Predicting Failure of Conservative Airway Management in Infants with Robin Sequence: The EARN Factors.

OBJECTIVE: Evaluate infants with Robin Sequence (RS) who were successfully treated with conservative airway measures alone vs. those who failed and eventually underwent surgical airway intervention after a protracted course of conservative management. DESIGN: Retrospective review of prospectively gathered database. SETTING: Large tertiary care institution. PATIENTS: Infants diagnosed with RS (n = 122) who underwent primary airway management at a single institution from 1994-2020. MAIN OUTCOME MEASURE: Patient demographics, nutritional and respiratory status, laboratory values, and polysomnographic results were compared between patients who were discharged after successful conservative airway management (Group 1, n = 61) and patients that underwent surgical airway intervention after failing a prolonged course of conservative management (Group 2, n = 61). Receiver operating characteristic (ROC) curve analysis was done to assess continuous variables that may predict failure of conservative airway management. RESULTS: 122 infants with RS were investigated. While several variables were significantly different between groups, the following polysomnographic EARN factors, with cut points, were identified as most predictive of failed conservative airway management: ETCO2 (max) > 49 mmHg, AHI > 16.9 events/hour, OAHI REM >25.9 events/hour, OAHI Non-REM > 23.6 events/hour. CONCLUSIONS: We identified factors in infants with RS that were associated with severe UAO that failed to improve despite weeks of conservative airway management. Our results may expedite earlier definitive treatment of these critical patients and reduce risks for known complications of prolonged UAO.

Predicting failure of detection of peritonsillar abscess with ultrasound in pediatric populations.

PURPOSE: Some patients require additional imaging following ultrasound (US) to definitively diagnose a peritonsillar abscess (PTA), delaying intervention and disease resolution. We seek to evaluate patient characteristics which may predispose to a secondary imaging requirement to diagnose PTA, in order to better understand ultrasound limitations and predict who will require additional studies. MATERIALS AND METHODS: Retrospective chart review of patients with an US for suspected PTA between July 2017 and July 2020. Patient age, weight, and clinical characteristics, such as pain, trismus, and reduced neck range of motion (ROM) were collected. The need for additional imaging, subsequent surgical intervention, and hospital length of stay (LOS) were also recorded. RESULTS: Of 411 qualifying patients, 73 underwent additional imaging. Patients who required additional imaging were younger (9.8 vs 11.3 years, p = 0.026) and more likely to have decreased neck ROM (17.8 vs 5.3 %, p = 0.001). Surgical intervention was performed more commonly (27.4 vs 14.8 %, p = 0.015) and hospital LOS was longer (24.0 vs 5.0 h, p < 0.001) in those with secondary imaging. CONCLUSIONS: Specific patient characteristics, such as younger age and decreased neck range of motion, are associated with a higher need for additional imaging. Additionally, the need for additional imaging is associated with a longer hospital LOS and increased likelihood of surgical intervention. Nearly 18 % of patients who underwent US evaluation of PTA required secondary imaging. Although transcervical US remains an excellent tool for diagnosing PTA, this data supports the utility of secondary imaging in certain instances.

Facial Nerve Dysfunction After Mandibular Distraction Osteogenesis in Patients with Robin Sequence: A Systematic Review and Meta-Analysis.

OBJECTIVE: Robin Sequence (RS), characterized by micrognathia, glossoptosis, and upper airway obstruction, is an increasingly recognized diagnosis. An effective surgical intervention is mandibular distraction osteogenesis (MDO). This study analyzes published evidence regarding facial nerve dysfunction (FND) associated with MDO. DESIGN AND SETTING: According to PRISMA guidelines, a systematic review was carried out with databases queried in June 2019 using MESH terms, or equivalent terms, as follows: "distraction osteogenesis" and "Robin Sequence". A review of original Spanish and English articles, were included. Outcome measures included the prevalence of FND; the affected branches; the rate of permanent vs. transient FND; the use of an internal vs. external device; the daily distraction rate; and finally, the overall distraction length. Subsequently, a meta-analysis was conducted to collate results regarding the prevalence of FND and the factors associated with it. RESULTS: Of 239 unique studies identified, 19 studies with 729 patients met inclusion criteria; 52 patients developed FND after MDO. A random-effects meta-analysis yielded a pooled prevalence of FND of 6.40%, with moderately heterogeneous studies (I2 = 41%, τ2 = 0.006). Marginal mandibular nerve involvement was most commonly noted. Nine studies reported transient FND, six permanent, one both, and two unspecified. Internal distractors were used in 8 studies and external in 3 and both in 2. Distraction rate was 1.00 to 2.00 mm/day and total distraction length ranged from 13.00 to 22.3 mm. Sample size was the only parameter inversely associated with rate of FND (p = 0.04). CONCLUSION: This analysis of FND associated with MDO for patients with RS demonstrates a lack of consistent documentation. MDO-associated FND does not appear to be uncommon, and permanent dysfunction can occur. This review underscores the importance of thorough documentation to elucidate the mechanism of FND.

