 and 2013 were retrospectively reviewed for age, gender, co-morbidities, perforation size and location, pre- and postoperative pure tone averages of air/bone thresholds at 500, 1,000, 2,000 and 3,000 Hz, graft material, postoperative complications and surgical outcome. The most frequent co-morbidities included hypertension (n = 8), hyperlipidemia (n = 7), diabetes mellitus (n = 5) and ischemic heart disease (n = 4). Fifteen patients had two or more co-morbidities. All surgeries were performed via a trans-canal approach. Seventeen patients had central perforations and four patients had marginal perforations. Temporalis fascia, perichondrium or chondro-perichondrial graft and fat were used as grafting material in 9, 11 and 1 patient, respectively. The post-operative complications were infection (n = 4) and tragal seroma (n = 1). Surgical outcome was successful in 16/21 patients with graft take rates of 89, 72 and 0% for temporalis fascia, perichondrium/cartilage, and fat, respectively. Pre-operative audiometric data were available for all 21 patients; however, the post-operative data were available for only 15 of them. Myringoplasty in older people was a safe procedure with a 76.2% surgical success rate in the current study. The choice of graft material, perforation size, gender and associated co-morbidities had no significant effect on achieving an intact tympanic membrane and a dry ear. The audiometric results did not show significant changes following myringoplasty.

Mechanisms of Resistance and Therapeutic Perspectives in Immunotherapy for Advanced Head and Neck Cancers.

Immunotherapy is emerging as an effective treatment for advanced head and neck cancers and interest in this treatment modality has led to rapid expansion of this research. Pembrolizumab and nivolumab, monoclonal antibodies directed against the programmed cell death-1 (PD-1) receptor, are US Food and Drug Administration (FDA)- and European Medical Agency (EMA)-approved immunotherapies for head and neck squamous cell carcinoma (HNSCC). Resistance to immunotherapy is common, with about 60% of patients with recurrent or metastatic HNSCC not responding to immunotherapy and only 20-30% of patients without disease progression in the long term. Overcoming resistance to immunotherapy is therefore essential for augmenting the effectiveness of immunotherapy in HNSCC. This review details the innate and adaptive mechanisms by which head and neck cancers can become resistant to immunotherapeutic agents, biomarkers that can be used for immunotherapy patient selection, as well as other factors of the tumor microenvironment correlated with therapeutic response and prognosis. Numerous combinations and novel immunotherapies are currently being trialed, based on better understood immune evasion mechanisms. These potential treatments hold the promise of overcoming resistance to immunotherapy in head and neck cancers.

A Comprehensive Update of the Incidence and Demographics of Laryngoceles in Adults.

OBJECTIVE: To provide updated data on the incidence, types, and demographics of laryngoceles in the adult population. METHODS: We searched the medical archives of our institute for computed tomography (CT) studies acquired between January 1, 2007 and December 31, 2017 in which the term "laryngocele" appeared in the radiology reports. Two of the authors reviewed relevant images for the presence, type, distribution, and laterality of true laryngoceles. Demographic and clinical data were extracted from medical records and the incidence was calculated. RESULTS: Laryngoceles were detected in 53 out of the 79 893 patients with relevant CT data, which equates to an incidence of 151 per 2.5 million (0.06:1000) patients per year. The male:female ratio was 3:1, average age was 60 (±18) years, and incidence peaked among patients in the sixth decade of life. Nine patients (17%) had known laryngeal cancer; however, the majority of the cohort did not have follow up clinic visits. CONCLUSION: Our study demonstrates that the incidence of laryngoceles is much greater than previously reported. In most cases, the diagnosis of a laryngocele was an incidental radiological finding. Male gender predilection and age at presentation are in agreement with previous reports. Association of laryngoceles with laryngeal cancer could not be calculated due to low rates of follow ups. LEVEL OF EVIDENCE: 3.

Terminology, Definitions, and Classification in the Imaging of Laryngoceles.

OBJECTIVE: We aim to better define the anatomy, criteria, and classification of laryngoceles, and to raise the awareness to potential mimickers and anatomical variants leading to misdiagnosis. METHODS: A retrospective review of all computed tomography studies, performed over a decade, with the diagnosis of "laryngocele" in the radiological report in a tertiary medical center. All relevant studies were reviewed by two independent readers for the presence of true laryngoceles. RESULTS: One hundred and twelve patients were included; average age was 54 (±18). Re-read of scans with 3D reconstructions resulted in detecting 58 (52%) true laryngoceles, with 19.5% bilateral laryngoceles. Anatomical variants and laryngocele mimickers formerly misdiagnosed as laryngoceles included 26/54 (48%) prominent ventricles, 19/54 (35%) saccules not meeting criteria for laryngocele, 8/54 (15%) prominent pyriform sinuses and one tracheal diverticulum. CONCLUSIONS: Intimate knowledge of the laryngeal anatomy, the criteria for a laryngocele and anatomical variants as well mimickers, is the key to avoid radiological misdiagnosis.

A model for classification of invasive fungal rhinosinusitis by computed tomography.

Our purpose was to classify acute invasive fungal rhinosinusitis (AIFR) caused by Mucor versus Aspergillus species by evaluating computed tomography radiological findings. Two blinded readers retrospectively graded radiological abnormalities of the craniofacial region observed on craniofacial CT examinations obtained during initial evaluation of 38 patients with eventually pathology-proven AIFR (13:25, Mucor:Aspergillus). Binomial logistic regression was used to analyze correlation between variables and type of fungi. Score-based models were implemented for analyzing differences in laterality of findings, including the 'unilateral presence' and 'bilateral mean' models. Binary logistic regression was used, with Score as the only predictor and Group (Mucor vs Aspergillus) as the only outcome. Specificity, sensitivity, positive predictive value, negative predictive value and accuracy were determined for the evaluated models. Given the low predictive value of any single evaluated anatomical site, a 'bilateral mean' score-based model including the nasal cavity, maxillary sinuses, ethmoid air cells, sphenoid sinus and frontal sinuses yielded the highest prediction accuracy, with Mucor induced AIFR correlating with higher prevalence of bilateral findings. The odds ratio for the model while integrating the above anatomical sites was 12.3 (p < 0.001). PPV, NPV, sensitivity, specificity and accuracy were 0.85, 0.82, 0.92, 0.69 and 0.84 respectively. The abnormal radiological findings on craniofacial CT scans of Mucor and Aspergillus induced AIFR could be differentiated based on laterality, with Mucor induced AIFR associated with higher prevalence of bilateral findings.