Sociodemographic and Healthcare System Barriers to PAP Alternatives for Adult OSA: A Scoping Review.

OBJECTIVE: To investigate sociodemographic and healthcare system barriers to access and utilization of alternative treatments to positive airway pressure (PAP) in the management of adult obstructive sleep apnea (OSA). DATA SOURCES: PubMed, Embase, and Web of Science databases were searched from 2003 to 2023 for English-language studies containing original data on sociodemographic and healthcare system barriers to PAP-alternative treatments for adult OSA. REVIEW METHODS: Studies were assessed using the Preferred Reporting Items for Systematic Reviews and Meta-analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines. Title and abstract screening, full-text review, and data collection were conducted by two investigators independently. RESULTS: Out of 1,615 studies screened, 13 studies met inclusion criteria and reported on a total of 1,206,115 patients who received PAP alternative treatments, including surgery (n = 9 studies), and oral appliances (OAs) (n = 3 studies). The chance of receiving a PAP-alternative treatment such as surgery was greater among patients aged 39 years or younger, had body mass index below 30 kg/m2, fewer comorbidities, private insurance, and a higher occupational and income status. The decision of individuals to receive PAP alternative treatments was influenced by increased patient education from providers, as well as improvements in daytime sleepiness and partner perception of snoring and apnea. CONCLUSION: Cumulative evidence suggests that several sociodemographic and healthcare system factors are associated with decreased use of PAP alternatives when PAP therapy fails. Investigation of interventions to eliminate these potential barriers may improve access and treatment outcomes. Laryngoscope, 2024.

Sex Differences in Obstructive Sleep Apnea Including Pregnancy and Response to Treatment.

This article highlights the sex differences in obstructive sleep apnea (OSA) and sheds light on the varying presentations, diagnostic challenges, as well as treatment responses observed in men and women. The disparities in prevalence, manifestations, and therapeutic outcomes underscore the need for a nuanced approach to OSA diagnosis and management that considers sex-specific factors. Furthermore, this article highlights the importance of recognizing and treating OSA during pregnancy, as it poses unique challenges and potential risks to both maternal and fetal health.

Leadership Training Curriculum for Otolaryngology-Head and Neck Surgery Residents: A Scoping Review.

OBJECTIVE: Otolaryngologists take on various leadership roles throughout their daily practice, but specific training focused on leadership development during otolaryngology-head and neck surgery (OHNS) residency is not well-defined. This project explores the current state of leadership curricula for OHNS residents. DATA SOURCES: Google Scholar, Embase, PubMed, and MedEdPORTAL. REVIEW METHODS: A scoping review was performed on English-language, full-text, peer-reviewed articles that describe leadership curricula for OHNS residents. Investigators reviewed curriculum settings, content, delivery methods, and assessment; curriculum effectiveness was evaluated using Kirkpatrick effectiveness scores and article quality was assessed using the Best Evidence in Medical Education (BEME) index. CONCLUSION: Three thousand four hundred sixteen articles met search criteria, 198 articles were included for full-text review, and 4 articles met inclusion criteria. Curriculum content and delivery methods were diverse. Curriculum cadence ranged from 2-day immersion trainings to year-long longitudinal programs. Only one of the included studies utilized a needs assessment to inform curriculum development. Two articles achieved Kirkpatrick effectiveness scores of 2, indicating changes in the attitudes or perceptions among participants and a quality measure of 3, indicating clear conclusions drawn from the results. IMPLICATIONS FOR PRACTICE: The current state of leadership training in OHNS residency is limited and nonuniform. These data align with descriptions of leadership training in other surgical residencies which are reported as heterogenous and lacking in effectiveness. This review highlights the need for standardized leadership training for OHNS residents. The high-quality leadership development initiatives within graduate medical education are reviewed to inform future directions for effective curriculum development and assessment.

Association of Pain Disorder and Psychiatric Disease With Surgical Management of Obstructive Sleep Apnea.

