ABSTRACT
INTRODUCTION: In March 2020, the World Health Organization declared COVID-19 a pandemic, initiating stay-at-home orders which delayed cancer care and screening. The impact on head and neck cancer care in populations at risk has yet to be elucidated. The objective of this investigation is to evaluate how the presentation, diagnosis, and treatment of head and neck squamous cell carcinoma cancer patients at a county hospital were affected by the pandemic. METHODS: A retrospective review of patients with head and neck squamous cell carcinoma that were diagnosed at a county hospital 365 days before and after stay-at-home orders were initiated. The primary outcomes were duration between diagnosis from imaging and initiation of treatment. Secondary outcomes included mortality, stage, nodal status, and distant metastasis at presentation. RESULTS: There was a total of 105 diagnoses. Sixty-five (62 %) head and neck squamous cell carcinoma diagnoses were diagnosed before the stay-at-home orders were initiated, and 40 (38 %) after. Eighty percent (32/40) of diagnoses presenting after had stage IV disease compared to 58 % (38/65) in those before (p < 0.05). A higher percentage of patients who presented later had a >30-day delay to biopsy (43 % v. 20 %, OR: 3.0, p < 0.05). This difference was exacerbated by those with laryngeal, oral cavity, or oropharyngeal cancer (45 % v. 15 %, OR: 4.5, p < 0.05). There was a larger delay from diagnosis to treatment after the orders were initiated (68 v. 53, p < 0.05) however there was no difference in one-year mortality (25 % v. 23 %, p > 0.05). This investigation found a 14 % loss to follow-up. CONCLUSIONS AND RELEVANCE: In this cohort of head and neck squamous cell carcinoma diagnoses at a county hospital, those diagnosed after the stay-at-home orders were initiated presented with more advanced disease. They also had more delays in diagnosis and initiation of treatment. There was no difference in one-year mortality rates between the two groups however there was a significant loss to follow-up, limiting prognostication. These findings serve to better prepare healthcare providers to implement optimized care during future shutdowns related to public health crises. LEVEL OF EVIDENCE: III.
Subject(s)
Carcinoma, Squamous Cell , Head and Neck Neoplasms , Humans , Squamous Cell Carcinoma of Head and Neck/therapy , Carcinoma, Squamous Cell/diagnosis , Carcinoma, Squamous Cell/therapy , Carcinoma, Squamous Cell/pathology , Hospitals, County , Pandemics , Head and Neck Neoplasms/diagnosis , Head and Neck Neoplasms/therapy , Retrospective StudiesABSTRACT
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.
Subject(s)
Hearing Loss, Noise-Induced , Noise, Occupational , Occupational Exposure , Otolaryngology , Humans , Child , Hearing Loss, Noise-Induced/epidemiology , Hearing Loss, Noise-Induced/etiology , Hearing Loss, Noise-Induced/prevention & control , Noise, Occupational/adverse effects , Tertiary Healthcare , Sound , Ambulatory Care Facilities , Occupational Exposure/adverse effectsABSTRACT
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.
Subject(s)
COVID-19/prevention & control , Decontamination/methods , Equipment Reuse , Infectious Disease Transmission, Patient-to-Professional/prevention & control , N95 Respirators/microbiology , SARS-CoV-2/isolation & purification , COVID-19/transmission , Colony Count, Microbial , Hot Temperature , Humans , Prospective Studies , Time Factors , Ultraviolet RaysABSTRACT
OBJECTIVE: To determine if cochlear implant (CI) is safe and effective in patients with radiation therapy (XRT)-induced sensorineural hearing loss and to discuss considerations in this population through a retrospective cohort review, systematic review, and meta-analysis. DATABASES REVIEWED: PubMed, Cochrane Library, and Embase. METHODS: We retrospectively reviewed all CI cases after head and neck (HN) XRT at our institution, noting intraoperative findings, postoperative complications, and hearing outcomes. Change in speech discrimination scores (SDSs) was the primary outcome measure. Systematic review was performed to identify all cases of CI after HNXRT. A meta-analysis was performed to assess SDS change. RESULTS: The retrospective cohort review identified 12 patients who underwent CI after HNXRT. One patient with HN cancer (HNC) and one with central nervous system pathology (CNSP) received bilateral implants. Six had HNC, three had CNSP, and one had Langerhans cell histiocytosis. Eleven had abnormal findings during CI. There were no postoperative complications. Twenty articles with an additional 97 patients were suitable for systematic review inclusion. Of the 109 patients, 67 (61.5%) had HNC and 18 (16.5%) had CNSP. Abnormal intraoperative findings were common (30.3%), most frequently in the mastoid (66.7%). Postoperative complications, including wound dehiscence and infection with some requiring explantation, occurred in 10.1% of patients. Sixty-six patients were included in the meta-analysis. All demonstrated SDS improvement (mean increase, 56.2%). CONCLUSION: Patients with prior HNXRT benefit from CI. Paying careful attention to surgical planning and technique, postoperative care, and patient expectations is imperative, as complications are not uncommon.
