RESUMO
BACKGROUND: The Occupational Safety and Health Administration (OSHA) considers acoustic exposure of 90 decibels (dB) an occupational risk for noise-induced hearing loss. Pediatric healthcare clinicians are exposed to considerable noise especially during invasive procedures, predisposing them to noise-induced hearing loss, increased work-related stress, and increased complications associated with intense noise exposure. While there has been extensive research in noise exposure in dentistry, to date there has been no research on noise exposure in the pediatric otolaryngology clinic setting. The objective of this study is to quantify the degree of noise exposure that pediatric otolaryngologists encounter in the clinical setting. METHODS: A sound survey was performed of 420 pediatric otolaryngology clinic visits within a single-institution tertiary care facility from January 2022 to March 2022, with a total of 409 visits included. At each visit, noise was measured using a calibrated National Institute for Occupational Safety and Health (NIOSH) Sound Meter application, an iPad, and a microphone. The Equivalent Continuous Sound Pressure Level (LAeq), peak sound pressure level (SPL), C-weighted peak noise level (LCpeak), and the 8-hour time-weighted average (TWA) sound level were recorded. RESULTS: The average LAeq was 61.1 dB, the median LAeq was 60.3 dB, and the average peak SPL was 80.5 dB. Only 0.5 % of visits reached an LAeq above 80 dB, however, 51 % were above 60 dB and 99 % were above 45 dB. No clinicians were exposed to noise exceeding established limits of safety. Patients younger than ten years old (p < 0.001) and those who underwent procedures such as cerumen removal (p < 0.001) elicited higher ranges of elevated noise. Multivariate analysis confirmed that increased age decreased acoustic exposure while procedures increased acoustic exposure. CONCLUSIONS: The results of this study suggest that pediatric otolaryngology clinicians do not exceed hazardous noise limit exposure. However, they are exposed to levels above those which have been linked to stress, poor productivity, and stress-related disorders. This analysis also reports that patients who are younger and those that undergo procedures, specifically cerumen removal, tend to expose their providers to the highest levels of noise. This is the first study examining noise exposure in pediatric otolaryngology, and further research should evaluate the risks of noise exposure in this environment.
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Perda Auditiva Provocada por Ruído , Ruído Ocupacional , Exposição Ocupacional , Otolaringologia , Humanos , Criança , Perda Auditiva Provocada por Ruído/epidemiologia , Perda Auditiva Provocada por Ruído/etiologia , Perda Auditiva Provocada por Ruído/prevenção & controle , Ruído Ocupacional/efeitos adversos , Atenção Terciária à Saúde , Som , Instituições de Assistência Ambulatorial , Exposição Ocupacional/efeitos adversosRESUMO
BACKGROUND: Reliable use of surgical navigation depends upon the registration process. The gold standard is paired-point registration with bone-anchored fiducials, but contour-map registration is more practical. Surgeons may employ variable contour maps and less experienced team members often perform this critical step. The impact of these practices on target registration error (TRE) is not well-studied. METHODS: A dry lab set-up consisting of a navigation system (Fusion ENT, Medtronic, Jacksonville, FL) and a sinus phantom with 2 mm radiopaque spheres in the sphenoid and ethmoid regions was developed. A CT (0.625 mm slice thickness) was obtained. Registration was performed with a contour-based protocol. Accuracy was determined using the software's distance measurement tool. Registration was performed with narrow-field (NF; forehead points medial to the mid-pupillary line) and wide field (WF; entire forehead) contour maps. An experienced rhinologist and a resident surgeon performed each registration in triplicate and TRE at the sphenoid and ethmoid markers was measured in triplicate. RESULTS: WF mapping had a lower TRE than NF (1.09 mm [95% Confidence Interval (CI) 0.96-1.22] vs 1.68 mm [95% CI 1.50-1.86]). The experienced surgeon had a lower TRE compared to the resident (1.21 mm [95% CI 1.08-1.34] vs 1.54 mm [95% CI 1.35-1.74]). CONCLUSIONS: In this navigation model, wide field mapping offers better accuracy than narrow-field mapping, and an experienced surgeon seemed to achieve better accuracy than a resident surgeon. These observations have potential implications for the use of this technology in the operating room.