OBJECTIVE: Patients undergoing surgical management for obstructive sleep apnea (OSA) are likely medically distinct from their counterparts not treated surgically. This study examined the associations between psychiatric and pain comorbidities and the likelihood of undergoing sleep surgery. STUDY DESIGN: A retrospective cohort study of adults with OSA. SETTING: Large integrated healthcare system. METHODS: The primary outcome was nonnasal, nonbariatric sleep surgery. The associations of baseline demographic and comorbid conditions with surgery to treat underlying OSA were examined using bivariable and multivariable analyses. RESULTS: Among 172,854 adults with OSA, 2456 received sleep surgery. Comorbid pain disorder and/or pain medication treatment was associated with 41% higher odds of surgery (95% confidence interval: 1.29-1.54). In bivariable analyses, those with a history of headache (p = .004), particularly migraine (p = .003), disorders of adult personality or behavior (p = .025), or behavioral/emotional disorder (p < .001) were more likely to undergo surgery. Younger adults were also more likely to undergo surgery (mean age at diagnosis 39.8 ± 12.6 vs 54.7 ± 14 years), as were men, Asian/Pacific Islander or Hispanic adults, those with lower body mass index (32 ± 7 vs 34.3 ± 8.1 kg/m2 ), or those with Charlson Comorbidity Index of zero (p < .001). CONCLUSION: Our study suggests a history of pain disorder (including receipt of pain medication), migraine, or certain behavioral and personality disorders are associated with an increased likelihood of undergoing sleep surgery. The findings may better characterize comorbid predictors of sleep surgery and potentially help clinicians tailor expectations, postoperative pain management, and overall sleep outcomes.

Characteristics of Adults Undergoing Soft Tissue and Orthognathic Surgery for Obstructive Sleep Apnea.

OBJECTIVE: To identify clinical and demographic characteristics of adults with obstructive sleep apnea (OSA) undergoing soft tissue and orthognathic sleep surgery, assess temporal trends in surgery type and proportion of women undergoing surgery, and provide clinical perspective before wide-spread implementation of hypoglossal nerve stimulation (HGNS). METHODS: In a retrospective cohort study, adults diagnosed with OSA from 2009 to 2016 were identified in a large integrated healthcare system. Characteristics between cohort members who did and did not undergo sleep surgeries were compared. Multivariable logistic regression models examined associations of different characteristics with whether surgery was performed. RESULTS: Of 172,216 adults with OSA, 2,262 (1.3%) underwent sleep surgery during 2009-2017. The most common sleep surgery was palate surgery (56.9%), which decreased proportionately over time. In multivariable analysis, older age and obesity were associated with lower odds of undergoing surgery. Those who underwent tonsillectomy and adenoidectomy were more likely to have larger tonsils and not require additional surgery, whereas tongue reduction recipients were more likely to have severe OSA and require multiple surgery types. The proportion of women undergoing surgery increased over time (p < 0.001 from trend test). CONCLUSION: Clinical and demographic characteristics associated with soft tissue and orthognathic sleep surgery were identified in a large adult cohort prior to widespread implementation of HGNS. An increase in sleep surgery among women and a decrease in palate surgery over time were observed. The findings provide clinical perspective on sleep surgery performed prior to implementation of HGNS and may inform future studies examining its associations with patient characteristics. LEVEL OF EVIDENCE: 3 Laryngoscope, 133:1262-1270, 2023.

International Consensus Statement on Obstructive Sleep Apnea.

BACKGROUND: Evaluation and interpretation of the literature on obstructive sleep apnea (OSA) allows for consolidation and determination of the key factors important for clinical management of the adult OSA patient. Toward this goal, an international collaborative of multidisciplinary experts in sleep apnea evaluation and treatment have produced the International Consensus statement on Obstructive Sleep Apnea (ICS:OSA). METHODS: Using previously defined methodology, focal topics in OSA were assigned as literature review (LR), evidence-based review (EBR), or evidence-based review with recommendations (EBR-R) formats. Each topic incorporated the available and relevant evidence which was summarized and graded on study quality. Each topic and section underwent iterative review and the ICS:OSA was created and reviewed by all authors for consensus. RESULTS: The ICS:OSA addresses OSA syndrome definitions, pathophysiology, epidemiology, risk factors for disease, screening methods, diagnostic testing types, multiple treatment modalities, and effects of OSA treatment on multiple OSA-associated comorbidities. Specific focus on outcomes with positive airway pressure (PAP) and surgical treatments were evaluated. CONCLUSION: This review of the literature consolidates the available knowledge and identifies the limitations of the current evidence on OSA. This effort aims to create a resource for OSA evidence-based practice and identify future research needs. Knowledge gaps and research opportunities include improving the metrics of OSA disease, determining the optimal OSA screening paradigms, developing strategies for PAP adherence and longitudinal care, enhancing selection of PAP alternatives and surgery, understanding health risk outcomes, and translating evidence into individualized approaches to therapy.