Subject(s)
Cochlear Implantation , Head and Neck Neoplasms , Hearing Loss, Sensorineural , Humans , Cochlear Implantation/methods , Cochlear Implantation/adverse effects , Hearing Loss, Sensorineural/etiology , Hearing Loss, Sensorineural/surgery , Male , Middle Aged , Head and Neck Neoplasms/radiotherapy , Head and Neck Neoplasms/surgery , Female , Aged , Retrospective Studies , Treatment Outcome , Adult , Radiotherapy/adverse effects , Postoperative Complications/epidemiology , Postoperative Complications/etiologyABSTRACT
OBJECTIVE: To evaluate the contribution of postnasal drip (PND) and chronic cough (CC) to symptoms of patients with chronic rhinitis treated with temperature-controlled radiofrequency (TCRF) neurolysis of the posterior nasal nerve (PNN), and correlate PND and CC scores with components of the reflective total nasal symptom score (rTNSS). METHODS: Pooled data from three prospective studies: two single-arm studies and the index active treatment arm of a randomized controlled trial. Adult patients with baseline rTNSS ≥6 were treated with TCRF neurolysis at nonoverlapping regions of the PNN. PND and CC symptoms were evaluated on a 0 (none) to 3 (severe) scale. RESULTS: Data from 228 patients (57.9% women, 42.1% men) were included. The mean baseline rTNSS was 8.1 (95% confidence interval [CI], 7.8-8.3), which decreased to 3.2 (95% CI, 2.9-3.5) at 6 months. At baseline, 97.4% of patients had PND and 80.3% had CC. Median baseline PND and CC symptom scores were 3 (interquartile range [IQR], 2-3) and 2 (IQR, 1-2), respectively. At 6 months, this decreased to 1 (IQR, 0-2) and 0 (IQR, 0-1), respectively, showing significant improvement from baseline (both p < 0.001). Spearman correlation coefficients with components of rTNSS (rhinorrhea, congestion, itching, sneezing) were 0.16 to 0.22 for CC and 0.19 to 0.46 for PND, indicating only a weak to moderate correlation. CONCLUSION: PND and CC contribute to the symptomatology of chronic rhinitis and are significantly improved after TCRF neurolysis of the PNN. The inclusion of PND and CC symptoms in a chronic rhinitis assessment instrument could provide important additional information for the characterization of the disease state and outcomes after any therapeutic treatment.
Subject(s)
Chronic Cough , Rhinitis , Adult , Female , Humans , Male , Cough/therapy , Nasal Mucosa , Prospective Studies , Rhinitis/drug therapy , Rhinorrhea , Temperature , Randomized Controlled Trials as TopicABSTRACT
PURPOSE OF REVIEW: Ménière's disease is a disorder characterized by recurrent episodes of vertigo, hearing loss, tinnitus, and pressure in the ear. Its pathogenesis and optimal management continue to be the subject of ongoing debate. Although it is classically believed to be a primary disorder of the inner ear, some clinicians have hypothesized that it is a form of vestibular migraine. RECENT FINDINGS: Evidence supporting vestibular migraine in the differential of Ménière's disease includes overlap of symptoms, high prevalence of migraines in patients with Ménière's disease, and the efficacy of migraine treatments for symptoms of Ménière's disease in some patients. However, there is far more evidence to support Ménière's disease as a disorder of the inner ear, including genetic and histologic changes of hydrops, imaging studies showing hydropic changes, predominance of low-frequency hearing loss, clinical efficacy of treatments targeted at inflammatory change/hydrops, and clinical efficacy of ablating the vestibular end-organ. SUMMARY: Although there is conflicting evidence regarding the cause and treatment of Ménière's disease, current evidence favors it as a disorder of the inner ear. Further research is needed to fully understand the mechanisms of Ménière's disease and how to improve diagnosis and treatment outcomes.
Subject(s)
Deafness , Meniere Disease , Migraine Disorders , Vestibule, Labyrinth , Humans , Meniere Disease/diagnosis , Meniere Disease/etiology , Meniere Disease/therapy , Migraine Disorders/diagnosis , Migraine Disorders/etiology , Migraine Disorders/therapy , EdemaABSTRACT
Unified airway disease describes the shared epidemiologic and pathophysiologic relationship among the chronic inflammatory diseases of the upper and lower airways including allergic rhinitis, chronic rhinosinusitis, asthma, and chronic otitis media. This concept proposes that these diseases are manifestations of a single inflammatory process and require an integrated diagnostic and therapeutic approach to achieve global disease control. Future directions to further establish this entity should focus on pathophysiology, diagnostic markers, flora microbes with particular emphasis on fungi, the role of type 3 inflammation, and targeted therapeutics including biologics, JAK inhibitors, and synthetic peptides.
