Respiratory and otolaryngological disorders in Down syndrome from one center in Brazil.

Down syndrome (DS) is the most common chromosomal condition. Anatomical and functional variations in the upper and lower airways are component manifestations of the syndrome and increase the risk of various medical problems. The objective of this study was to determine the prevalence of otorhinolaryngological and respiratory diseases in a DS outpatient clinic over a 3-year period. Medical records data from 1207 patients were retrospectively reviewed. Newborn Hearing Screening was positive in 7.1% of patients. Brainstem auditory evoked potential was performed in 1101 children and showed a hearing loss of 19.8% in the first year. It was positive in 21% of 1021 exams. Audiometry was altered in 64 of 994 exams (6.4%), showing a conductive loss in 90%. Adenotonsillectomy was performed in 308 (25.5%) patients, and 169 (14.0%) required serous otitis ventilation tubes. Asthma was observed in 140 (11.6%) patients, and allergic rhinitis in 544 (56.6%). There were hospitalizations for invasive infection in 480 (39.8%) children, and two (0.2%) patients had severe septicemia from pulmonary focus. Five (0.4%) infants had laryngotracheomalacia, and one patient had anomalous right tracheal bronchus. Recognizing the prevalence of respiratory and otorhinolaryngological disorders in patients with DS allows the promotion of optimal follow-up and early treatment, preventing the development of sequelae.

Prevalence of Eustachian Tube Dysfunction in the US Elderly Population.

OBJECTIVE: To investigate the prevalence of eustachian tube dysfunction (ETD) in elderly adults in the United States and its association with other upper aerodigestive inflammatory processes. STUDY DESIGN: Cross-sectional study. SETTING: Population based. SUBJECTS AND METHODS: In total, 147,805 patients without malignancy were compared to 13,804 demographically matched patients with malignancy of the upper aerodigestive tract (UADT) by querying the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database for patients aged 66 to 99 years between 2003 and 2011. The prevalence of ETD and inflammatory diseases among these patients was compared. Association between ETD, other upper aerodigestive inflammatory processes, and UADT malignancies was evaluated. RESULTS: The prevalence of ETD was 5.44% among patients without malignancy and 9.08% in those with cancer (odds ratio [OR], 1.73; 95% CI, 1.63-1.84). Patients with ETD in the control population were more likely (OR, 95% CI) to be diagnosed with chronic rhinitis (5.00, 4.70-5.33), chronic sinusitis (4.20, 3.98-4.43), allergic rhinitis (4.27, 4.08-4.47), and gastroesophageal reflux disease (GERD) (2.42, 2.31-2.53). Patients with ETD and chronic rhinitis (1.43, 1.24-1.65), chronic sinusitis (1.57, 1.38-1.78), and acute otitis media (1.33, 1.08-1.65) were associated with higher rates of UADT malignancy. CONCLUSION: Over 5% of patients older than 65 in the United States are diagnosed with ETD in the absence of UADT malignancy. Associations between ETD and chronic rhinitis, chronic sinusitis, allergic rhinitis, and GERD in the absence of UADT malignancy suggest that some patients may benefit from treatment of inflammatory disease as a cause of ETD.

Management of the Clinical and Academic Mission in an Urban Otolaryngology Department During the COVID-19 Global Crisis.

OBJECTIVE: The objective of this study was to assess the strategic changes implemented in the departmental mission to continue safe delivery of otolaryngology care and to support the broader institutional mission during the COVID-19 pandemic response. STUDY DESIGN: Retrospective assessment was performed to the response and management strategy developed to transform the clinical and academic enterprise. SETTING: Large urban tertiary care referral center. RESULTS: The departmental structure was reorganized along new clinical teams to effectively meet the system directives for provision of otolaryngology care and support for inpatient cases of COVID-19. A surge deployment schedule was developed to assist frontline colleagues with clinical support as needed. Outpatient otolaryngology was consolidated across the system with conversion of the majority of visits to telehealth. Operative procedures were prioritized to ensure throughput for emergent and time-critical urgent procedures. A tracheostomy protocol was developed to guide management of emergent and elective airways. Educational and research efforts were redirected to focus on otolaryngology care in the clinical context of the COVID-19 crisis. CONCLUSION: Emergence of the COVID-19 global health crisis has challenged delivery of otolaryngology care in an unparalleled manner. The concerns for preserving health of the workforce while ethically addressing patient career needs in a timely manner has created significant dilemmas. A proactive, thoughtful approach that reorganizes the overall departmental effort through provider and staff engagement can facilitate the ability to meet the needs of otolaryngology patients and to support the greater institutional mission to combat the pandemic.

