Posterior fossa volume in idiopathic intracranial hypertension: a magnetic resonance imaging-based study.

BACKGROUND: The etiology of idiopathic intracranial hypertension (IIH) is uncertain. Studies suggest the fundamental cause of the Chiari 1 malformation, a congenitally hypoplastic posterior fossa, may explain the genesis of IIH in some patients. PURPOSE: To assess the hypothesis that linear and volumetric measurements of the posterior fossa (PF) can be used as predictors of IIH. MATERIAL AND METHODS: A retrospective analysis of magnetic resonance imaging (MRI) studies on 27 patients with IIH and 14 matched controls was performed. A volumetric sagittal magnetization prepared rapid acquisition gradient echo sequence was used to derive 10 linear cephalometric measurements. Total intracranial and bony posterior fossa volumes (PFVs) were derived by manual segmentation. The ratio of PFV to total intracranial volume was calculated. RESULTS: In total, 41 participants were included, all women. Participants with IIH had higher median body mass index (BMI). No significant differences in linear cephalometric measurements, total intracranial volumes, and PFVs between the groups were identified. Linear measurements were not predictive of volumetric measurements. However, on multivariate logistic regression analysis, the likelihood of IIH decreased significantly per unit increase in relative PFV (odds ratio [OR]=3.66 × 10-50; 95% confidence interval [CI]=1.39 × 10-108 to 1.22 × 10-5; P = 0.04). Conversely, the likelihood of IIH increased per unit BMI increase (OR=1.19; 95% CI=1.04-1.47; P = 0.02). CONCLUSION: MRI-based volumetric measurements imply that PF alterations may be partly responsible for the development of IIH and Chiari 1 malformations. Symptoms of IIH may arise due to an interplay between these and metabolic, hormonal, or other factors.

Facial Trauma Management During the Coronavirus Disease 2019 Pandemic.

IMPORTANCE: Facial trauma is managed with open or closed treatment modalities; however, the impact of the coronavirus disease 2019 (COVID-19) pandemic on facial trauma management remains unclear. OBJECTIVE: To determine whether the management of facial trauma varied during the COVID-19 pandemic. DESIGN SETTING, PARTICIPANTS: A retrospective review of 127 adults at The R Adams Cowley Shock Trauma Center at the University of Maryland between March 2019 and March 2021. Adults were stratified into pre-COVID (before March 2020) and post-COVID groups. MAIN OUTCOMES AND MEASURES: Open reduction internal fixation alone, maxillomandibular fixation (MMF) alone, Open reduction internal fixation and MMF, and closed reduction. RESULTS: Of the 127 patients, 66 were treated pre-COVID (52%) and 61 post-COVID (48%). While the prevalence of mandible fractures did not differ (pre-COVID, n = 39, 59%; post-COVID, n = 42, 69%; P = 0.33), the use of MMF alone decreased (pre-COVID, n = 9, 23%; post-COVID, n = 1, 2%; P = 0.005). In contrast, while the prevalence of displaced nasal bone fractures decreased (pre-COVID, n = 21, 32%; post-COVID, n = 4, 7%; P = 0.0007), management with closed reduction did not differ (pre-COVID, n = 23, 96%; post-COVID, n = 11, 85%; P = 0.27). CONCLUSIONS AND RELEVANCE: Although the clinical characteristics of patients with facial fractures did not differ during the COVID-19 pandemic, the use of MMF for mandible fractures changed significantly. LEVEL OF EVIDENCE: Level IV.

Presence of hearing loss is predictive of return for further stages of tinnitus therapy following initial education and counseling.

OBJECTIVE: Identify clinical factors that predict the likelihood of patients returning for further evaluation and treatment following stage 1 education and counselling in a staged tinnitus habituation program. DESIGN: Retrospective cross-sectional study. Demographics, audiometric findings and Tinnitus Handicap Inventory (THI) scores were used for predictive modelling to determine the likelihood of patients returning for subsequent therapy. STUDY SAMPLES: One hundred and ninety consecutive patients treated in an outpatient, staged tinnitus habituation program. RESULTS: Improvements in THI scores were observed in all subjects (n = 119, d = 0.49, p < 0.001), both for those without hearing loss (n = 13, d = 0.54, p = 0.03) and those with hearing loss (n = 106, d = 0.48, p < 0.001) following Stage 1 education and counselling. Subjects with hearing loss were 14 times more likely to return for Stage 2 evaluation (p < 0.001) following completion of Stage 1 education and counselling. CONCLUSION: Subjects with idiopathic subjective non-pulsatile tinnitus across all degrees of tinnitus severity benefit from group education and counselling alone. Subjects with hearing loss, irrespective of most hearing loss configurations, are more likely to return for subsequent stages of the program.