Subject(s)
Asthma , Rhinitis, Allergic , Sinusitis , Humans , Sinusitis/diagnosis , Sinusitis/therapy , Asthma/diagnosis , Asthma/therapy , Respiratory System , Inflammation , Chronic DiseaseABSTRACT
OBJECTIVE: To identify differences in inpatient otolaryngology consultations and interventions for patients based on COVID-19. METHODS: Records were reviewed for all patients for whom otolaryngology was consulted at a high-volume tertiary care hospital from April 30, 2020 to October 1, 2020. Demographic information, length of stay, COVID-19 status, indication for consultation, and otolaryngology interventions were recorded. Statistical analysis was performed using R software. RESULTS: Bleeding composed a significantly higher proportion of otolaryngology consults in COVID-19 positive patients (28% vs. 8.4%, p<0.0001). Management of bleeding was the most common procedure performed in positive patients (n=37, 35%), and they had a higher median number of interventions performed when compared to bleeding patients who tested negative (1, IQR 1-2 vs. 1, IQR 0-1, p=0.04). COVID-19 positive patients with bleeding were more likely to expire than those with other indications for otolaryngology consultation (50% vs. 7%, p<0.001). CONCLUSION: Bleeding and associated interventions comprised the predominant discrepancy between COVID-19 positive and negative patients in our cohort. We encourage routine use of simple and cost-effective methods to decrease risk of bleeding.
Subject(s)
COVID-19 , Otolaryngology , Humans , Retrospective Studies , Referral and Consultation , HemorrhageABSTRACT
A sound anesthesiologist-surgeon collaboration is crucial for the success of functional endoscopic sinus surgery (FESS). The aim of this narrative review was to describe if and how anesthetic choice can decrease bleeding and improve visibility in the surgical field (VSF) and thus contribute to successful FESS. A literature search was conducted on evidence-based practices published from 2011 to 2021 describing perioperative care, intravenous/inhalation anesthetics, and operative approaches for FESS and their effects on blood loss and VSF. With regards to preoperative care and operative approaches, best clinical practices include topical vasoconstrictors at the time of surgery, medical management (steroids) preoperatively, and patient positioning, as well as anesthetic techniques including controlled hypotension, ventilation settings, and anesthetics choices. Four out of five meta-analyses and six out of 11 randomized controlled trials favored total intravenous anesthesia (TIVA) over inhalation anesthesia (IA) for improved VSF. The effects on VSF were more dependent on adjunct medications used (remifentanil, alpha-2 agonists, etc.), rather than the choice of anesthetic technique (i.e., TIVA vs. IA). The current literature is inconclusive regarding the impact of anesthetic choice on VSF during FESS. We recommend that anesthesiologists use the anesthetic technique with which they are most comfortable to facilitate efficiency, recovery, cost, and collaboration with the perioperative team. Future studies should be designed to consider disease severity, the method for measuring blood loss, and a standardized VSF score. Studies should also investigate the long-term effects of TIVA- and IA- induced hypotension.
Subject(s)
Anesthetics, Inhalation , Propofol , Humans , Endoscopy/methods , Anesthetics, Intravenous , Anesthesia, Inhalation , Anesthesia, General/methods , Anesthesia, Intravenous/methodsABSTRACT
Background: Endoscopic sinus surgery presents significant visuospatial challenges to surgical trainees. We tested the utility of novel 3D printed models to simulate sinus surgery tasks to improve endoscopic skillsets in resident trainees. Methods: This was a prospective quality improvement study of 10 ENT residents (PGY1-5). Participants rotated through 4 stations with different 3D simulation training modules designed to enhance endoscopic skillsets in the axial, sagittal and coronal planes (e.g., straight forceps to grasp a bead from a ledge, angled instruments to cannulate openings). Participants completed a self-assessment survey on the subjective sinus surgical skills using a visual analog scale before and after tasks. Two- tailed paired T-tests were used to analyze the data. Results: All residents rated their post-intervention "overall sinus surgery skills" higher than pre-intervention. They rated simulations to provide more significant utility as an adjunct to surgical education after the intervention. All but one participant reported improved spatial awareness working with the endoscopes and surgical instruments. There was subjectively improved proficiency in using 0-degree and angled endoscopes as well as cutting, grasping, and curved instruments after the intervention. The simulations led to subjective improvements in spatial awareness, bimanual dexterity, and increased confidence in selecting correct surgical instruments. Conclusion: Our set of novel 3D printed models to improve sinus surgery skillset was well accepted by the resident cohort. The 3D models can serve as an adjunct tool to traditional residency education.