Algorithm-Based Pediatric Otolaryngology Management During the COVID-19 Global Pandemic: A Children's Hospital of Philadelphia Clinical Consensus.

OBJECTIVE: The coronavirus disease 2019 (COVID-19) pandemic requires clinicians to explore alternatives to routine patient management. Otolaryngologists caring for children commonly depend on physical examination, laboratory data, and ambulatory surgical procedures. Limiting patient care, mindful allocation of resources, and concern for safety have challenged all aspects of our health care system. This evidence-based clinical consensus is designed to guide practitioners of pediatric otolaryngology for common scenarios during this time. DATA SOURCES: Peer-reviewed literature, published reports, institutional guidelines, and expert consensus. REVIEW METHODS: A clinical consensus on 6 common scenarios in pediatric otolaryngology developed with evidence-based strategies. CONCLUSIONS: Providers should suspend all in-person nonessential office visits and elective surgical procedures. An emphasis on medical management and caregiver education will provide reasonable approaches to many of the common outpatient concerns. Surgery for chronic otitis media, obstructive sleep apnea, and acute rhinosinusitis should occur only in response to severe complications or failure of medical regimens. The approach to the pediatric neck mass focuses on timely management for oncologic etiologies and cautious surgical intervention for abscess drainage or tissue sampling. Finally, epistaxis and otorrhea must be triaged and addressed without the usual ambulatory procedures. IMPLICATIONS FOR PRACTICE: Adaptation of practice patterns during this unprecedented moment for our health care system requires thoughtful planning. The strategies described allow for safe handling of common pediatric otolaryngology diagnoses. Ultimately, otolaryngologists must be stewards of our global health community while advocating for the care of individual pediatric patients.

Telehealth Opportunities for the Otolaryngologist: A Silver Lining During the COVID-19 Pandemic.

The utilization of telemedicine has seen a relatively slow progression over the past 50 years in the US health care system. Technological challenges limiting the ease of use of robust video platforms have been a major factor. Additionally, the perception by many health care providers that telehealth is reserved for only the rural population or that it provides limited value due to the inability to perform in-depth physical examinations contributes to the slow adoption. The COVID-19 pandemic, with its massive disruption in social interaction by way of "stay at home" orders, is serving as a catalyst for improving telehealth. Large health systems are investing millions of dollars and increasing telehealth visit numbers 100-fold to access patients. The "telehealth movement" is here to stay and will undoubtedly be incorporated into providers' daily lives years after the COVID-19 pandemic. By embracing virtual access to health care, otolaryngologists will be able to influence improvements to these systems and broaden access options for patient care well into the future.

Upholding the Tripartite Mission in Times of Crisis: Purpose and Perseverance in the COVID-19 Pandemic.

Academic otolaryngology has historically comprised a tripartite mission of research, education, and clinical care. This mission is greatly strained by the COVID-19 pandemic. Research laboratories are fallow, surgical cases are deferred, and clerkships are canceled. Otolaryngologists are adapting to new circumstances ranging from virtual patient care to urgent procedures in protective gear to deployment to provisional field hospitals. Amid these operational challenges, the specialty is demonstrating extraordinary resilience and grit, discovering new ways to serve learners, colleagues, and communities. Statements from leaders in otolaryngology reveal selfless acts and purposefulness. Necessity has spurred innovation in education, science, and novel models of care. Paragons strike notes of hope, inspiring us to persevere and serve. This commentary explores the present challenges and offers a vision for upholding the academic mission.

Outpatient Otolaryngology in the Era of COVID-19: A Data-Driven Analysis of Practice Patterns.

INTRODUCTION: Coronavirus disease 2019 (COVID-19) has induced a prioritization of acute care and telehealth, affecting the quantity of patients seen and the modality of their care. STUDY DESIGN: Retrospective review. SETTING: Single-institution study conducted within the Division of Otolaryngology at the Yale School of Medicine. SUBJECTS AND METHODS: Data on all outpatient appointments within the Division of Otolaryngology were obtained from administrative records of billing and scheduling from March 16 to April 10, 2020. For comparison, a corresponding period from 2019 was also utilized. RESULTS: Of 5913 scheduled visits, 3665 (62.0%) were seen between March 18 and April 12, 2019, in comparison with 649 of 5044 (12.9%) during the corresponding COVID-19-affected period. The majority of completed visits performed in weeks 1 and 2 were in person, while the majority in weeks 3 and 4 were via telehealth. Among subspecialties, a larger proportion of completed visits in 2020 were performed by pediatric and head and neck oncology otolaryngologists as compared with general/specialty otolaryngologists (P < .001). Older adults (≥65 years) were less likely to have telehealth visits than younger adults (18-64 years; 45.6% vs 59.6%, P = .003). CONCLUSIONS: A major decrease in the completion rates of scheduled visits was seen in the COVID-19-affected period, though this was not proportional among subspecialties. An associated increase in telehealth visits was observed. After COVID-19-related hospital policy changes, approximately 2 weeks passed before telehealth visits surpassed in-person visits, though this was not true among older adults.

