A New Patient-reported Outcomes Measure for Surgically Treated Epiphora: Tearing Assessment and Rating Scale-12 (TEARS-12).

BACKGROUND: No widely accepted, validated instrument currently exists to measure clinical outcomes in patients who undergo dacryocystorhinostomy (DCR) for treatment of epiphora. OBJECTIVE: To develop a patient-reported outcome measure applicable to this population. METHODS: Psychometric evaluations, consultation with experts, and review of the literature informed item generation of a 12-question questionnaire to incorporate the most relevant symptoms experienced by patients with nasolacrimal duct obstruction. This questionnaire, known as the Tearing Assessment and Rating Scale-12 (TEARS-12), was administered to 32 patients before and after intervention, in the form of endoscopic DCR. Statistical analysis was performed to measure internal consistency, responsiveness, and test-retest reliability. RESULTS: Pre-operative and post-operative TEARS-12 scores (28.2 [standard error (SE) 3.19] vs 11.8 [SE 3.25], respectively, P = 0.001) demonstrated improved patient outcome within 6 weeks following endoscopic DCR. Cronbach's alpha for the questionnaire was 0.90, indicating high overall reliability. Additionally, each question demonstrated internal reliability, with a corrected item-total correlation greater than 0.30. The intraclass correlation between the two pre-operative scores was 0.858 (P < 0.001), indicating high test-retest reliability. CONCLUSION: TEARS-12 is a statistically valid, easy-to-administer instrument to measure clinical outcomes in patients who undergo endoscopic DCR.

Endoscopic sinus surgery for chronic rhinosinusitis: 22-item Sino-Nasal Outcome Test 5-year results.

BACKGROUND: Currently, limited data exist as to long-term disease-specific outcomes after endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS). In this report, we present outcomes data collected over 5 years in a large prospective cohort of patients who underwent surgical treatment for CRS. METHODS: Patients who completed the 22-item Sino-Nasal Outcome Test (SNOT-22) before ESS were asked to complete the same survey at yearly intervals for 5 years thereafter. The impact of patients' demographics and clinical characteristics on clinical outcome was measured using mixed effects modeling for univariate and multivariable analysis. Multivariable logistic regression threshold analyses were also performed. RESULTS: Among the 925 patients enrolled in the study, the SNOT-22 was completed after ESS by 641 patients (69.3%) at 1 year and 338 patients (36.5%) at 5 years. The mean preoperative SNOT-22 score of 48.5 (standard error [SE], 0.69) improved at all subsequent yearly time-points, including 5 years (mean, 25.8; SE, 1.08; p < 0.0001). SNOT-22 scores over time were impacted by nasal polyps (p < 0.001), environmental allergies (p = 0.010), diabetes (p = 0.032), and preoperative Lund-Mackay score (p < 0.001). CONCLUSION: Endoscopic sinus surgery appears to be effective at improving the quality of life of patients with CRS for both the short and long term. The successful outcome of such surgery, however, is influenced by a variety of clinical factors, which should be taken into account by clinicians who are considering surgical treatment of CRS for select patients.

A Blinded Randomized Trial Comparing 2 Needle Gauges for Fine-Needle Biopsy of Thyroid Nodules.

OBJECTIVE: To compare diagnostic capability and patient pain between 25-gauge (25G) and 27G needles for ultrasound-guided fine-needle biopsy of thyroid nodules. STUDY DESIGN: Prospective blinded randomized trial. SETTING: Thyroid clinic in otolaryngology practice in a community. METHODS: A prospective randomized blinded trial was conducted on 148 thyroid nodules in 107 patients undergoing ultrasound-guided fine-needle biopsy. Needle gauge was randomized to individual nodule. Patients were blinded to the needle size used. All specimens were assessed via the Bethesda System for Reporting Thyroid Cytopathology and assigned a morphologic quantitative score based on number of thyroid cells and lymphocytes, amount of colloid, and degree of blood/fibrin artifact in each sample. Patient pain experience was scored. A chi-square test was used to compare nondiagnostic rates, and differences in cytologic morphology and pain scores were compared with 2-sample Student t tests. RESULTS: Of the 148 nodules, 77 were biopsied with 25G needles and 71 with 27G needles. Twenty-five percent (19/77) of the samples obtained with 25G needles yielded a nondiagnostic cytology result (Bethesda category 1) as compared with 11% (8/70) in the 27G group (P = .0282; 95% CI, 1.47%-25.97%). On average, samples from 25G needles had a higher blood/fibrin quantitative score (P = .043; 95% CI, -0.64 to -0.010). There were no differences in pain between groups. CONCLUSION: Use of a 27G needle for fine-needle biopsies is not only safe and feasible but desirable and highly recommended, as it yields better diagnostic information.