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Competência Clínica , Endoscopia , Processamento de Imagem Assistida por Computador , Seios Paranasais/cirurgia , Imagens de Fantasmas , Cirurgia Assistida por Computador , Marcadores Fiduciais , Humanos , Modelos Anatômicos , Seios Paranasais/diagnóstico por imagem , Projetos Piloto , Tomografia Computadorizada por Raios XRESUMO
OBJECTIVES: Adenotonsillectomy (T&A) is one of the most common surgical procedures performed in the United States. Several studies have defined the safety of laryngeal mask airway (LMA) during this surgery, and conflicting evidence exists describing the role it plays in reducing intraoperative times. Our objective is to describe the role LMA and operating on a stretcher have on reducing intraoperative time during pediatric T&A. METHODS: This is a retrospective review between October 2017 and January 2020. We included patients between the ages of 4-18 years old undergoing T&A. We excluded medically complex patients with chromosomal, craniofacial, and metabolic abnormalities, patients with cerebral palsy, and those who were tracheostomy dependent. Patient demographics included surgical indication, age, sex, obesity, use of preoperative midazolam, type of airway used, use of traditional operating room (OR) bed versus transport stretcher, surgeon type, and intraoperative times. Data was analyzed with univariate t-test and multivariate linear regression. RESULTS: One hundred seventy-nine patients were included with an average age of 7.2 years. LMA and stretcher were used on 46.4% and 40.2% of patients, respectively. On multivariate linear regression LMA reduced emergence time by 4.4 min (p ≤ 0.001, 95% CI -6.7 to -2.1) and transport stretcher reduced induction time by 2.5 min (p = 0.04, 95% CI -4.9 to -0.1). Use of LMA and stretcher did not have a statistically significant difference on actual procedure time. CONCLUSION: Our study further supports the role LMA has in reducing intraoperative times in addition to describing a novel method of reducing intraoperative time by operating on a transport stretcher for healthy children undergoing T&A. LEVEL OF EVIDENCE: 3.
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Adenoidectomia/métodos , Máscaras Laríngeas , Duração da Cirurgia , Macas , Tonsilectomia/métodos , Adolescente , Fatores Etários , Criança , Pré-Escolar , Feminino , Humanos , Modelos Lineares , Masculino , Estudos Retrospectivos , Fatores de TempoRESUMO
Hyperaccumulators store metals in the vacuoles of leaf cells. To investigate the role of vacuolar compartmentalization in Cd accumulation, chelation and induced antioxidation, we quantified the amounts of total cadmium (Cd), Cd2+, glutathione (GSH) and reactive oxygen species (ROS) in leaf cells of Solanum nigrum L. The results confirmed that vacuoles were, indeed, the main storage compartments for Cd. We then found that with increased Cd treatment concentration, the proportion of vacuolar Cd in protoplasts showed its ultimate storage capacity (82.24 %-83.40 %), and the Cd concentration stored in the protoplast maintained at a certain level (73.81-77.46 mg L-1). Besides, studies on different forms of Cd showed that the chelation state was dominant in the protoplast. The large level appearance of Cd2+ outside the vacuole revealed the limitations of vacuolar Cd2+ sequestration. The relationships between the combined forms of Cd and GSH outside the vacuole (R2 = 0.9906) showed GSH was mainly distributed to important compartments for chelation, not to vacuoles. We also demonstrated the presence of ROS-induced oxidative stress and detoxification mediated by the antioxidant GSH in vacuoles, suggesting that sequestration into vacuoles is an active process accompanied by chelation and antioxidant-mediated detoxification.
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Cádmio/toxicidade , Raízes de Plantas/metabolismo , Solanum nigrum/metabolismo , Antioxidantes/metabolismo , Glutationa/metabolismo , Microscopia de Fluorescência , Raízes de Plantas/efeitos dos fármacos , Protoplastos/efeitos dos fármacos , Protoplastos/metabolismo , Espécies Reativas de Oxigênio/metabolismo , Solanum nigrum/efeitos dos fármacosRESUMO
PURPOSE: To evaluate the effectiveness and ease of N95 respirator decontamination methods in a clinic setting and to identify the extent of microbial colonization on respirators associated with reuse. METHODS: In a prospective fashion, N95 respirators (n = 15) were randomized to a decontamination process (time, dry heat, or ultraviolet C light [UVC]) in outpatient clinics. Each respirator was re-used up to 5 separate clinic sessions. Swabs on each respirator for SARS-CoV-2, bacteria, and fungi were obtained before clinic, after clinic and post-treatment. Mask integrity was checked after each treatment (n = 68). Statistical analyses were performed to determine factors for positive samples. RESULTS: All three decontamination processes reduced bacteria counts similarly. On multivariate mixed model analysis, there were an additional 8.1 colonies of bacteria (95% CI 5.7 to 10.5; p < 0.01) on the inside compared to the outside surface of the respirators. Treatment resulted in a decrease of bacterial load by 8.6 colonies (95% CI -11.6 to -5.5; p < 0.01). Although no decontamination treatment affected the respirator filtration efficiency, heat treatments were associated with the breakdown of thermoplastic elastomer straps. Contamination with fungal and SARS-CoV-2 viral particles were minimal to non-existent. CONCLUSIONS: Time, heat and UVC all reduced bacterial load on reused N95 respirators. Fungal contamination was minimal. Heat could permanently damage some elastic straps making the respirators nonfunctional. Given its effectiveness against microbes, lack of damage to re-treated respirators and logistical ease, UVC represents an optimal decontamination method for individual N95 respirators when reuse is necessary.
