The Effect of Delay Following the Clinical Decision to Perform Tracheostomy in the Critical Care Setting.

BACKGROUND: Tracheostomy in patients who are critically ill is generally performed due to prolonged mechanical ventilation and expected extubation failure. However, tracheostomy criteria and ideal timing are poorly defined, including equivocal data from randomized controlled trials and median intubation to tracheostomy times that range from 7-21 d. However, a consistent finding is that only ∼50% of late tracheostomy groups actually undergo tracheostomy, with non-performance due to recovery or clinical deterioration. Unlike in many jurisdictions, elective surgical procedures in our institution require a court-appointed guardian, which necessitates an approximately 1-week delay between the decision to perform tracheostomy and surgery. This offers a unique opportunity to observe patients with potential tracheostomy during a delay between the decision and the performance. METHODS: ICU patients who were ventilated were identified for inclusion retrospectively by an application for guardianship relating to tracheostomy, the intention-to-treat point. The main outcomes of tracheostomy, extubation, or death/palliative care after inclusion were noted. Demographics, outcomes, and event timing were compared for the 3 outcome groups. RESULTS: Tracheostomy-related guardianship requests were made for 388 subjects. Of these, 195 (50%) underwent tracheostomy, whereas 127 (33%) were extubated and 66 (17%) either died before tracheostomy (46 [12%]) or were transitioned to palliative care (20 [5%]). The median time (interquartile range) from guardianship request until a defining event was the following: 6.2 (4.0-11) d for tracheostomy, 5.0 (2.9-8.2) d for extubation (P < .001 as compared to tracheostomy group), and 6.5 (2.5-11) d for death/palliative care (P = .55 as compared to tracheostomy). Neurological admissions were more common in the tracheostomy group and less common in the palliative group. Other admission demographics and hospitalization characteristics were similar. Hospital mortality was higher for subjects undergoing tracheostomy (58/195 [30%]) versus extubation (24/127 [19%]) (P = .03). CONCLUSIONS: Delay in performing tracheostomy due to legal requirements was associated with a 50% decrease in the need for tracheostomy. This suggests that decision-making with regard to ideal tracheostomy timing could be improved, saving unnecessary procedures.

Trans-mastoid plugging of superior semicircular canal dehiscence: long-term follow-up.

OBJECTIVE: To evaluate the long-term outcomes of trans-mastoid plugging of superior semicircular canal dehiscence (SSCD), focusing on complicated cases. METHODS: In this cohort study, we included all patients who underwent trans-mastoid plugging of SSCD between 2009 and 2019. We evaluated the symptoms (autophony, sound-/pressure-induced vertigo, disequilibrium, aural fullness and pulsatile tinnitus) before and 1 year after surgery in the medical records. We systematically assessed the current symptoms 6.2 ± 3 years postoperative (range 2.2-12.3 years) using questionnaires sent by post and validated by telephone interviews. We also documented any complications and the need for further procedures. We compared pure tone and speech audiometry before and 1 year after surgery. Finally, the degree of mastoid pneumatisation and mastoid tegmen anatomy were reviewed on preoperative CT scans. RESULTS: We included 24 ears in 23 patients. No complications were recorded, and none required a second procedure for SSCD. Following surgery, oscillopsia and Tullio phenomena resolved in all patients. Hyperacusis, autophony, and aural fullness were also settled in all patients except one. Balance impairment persisted to some degree in 35% of patients. No deterioration over the years was reported regarding the above symptoms. On average, bone conduction pure tone average pre- and 1 year postoperative were 13.7 ± 17 and 20.5 ± 18 dB, respectively (P = 0.002). Air bone gaps were reduced from 12.7 ± 8 to 5.9 ± 6 (P = 0.001). Two patients had a significant sclerotic mastoid, three had a prominent low-lying mastoid tegmen, and two had both. Anatomy had no effect on outcome. CONCLUSION: Trans-mastoid plugging of SSCD is a reliable and effective technique which achieves long-lasting symptom control, even in cases with sclerotic mastoid or low-lying mastoid tegmen.

The management of acute supraglottitis patients at the intensive care unit.

INTRODUCTION: Acute supraglottitis is a potentially life-threatening condition that often necessitates intensive care unit (ICU) admission for airway monitoring. The objective of this study was to identify clinical criteria that predict a benign course for patients with acute supraglottitis. METHODS: A prospective observational study was performed. Adult patients hospitalized in the ICU between 2007 and 2019 diagnosed with acute supraglottitis were included. All patients were treated with antibiotics and corticosteroids. Fiber optic laryngoscopy (FOL) was performed every 12 h, with each exam defined as "improving", "no change" or "deteriorating" based on the presence of airway edema. Need for airway intervention was correlated to changes in the FOL exam. RESULTS: Of 146 patients included, 14 (10%) required intubation, ten on admission, and four during the first 6 h of ICU admission. FOL follow-up was performed on 528 occasions-427 (81%) exams showed improvement, 16 (3%) deterioration, and 85 (16%) with no change. On no occasions was improvement in FOL followed by deterioration. The median ICU length of stay was 3 (IQR 2-3.5) vs. 1 (IQR 1.0-1.25) day for patients who did or did not require intubation (p < 0.001), respectively. CONCLUSION: Improvement in FOL exam accurately predicted the absence of need for intubation and might represent a criterion for early ICU discharge.