Timing and Duration of Facial Nerve Dysfunction After Mandibular Distraction Osteogenesis for Robin Sequence.

OBJECTIVE: Collect data from craniofacial surgeons to analyze mandibular distraction osteogenesis (MDO) protocols, and facial nerve dysfunction (FND) to characterize this common, but poorly documented complication after MDO in infants with Robin Sequence (RS). DESIGN, SETTING, AND PARTICIPANTS: A 16-question anonymous survey designed through REDCap was digitally distributed to members of the American Cleft Palate-Craniofacial Association and International Society of Craniofacial Surgery (ISCFS). MAIN OUTCOME MEASURE(S): Demographic information, MDO perioperative variables, surgeon experience with FND after MDO for patients with RS, and the timing and duration of FND were analyzed. RESULTS: Eighty-four responses were collected, with 80 included for analysis. Almost two-thirds of respondent surgeons reported FND as a complication of MDO in patients with RS (51, 63.8%); 58.8% (n = 47) transient FND and 5% (n = 4) with permanent facial nerve palsy only. Both transient and permanent FND was documented by 13 (16.3%) respondents. Among respondents, FND was observed immediately following initial device placement/osteotomies in 45.1%, during distraction in 45.1%, during consolidation in 19.6%, and following device removal in 43.1%. Twenty-five of these respondent surgeons reported resolution of FND between 1 and 3 months (53.2%, n = 25). CONCLUSIONS: FND after MDO in patients with RS was noted by most respondents in this survey study. While most surgeons noted temporary FND, one-fifth reported long-term dysfunction. FND was documented most commonly following device placement/osteotomies or during active distraction. Further research should seek to establish risk factors associated with FND and identify surgical and perioperative prevention strategies.

Comparison of quality of life outcomes in a de-intensification treatment regimen for p16 + oropharyngeal cancer.

BACKGROUND: Platinum and taxane-based neoadjuvant chemotherapy with surgery (NAC + S) is a novel de-intensified treatment modality that is currently under investigation. METHODS: All patients treated for HPV positive OPSCC with NAC + S at a single institution between 2006 and 2020 were contacted to complete the University of Washington Quality of life questionnaire (UW-QOL) at least 2 years following the completion of treatment. RESULTS: The UW-QOL surveys were received from 25 of 48 eligible patients (52.1%). The mean follow-up time was 4.3 years (range 2.0-7.6 years). The overall mean score for the physical subscale was 92.4 (Standard deviation, SD = 10.9), and the social-emotional subscale was 91.1 (11.8). Compared to the normative cohort, the NAC + S cohort had a worse appearance (Mean scores Normative vs. NAC + S: 93 vs. 84.0, p = 0.009). CONCLUSION: NAC + S offers favorable long-term QOL, as evidenced by near-normal scores in most QOL domains.

Swallowing Function Following Neoadjuvant Chemotherapy and Transoral Robotic Surgery for Oropharyngeal Carcinoma: A 2-Year Follow-up.

OBJECTIVE: To evaluate 2-year follow-up swallowing function in patients with human papillomavirus-related oropharyngeal squamous cell carcinoma (HPV+ OPSCC) who completed neoadjuvant chemotherapy and transoral robotic surgery (NAC+S). STUDY DESIGN: Retrospective analysis of patients with OPSCC treated with NAC+S between 2010 and 2021. SETTING: A single academic institution. METHODS: This is a cross-sectional study of patient-reported swallowing function, assessed with the MD Anderson Dysphagia Inventory (MDADI) at least 2 years after completion of treatment. The inclusion criteria are patients with HPV+ OPSCC who underwent NAC+S at least 2 years ago. Those requiring adjuvant radiation or chemoradiation or experiencing relapse were excluded from the study. RESULTS: Completed MDADIs were received from 37 patients at a median 3.8 years posttreatment (interquartile range, 2.0-8.6 years). Of those, 94.6% (n = 35) were male and 81.1% (n = 30) were White. The median age at OPSCC diagnosis was 59.0 years (interquartile range, 41-80 years). The most frequent primary subsite of OPSCC was the base of the tongue (n = 20, 54.1%), followed by the tonsils (n = 16, 43.2%). In addition, 75.7% (n = 28) had stage IVa disease (TNM seventh edition), and 29 (78.4%) had scores ≥80, classified as optimal function. When compared with patients who received bilateral neck dissection, patients who received unilateral neck dissection were associated with an age <65 years old (P = .036) and lower clinical TNM stage (P = .04), as well as higher composite, emotional, functional, and physical MDADI scores (P = .017, .046, .013, and .05, respectively). CONCLUSION: Patients with OPSCC who were treated with NAC+S achieved satisfactory long-term swallowing outcomes. Unilateral neck dissection was significantly associated with higher MDADI scores in this patient cohort.