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COVID-19/prevenção & controle , Descontaminação/métodos , Reutilização de Equipamento , Transmissão de Doença Infecciosa do Paciente para o Profissional/prevenção & controle , Respiradores N95/microbiologia , SARS-CoV-2/isolamento & purificação , COVID-19/transmissão , Contagem de Colônia Microbiana , Temperatura Alta , Humanos , Estudos Prospectivos , Fatores de Tempo , Raios UltravioletaRESUMO
OBJECTIVES: To compare outcomes of early and late tracheostomy change in neonatal patients. Early tracheostomy change (ETC) occurred 3 to 4 days after surgery, and late tracheostomy change (LTC) occurred 5 to 7 days after surgery. STUDY DESIGN: Retrospective cohort. SETTING: Tertiary neonatal/pediatric intensive care unit. METHODS: A retrospective review of patients who underwent tracheostomy from 2015 to 2019 was performed for infants <1 year old. Data were recorded regarding age at tracheostomy, days until tracheostomy tube change, postoperative complications, and total number of days on sedative or paralytic drugs. RESULTS: Forty-six patients were included: 18 (39%) were male, with a mean age of 140 days (SD, 78). Of these, 28 (61%) received ETC. There were no accidental decannulation events in either group. Wound breakdown developed in 4 (14%) patients with ETC versus 5 (28%) with LTC (P = .3). Use of FlexTend tracheostomy tubes was associated with decreased odds of breakdown (odds ratio, 0.03; P = .01). Postoperatively, 46 (100%) patients received sedation, and 12 (26%) received paralysis. Mean duration of paralysis was 0.5 days in ETC as opposed to 2.2 days in LTC (P = .02) on univariate analysis, but the significance was not maintained on multivariate regression (P = .07). CONCLUSIONS: ETC appears to be feasible in children less than a year of age. There does not appear to be an increased risk of accidental decannulation events or false passage tracts. Further investigations are warranted to investigate safety and possible impact on wound breakdown.
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Traqueostomia , Adolescente , Feminino , Humanos , Lactente , Recém-Nascido , Unidades de Terapia Intensiva Neonatal , Unidades de Terapia Intensiva Pediátrica , Masculino , Complicações Pós-Operatórias , Estudos RetrospectivosRESUMO
OBJECTIVES: Clinical trials have reported increases in the survival of pediatric rhabdomyosarcoma (RMS) from 25% in 1970 to 73% in 2001. The purpose of this study was to examine whether survival of pediatric patients with RMS of the head and neck improved at the US population level. METHODS: A population-based cohort of patients with rhabdomyosarcoma of the head and neck aged 0-19 years in the Surveillance, Epidemiology, and End Results (SEER) registry from 1973 to 2013 was queried. The cumulative incidence competing risks (CICR) method was used to estimate risk and survival trends. RESULTS: 718 cases were identified for analysis. Survival rates at 1-, 5-, and 10-years after diagnosis were 91.2%, 73.2%, and 69.4% respectively. Survival rates at 1 year after diagnosis increased from 82.6% to 93.1% during the study period. In the subdistributional hazard analysis, there was a significantly improved disease-specific risk of death in the first year after diagnosis. Overall risk of death did not improve significantly. Favorable prognostic factors included age <10 years at diagnosis, smaller tumor size, absence of distant metastasis, localized tumors, earlier stage at presentation, grossly complete surgical resection, and embryonal or botryoid histology. CONCLUSIONS: Disease-specific survival in the first year following diagnosis improved, but the change in overall survival at the population level was not statistically significant. These findings should be interpreted in light of the inclusion of patients with distant metastasis at diagnosis, who have poor prognoses, together with the limited statistical power afforded in studies of rare diseases.
