Detection of Cerebrospinal Fluid Leaks Using the Endoscopic Fluorescein Test in the Postoperative Period following Pituitary and Ventral Skull Base Surgery.

Objective Diagnosis of cerebrospinal fluid (CSF) leaks is sometimes challenging in the postoperative period following pituitary and ventral skull base surgery. Intrathecal fluorescein (ITF) may be useful in this setting. Design Retrospective chart review. Setting Tertiary care center. Methods and Participants All patients who underwent pituitary and ventral skull base surgery performed by a single rhinologist between January 2017 and March 2020 were included. There were 103 patients identified. Eighteen patients received 20 ITF injections due to clinical suspicion for CSF leak during the postoperative period without florid CSF rhinorrhea on clinical exam. Computed tomography scans with new or increasing intracranial air and intraoperative findings were used to confirm CSF leaks. Clinical courses were reviewed for at least 6 months after initial concern for leak as the final determinate of CSF leak. Main Outcome Measures Specificity and safety of ITF. Results Eleven (61%) ITF patients were female and 7 (39%) were male. Average patient age was 52.50 ± 11.89. There were six patients with confirmed postoperative CSF leaks, 3 of whom had evaluations with ITF. ITF use resulted in 2 true positives, 1 false negative, 17 true negatives, and 0 false positives. ITF sensitivity was 67%, specificity was 100%, and positive and negative predictive values were 100 and 94.4%, respectively. There were no adverse effects from ITF use. Conclusions Existing modalities for detecting postoperative CSF leaks suffer from suboptimal sensitivity and specificity, delayed result reporting, or limited availability. ITF represents a specific and safe test with potential utility in the postoperative setting.

Adherence to Subspecialty Guidelines in the Emergency Department.

OBJECTIVES/HYPOTHESIS: The American Academy of Otolaryngology-Head and Neck Surgery has published clinical practice guidelines (CPGs) to guide management of common otolaryngologic (ENT) conditions. While these CPGs have been disseminated within specialty journals, many patients' first presentation of certain ENT complaints is to primary and acute care settings, including the emergency department (ED). It is less clear whether practice in these settings is concordant with specialty CPGs. STUDY DESIGN: Retrospective cohort study. METHODS: A retrospective review of medical records was performed at an academic tertiary care center with ED diagnoses of 1) Bell's palsy/facial weakness (BP) or 2) acute otitis externa (AOE) from May 2014-June 2018. Individual chart abstraction was performed for all encounters with these diagnoses for the purpose of assessing providers' adherence to CPGs. RESULTS: During the study period, 224 patients were diagnosed with BP and 465 patients were diagnosed with AOE. Of the patients diagnosed with BP, 94% (n = 211/224) were prescribed oral steroids, concordant with guidelines, while 36% of these patients received head computed tomography (CT) scans and 43% received laboratory tests, counter to the guidelines. For those with a diagnosis of AOE, 28.6% received topical antibiotics only as primary treatment (n = 133/465) in accordance with guidelines while systemic antibiotics were prescribed in 42.2% (n = 196/465) discordant with the guidelines and 29.2% received both topical and systemic antibiotics (n = 136/465). CONCLUSIONS: CPGs developed by subspecialty societies provide evidence-based recommendations for the care of patients with particular conditions, but may not be disseminated broadly outside of the specialty. Further research is required to understand the reasons behind divergent management of such conditions. LEVEL OF EVIDENCE: 3 Laryngoscope, 131:1266-1270, 2021.

Early Outcomes From Early Tracheostomy for Patients With COVID-19.