Race, Income, and the Timeliness of Cleft Palate Repair in the United States.

Objective To determine if differences exist in the timing of cleft palate repair with respect to sex, race, income, and geographical location within the United States. Design Retrospective cross-sectional study using the Kids' Inpatient Database (KID) from 1997 to 2009. Setting Inpatient. Patients Children with cleft palate with or without cleft lip undergoing inpatient cleft palate repair. Main outcome measures Age at the time of palatoplasty (in months) by sex, race, income quartile, and geographic location. Results A total of 7,218 children with cleft palate underwent repair at a mean age of 12.1 months (95% CI 12.0-12.3). Females underwent palatoplasty at an older age (13.6 months) than males (13.2 months), a difference of 0.47 months (SE: 0.19, p=0.015). White children underwent surgery at an earlier age (12.1 months) than Black (12.9 months) (difference: 0.73 months, SE: 0.37, p=0.045), Hispanic (12.7 months) (difference: 0.57 months, SE 0.25, p=0.025), and Asian children (15.7 months) (difference: 3.60 months, SE 0.49, p<0.0001). Asian children were also found to undergo repair later than Hispanic (difference 3.03 months, SE 0.51, p<0.0001) and Black (difference: 2.87 months, SE 0.59, p<0.0001) children. Patients born into the highest income brackets were repaired 0.75 months earlier than those in the lowest bracket (SE: 0.26, p=0.005). Patients in the Midwest underwent palatoplasty later (14.3 months) than in the Northeast (12.9 months) (difference: 1.36 months, SE: 0.31, p<0.0001), South (13.2 months) (difference: 1.05 months, SE: 0.36, p=0.004), and West (13.2 months) (difference: 1.09 months, SE: 0.32, p=0.0007). Conclusions After controlling for confounding factors, our results suggest that in recent history, Black, Hispanic, and Asian children with cleft palate were repaired later than their White counterparts. In addition, children of affluent families were repaired earliest, and economically disadvantaged children were repaired later than their peers.

Total Thyroidectomy as an Ambulatory Procedure in Community Practice.

OBJECTIVE: Increasingly, total thyroidectomy is offered as an ambulatory procedure. Most of the relevant outcomes research derives from academic centers, but most thyroid surgeries are performed in the community. The goal of this study is to evaluate the safety of total thyroidectomy performed as an ambulatory procedure in a community otolaryngology practice. STUDY DESIGN: Retrospective review and national database analysis. SETTING: A single community otolaryngology practice. METHODS: Adult patients undergoing total thyroidectomy by a single otolaryngologist between 2013 and 2019 were divided into 2 cohorts: planned ambulatory and planned admission. Charts were reviewed for demographics and surgical outcomes in the 2 groups. The Healthcare Cost and Utilization Project databases for New York and Florida between 2015 and 2016 were also analyzed to compare outcomes of thyroidectomy as an ambulatory surgery between different practice settings. RESULTS: A total of 99 total thyroidectomies were performed during the study time period; 66 of 99 (67%) were planned as ambulatory procedures and 33 of 99 (33%) were planned admissions. Five of the 66 (8%) planned outpatient surgeries required admission. Complications of vocal fold dysfunction, symptomatic hypocalcemia, and seroma formation were more commonly seen in the inpatient cohort. Only 2 ambulatory patients required admission after discharge. Nationally, odds of complication were higher for ambulatory total thyroidectomy at nonteaching practice sites, which is not duplicated in our study. CONCLUSIONS: Ambulatory total thyroidectomy can be undertaken safely in the community in carefully selected cases.