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Neoplasias de Cabeça e Pescoço , Rabdomiossarcoma Embrionário , Rabdomiossarcoma , Criança , Neoplasias de Cabeça e Pescoço/terapia , Humanos , Prognóstico , Rabdomiossarcoma/epidemiologia , Rabdomiossarcoma/terapia , Programa de SEER , Taxa de SobrevidaRESUMO
PURPOSE: Identify variables that are predictive of morbidity and mortality in children under the age of two undergoing tracheostomy and to provide longitudinal data on this patient population. METHODS: Patients were retrospectively identified using Current Procedural Terminology codes 31600, 31601, 31610 from 2009 to 2016. RESULTS: Median age at time of tracheostomy was 0.43 years (interquartile range, 0.27-0.61). Patients were followed for a median of 1.39 years (range 0.03-4.25). Overall mortality rate in this cohort was 23.5% with the majority (81.3%) of deaths occurring >30 days following tracheostomy. The most frequently encountered major complication was cardiopulmonary arrest (10.29%) in the short-term follow up period (<30 days) and accidental decannulation (32.81%) during long-term follow up (>30 days). Peristomal skin breakdown was less likely to develop in patients who did not receive paralytics following tracheostomy. Most patients (54.4%) were discharged to home following initial admission and experienced a mean of 2.10 readmissions for any reason during the follow-up period. 64.4% of patients underwent surveillance direct laryngoscopy and bronchoscopy during the follow-up period and suprastomal granuloma formation was detected in 31.2% of these patients. 9 patients underwent decannulation at a median of 2 years from original tracheostomy placement. CONCLUSION: Pediatric patients under the age of 2 undergoing tracheostomy exhibit high morbidity during both the initial hospital admission and the subsequent months following discharge. However, major complications were low and mortality was not directly related to tracheostomy status in any case.
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Traqueostomia , Fatores Etários , Cateterismo/efeitos adversos , Estudos de Coortes , Feminino , Seguimentos , Granuloma/epidemiologia , Parada Cardíaca/epidemiologia , Humanos , Lactente , Masculino , Complicações Pós-Operatórias/epidemiologia , Fatores de Tempo , Traqueostomia/mortalidade , Resultado do TratamentoRESUMO
OBJECTIVE: Chronic rhinosinusitis (CRS) has been associated with comorbid depression, yet the prevalence of depression among all patients with CRS is not well described. The Patient Health Questionnaire-9 (PHQ-9), a validated instrument for diagnosing depression, has been used to assess depression in a variety of clinical settings. PHQ-9 scores ≥10 are the threshold for a depression diagnosis. The purpose of this study was to assess the prevalence of depression in a rhinology practice and compare the PHQ-9 with the 22-item Sinonasal Outcome Test (SNOT-22). STUDY DESIGN: Retrospective chart review. SETTING: Tertiary rhinology practice. SUBJECTS AND METHODS: During the 2-month period ending April 30, 2018, all rhinology patients were asked to complete the PHQ-9 and SNOT-22. RESULTS: Among 216 patients, 46 (21.3%) had a self-reported history of depression, and 39 (18.1%) had a PHQ-9 score ≥10. Of the 39 patients screening positive for depression, 18 (41.9%) had no history of depression. Comparison of PHQ-9 with overall SNOT-22 score had a Pearson's coefficient of 0.632 (P < .005). Logistic regression showed that the highest 2 quintiles of SNOT-22 scores had an odds ratio of 60.6 (95% CI, 9.7-378.3) for a positive depression screen (PHQ-9 score ≥10). CONCLUSION: Depression rates (estimated by PHQ-9 responses) among rhinology patients are similar to chronic disease populations; depression may be underdiagnosed in rhinology patients. Higher SNOT-22 scores were associated with higher PHQ-9 scores. Further studies are warranted to understand the impact of comorbid conditions of depression and CRS in patient quality of life.