Importance: Decision-making in the timing of tracheostomy in patients with coronavirus disease 2019 (COVID-19) has centered on the intersection of long-standing debates on the benefits of early vs late tracheostomy, assumptions about timelines of infectivity of the novel coronavirus, and concern over risk to surgeons performing tracheostomy. Multiple consensus guidelines recommend avoiding or delaying tracheostomy, without evidence to indicate anticipated improvement in outcomes as a result. Objective: To assess outcomes from early tracheostomy in the airway management of patients with COVID-19 requiring mechanical ventilation. Design, Setting, and Participants: A retrospective medical record review was completed of 148 patients with reverse transcriptase-polymerase chain reaction-confirmed COVID-19 requiring mechanical ventilation at a single tertiary-care medical center in New York City from March 1 to May 7, 2020. Interventions: Open or percutaneous tracheostomy. Main Outcomes and Measures: The primary outcomes were time from symptom onset to (1) endotracheal intubation, (2) tracheostomy; time from endotracheal intubation to tracheostomy; time from tracheostomy to (1) tracheostomy tube downsizing, (2) decannulation; total time on mechanical ventilation; and total length of stay. Results: Participants included 148 patients, 120 men and 28 women, with an overall mean (SD) age of 58.1 (15.8) years. Mean (SD; median) time from symptom onset to intubation was 10.57 (6.58; 9) days; from symptom onset to tracheostomy, 22.76 (8.84; 21) days; and from endotracheal intubation to tracheostomy, 12.23 (6.82; 12) days. The mean (SD; median) time to discontinuation of mechanical ventilation was 33.49 (18.82; 27) days; from tracheostomy to first downsize, 23.02 (13.76; 19) days; and from tracheostomy to decannulation, 30.16 (16.00; 26) days. The mean (SD; median) length of stay for all patients was 51.29 (23.66; 45) days. Timing of tracheostomy was significantly associated with length of stay: median length of stay was 40 days in those who underwent early tracheostomy (within 10 days of endotracheal intubation) and 49 days in those who underwent late tracheostomy (median difference, -8; 95% CI, -15 to -1). In a competing risks model with death as the competing risk, the late tracheostomy group was 16% less likely to discontinue mechanical ventilation (hazard ratio, 0.84; 95% CI, 0.55 to 1.28). Conclusions and Relevance: This cohort study from the first 2 months of the pandemic in New York City provides an opportunity to reconsider guidelines for tracheostomy for patients with COVID-19. Findings demonstrated noninferiority of early tracheostomy and challenges recommendations to categorically delay or avoid tracheostomy in this patient population. When aligned with emerging evidence about the timeline of infectivity of the novel coronavirus, this approach may optimize outcomes from tracheostomy while keeping clinicians safe.

Cost Analysis of Channeled, Distal Chip Laryngoscope for In-office Laryngopharyngeal Biopsies.

OBJECTIVE: Given that financial considerations play an increasingly prominent role in clinical decision-making, we sought (1) to determine the cost-effectiveness of in-office biopsy for the patient, the provider, and the health-care system, and (2) to determine the diagnostic accuracy of in-office biopsy. STUDY DESIGN: Retrospective, financial analyses were performed. METHODS: Patients who underwent in-office (Current Procedural Terminology Code 31576) or operative biopsy (CPT Code 31535) for laryngopharyngeal lesions were included. Two financial analyses were performed: (1) the average cost of operating room (OR) versus in-office biopsy was calculated, and (2) a break-even analysis was calculated to determine the cost-effectiveness of in-office biopsy for the provider. In addition, the diagnostic accuracy of in-office biopsies and need for additional biopsies or procedures was recorded. RESULTS: Of the 48 patients included in the current study, 28 underwent in-office biopsy. A pathologic sample was obtained in 26 of 28 (92.9%) biopsies performed in the office. Of these patients, 16 avoided subsequent OR procedures. The average per patient cost was $7000 and $11,000 for in-office and OR biopsy, respectively. Break-even analysis demonstrated that the provider could achieve a profit 2 years after purchase of the necessary equipment. CONCLUSION: In-office laryngopharyngeal biopsies are accurate and, overall, more cost-effective than OR biopsies. Purchase of the channeled, distal chip laryngoscope and biopsy forceps to perform in-office biopsies can be profitable for a provider with a videolaryngoscopy tower. In-office biopsy should be considered the initial diagnostic tool for suspected laryngopharyngeal malignancies noted on videolaryngoscopy.