Anxiety, Depression, and Symptom Severity in Patients with Pulsatile and Non-Pulsatile Tinnitus.

OBJECTIVE(S): To compare the rates of anxiety and depression between patients with pulsatile (PT) and non-pulsatile tinnitus (NPT), and their correlation with tinnitus severity. METHODS: A prospective cross-sectional study of consecutive patients presenting either to the otolaryngology clinic for pulsatile (PT) and NPT or to a tertiary care tinnitus habituation program (THP) were administered the tinnitus handicap inventory (THI), 7-item general anxiety disorder scale (GAD-7), and 9-item patient health questionnaire (PHQ-9). Median scores between groups and correlation of scores within groups were calculated and compared. RESULTS: Median THI scores were significantly higher for THP and PT patients as compared with unselected NPT patients (58 and 44 vs. 20, p ≤ 0.001). Median GAD-7 (10 vs. 2.5 and 2, p ≤ 0.001) and PHQ-9 (7 vs. 4 and 4, p = 0.04) scores were highest in THP patients compared with PT and NPT. The strongest correlation between tinnitus handicap and psychiatric measures was seen in THP patients. CONCLUSION: THP patients report higher levels of anxiety and depression compared with PT and other NPT patients. Tinnitus severity correlates more strongly with GAD-7 and PHQ-9 scores in THP patients compared with other patient groups. PT patients have a greater self-perceived tinnitus handicap than the general cohort of NPT patients, statistically comparable to THP patients. Despite this, anxiety and depression are not more severe in patients with PT as they are in THP patients. LEVEL OF EVIDENCE: 2B Laryngoscope, 133:683-688, 2023.

Stratifying the Risk of Cardiovascular Disease in Obstructive Sleep Apnea Using Machine Learning.

OBJECTIVES/HYPOTHESIS: Obstructive sleep apnea (OSA) is associated with higher risk of morbidity and mortality related to cardiovascular disease (CVD). Due to overlapping clinical risk factors, identifying high-risk patients with OSA who are likely to develop CVD remains challenging. We aimed to identify baseline clinical factors associated with the future development of CVD in patients with OSA. STUDY DESIGN: Retrospective analysis of prospectively collected data. METHODS: We performed a retrospective analysis of 967 adults aged 45 to 84 years and enrolled in the Multi-Ethnic Study of Atherosclerosis. Six machine learning models were created using baseline clinical factors initially identified by stepwise variable selection. The performance of these models for the prediction of additional risk of CVD in OSA was calculated. Additionally, these models were evaluated for interpretability using locally interpretable model-agnostic explanations. RESULTS: Of the 967 adults without baseline OSA or CVD, 116 were diagnosed with OSA and CVD and 851 with OSA alone 10 years after enrollment. The best performing models included random forest (sensitivity 84%, specificity 99%, balanced accuracy 91%) and bootstrap aggregation (sensitivity 84%, specificity 100%, balanced accuracy 92%). The strongest predictors of OSA and CVD versus OSA alone were fasting glucose >91 mg/dL, diastolic pressure >73 mm Hg, and age >59 years. CONCLUSION: In the selected study population of adults without OSA or CVD at baseline, the strongest predictors of CVD in patients with OSA include fasting glucose, diastolic pressure, and age. These results may shape a strategy for cardiovascular risk stratification in patients with OSA and early intervention to mitigate CVD-related morbidity. LEVEL OF EVIDENCE: 3 Laryngoscope, 132:234-241, 2022.

The impact of sleep events on weight gain following early adenotonsillectomy compared to supportive care for pediatric OSA.