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Transtorno Depressivo/diagnóstico , Questionário de Saúde do Paciente , Rinite/diagnóstico , Teste de Desfecho Sinonasal , Sinusite/diagnóstico , Adulto , Idoso , Doença Crônica , Estudos de Coortes , Comorbidade , Transtorno Depressivo/epidemiologia , Feminino , Seguimentos , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Prevalência , Curva ROC , Estudos Retrospectivos , Rinite/epidemiologia , Índice de Gravidade de Doença , Sinusite/epidemiologia , Estados UnidosRESUMO
CXCR5 mediates homing of both B and follicular helper T (TFH) cells into follicles of secondary lymphoid organs. We found that CXCR5+CD8+ T cells are present in human tonsils and follicular lymphoma, inhibit TFH-mediated B cell differentiation, and exhibit strong cytotoxic activity. Consistent with these findings, adoptive transfer of CXCR5+CD8+ T cells into an animal model of lymphoma resulted in significantly greater antitumor activity than CXCR5-CD8+ T cells. Furthermore, RNA-Seq-based transcriptional profiling revealed 77 differentially expressed genes unique to CXCR5+CD8+ T cells. Among these, a signature comprised of 33 upregulated genes correlated with improved survival in follicular lymphoma patients. We also showed that CXCR5+CD8+ T cells could be induced and expanded ex vivo using IL-23 plus TGF-ß, suggesting a possible strategy to generate these cells for clinical application. In summary, our study identified CXCR5+CD8+ T cells as a distinct T cell subset with ability to suppress TFH-mediated B cell differentiation, exert strong antitumor activity, and confer favorable prognosis in follicular lymphoma patients.
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Linfócitos T CD8-Positivos/citologia , Receptores CXCR5/metabolismo , Subpopulações de Linfócitos T/citologia , Transferência Adotiva , Animais , Linfócitos B/citologia , Diferenciação Celular , Técnicas de Cocultura , Feminino , Centro Germinativo/imunologia , Humanos , Leucócitos Mononucleares/citologia , Ativação Linfocitária , Linfoma Folicular/imunologia , Masculino , Camundongos , Camundongos Knockout , Camundongos Transgênicos , Tonsila Palatina/citologia , Receptores de Antígenos de Linfócitos T/genética , Transcrição Gênica , Fator de Crescimento Transformador beta/metabolismoRESUMO
OBJECTIVE: Children with single ventricle cardiac physiology (SVC) often require airway procedures as an adjunct to their care. Descriptive analysis with a focus on outcomes of airway procedures in SVC patients have not been fully described in the literature. METHODS: Retrospective, single-center cohort review of 270 patients born between Aug-2007 and Jan-2017. Patients were identified by cardiac database for single ventricle pathophysiology. A subset of these patients were identified to have been evaluated by otolaryngology with airway evaluations and/or interventions. RESULTS: 88/270 patients (32.6%) required investigation or intervention for airway pathology. The most frequent procedure was flexible fiberoptic laryngoscopy (58/88 patients); it was the only procedure performed in 40 patients. Seventeen patients required tracheostomies with an associated increased length of stay (pâ¯<â¯0.001). Patients with cardiac procedures involving dissection around the aortic arch were considered higher airway risk due to the threat of recurrent laryngeal nerve injury, and were more likely to have vocal cord paralysis (58%) compared to patients with lower risk procedures (21%; pâ¯<â¯0.001). However, on multivariate logistic regression, vocal cord paralysis did not statistically impact the odds for tracheostomy placement, although the presence of subglottic stenosis increased the odds ratio of tracheostomy by 14.7 (pâ¯=â¯0.02). CONCLUSIONS: Children with SVC often require airway evaluation and intervention. Patients with high risk cardiac procedures had a higher risk of recurrent laryngeal nerve injury but the presence of subglottic stenosis was the best predictor for a tracheostomy. This study represents one of the largest series of SVC children evaluated for airway pathology.