Otolaryngology Community Operating With Collaboration and Productive Resolve During the COVID-19 Pandemic.

In the wake of the tremendous fallout from the COVID-19 pandemic that was mostly negative, I find great optimism and encouragement from the ability of society at all levels to focus on a common problem with a collaborative and productive resolve to address this millennial event. The rapid response was made possible by marshaling the resources available from many sources, not the least of which was the medical association community. It has been particularly gratifying to work hand-in-hand with our specialty societies within and outside the otolaryngology family to produce educational and scientific information that is consistent and that has and will continue to affect policy favorably. The groups that enable these inspirational collaborative accomplishments through their dedication, innovation, and imagination are the practicing physicians who have given freely and generously of their time and talents to help the whole health care community provide the most up-to-date care possible.

Approaching Otolaryngology Patients During the COVID-19 Pandemic.

Objective. To describe coronavirus disease 2019 (COVID-19) patient presentations requiring otolaryngology consultation and provide recommendations for protective measures based on the experience of ear, nose, and throat (ENT) departments in 4 Chinese hospitals during the COVID-19 pandemic. Study Design. Retrospective case series. Setting. Multicenter. Subjects and Methods. Twenty hospitalized COVID-19 patients requiring ENT consultation from 3 designated COVID-19 hospitals in Wuhan, Shanghai, and Shenzhen were identified. Data on demographics, comorbidities, COVID-19 symptoms and severity, consult reason, treatment, and personal protective equipment (PPE) use were collected and analyzed. Infection control strategies implemented for ENT outpatients and emergency room visits at the Eye and ENT Hospital of Fudan University were reported. Results. Median age was 63 years, 55% were male, and 95% were in severe or critical condition. Six tracheotomies were performed. Posttracheotomy outcomes were mixed (2 deaths, 2 patients comatose, all living patients still hospitalized). Other consults included epistaxis, pharyngitis, nasal congestion, hyposmia, rhinitis, otitis externa, dizziness, and tinnitus. At all hospitals, powered air-supply filter respirators (PAPRs) were used for tracheotomy or bleeding control. PAPR or N95-equivalent masks plus full protective clothing were used for other complaints. No inpatient ENT providers were infected. After implementation of infection control strategies for outpatient clinics, emergency visits, and surgeries, no providers were infected at the Eye and ENT Hospital of Fudan University. Conclusions and Relevance. COVID-19 patients require ENT consultation for many reasons, including tracheotomy. Otolaryngologists play an indispensable role in the treatment of COVID-19 patients but, due to their work, are at high risk of exposure. Appropriate protective strategies can prevent infection of otolaryngologists.

Clinical evidence based review and recommendations of aerosol generating medical procedures in otolaryngology - head and neck surgery during the COVID-19 pandemic.

BACKGROUND: Aerosol generating medical procedures (AGMPs) present risks to health care workers (HCW) due to airborne transmission of pathogens. During the COVID-19 pandemic, it is essential for HCWs to recognize which procedures are potentially aerosolizing so that appropriate infection prevention precautions can be taken. The aim of this literature review was to identify potential AGMPs in Otolaryngology - Head and Neck Surgery and provide evidence-based recommendations. METHODS: A literature search was performed on Medline, Embase and Cochrane Review databases up to April 3, 2020. All titles and abstracts of retrieved studies were evaluated and all studies mentioning potential AGMPs were included for formal review. Full text of included studies were assessed by two reviewers and the quality of the studies was evaluated. Ten categories of potential AGMPs were developed and recommendations were provided for each category. RESULTS: Direct evidence indicates that CO2 laser ablation, the use of high-speed rotating devices, electrocautery and endotracheal suctioning are AGMPs. Indirect evidence indicates that tracheostomy should be considered as potential AGMPs. Nasal endoscopy and nasal packing/epistaxis management can result in droplet transmission, but it is unknown if these procedures also carry the risk of airborne transmission. CONCLUSIONS: During the COVID-19 pandemic, special care should be taken when CO2 lasers, electrocautery and high-speed rotating devices are used in potentially infected tissue. Tracheal procedures like tracheostomy and endotracheal suctioning can also result in airborne transmission via small virus containing aerosols.

Sustaining Otolaryngology Services for the Long Haul during the COVID-19 Pandemic: Experience from a Tertiary Health System.