OBJECTIVES: Children with obstructive sleep apnea (OSA) who undergo adenotonsillectomy (AT) often experience post-operative weight gain, although the mechanism remains unclear. Our aim is to understand how changes in sleep events impact changes in weight in children with OSA following adenotonsillectomy compared to watchful waiting with supportive care. METHODS: We performed a secondary analysis of the Childhood adenotonsillectomy trial (CHAT) dataset in which children with OSA were randomized to undergo early adenotonsillectomy (eAT) or watchful waiting with supportive care (WWSC). The primary outcome measures included changes in body mass index (BMI) percentile, apnea-hypopnea index (AHI) and arousal index (AI) during rapid eye movement (REM) sleep. The change in BMI percentile attributable to changes in AHI and AI during REM sleep was determined using causal mediation analysis. RESULTS: Of the 453 children with OSA randomized to eAT or WWSC, 397 children were included in the analysis. Children in the eAT arm experienced a greater increase in their weight as measured by BMI percentile, compared to children who received WWSC (WWSC 4.12 (2.70, 5.55) vs. eAT 6.62 (4.87, 8.38), Cohen's d = 0.22 (0.02, 0.42), p = 0.02). A significant proportion of the weight gain was attributable to decreases in apneic events (proportion mediated 19% (2-97%), p = 0.03) and arousals (proportion mediated 20% (5-78%), p = 0.01) during REM sleep. CONCLUSION: A significant proportion of post-adenotonsillectomy weight gain in children with OSA is attributable to polysomnographic changes during REM sleep, potentially due to the mitigation of REM-related sleep fragmentation and subsequent reduction in metabolic expenditure.

Predictors of Postoperative Complications After Paramedian Forehead Flaps.

Importance: The predictors of postoperative complications after paramedian forehead flaps (PMFF) are unknown. Objective: To determine whether preoperative factors can predict post-PMFF complications. Design, Setting, Participants: A retrospective review of 1438 adults from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database who underwent PMFF between 2010 and 2018. Main Outcomes and Measures: Surgical complications, medical complications, and all-cause mortality. Results: Of the 1438 patients, 75 experienced postoperative complications (5.2%). Of these, 36 developed isolated surgical complications (2.5%), 29 developed isolated medical complications (2.0%), and 8 developed concurrent surgical and medical complications (0.5%). Of the three mortalities (0.2%), one patient developed concurrent surgical and medical complications. A dirty or infected wound classification was the strongest predictor of postoperative complications (odds ratio [OR] 13.5; confidence interval [95% CI] 3.4-49.5). In contrast, the likelihood of postoperative complications decreased significantly with outpatient procedures (OR 0.4; 95% CI 0.2-0.8). Conclusions and Relevance: A dirty or infected wound classification is the strongest predictor of postoperative complications after PMFF.

Baseline apnea-hypopnea index threshold and adenotonsillectomy consideration in children with OSA.

OBJECTIVES: Adenotonsillectomy (AT) is the first line of treatment for pediatric obstructive sleep apnea (OSA). In some treatment guidelines, children with moderate to severe OSA, defined as apnea-hypopnea index (AHI) ≥ 5, may be recommended AT regardless of symptoms. The differences in outcomes between children randomized to watchful waiting with supportive care (WWSC) or AT were compared based on baseline OSA severity threshold of AHI≥ 5. METHODS: A secondary analysis of the Childhood Adenotonsillectomy Trial, a randomized controlled trial of children with OSA aged 5-9 years who underwent AT or WWSC, was performed. The primary outcome was the change in neurocognition measured by Developmental Neuropsychological Assessment (NEPSY). Secondary outcomes included changes in behavior, symptoms of OSA, and quality of life. Outcomes were measured at baseline and the seven-month follow-up after grouping children based on whether their AHI was greater than or equal to 5. Comparisons were performed using two-way analysis of covariance (ANCOVA) while controlling for age, sex and race. Differences in treatment effect were measured using Cohen's d. RESULTS: Of the 397 children included, 203 received WWSC and 194 underwent AT. The treatment effects on post-randomization changes in neurocognition, measured by NEPSY in children with AHI ≥5 (Cohen's d = 0.1 [95% CI, -0.1 to 0.4]) was not significantly different from children with AHI <5 (Cohen's d = 0.1 [95% CI, -0.1 to 0.4]). Furthermore, among children in the AT group alone, the effects of AT on post-treatment changes in NEPSY did not differ based on AHI threshold (Cohen's d = -0.06 [95% CI, -0.3 to 0.2]). Additionally, the treatment effects on post-randomization changes in behavior, symptoms, and quality of life did not vary based on AHI threshold. CONCLUSION: The outcomes of neurocognition, behavior, symptoms, and quality of life did not differ between children with OSA randomized to WWSC or AT based on OSA severity threshold alone. Additionally, the effects of AT on post-treatment outcomes did not differ based on AHI threshold.