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Cardiopatias Congênitas/complicações , Ventrículos do Coração/anormalidades , Laringoscopia/estatística & dados numéricos , Laringoestenose/etiologia , Traumatismos do Nervo Laríngeo Recorrente/etiologia , Traqueostomia/estatística & dados numéricos , Paralisia das Pregas Vocais/etiologia , Adolescente , Criança , Pré-Escolar , Feminino , Cardiopatias Congênitas/cirurgia , Ventrículos do Coração/cirurgia , Humanos , Lactente , Recém-Nascido , Laringoestenose/epidemiologia , Modelos Logísticos , Masculino , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Traumatismos do Nervo Laríngeo Recorrente/epidemiologia , Estudos Retrospectivos , Fatores de Risco , Paralisia das Pregas Vocais/epidemiologiaRESUMO
Background The etiology of spontaneous cerebrospinal fluid (CSF) rhinorrhea remains unknown, though emerging evidence suggests that this likely represents a variant of idiopathic intracranial hypertension. Long-term success rates for repair and postoperative management strategies remain variable. Methods Retrospective review of patients undergoing surgical management of spontaneous CSF rhinorrhea was conducted over a 5-year period. Analysis was performed to correlate recurrence with demographics and perioperative variables. Lumbar puncture usage and neuro-ophthalmological examinations in clinical management were also assessed. Results Forty-eight patients were included in the study. The mean age was 51.4 years with 94% females. Leaks were most commonly located in the sphenoid (43.8%) and cribriform region (33.3%). The most common findings on magnetic resonance imaging were empty sella (48%) and Meckel's cave diverticula (24%). Nine patients (18.8%) had recurrent CSF leaks. Six occurred >1 month postoperatively. Three had repeat endoscopic repairs, two received ventriculoperitoneal shunts, and one was managed with a lumbar drain, with overall success rate of 93.8%. Acetazolamide was utilized in 19 cases (39.6%) postoperatively. Overall, 59% of patients had elevated opening pressures on postoperative lumbar puncture ( n = 32). Neuro-ophthalmology evaluated 28 patients; 25% had visual field deficits, and 7.1% had papilledema. Conclusions Management of spontaneous CSF leaks remains a significant challenge. Endoscopic repair is successful in most patients with little morbidity; however, postoperative management remains inconsistent, and further studies are warranted to establish consensus on post-surgical care. The association with elevated intracranial pressure and visual field deficits/papilledema suggests opening pressures, and neuro-ophthalmologic evaluation should be considered in the treatment algorithm.
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PURPOSE: To review rates of post-tonsillectomy hemorrhage (PTH) at a quaternary medical center, including the impact of narcotic versus nonsteroidal anti-inflammatory drug (NSAID) postoperative pain management. MATERIALS AND METHODS: A retrospective review was performed of tonsillectomies conducted at a single institution between 1/1/2013 and 1/1/2017. The rates of PTH and subsequent intervention were calculated. These were categorized into patients having surgery pre- and post-July 1, 2015, the former group receiving narcotics and the latter ibuprofen with acetaminophen. RESULTS: Of 1351 total tonsillectomies, 3.04% had PTH requiring return to the hospital. 0.74% required no further surgical intervention, whereas 2.30% required secondary surgical control. The bleed rate prior to July 2015 was 3.15%, with 1.05% non-surgical bleeds and 2.10% requiring surgery. Post-July 2015, the bleed rate was 2.92%, with 0.44% non-surgical bleeds and 2.49% requiring surgery. There were no statistically significant differences between the two groups with respect to overall, non-surgical, and surgical hemorrhage rates (pâ¯>â¯0.05). Of the total bleeds, the need for secondary surgery in the narcotic group was 66.7% and 85% in the NSAID group (pâ¯=â¯0.18). During the study period, 36 patients with PTH had their initial tonsillectomy performed at outside institutions; 53% required surgical intervention. CONCLUSIONS: Secondary hemorrhage remains a significant cause of morbidity in post-tonsillectomy patients, often requiring surgical intervention. This review found no increased bleeding risk associated with use of ibuprofen and acetaminophen as opposed to narcotic pain relief. LEVEL OF EVIDENCE: III.
Assuntos
Anti-Inflamatórios não Esteroides/uso terapêutico , Entorpecentes/uso terapêutico , Dor Pós-Operatória/tratamento farmacológico , Hemorragia Pós-Operatória/etiologia , Tonsilectomia/efeitos adversos , Humanos , Dor Pós-Operatória/diagnóstico , Dor Pós-Operatória/etiologiaRESUMO
Objectives: Historically at a multi-hospital residency program, there was an unexpected number of non-urgent consults from the county hospital emergency room (ER) that caused residents to make more trips between hospitals and come closer to violating duty hours. Moreover, there was also a poor follow-up rate for these patients. An alternate pathway to redirect such consults to the Otorhinolaryngology-Head and Neck Surgery (ORL-HNS) clinic, staffed by an attending physician, was devised. This study illustrates how an undemanding process change can improve access to care, and resident duty hours and satisfaction. Study Design: Quality Improvement Study. Methods: The average rate of no-show appointments and overall number of patients referred from the county hospital ER; a survey of impact on resident workload; and an average number of on-call resident trips to county hospital were compared in the 12 months before and after implementation of an expedited ER referral pathway. Results: The overall number of patients referred to clinic from ER increased by 35% (123 to 166 patients). The average number of completed visits for patients referred to the ORL-HNS clinic from the ER increased by 29% (91 to 117 patients). There was no statistically significant change in the no-show rate of said patients. The average number of overnight resident trips to the county hospital, frequency of resident unpreparedness for routine clinical duty and need to alter schedule to avoid duty hour violations all decreased, while resident satisfaction increased. Conclusions: An undemanding process change in a safety-net, publicly-funded, county hospital setting can decrease resident workload and improve satisfaction while possibly improving patient access to specialty clinic care and follow-up rates for patients. Level of Evidence: clinical outcomes, level IV.