Real Time Monitoring During Cochlear Implantation: Increasing the Accuracy of Predicting Residual Hearing Outcomes.

OBJECTIVES: Real-time electrocochleography (rt-ECochG) is a method to detect intracochlear potential changes during cochlear implantation (CI). Steep amplitude drops of the cochlear microphonic (CM) signal (so called "ECochG events") have been correlated with worse residual hearing outcomes. However, the sensitivity and specificity of monitoring CM amplitude on its own are too low to use it as a biomarker. The aim of this article was to establish if additional signal components would help to better predict postoperative hearing outcomes. DESIGN AND SETTING: Single-center, prospective cohort study at a tertiary referral hospital. PARTICIPANTS AND INTERVENTIONS: Between 2017 and 2020, we included 73 adult patients receiving a lateral wall cochlear implant electrode. During electrode insertion, rt-ECochG measurements were performed. MAIN OUTCOMES: We calculated a multiple regression analysis for patients with one ECochG event. The dependant variable was the relative acoustic hearing result 4 weeks after surgery. Independent variables were CM latency, a ratio of the auditory nerve neurophonic to the CM (the ANN/CM index) as well as CM signal recovery. RESULTS: The change of the ANN/CM index linearly correlated with acoustic hearing outcomes 4 weeks after surgery. Adding this factor led to a statistically significant increase in the variance accounted for by the regression model. CONCLUSIONS: When monitoring the implantation process with rt-ECochG, prediction of postoperative hearing thresholds is improved by addition of the ANN/CM index to a model that includes CM amplitude fluctuation.

Toward a Better Understanding of Electrocochleography: Analysis of Real-Time Recordings.

OBJECTIVES: Real-time electrocochleography (ECochG) has been used as a monitoring tool during cochlear implantation (CI), whereby, amplitude drops have been correlated with postoperative acoustic hearing results. However, no consensus has been reached as to how a single event of an amplitude drop should be characterized. The aim of this study was to identify ECochG events that predict loss of hearing 1 month after surgery. DESIGN: Fifty-five patients were included in this prospective cohort study. Real-time ECochG measurements were performed during CI electrode insertion. Single ECochG events were characterized according to their amplitude loss and slope steepness. RESULTS: Using receiver operating characteristic analyses, the most efficient cut-off criterion for a relative hearing loss of 25% was an amplitude loss of 61% at a fixed slope steepness of 0.2 µV/sec. Three-quarters of our population had at least one such event during implantation. Most events occurred shortly before full insertion. With increasing number of events, median residual hearing thresholds deteriorated for all frequencies. Larger amplitude drops trended toward worse hearing preservation. Signal recovery after an ECochG event could not be correlated to acoustic hearing outcomes. CONCLUSIONS: Our data suggest that amplitude drops exceeding 61% of the ongoing signal at a slope steepness of 0.2 µV/sec are correlated with worse acoustic hearing preservation. Clearly defined ECochG events have the potential to guide surgeons during CI in the future. This is essential if a fully automated data analysis is to be employed or benchmarking undertaken.

Revision cochlear implantation using a double array device in the post-meningitis ossified cochlea.

PURPOSE: To describe the surgical technique and outcome in a series of patients who underwent revision cochlear implantation using a double array or split electrode device. All patients developed ossified cochleae due to meningitis and were functioning poorly with the previous implant. METHODS: Four patients between the ages of 4-15 years underwent revision with five double-array cochlear implant devices. One patient underwent bilateral revision surgery. All patients had previous meningitis with CT and MRI imaging studies that demonstrated completely ossified cochleae. The time interval range between the disease and the initial cochlear implantation and was 4 months to 3 years. The patient's data were retrospectively analyzed with emphasis on the surgical technique, the number of electrodes inserted, and the number of active electrodes at follow-up. In addition, pre and post-revision surgery function was compared. RESULTS: The revision surgery was carried out 2-11 years after the initial surgery. Two tunnels, basal and apical, were drilled in the ossified cochlea. In each of the tunnels, 5 to 11 electrodes were inserted. While the number of active electrodes before revision was 0-5, after revision with the double array, it was increased to 8-12, resulting in improved auditory and speech function. CONCLUSION: Revision cochlear implantation with a double array implant using the two tunnel technique can increase the number of active electrodes. This leads to a better outcome in post-meningitis children with completely ossified cochleae and a poor functioning previous device.

Four-point impedance as a biomarker for bleeding during cochlear implantation.

Cochlear implantation has successfully restored the perception of hearing for nearly 200 thousand profoundly deaf adults and children. More recently, implant candidature has expanded to include those with considerable natural hearing which, when preserved, provides an improved hearing experience in noisy environments. But more than half of these patients lose this natural hearing soon after implantation. To reduce this burden, biosensing technologies are emerging that provide feedback on the quality of surgery. Here we report clinical findings on a new intra-operative measurement of electrical impedance (4-point impedance) which, when elevated, is associated with high rates of post-operative hearing loss and vestibular dysfunction. In vivo and in vitro data presented suggest that elevated 4-point impedance is likely due to the presence of blood within the cochlea rather than its geometry. Four-point impedance is a new marker for the detection of cochlear injury causing bleeding, that may be incorporated into intraoperative monitoring protocols during CI surgery.