Clinical Outcomes and Technical Approach of Thymectomy in the Veterans Health Administration.

BACKGROUND: Thymectomy is traditionally performed through a transsternal incision, but less invasive modalities have emerged, including transcervical, thoracoscopic, and robotic approaches. Despite the advantages of video-assisted thoracoscopic surgery (VATS) over thoracotomy, most thymectomies are performed through sternotomy. This study compared the use and 30-day postoperative outcomes of transsternal, transcervical, and VATS thymectomy in the Veterans Health Administration. METHODS: This was a retrospective review of veterans who underwent thymectomy through the Veterans Affairs Surgical Quality Improvement Program. Their 30-day outcomes were compared among techniques, by adjusting for confounding covariates. Temporal trends were analyzed using the Spearman' rank correlation coefficient, rho(ρ). RESULTS: From 2008 to 2019, 594 thymectomies were performed: 376 (63.3%) transsternal, 113 (19.0%) VATS (including robotic approaches), and 105 (17.7%) transcervical cases. VATS use increased from 0% in 2008 to 61% of case volume in 2019. Relative to the transsternal technique, VATS thymectomy was associated with decreased odds of pulmonary complications (adjusted odds ratio, 0.06; P = .028) and shorter hospital stay (2.9 ± 0.4 days shorter; P < .001). No difference in outcomes was detected between VATS and transcervical thymectomy. The postoperative complication rate decreased from 17.7% in 2008 to 5.6% in 2019 (ρ = -0.101; P = .014). Length of stay decreased from median 4 days in 2008 to 3 days in 2019 (ρ = -0.093; P = .026). In thymic cancer, VATS 5-year overall survival was noninferior to the transsternal approach (71.3% vs 74.6%; P = .54). CONCLUSIONS: The transsternal approach comprised most thymectomy cases in veterans, whereas VATS thymectomy use increased over time and was associated with favorable outcomes. The 30-day outcomes after thymectomy improved over time, which may reflect a trend toward wider use of less invasive approaches. Future studies should examine long-term outcomes.

Impact of the novel coronavirus on surgical practices at a tertiary pediatric hospital: A 3 year cross-sectional study.

OBJECTIVE: The novel coronavirus (COVID-19) forced unprecedented changes in pediatric otolaryngology workflow in the early pandemic, particularly due to the postponement of elective procedures. In turn, this has impacted timely treatment of patients and ability to train residents and fellows. The objective is to characterize how surgical practices in pediatric otolaryngology have been impacted by the pandemic through a cross sectional analysis over three years. METHODS: This cross-sectional study focuses on patients who underwent surgical procedures within the department of otolaryngology at a single tertiary pediatric hospital. Descriptive statistical analysis was used to compare subsets of patients from pre-pandemic in 2019, early-pandemic in 2020, and late-pandemic in 2021. RESULTS: Operative volume decreased by 87.57% in the early pandemic and 36.86% in the late pandemic. In the early pandemic, the greatest decreases were seen in airway reconstruction (100%), adenotonsillectomy (96.4%), adenoidectomy (94.7%), myringotomy with tympanostomy tube insertion (94.6%), frenulectomy (94.1%), and sinonasal procedures (93.3%), while in the late-pandemic adenotonsillectomy (42.4%) and myringotomy with tympanostomy tube insertion (70.1%) remained reduced when compared to pre-pandemic volume. Increased average case lengths in the early-pandemic (78.28 ± 51.95 min) and late-pandemic (71.91 ± 70.76 min) were observed when compared to pre-pandemic (52.26 ± 39.20 min) (p < 0.001). An increased proportion of multidisciplinary cases were completed in 2020 and 2021 (p < 0.001). In the 2020, 25% of cases were completed without trainee involvement. There was an overall decrease in case numbers for trainees and increase in cases without their involvement when compared to 2019 and 2021. CONCLUSION: The COVID-19 pandemic resulted in a decrease in pediatric otolaryngology surgical procedures, particularly at the onset of the pandemic. While surgical trainees saw a dramatic reduction in case numbers early on, one year into the pandemic case volume is increasing and trending to pre-pandemic numbers. More complex cases, as represented by patients requiring longer operative times, inpatient status, and more frequently multidisciplinary care, were seen in the early pandemic, while drastic reductions were seen in routine outpatient procedures.

Temporomandibular disorder treatment algorithm for otolaryngologists.