Hairy polyps: A new case presentation and a pathogenetic hypothesis.

Hairy polyps are benign lesions found in the oropharynx or nasopharynx that are thought to be present at birth and can lead to upper airway obstruction in infants. Also known as naso-oropharyngeal choristoma, they are increasingly viewed as aggregates of bigeminal tissue, likely from the first or second branchial arches, found in aberrant locations. They are benign lesions that are usually successfully treated by surgical excision. Here we present a rare case of a hairy polyp originating in the eustachian tube of a 7-week-old male, discuss our management of the patient, and put forth a new hypothesis as to the origin of these lesions. Laryngoscope, 129:2398-2402, 2019.

Comparing the real and perceived cost of adenotonsillectomy using time-driven activity-based costing.

OBJECTIVE: This study aims to measure the costs of treating obstructive sleep apnea (OSA) in children with an adenotonsillectomy using time-driven activity-based costing (TDABC) and explore how this differs from cost estimates using traditional forms of hospital accounting. STUDY DESIGN: Prospective observational study. METHODS: A total of 53 pediatric patients with symptoms of OSA or sleep-related breathing disorder were followed from their initial appointment through surgery to their postoperative visit at an academic medical center. Personnel timing and overhead costs were calculated for TDABC analysis. RESULTS: Treating OSA with an adenotonsillectomy in a pediatric patient costs $1,192.61. On average, outpatient adenotonsillectomy costs $957.74 (80.31%); $412.18 of this cost ($4.89 per minute) was attributed to the overhead cost of the operating room. Traditional hospital accounting estimates outpatient adenotonsillectomy costs $2,987, with overhead attributing $11.27 per minute or $949.23 per case. 57% ($6.38 per minute) of the hospital's estimate for overhead was actually for equipment and implants used by different hospital services and not for equipment used in adenotonsillectomies. CONCLUSION: Through TDABC, we were able to highlight how traditional RVU-based hospital accounting systems apportion all overhead costs, including items such as orthopedic implants, evenly across specialties, thus increasing the perceived cost of equipment-light procedures such as adenotonsillectomies. We suspect that providers who perform a TDABC analysis at their home institution or practice will find their own unique insights, which will help them understand and control the different components of healthcare costs. LEVEL OF EVIDENCE: 2 Laryngoscope, 129:1347-1353, 2019.

High rates of subglottic stenosis seen in African-American children admitted with severe croup to hospitals in the United States between 2003 and 2013.

BACKGROUND: To assess whether differences exist in the epidemiology and the treatment of croup with respect to gender, race, income and geographical location. METHODS: Retrospective weighted analysis of patients under 19 admitted with a diagnosis of croup with a subcohort of patients requiring intubation or diagnostic bronchoscopy from the National Inpatient Sample and Kids' Inpatient Database from 2003 to 2013. ICD-9 codes and demographics were analyzed; cross tabulations and linear regression modeling were performed. RESULTS: Between 2003 and 2013, 202,188 pediatric patients were admitted with a diagnosis of croup, equivalent to 1-per-100 pediatric admissions. Males were more likely to be admitted for croup than females [OR 2.13 (2.08-2.17)]. Incidence of croup is highest in Caucasians and lowest in Asian and African-American patients. African-American children are more likely to undergo diagnostic bronchoscopy or require intubation [OR 1.23 (1.08-1.401)] than other races. A higher rate of subglottic stenosis was seen in African-American children who required bronchoscopy than expected (39.1% vs 26.7%). After controlling for subglottic stenosis, African-American patients were no longer more likely to undergo diagnostic bronchoscopy or require intubation than other races [OR 1.129 (0.959-1.33)]. CONCLUSION: African-American children admitted with a diagnosis of croup appear to have an increased rate of intubation or bronchoscopy. This may be related to the high incidence of subglottic stenosis in this population. After controlling for subglottic stenosis, no difference in intervention rates was seen.