Representation of Race and Sex in Sleep Surgery Studies.

OBJECTIVE: Obstructive sleep apnea (OSA) is a highly prevalent disorder with many treatment modalities, including surgical intervention. While OSA is known to be more prevalent in males and Black Americans, the representation of race and sex in sleep surgery studies is unknown. The aim of this systematic review is to assess the race and sex demographics represented in sleep surgery studies relative to known OSA demographics. DATA SOURCES: PubMed, MEDLINE, and OVID databases. REVIEW METHODS: A systematic review was conducted to identify studies published between 2016 and 2020 that investigated sleep outcomes following nonnasal surgical intervention for OSA in adults. Pooled racial, ethnic, and sex data of the enrolled subjects in selected studies were analyzed. RESULTS: The 148 included studies comprised 13,078 patients. Of the 137 studies that reported sex, 84.0% of participants were male, exceeding the population prevalence of OSA in males, which is estimated at 66%. Only 13 studies reported racial/ethnic demographic data. Of these, 87.8% of patients were White. Out of 30 studies of primarily American patients, only 4 reported race demographic data, with an average of 82.8% White participants. CONCLUSION: There is a racial/ethnic and sex inclusion bias among sleep surgery studies. Future studies should better document the demographics of enrolled participants as well as recruit participants who better represent the demographics of adults with OSA in the general population.

Survey of Pediatric Otolaryngology Frenotomy Practice Patterns.

OBJECTIVES: Assess current frenotomy practice patterns of pediatric otolaryngologists via a cross-sectional survey. STUDY DESIGN: Survey study. METHODS: A 31-question electronic survey assessing frenotomy practice patterns was distributed to all American Society of Pediatric Otolaryngology (ASPO) members. Descriptive statistics were used to summarize responses and demographics of respondents. RESULTS: Of all ASPO members, 41% (240/588) completed the survey. Most respondents, 185 (77%), reported increased frenotomy referrals over the last 5 years and 144 (60%) described the current number of referrals as "too many." The two primary lingual frenotomy indications identified in infants were: breastfeeding/nipple pain (92%) and inability to latch (83%). For older children, speech difficulty (87%) was the primary indication. Maxillary frenotomy indications in infants varied amongst respondents. For analgesia during in-office frenotomy procedures, respondents used glucose/sucrose drops (48%), topical lidocaine (29%), or no pain control measure (27%). For post-procedure care, respondents recommended continuing lactation support (45%), massaging/stretching the wound (38%), or none (40%). Most respondents, 143 (60%), reported having seen a complication from frenotomy, and the most reported frenotomy complications were frenulum re-attachment and excessive bleeding. CONCLUSIONS: In the last 5 years, otolaryngologists have seen an increase in referrals for frenotomy. Pediatric otolaryngologists have varying practice patterns with regards to ankyloglossia diagnosis and treatment. The reported indications for frenotomy varied amongst pediatric otolaryngologists especially with respect to maxillary frenotomy. Practice patterns also varied with respect to procedural pain control and frenotomy aftercare recommendations. More frenotomy research is needed to establish a standard of care for patients with ankyloglossia. LEVEL OF EVIDENCE: 4 Laryngoscope, 132:2505-2512, 2022.

Patient-Defined Goals for Obstructive Sleep Apnea Treatment.