The impact of the COVID-19 pandemic has been far-reaching and has profoundly affected the practice of otolaryngology in an unprecedented way. In this commentary, we draw from our experience in the first 90 days of the pandemic and discuss a set of workflow measures, personal protection equipment protocols, and strategic goals that can provide a safe environment for patients and staff to continue managing a significant proportion of patients in the otolaryngology service during the pandemic.

Clinical potential of pupillary light reflex and heart rate variability parameters as biomarkers for assessing pain relief effects on autonomic function: a prospective longitudinal study.

OBJECTIVE: To investigate the association between subjective pain intensity and objective parameters obtained from two autonomic function tests in a longitudinal study targeting acute pain model in otolaryngology-head and neck region: pupillary light reflex (PLR) and heart rate variability (HRV). APPROACH: We enrolled 35 patients with acute otolaryngology-head and neck region inflammatory disorders at pre-treatment stage. The acute inflammatory disorders were defined as acute tonsillitis, peritonsillar abscess, acute epiglottitis, acute sinusitis, and deep neck space abscess. Patients underwent a numeric rating scale (NRS) to monitor subjective pain intensity, PLR, and HRV as objective tests at 4 time-points during the follow-up term. As main outcome variables, we used 15 analyzable PLR/HRV parameters. To improve robustness of conclusions about the association between NRS and PLR/HRV parameters, we prepared four linear mixed-effects models (LMMs) including predictor variables such as NRS, sociodemographic factors, and individual variability. And then, we selected the better-fit model based on the lowest Akaike's information criterion. MAIN RESULTS: NRS significantly decreased due to treatments. In 14 out of 15 parameters, better-fit models were models including not only sociodemographic factors but also individual variability. We observed significant parameter alterations to one unit change of NRS in five PLR and four HRV parameters. SIGNIFICANCE: The current study revealed that PLR/HRV parameters can be used as biomarkers reflecting pain relief effects. In addition, the findings suggest the importance of adjusting predictor variables, especially individual variability defined as random effects in LMMs, for obtaining more accurate parameter estimation in the longitudinal study.

Brain abscess in children, a two-centre audit: outcomes and controversies.

OBJECTIVE: The aim of this study was to better characterise clinical presentation, management and outcome in infants and children with brain abscess. METHODS: The authors conducted a retrospective, multicentre study in two national reference centres over a 25-year period (1992-2017). During this period, 116 children and 28 infants (age <1 year) with brain abscess were treated. RESULTS: The median age at diagnosis was 101.5 (range: 13-213) months in children and 1 (0-11) month in infants. Significant differences were observed between children and infants. The most common predisposing factor was meningitis in infants (64% of cases vs 3% in children), while it was otolaryngology-related infection in children (31% of cases vs 3.6% in infants). Infants presented more frequently with fever and meningism compared with children. 115 patients were treated with aspiration and 11 with excision. Reoperation was required in 29 children vs 1 infant. The overall mortality rate was 4% (3.4% for children, 7.1% for infants). At 3-month follow-up, the outcome was favourable in 86% of children vs in 68% of infants. CONCLUSION: There is a clear difference between children and infants with brain abscess in terms of predisposing factors, causative organisms and outcome. Despite surgical drainage and directed antibiotic therapy, 25% of patients with brain abscess require reoperation. Mortality is improved compared with historical series; however, long-term morbidity is significant particularly in the infant population.

Current knowledge of medical complications in adults with achondroplasia: A scoping review.

This article provides an overview of the current knowledge on medical complications, health characteristics, and psychosocial issues in adults with achondroplasia. We have used a scoping review methodology particularly recommended for mapping and summarizing existing research evidence, and to identify knowledge gaps. The review process was conducted in accordance with the PRISMA-ScR guidelines (Preferred Reporting Items for Systematic reviews and Meta-Analyses Extension for Scoping Reviews). The selection of studies was based on criteria predefined in a review protocol. Twenty-nine publications were included; 2 reviews, and 27 primary studies. Key information such as reference details, study characteristics, topics of interest, main findings and the study author's conclusion are presented in text and tables. Over the past decades, there has only been a slight increase in publications on adults with achondroplasia. The reported morbidity rates and prevalence of medical complications are often based on a few studies where the methodology and representativeness can be questioned. Studies on sleep-related disorders and pregnancy-related complications were lacking. Multicenter natural history studies have recently been initiated. Future studies should report in accordance to methodological reference standards, to strengthen the reliability and generalizability of the findings, and to increase the relevance for implementing in clinical practice.

The association between vitamin deficiency and otolaryngologic diseases: A therapeutic target.