Cervical Lymphatic Filariasis in a Pediatric Patient: Case Report and Database Analysis of Lymphatic Filariasis in the United States.

Lymphatic filariasis is a mosquito-borne parasitic infection caused by Wuchereria bancrofti and Brugia spp. Commonly seen in tropical developing countries, lymphatic filariasis occurs when adult worms deposit in and obstruct lymphatics. Although not endemic to the United States, a few cases of lymphatic filariasis caused by zoonotic Brugia spp. have been reported. Here we present a case of an 11-year-old female with no travel history who was seen in our clinic for a 1-year history of painless left cervical lymphadenopathy secondary to lymphatic filariasis. We review the literature of this infection and discuss the management of our patient. Using the National Inpatient Sample (NIS), the largest publicly available all-payer inpatient care database in the United States, we also examine the demographics of this infection. Our results show that chronic lymphadenopathy in the head and neck is the most common presenting symptoms of domestic lymphatic filariasis. Diagnosis is often made after surgical lymph node excision. Examination of the NIS from 2000 to 2014 revealed 865 patients admitted with a diagnosis of lymphatic filariasis. Most patients are in the mid to late sixties and are located on the eastern seaboard. Eight hundred and twenty six cases (95.5%) were likely due to zoonotic Brugia spp. and 39 (4.5%) due to W. bancrofti. Despite being rare, these data highlight the need to consider filariasis in patients presenting with chronic lymphadenopathy in the United States.

Neonatal Macroglossia: Demographics, Cost of Care, and Associated Comorbidities.

OBJECTIVES: To examine the birth prevalence of congenital macroglossia and identify demographic variables and comorbidities that may influence length of stay and cost of care. STUDY DESIGN: Retrospective cross-sectional study using the Kids' Inpatient Database 2003, 2006, 2009, and 2012. METHODS: Demographics were analyzed. Linear regression modeling and multivariate analyses were performed. RESULTS: The birth prevalence of congenital macroglossia was 4.63/100 000 births. Patients were classified as isolated (n = 349, 48.1%) or syndromic (n = 377, 51.9%). A higher incidence of isolated macroglossia was seen in females (odds ratio, OR [95% confidence interval, 95% CI]: 1.93 [1.45-2.56] and African Americans (2.02 [1.41-2.88]). Length of stay was higher for syndromic patients than for nonsyndromic patients (22.6 days [18.6-26.6] vs 7.93 days [5.95-9.90], as were inpatient costs ($3619USD [$27 628-$44 754] vs $10 168USD [$6272-$14 064]. After accounting for gender, race, location, and socioeconomic status, the presence of macroglossia alone increased length of stay by 4.07 days (0.42-7.72 days) in nonsyndromic patients and 12.02 days (3.63-20.4 days) in syndromic patients. The cost of care increased by $6207USD ($576-$11 838) among nonsyndromic newborns and $17 205USD ($374-34 035) among syndromic patients. CONCLUSION: The birth prevalence of congenital isolated macroglossia appears to vary by sex and race. Prolonged length of stay and increased costs are associated with both isolated macroglossia and syndromic macroglossia, even after controlling for other syndromic comorbidities.

National trends in tongue reduction surgery for macroglossia in children.

OBJECTIVES: To examine the frequency of partial glossectomy performed for the indication of macroglossia in children within the United States, assessing for differences in rates of intervention across various demographics. To identify potential morbidities associated with partial glossectomy in this population and determine how such factors may influence length of stay and cost of admission following tongue reduction surgery. STUDY DESIGN: Retrospective cross-sectional study. SETTING: The Kids' Inpatient Database 2003, 2006, 2009, and 2012. SUBJECTS: Patients under age 5 diagnosed with macroglossia who underwent partial glossectomy. METHODS: Demographics were analyzed and cross tabulations, linear regression modeling, and multivariate analysis were performed. RESULTS: During the four-years studied, partial glossectomy was performed in 196 children under age 5 with macroglossia. A disproportionately higher rate of intervention was seen in white children (p = 0.001), patients undergoing surgery in the mid-west (p < 0.001) and patients in the highest socioeconomic quartile (p = 0.015). Most patients underwent glossectomy in their second year of life. The average length of stay in patients who underwent partial glossectomy for macroglossia was 9.59 days (Range 1-211 days, median 3.45 days) and the average cost was $56,602 (median $16,330). CONCLUSION: Partial glossectomy for macroglossia is typically performed prior to age 2 in the United States. A higher rate of intervention is seen in white children, those who have surgery in the mid-west and affluent children even when controlling for confounding variables. LEVEL OF EVIDENCE: III.