OBJECTIVES: To characterize the treatment goals and values of adult patients with obstructive sleep apnea (OSA). STUDY DESIGN: Mixed methods design based on semistructured interviews followed by cross-sectional surveys. SETTING: Academic medical center and integrated managed care consortium. METHODS: Phase 1 involved qualitative analysis of focus groups and interviews to define treatment goal categories. Phase 2 included analysis of cross-sectional surveys on most important treatment goals from patients with OSA presenting to sleep surgery clinic. Positive airway pressure (PAP) use, Epworth Sleepiness Scale score, and apnea-hypopnea index were obtained to determine influences on goal choices. RESULTS: During focus groups and interviews, treatment goal themes identified included improving sleep quality, reducing daytime sleepiness, snoring sound reduction, and health risk reduction. In phase 2, 536 patients were surveyed, and they reported the primary treatment goals of health risk reduction (35%), sleep quality improvement (28%), daytime sleepiness improvement (21%), and snoring sound reduction (16%). The primary treatment goal was associated with age (P < .0001), excessive daytime sleepiness (Epworth Sleepiness Scale score >10, P < .0001), PAP use status (P < .0001), and OSA severity (apnea-hypopnea index, P < .0001). Severity of OSA was associated with increasing proportion of patients choosing health risk reduction as the main treatment goal (P < .05). CONCLUSIONS: Adult OSA treatment goal choices vary with age, symptoms, PAP history, and OSA severity. Understanding patient-specific goals is the essential first step in the shared decision-making process when choosing surgical or nonsurgical treatments. Ultimately, goal-focused discussions ensure alignment of priorities and definitions of success between the patient and the provider.

Ten-year Thyroid Cancer Incidence in an Integrated Healthcare Delivery System.

INTRODUCTION: The incidence of papillary thyroid cancer (PTC) has increased in recent decades, but data from community-based settings are limited. This study characterizes PTC trends in a large, integrated healthcare system over 10 years. METHODS: The annual incidence of PTC (2006-2015) was examined among Kaiser Permanente Northern California adults aged 21 to 84 years using Cancer Registry data, including tumor size and stage. Incidence estimates were age-adjusted using the 2010 US Census. RESULTS: Of 2990 individuals newly diagnosed with PTC (76.8% female, 52.7% non-Hispanic White), 38.5% and 61.5% were aged < 45 and < 55 years, respectively. At diagnosis, 60.9% had PTC tumors ≤ 2 cm, 9.2% had tumors > 4 cm, and 66.1% had Stage I disease. The annual age-adjusted incidence of PTC increased from 9.4 (95% confidence interval [CI] = 8.1-10.7) to 14.5 (95% CI = 13.1-16.0) per 100,000 person-years and was higher for female patients than for male patients. Incidence tended to be higher in Asian/Pacific Islanders and lower in Black individuals. Increasing incidence was notable for Stage I disease (especially 2006-2012) and evident across a range of tumor sizes (3.0-4.6 for ≤ 1 cm, 2.5-3.5 for 1-2 cm, and 2.4-4.7 for 2-4 cm) but was modest for large tumors (0.9-1.5 for > 4 cm) per 100,000 person-years. DISCUSSION: Increasing PTC incidence over 10 years was most evident for tumors ≤ 4 cm and Stage I disease. Although these findings may be attributable to greater PTC detection, the increase across a range of tumor sizes suggests that PTC burden might also have increased.

The efficacy of surgery for upper airway resistance syndrome: A systematic review, meta-analysis and case series.

PURPOSE: Upper airway resistance syndrome (UARS) is a sleep related breathing disorder that was first described in 1993. This goal of this study is to determine the efficacy of surgical intervention for UARS. MATERIALS AND METHODS: Systematic review of the literature and a case series of UARS patients at a large integrated healthcare system. Meta-analysis was performed. RESULTS: For the systematic review, 971 abstracts were reviewed and 3 articles were included, yielding 49 subjects. All of the included studies were of level 3 or 4 evidence. Significant improvement in Epworth Sleepiness Scale (ESS) score was noted after surgery in two level 4 studies. No significant change in ESS was noted in one level 3 study. Our retrospective chart review of eleven UARS patients compared preoperative and postoperative ESS scores, as well as sleep study data. Patients underwent a variety of surgical procedures. Our findings show a significant improvement in mean ESS scores after surgery, from 11.0 (±3.5) to 7.0 (±4.8) with p = 0.01, though no difference in apnea hypopnea index (AHI) and respiratory disturbance index (RDI) were identified. Meta-analysis was performed on 2 studies from the systematic review and our cases series data. UARS surgery showed a mean change in ESS of -5.89 (95% CI, -8.29 to -3.50). CONCLUSIONS: This systematic review, meta-analysis and retrospective case series indicate that surgery may improve ESS scores in patients with UARS. AHI and RDI are unlikely to be impacted by surgery.

Otolaryngology Resident Wellness, Training, and Education in the Early Phase of the COVID-19 Pandemic.