Vitamins are indispensable nutrients for metabolism. Adequate vitamin intake plays vital role in physiological processes including embryonic development, cellular and immunity proliferation and differentiation, DNA synthesis and oxidative response. In contrast, insufficient vitamin levels usually lead to a large number of clinical manifestations including xerophthalmia, nyctalopia, hyperpigmentation, vitiligo, jaundice, megaloblastic anemia, glossitis, scurvy, stroke, cancer, coronary heart disease, Alzheimer's disease, multiple sclerosis and Parkinson's disease. In recent years, more and more researches have focused on the relationship between vitamin family and otorhinolaryngologic diseases. This review will summarize the current knowledge of vitamin family and vitamin-mediated regulating role in those related otorhinolaryngologic diseases.

Descending cervical mediastinitis: the multidisciplinary surgical approach.

PURPOSE: Descending cervical mediastinitis (DCM) is defined as spread of oropharyngeal or odontogenic infection into the mediastinum. It occurs uncommonly and has a high mortality rate. METHODS: Six patients underwent surgery at our centre for DCM between November 2013 and October 2016. Five of six patients underwent drainage of neck collections via a cervical approach, and all six patients subsequently underwent thoracic surgery for drainage of pleural and mediastinal collections. RESULTS: Four patients required further surgical intervention, of which two subsequently required a third thoracic operation. The average length of stay was 73 days (range 4-193). There were no in-hospital deaths and all patients were discharged from our hospital. CONCLUSIONS: Following diagnosis, prompt surgical intervention from ENT and cardiothoracic surgeons is essential. Our experience demonstrates that favourable outcomes can be achieved in patients with DCM when they are managed aggressively and promptly in specialist centres with appropriate multidisciplinary team involvement.

Amyloidosis of the Upper Aerodigestive Tract: Management of a Rare Disease and Review of the Literature.

Amyloidosis in the upper aerodigestive tract is a very rare disease with mainly case reports documented so far. In the pathogenesis, amyloid protein fibers are deposited in organs and tissue. In the upper aerodigestive tract, mostly localized amyloidosis occurs with unspecific symptoms, e.g., dysphagia. We conducted a retrospective multicenter study with two study centers in Germany (tertiary referral hospitals), the University Hospital of Bonn and the University Hospital of Goettingen. For a period of the last 7 years, data were analyzed and patients were recruited consecutively. 14 cases were included to the study. The most common manifestation was in the larynx (n = 11); in one case each localized amyloidosis was found in the tongue, trachea and in the pharynx. Since the majority of our cases (n = 13; 92.6%) presented with unspecific symptoms, biopsy results confirmed the diagnosis of localized amyloidosis. Resection of the lesion was only performed in patients reporting of symptoms, in asymptomatic patients only a non-invasive biopsy was done. In two patients (14.2%), in addition to the focal lesion a systemic amyloidosis was found. Amyloidosis in the upper aerodigestive tract is a rare disease. Nonetheless, every otorhinolaryngologist should be aware of this disease. When detected it is a straight forward to treat illness. The appearance of a systemic amyloidosis needs to be ruled out; thus, there is a chance to develop a multiple myeloma. Given the slow progressive character of amyloidosis, a long-term follow-up up to 10 years is inevitable.

Prevalence of depression and anxiety among otolaryngology outpatients at Jordan University Hospital.

PURPOSE: To determine the prevalence of depression and anxiety among otolaryngology outpatients at Jordan University Hospital. METHODS: A cross-sectional observational study was conducted between January 2017 and February 2018. The sample included 1328 otolaryngology adult outpatients, who completed (PHQ-9) and (GAD-7) questionnaires for depression and anxiety. Sociodemographic and clinical data were recorded. RESULTS: Depression and anxiety prevalence rates were 36.1% and 22.9%. The significant risk factors found for them were: age range 30 to 50 years, female sex, divorced status, smoking, alcohol drinking, asthma, family history of psychiatric illness, chronic illnesses, negative life events, secondary education, unemployment, low income, globus pharyngeus, tinnitus, and dizziness. PRACTICE IMPLICATIONS: Healthcare providers should have the vigilance to suspect and treat these disorders to improve patients' symptoms and quality of life.

Frailty and Polypharmacy in Older Patients with Otolaryngologic Diseases.

Frailty and Polypharmacy commonly impact disease processes and treatment of patients with otolaryngologic disorders. Although well known to geriatricians, the 2 concepts often elude other physicians, including otolaryngologists. This article reviews the common manifestations likely to be encountered in otolaryngology patients, reviews frailty measures in surgical patients, and makes recommendations regarding education of nongeriatricians.