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Estesioneuroblastoma Olfatório/patologia , Síndrome de Secreção Inadequada de HAD/etiologia , Neoplasias do Seio Maxilar/patologia , Adolescente , Estesioneuroblastoma Olfatório/cirurgia , Humanos , Imageamento por Ressonância Magnética , Masculino , Neoplasias do Seio Maxilar/cirurgia , Síndromes Paraneoplásicas/etiologiaRESUMO
OBJECTIVES: To determine the prevalence of MRI abnormalities in adults undergoing cochlear implantation and to correlate abnormalities to audiology data. STUDY DESIGN: Case series. SETTING: Academic medical center. METHODS: Adult patients (>18 yr old) undergoing cochlear implant evaluation from January 2008 to December 2012 were identified based on CPT code search. Demographics, preoperative MRI findings, operative findings, and audiometric data were collected. RESULTS: The study included 188 patients. Seventeen (9%) patients had significant otic capsule or vestibulocochlear nerve pathologies: 5 vestibular schwannomas, 4 enlarged vestibular aqueducts, 2 hypoplastic cochlear nerves, 2 labyrinthitis ossificans, 1 cochlear aplasia, 1 posterior semicircular canal malformation, 1 calcified meningioma, and 1 cholesterol granuloma. MRI results were normal (65%) or with findings not directly related to hearing loss (incidental findings, 25%) in the remaining patients. Mean pure tone average (PTA) differences (between the implanted and contralateral ear) did not significantly vary between normal-incidental and abnormal MRI scans (-6.6 dB versus -6.7 dB, p = 0.99) nor did speech discrimination scores (SDS) scores (8.5% versus 8.4%, p = 0.99). No significant difference was found in HINT scores for patients with a normal versus an abnormal MRI (19% versus 16,%, p = 0.62). CONCLUSION: Although the majority of precochlear implantation MRIs were normal or demonstrated incidental findings, such as white matter changes, significant MRI findings affecting implantation site and patient counseling were found in almost 10% of patients. Audiogram findings did not correlate with abnormal findings on MRIs. Routine use of MRI in adult cochlear implant candidates may be warranted.
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Cóclea/patologia , Cóclea/cirurgia , Perda Auditiva Neurossensorial/patologia , Perda Auditiva Neurossensorial/cirurgia , Imageamento por Ressonância Magnética , Adulto , Idoso , Audiometria , Implante Coclear/métodos , Implantes Cocleares , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Adulto JovemAssuntos
Região Branquial/anormalidades , Doenças Fetais/diagnóstico , Seio Piriforme/anormalidades , Região Branquial/cirurgia , Branquioma/diagnóstico , Diagnóstico Diferencial , Doenças Fetais/diagnóstico por imagem , Neoplasias de Cabeça e Pescoço/diagnóstico , Humanos , Imageamento por Ressonância Magnética , Masculino , Seio Piriforme/cirurgia , Ultrassonografia Pré-NatalRESUMO
OBJECTIVE: To determine the frequency and clinical significance of abnormalities on postoperative computerized tomography (CT) scans performed within 24 hours after lateral skull base surgery. STUDY DESIGN: Case series with chart review. Setting Inpatient tertiary care hospital. METHODS: Adult patients undergoing lateral skull base surgery were identified using CPT code search from January 2010 to January 2013. Patient demographics, type of skull base lesion, surgical approach, length of operation, time between end of the surgery and CT scan, CT scan findings, and patients' postsurgical neurologic status were collected. RESULTS: One hundred and seventy-two patients were identified who had a postoperative CT scan after lateral skull base surgery. Diagnoses included schwannoma (95), cerebrospinal fluid fistula (29), middle fossa encephaloceles (9), meningioma (13), superior semicircular canal dehiscence (12), and other disease processes (14). The approaches were middle fossa (64), translabyrinthine (70), suboccipital (17), infratemporal (8), and combined/other (13). Mild pneumocephalus was almost always found, along with mild extra-axial blood. Twenty-four patients had significant mass effect found on CT scan, but this was present preoperatively. Three patients had a mild subdural without neurological decline. No patient suffered any clinically significant neurological decline, although 5 patients reported finger numbness that resolved spontaneously and 2 patients had confusion in the immediate postoperative period. CONCLUSION: Clinically significant abnormalities on immediate postoperative CT scans were rare, as were cases of neurological decline. Further prospective studies could determine a more cost-effective algorithm for routine use of postoperative imaging.