OBJECTIVE: To determine changes in the residency experience early in the COVID-19 pandemic and evaluate wellness measures among otolaryngology residents. METHODS: A web-based survey was administered to U.S. otolaryngology residents. Responses to the Shirom-Melamed Burnout Measure (SMBM) and the Generalized Anxiety Disorder-7 scale were recorded along with data on burnout, demographics, wellness, sleep, training, and education. RESULTS: 119 U.S. otolaryngology residents representing 27 of 42 states with otolaryngology residency programs responded to the survey. 24.4% (95% CI 17.0-31.8%) self-reported some level of burnout, while 10.9% met SMBM criteria for "clinically relevant" burnout. 51.3% experienced more stress, and 58.8% reported more anxiety during the COVID-19 pandemic. Compared to males, females had a higher prevalence of burnout (38.9% vs 12.3%, P = .001) and anxiety (75.9% vs 43.8%, P < .001). PGY-2s had a greater mean SMBM index (3.64) and higher rates of self-reported burnout (54.2%) than their counterparts at other levels of training. Residents reported less time spent in the hospital, lower surgical volume, and less procedural independence. Educational didactics, primarily via videoconference, were more frequent for 63.9% of respondents. CONCLUSION: While burnout among otolaryngology residents was low early in the COVID-19 pandemic, likely due to separation from the workplace environment, trainees had higher levels of anxiety and stress. The surgical experience was negatively impacted by the pandemic, but remote didactics and educational opportunities increased. These findings may inform otolaryngology residency programs on the need to promote resident wellness and aid in devising strategies to improve the educational experience during this unique global health crisis as well as in the long term.

Topical nasal treatment efficacy on adult obstructive sleep apnea severity: a systematic review and meta-analysis.

BACKGROUND: Nasal obstruction is a common complaint in patients with sleep-disordered breathing and obstructive sleep apnea (OSA). Although topical nasal treatments (TNTs) have been shown to reduce nasal resistance and improve nasal obstruction, there is conflicting evidence regarding the role of TNTs in adult OSA. In this systematic review and meta-analysis we aim to evaluate the role of TNTs in adults with OSA. Data sources used included PubMed, Ovid MEDLINE, and Cochrane Central, from January 2001 to July 2019. METHODS: Inclusion criteria were English-language studies containing original data on TNTs in adults (≥18 years) with OSA (apnea-hypopnea index [AHI] ≥5). Exclusion criteria were case reports, studies without outcome measures, and concurrent non-TNT treatment for OSA. Two investigators independently reviewed all articles and performed quality assessment using validated tools. Meta-analysis and quality assessment were performed. RESULTS: Of the 2180 abstracts identified, 8 studies met inclusion criteria. TNTs included decongestants (4 of 8 studies), corticosteroids (3 of 8), and antihistamines (1 of 8). Outcome measures included AHI (8 of 8), respiratory distress index (RDI; 1 of 8), oxygen-desaturation index (ODI; 3 of 8), minimum SaO2 (MinSaO2 ; 4 of 8), nasal resistance (4 of 8), endoscopic sinus surgery (4 of 8 studies) and standardized rhinoconjunctivitis quality of life questionnaire scores (1 of 8 studies). Qualitatively, all studies showed trends toward improving objective and subjective measures of OSA, although the significance of these improvements varied across studies. A meta-analysis was performed in 5 studies, but TNTs did not reveal a significant change in AHI (p > 0.05). CONCLUSION: TNTs may improve minimum oxygen saturation, ODI, RDI, and subjective/quality-of-life measures. Allergic patients may have more improvement in OSA measures compared with nonallergic patients. Future studies are indicated to accurately determine the efficacy of TNTs.

Otolaryngology Residency Interviews in a Socially Distanced World: Strategies to Recruit and Assess Applicants.

Due to concerns surrounding travel during the COVID-19 pandemic, the 2020-2021 otolaryngology residency application cycle will be conducted virtually for the first time. Residency programs should consider the logistics of video interviews, drawing on experiences of other programs that have successfully performed virtual interviews in the past. The lack of in-person interviews will create challenges in assessing applicants, and we recommend that programs develop structured and targeted questions and even consider having candidates answer standardized questions prior to the virtual interview day. From an applicant perspective, gauging the intangibles of individual residency programs, such as resident camaraderie, program culture, and program location, will be difficult. To address this, programs should consider hosting informal virtual gatherings, create videos that highlight the resident experience, and ensure that program websites are up-to-date. Ultimately, adaptability, resilience, and innovation will allow residency programs to achieve a successful 2021 otolaryngology match.