OBJECTIVE: To review current literature describing the management of temporomandibular disorder (TMD) and to propose an evidence-based algorithm for otolaryngologists. DATA SOURCES: A literature review using PubMed and Scopus was conducted to identify manuscripts that describe TMJ disorder etiology, diagnostic methods, and management across the fields of otolaryngology, general practice medicine, physical therapy, dentistry, and maxillofacial surgery. REVIEW METHODS: Two reviewers subjectively evaluated the studies based on the inclusion criteria, incorporating them into a comprehensive algorithm. CONCLUSIONS: TMD is one of the most common conditions presenting to otolaryngology outpatient clinics. Etiologies of TMD vary widely, including myofascial, intraarticular, neurologic, traumatic, or psychiatric in origin. When conservative measures fail to produce symptom relief, alternative treatments and referral to outside specialists including psychiatry, physical therapy, dentistry, and maxillofacial surgery may be indicated. Premature or inappropriate referrals may lead to patients suffering TMD for extended periods of time, with alternating referrals between various specialists. Thus, we present a TMD treatment algorithm for otolaryngologists to aid in the decision-making process in managing TMD. IMPLICATIONS FOR PRACTICE: Patients frequently present to otolaryngology outpatient clinics for symptoms of TMD. Multidisciplinary practice may be necessary to effectively treat TMD of varying etiology and severity. Following conservative treatment, appropriate referrals and treatment plans will reduce ineffective use of resources, deferral of treatment, and patient suffering. For this reason, a comprehensive algorithm for otolaryngologists will improve resource utilization and efficiency of treatment to ultimately provide improved treatment outcomes for patients.

Adverse events associated with Bonebridge and Osia bone conduction implant devices.

PURPOSE: Active transcutaneous Bone Conduction Implants (BCIs) are relatively new to the market and may offer improved outcomes while reducing skin-related complications associated with previous models. The purpose of this study is to examine medical device reports (MDRs) submitted to the Food and Drug Administration's (FDA) Manufacturer and User Device Facility Experience (MAUDE) database to identify adverse events with the active, transcutaneous BCIs, Bonebridge and Osia. METHODS: A search of the FDA MAUDE database was conducted using product code "PFO" (for Active Implantable Bone Conduction Hearing System), brand names "Bonebridge" and "Osia." Data was collected on device malfunction, patient injury, inciting events, and subsequent interventions between July 1, 2018 and November 1, 2020. RESULTS: The search query yielded 83 reports that met inclusion criteria, 56 regarding Bonebridge and 27 regarding Osia. A total of 91 adverse events were reported, including 45 device malfunctions and 46 patient injuries. Of all adverse events reported for Bonebridge, 15 (26.3%, 15/57) documented patient injuries, while the majority (73.7%, 42/57) documented device malfunctions. Of all adverse events reported for Osia, 3 (8.8%, 3/34) were reported concerning malfunctions, while 31 (91.2%, 31/34) were reported for patient injuries. The most commonly reported adverse events included lack of conduction or hearing (n = 26, 28.6%), infection (n = 14, 15.4%), and intermittent or reduced conduction or hearing (n = 12, 13.2%). From the MAUDE database reported adverse events and the total number of Osia implants given to us from Cochlear over this 28 month period, we estimate patient injuries to occur in roughly 2.1% of patients. CONCLUSION: There are limitations to the database which make systemic analysis challenging. This study suggests that patients with transcutaneous, active BCIs may be experiencing fewer soft tissue injuries, but similar device malfunctions as those with previous models.

Patterns in On-time, Daily Submission of a Short Web-Based Personal Behavior Survey in a Longitudinal Women's Health Study.

We evaluated compliance with submitting a short Web-based personal behavior survey daily during a 10-week study (n = 52 women/3419 diaries). Time-stamped forms revealed that 50% of diaries were submitted within 24 hours of the email prompt, and 19% were missing or submitted more than 3 days late. Late submissions may affect data quality.

Identification of human short introns.

Canonical pre-mRNA splicing requires snRNPs and associated splicing factors to excise conserved intronic sequences, with a minimum intron length required for efficient splicing. Non-canonical splicing-intron excision without the spliceosome-has been documented; most notably, some tRNAs and the XBP1 mRNA contain short introns that are not removed by the spliceosome. There have been some efforts to identify additional short introns, but little is known about how many short introns are processed from mRNAs. Here, we report an approach to identify RNA short introns from RNA-Seq data, discriminating against small genomic deletions. We identify hundreds of short introns conserved among multiple human cell lines. These short introns are often alternatively spliced and are found in a variety of RNAs-both mRNAs and lncRNAs. Short intron splicing efficiency is increased by secondary structure, and we detect both canonical and non-canonical short introns. In many cases, splicing of these short introns from mRNAs is predicted to alter the reading frame and change protein output. Our findings imply that standard gene prediction models which often assume a lower limit for intron size fail to predict short introns effectively. We conclude that short introns are abundant in the human transcriptome, and short intron splicing represents an added layer to mRNA regulation.