Assuntos
Procedimentos Neurocirúrgicos , Neoplasias da Base do Crânio/diagnóstico por imagem , Base do Crânio/diagnóstico por imagem , Tomografia Computadorizada por Raios X/métodos , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Período Pós-Operatório , Estudos Prospectivos , Reprodutibilidade dos Testes , Base do Crânio/cirurgia , Neoplasias da Base do Crânio/cirurgia , Fatores de TempoRESUMO
OBJECTIVES/HYPOTHESIS: A variety of techniques for inferior turbinate reduction have been used in children, but to date practice patterns have not been studied. The purpose of this survey was to study the practice of inferior turbinate surgery among pediatric otolaryngologists. STUDY DESIGN: Cross-sectional survey study. METHODS: A questionnaire was sent electronically to American Society of Pediatric Otolaryngologists members. RESULTS: A total of 249 questionnaires were sent, and 103 (41%) were completed. Six questionnaires were eliminated due to incompleteness. Seventy-nine (81%) respondents performed inferior turbinate surgery. The most common reason for not performing the procedure was lack of outcomes data. Coblation was the most common technique used in 51% of respondents. A change in surgical technique in the last 2 to 5 years, most commonly to coblation or microdebridement, was reported by 53% of respondents. Nasal obstruction was the primary indication for turbinate reduction (81%), followed by sleep-disordered breathing (16%). Respondents reported that 20% of turbinate reductions were sole procedures, and 80% were with other procedures: adenotonsillectomy, septoplasty, and sinus surgery. Fifty-six (71%) responders were either satisfied or very satisfied with the results of pediatric turbinate surgery. Failure of the procedure, epistaxis, and nasal crusting were commonly reported complications, and 9% reported major complications. CONCLUSIONS: A high proportion of pediatric otolaryngologists perform inferior turbinate surgery, most commonly for nasal obstruction. Coblation is the most common technique used, and complications are mostly minor. Physician satisfaction rates are high despite a paucity of outcomes data on the procedure.
Assuntos
Otolaringologia , Pediatria , Padrões de Prática Médica , Conchas Nasais/patologia , Conchas Nasais/cirurgia , Criança , Estudos Transversais , Humanos , Hipertrofia/cirurgiaRESUMO
OBJECTIVE: To determine the natural history and management for patients with intracochlear schwannomas. STUDY DESIGN: Retrospective case series of intracochlear schwannomas confined to the otic capsule. SETTING: Tertiary referral center. PATIENTS: Ten patients were found to have schwannomas limited to the cochlea from 1998 to 2009. INTERVENTIONS: All subjects underwent at least 1 magnetic resonance imaging (MRI) study and had at least 1 audiogram. Two patients underwent a transotic excision for intractable symptoms. MAIN OUTCOME MEASURES: Presenting symptoms, initial and follow-up MRI findings, audiometric testing results, and need for surgical intervention were recorded for each subject. RESULTS: Hearing loss was present in all 10 patients at their initial presentation. Tinnitus was present in 50% of patients, and vertigo was present in 30% of patients. No patient presented with aural fullness or facial weakness. The pattern of hearing loss seemed to correlate with the location of the lesion within the cochlea. Of the 9 patients that had follow-up MRIs, 3 patients showed tumor growth. Two of the 10 patients underwent surgical excision for intractable vertigo that resulted in resolution of symptoms. CONCLUSION: Hearing loss is the most common finding in patients with intracochlear schwannomas, followed by tinnitus and vertigo. If the patient does not have symptoms of intractable vertigo, observation with serial MRI scans is indicated. Surgical excision should be reserved for patients with intractable vertigo or with significant tumor growth.