Evolving Otolaryngology Resident Roles and Concerns at the Peak of the US COVID-19 Pandemic.

BACKGROUND: The roles of US otolaryngology residents have changed in response to the coronavirus disease 2019 (COVID-19) pandemic. As the pandemic peaked in the United States, we characterized resident activities and concerns. METHODS: A cross-sectional study of US otolaryngology residents between April 20, 2020 and May 2, 2020. RESULTS: A total of 219 residents at 65/118 (55%) institutions responded. Thirty (14%) residents had been redeployed. Residents reported greatest concerns regarding education (P < .00001). Assuming adequate protective equipment, 55% desired active participation in high-risk procedures on COVID-19-positive patients. Redeployed residents had greater concern for burnout and reduced in-hospital well-being (P < .05). Resident satisfaction correlated with comfort communicating concerns to their department (odds ratio [OR] = 4.9, 95% confidence interval [CI] 1.4-17.3, P = .01) and inversely correlated with low perceived meaning in work (OR = 3.1, CI 1.1-9.1, P = .03). CONCLUSION: Otolaryngology resident concerns have evolved as the pandemic progressed. Residency programs should prioritize resident education, well-being in redeployed residents, and open communication as they transition toward recovery.

Risk of Mortality between Untreated and Treated Papillary Thyroid Cancer: A Matched Cohort Analysis.

OBJECTIVES: To examine the association between treatment status and mortality risk among patients with papillary thyroid cancer (PTC). METHODS: We identified 3,679 adults with PTC. Thirty-one untreated patients were matched to 155 treated patients. Hazards ratios (HR) and 95% confidence intervals (CIs) were calculated to estimate all-cause and disease-specific mortality. A low-risk subgroup was analyzed for differences in all-cause mortality. RESULTS: The adjusted HRs (95% CIs) for all-cause mortality at 5 and 10 years were 4.2 (1.7-10.3) and 4.1 (1.9-9.4) and for disease- specific mortality were 14.1 (3.4-59.3) and 10.2 (2.9-36.4), respectively, for untreated versus treated patients. The adjusted HRs (95% CIs) for all- cause mortality was 0.7 (0.1-6.4) for low-risk untreated versus matched treated patients. CONCLUSIONS: Compared to treated patients, untreated PTC patients were at higher risk of death while low-risk untreated PTC patients had comparable rate of metastasis and no increased risk of all-cause mortality. Level of evidence: 3.

Understanding the natural history of papillary thyroid cancer: Case series.

BACKGROUND: Papillary thyroid cancer (PTC) incidence continues to rise. We describe the natural history of untreated PTC patients. METHODS: Retrospective case series of 31 untreated PTC patients. RESULTS: We identified 31 untreated patients from the Kaiser Permanente Cancer Registry with PTC from 1973 to 2010. Patients were categorized as low risk (n = 16), high risk (n = 12), or low risk but medically contraindicated for surgery (n = 3). At diagnosis, 7 (58.3%) in the high-risk group had cervical lymph node metastases and 5 (41.7%) had distant metastases, compared to none in the low-risk group. Among the latter, three (18.8%) patients developed tumor growth >3 mm and one (6.3%) developed regional lymph node metastases without distant metastases. The 10-year overall survival was 71% and 35% for the low-risk and high-risk groups, respectively. CONCLUSIONS: Patients with low-risk untreated PTC were less likely to develop new regional or distant metastases and had better overall survival than patients with high-risk untreated PTC. LEVEL OF EVIDENCE: 4.

Diagnostic techniques and surgical outcomes for persistent pediatric obstructive sleep apnea after adenotonsillectomy: A systematic review and meta-analysis.