ABSTRACT
OBJECTIVE: Investigate the impact of medical comorbidities on treatment regimen and overall survival (OS) in patients with locally advanced laryngeal cancer. STUDY DESIGN: Retrospective Review of the National Cancer Database (NCDB). METHODS: The NCDB was queried for patients with T3 and T4 laryngeal cancer. Comorbidity scores were calculated from the Charlson-Deyo comorbidity index (CDCI). Univariate and multivariate analyses explored the association of CDCI scores on treatment regimen and OS. RESULTS: 14,053 patients were analyzed. 65% of patients had a CDCI score of 0, whereas 25%, 7%, and 3% had CDCI score of 1, 2, and ≥3, respectively. As patients' CDCI increased, they became more likely to receive treatment options other than a laryngectomy or chemoradiation therapy (CRT) (P < 0.0001). Patients with CDCI ≥1 were more likely have a laryngectomy than those with CDCI 0 (P < 0.0001). In patients with T3 tumors, OS did not differ between those receiving CRT versus laryngectomy with any CDCI score. In patients with T4 tumors, laryngectomy was associated with improved OS compared to CRT across all CDCI scores except CDCI ≥3. CONCLUSION: Our results support the current national guidelines with a recommendation for CRT or TL for T3 tumors and a preference for TL for T4 tumors. These outcomes are generally consistent in patients as their CDCI scores increases. LEVEL OF EVIDENCE: NA Laryngoscope, 130:1459-1464, 2020.
Subject(s)
Laryngeal Neoplasms/mortality , Laryngeal Neoplasms/therapy , Aged , Clinical Protocols , Female , Humans , Laryngeal Neoplasms/complications , Laryngeal Neoplasms/pathology , Male , Middle Aged , Neoplasm Staging , Retrospective Studies , Survival RateABSTRACT
Prophylactic arterial ligation has been proposed to reduce the severity of postoperative hemorrhage following transoral robotic surgery (TORS). Previous studies have shown a trend toward a reduction in major and severe bleeding. Search strategies were implemented in multiple databases and completed in August 2018. Inclusion and exclusion criteria were designed to capture studies examining adults undergoing TORS for oropharyngeal cancer. Four retrospective studies were selected appropriate for analysis by two reviewers who independently extracted data. PRISMA guidelines were followed. A random-effects model was used for meta-analysis. Meta-analysis of 619 patients in four retrospective reviews showed that the pooled RR of major and severe bleeding events was significantly lower in prophylactically ligated patients (RR, 0.28; 95% CI, 0.08-0.92; I2 = 0). Prophylactic arterial ligation of external carotid artery branches is associated with a decreased risk of major and severe bleeding events, although confounding factors remain incompletely analyzed.
Subject(s)
Oropharyngeal Neoplasms , Robotic Surgical Procedures , Adult , Humans , Ligation , Oropharyngeal Neoplasms/surgery , Postoperative Hemorrhage/prevention & control , Retrospective Studies , Robotic Surgical Procedures/adverse effectsABSTRACT
OBJECTIVES: (1) For patients with oral squamous cell carcinoma (OSCC) and mandibular invasion, to determine whether prior radiation to the head and neck region (PXRTHN) affects the density of osteoblasts, osteoclasts, or fibroblasts along the tumor interface invading the mandible and whether this is significantly associated with overall survival. (2) To identify clinicopathologic features that are associated with overall survival. STUDY DESIGN: Case series with chart review. SETTING: University of Missouri hospital. SUBJECTS AND METHODS: Retrospective review of 74 cases with pathologically confirmed mandible invasion by OSCC and surgical treatment between January 1, 2005, and December 31, 2015. A board-certified anatomic pathologist reviewed the slides from all mandibulectomy cases. RESULTS: The mean density of osteoclasts was 2.0 per linear mm among the patients with PXRTHN and 7.1 among those without PXRTHN ( P < .001). Positive soft tissue frozen section margin was significantly associated with overall survival on univariate analysis ( P < .001; hazard ratio [HR], 0.34; 95% CI, 0.19-0.62) and multivariate analysis ( P = .026; HR, 0.41; 95% CI, 0.19-0.90). Maximum tumor dimension was significantly associated with overall survival on univariate analysis ( P = .021; HR, 1.19; 95% CI, 1.03-1.38) and multivariate analysis ( P = .002; HR, 1.49; 95% CI, 1.16-1.93). Osteoclast, osteoblast, and fibroblast density were not associated with overall survival. CONCLUSIONS: (1) Osteoclast density along the tumor front is significantly lower among patients with PXRTHN. Stromal cell density was not associated with overall survival. (2) Positive soft tissue frozen section margin and maximum tumor dimension are significantly associated with overall survival among patients with mandibular invasion by OSCC.