Cholesteatoma as a complication of Langerhans Cell Histiocytosis of the temporal bone: A nationwide cross-sectional analysis.

OBJECTIVE: To determine if patients with Langerhans Cell Histiocytosis (LCH) of the temporal bone have a higher risk of developing cholesteatoma. METHODS: Review of literature and cross-sectional weighted analysis of patients under 19 with a diagnosis of LCH from the National Inpatient Sample (NIS) and Kids' Inpatient Database (KID) from 2000 to 2013. ICD-9 codes and demographics were analyzed; pairwise comparisons and multivariate analyses were performed. RESULTS: Only seven cases of cholesteatoma after the treatment for LCH of the temporal bone have been documented in the literature. No significant association between cholesteatoma and LCH was seen (OR 0.747 [0.149-3.751]). Patients with LCH did have a higher incidence of chronic otitis media, chronic otitis externa, chronic sinusitis, hearing loss, and otitis media with effusion. CONCLUSION: Our results show that patients with Langerhans Cell Histiocytosis do not appear to have a higher risk of developing cholesteatoma. However they are more likely to be diagnosed with chronic otitis externa which should be differentiated from cholesteatoma or recurrence of LCH.

Spontaneous CSF rhinorrhea from the trigeminal canal in an adolescent.

We report a case of a seventeen-year old, healthy, non-obese young woman who presented with retro-orbital headaches and metallictasting, left-sided rhinorrhea. Computed tomography revealed a defect along the medial wall of the canal of V2 within a well-pneumatized lateral recess of the left sphenoid sinus. Prior imaging obtained 4 years earlier in the context of nasal trauma showed no such defect - thus lending support for the arachnoid granulation hypothesis of spontaneous CSF leaks from the sphenoid sinus. We perform a literature review and describe a successful repair through an endoscopic transpterygoid approach, which allowed for resolution of symptoms with minimal postoperative morbidity.

Surgical resection of sinonasal hemangiopericytoma involving anterior skull base: Case reports and literature review.

Hemangiopericytomas are soft tissue tumors composed of pericytic cells that are characterized by their "staghorn" vascular branching and their variable clinical presentation. Fifteen to 25% of all HPC occur in the head and neck, with only 5% found in the nose or paranasal sinuses. Sinonasal hemangiopericytoma (SNHPC) is considered distinct from its soft tissue counterpart - the former showing a more uniform cellular organization, has convincing pericytic differentiation and is associated with a far better prognosis. With less than 200 cases of SNHPC reported in the literature, only limited assumptions can be made about this rare tumor. The purpose of this article is to add to the growing body of literature on this disease. We report two new cases of SNHCP - both in female patients who presented with epistaxis and anosmia. Pulsatile vascular masses were visualized with nasal endoscopy - one in the left middle meatus and the second one near the cribriform plate. CT and MRI studies show enhancing masses in the left nasal cavities with thinning and erosion of the skull base. Diagnoses were confirmed by pathology which reported spindle cell neoplasm staining positively for VEGF, NSE, factor XIIIa, S-100 protein, and CD34, and negative for actin, desmin, CD31, and pankeratin, consistent with hemangiopericytoma. In one patient, embolization of the sphenopalatine and labial artery as well as pre-operative radiation therapy was performed before complete endoscopic resection was undertaken. The second patient had a tumor invading the skull base, so a craniofacial resection was performed. Both patients remained free of disease two years after surgery. Review of the literature and treatment options are discussed.