OBJECTIVE: To evaluate the efficacy of upper airway surgery for children with persistent obstructive sleep apnea after adenotonsillectomy and to assess sleep study outcomes when Drug Induced Sleep Endoscopy, Cine MRI, or other imaging procedure is performed to assist in identifying the location of obstruction and planning surgery. METHODS: Systematic review and meta-analysis was performed. Inclusion criteria was English-language studies with original data including pediatric patients with persistent OSA after T&A. Exclusion criteria included case reports and lack of pre and post-operative sleep study data. Data Sources were PubMed, Cochrane Central, and Embase from 2000 to 2018. PRISMA standards were followed for the selection and review of articles. The Newcastle-Ottawa Quality Assessment scale was used to score the quality of evidence of the studies. All manuscripts were reviewed independently by two investigators. Primary outcome measures were apnea-hypopnea index and minimum oxygen saturation. Data was pooled using a random-effects model. RESULTS: Of the 1902 abstracts identified, 11 studies (214 patients) met inclusion criteria for systematic review, 5 with Drug Induced Sleep Endoscopy as the diagnostic technique, 4 with Cine MRI, and 2 with MRI/CT. All studies were case series. Most subjects had syndromic comorbidities and/or obesity. Ten studies (198 patients) were included in the meta-analysis. Overall, there was a change in apnea hypopnea index of -6.51 (95% CI, -8.17 to - 4.85; p < 0.001) and an increase in minimum oxygen saturation by 3.24% (95% CI, 1.49%-4.98%; p < 0.001) following surgical intervention. Both Drug Induced Sleep Endoscopy and Cine MRI directed surgeries resulted in significant improvement in sleep study parameters. The two techniques could not be directly compared due to significant differences in co-morbidity rates between patients. CONCLUSIONS: Surgery for pediatric persistent obstructive sleep apnea improves apnea hypopnea index and minimum oxygen saturation but does not resolve the disease. This is true when both Drug Induced Sleep Endoscopy and Cine MRI findings were used to direct surgery.

Factors Impacting Online Ratings for Otolaryngologists.

OBJECTIVE: To identify factors associated with online patient ratings and comments for a nationwide sample of otolaryngologists. METHODS: Ratings, demographic information, and written comments were obtained for a random sample of otolaryngologists from HealthGrades.com and Vitals.com . Online Presence Score (OPS) was based on 10 criteria, including professional website and social media profiles. Regression analyses identified factors associated with increased rating. We evaluated for correlations between OPS and other attributes with star rating and used chi-square tests to evaluate content differences between positive and negative comments. RESULTS: On linear regression, increased OPS was associated with higher ratings on HealthGrades and Vitals; higher ratings were also associated with younger age on Vitals and less experience on HealthGrades. However, detailed correlation studies showed weak correlation between OPS and rating; age and graduation year also showed low correlation with ratings. Negative comments more likely focused on surgeon-independent factors or poor bedside manner. CONCLUSION: Though younger otolaryngologists with greater online presence tend to have higher ratings, weak correlations suggest that age and online presence have only a small impact on the content found on ratings websites. While most written comments are positive, deficiencies in bedside manner or other physician-independent factors tend to elicit negative comments.

Systematic Review of Drug-Induced Sleep Endoscopy Scoring Systems.

Objective To systematically review the scoring systems used to report findings during drug-induced sleep endoscopy (DISE) for adults and children with obstructive sleep apnea. Data Sources PubMed, CINAHL, EBM Reviews, Embase, and Scopus databases. Review Methods This is a systematic review of all indexed years of publications referring to scoring of DISE for children and adults with obstructive sleep apnea. The type of DISE scoring system utilized was the primary outcome. PRISMA guidelines were followed to carry out this review; articles were independently reviewed by 2 investigators. All pediatric and adult studies that utilized ≥1 DISE grading systems were included. Results Of 492 identified abstracts, 44 articles (combined population, N = 5784) were ultimately included; 6 reported on children, 35 on adults, and 1 on children and adults. Twenty-one reporting methods were used in these studies, with the most common being the VOTE system (velum, oropharynx, tongue base, and epiglottis; 38.6%) and the Pringle and Croft classification (15.9%). The sites of obstruction most commonly included in a scoring system were the tongue base (62%), lateral pharynx/oropharynx (57%), palate (57%), epiglottis/supraglottis (38%), and hypopharynx (38%). Less commonly included sites were the larynx (29%), velum (23%), nose (23%), tongue (14%), adenoids (10%), and nasopharynx (10%). Conclusion There is no consensus regarding which scoring system should be utilized to report findings during DISE. The VOTE system and the Pringle and Croft classification were the most frequent scoring systems reported for patients undergoing DISE. Standardization of the reporting of DISE findings would improve comparability among studies.