English translation and validation of the Zurich chronic middle ear inventory (ZCMEI-21-E) assessing quality of life in chronic otitis media: A prospective international multicentre study.

OBJECTIVES: To translate and validate the Zurich Chronic Middle Ear Inventory (ZCMEI-21) for the English language in order to provide an English instrument to assess health-related quality of life in chronic otitis media (COM). DESIGN: Pilot translation study including cognitive debriefings, prospective multicentre cross-sectional psychometric validation study. SETTING: Four tertiary referral centres in three different English-speaking countries (UK, USA and Australia). PARTICIPANTS: Adult patients suffering from COM. MAIN OUTCOME MEASURES: The English translation of the ZCMEI-21 (ZCMEI-21-E) and the five-level version of the EQ-5D questionnaire. The EQ-5D, which constitutes a generic measure of health-related quality of life, consists of a descriptive system score and a visual analogue scale. Statistical outcomes included single-item descriptive statistics, internal consistency (Cronbach's α) as an indicator of reliability, as well as construct validity. RESULTS: A total of 124 patients suffering from COM were included. The mean age was 50.1 years (SD 16.9 years), and 72 (58.1%) were males. The Cronbach's α of the ZCMEI-21-E was 0.91, suggesting an excellent internal consistency. The Spearman's correlation coefficient of the ZCMEI-21-E total score was 0.55 (P < 0.0001) for convergent construct validity with EQ-5D descriptive system score and 0.57 (P < 0.0001) with the EQ-5D visual analogue scale. CONCLUSIONS: The ZCMEI-21-E is a new validated questionnaire that provides clinicians with a short, comprehensive and reliable instrument to quantify health-related quality of life in patients suffering from COM. The ZCMEI-21-E may be of use in clinical routine as well as in outcome research and monitoring.

Starplasty tracheostomy: case series and literature review.

OBJECTIVES: The starplasty tracheostomy (SPT) technique has been suggested to reduce the short-term complications of tracheostomy, including accidental decannulation and pneumothorax. The aim of the present study was to conduct a review of key parameters prior to and following treatment of neonates and children with the SPT technique, including indications, complications, perioperative department stay, and overall length of stay in one University-Affiliated Medical Center. METHODS: A retrospective chart review of all children under the age of 18 underwent SPT in a single center between February 2006 and January 2012. RESULTS: Among the 39 patients reviewed, the median age at the time of surgery was 14.5 months, ranging from 3 days to 8.8 years. The most common indication for SPT was respiratory insufficiency resulting from central nervous system disorders (15, 38.4%) followed by neuromuscular disorders (14, 35.9%). Ten (25.6%) operations were performed on neonatal intensive care unit (NICU) patients and 29 (74.4%) on pediatric intensive care unit (PICU) patients. The median postoperative hospital stay was 19.5 days (range of 3-207 days); however, the median postoperative stay in the PICU was 13.5 days. There were no decannulations or any other short-term complications after SPT, and no SPT-related deaths occurred. CONCLUSIONS: In our series, pediatric SPT was not associated with any major complications. Therefore, we conclude that SPT should be considered as a safe and advantageous alternative for traditional tracheotomy, especially in patients with low probability of future decannulation, and, therefore, at low risk of a persistent tracheocutaneous fistula.

Bipolar tonsillotomy: A novel and effective tonsillotomy technique.

OBJECTIVE: To present, for the first time, tonsil size reduction using reusable bipolar forceps electrocautery (RBFE), as a treatment for pediatric OSAS and to assess the safety and efficacy of the procedure. METHODS: A prospective interventional design study was performed. Thirty children aged 2-15 years with OSAS (AHI>5) diagnosed by means of polysomnography were included. All children were treated with adenoidectomy and RBFE tonsillotomy without dissection. Re-polysomnography was performed after 1 year. The size of the tonsils was blindly assessed by two ENT specialists and the parents were asked to fill out 'Pediatric Sleep Questionnaires' (PSQ), before surgery, and one month and one year after surgery. RESULTS: There were no complications during or after surgery. There were no events involving postoperative bleeding or dehydration. The surgery mean time, including adenoidectomy, was 20.6min. The AHI was 10.9 before surgery and decreased to 1.8 after surgery (p<0.001), minimum saturation (SaO2 min) increased from 86.1% to 93.2% (p<0.001). The size of the tonsils decreased from a mean of +3.3 before surgery to +1.3 and +1.4 one month and one year after surgery, respectively. The mean of the PSQ scores went down from 23.6 to 5.5 and to 6.2 one month and one year after surgery, respectively. CONCLUSION: We demonstrated that simple cauterization of the tonsils using a RBFE device with an adenoidectomy is a safe and effective treatment to decrease tonsil size in OSAS. In addition, the method is inexpensive, rapid and does not cause bleeding, which may be particularly interesting in the presence of coagulation problems.