Quality of Life Outcomes After Pediatric Otitis Media Surgery: A Systematic Review and Meta-Analysis.

OBJECTIVES: Systematically review of literature characterizing health-related quality of life (HRQoL) impact of surgery in pediatric otitis media (OM) patients, and meta-analysis of studies using the OM-6 questionnaire. DATA SOURCES: Pubmed, EMBASE, Cochrane Library, Scopus. REVIEW METHODS: A systematic review of literature of studies evaluating HRQoL outcomes for OM patients managed by surgery. Two investigators independently reviewed abstracts and full-length articles. Risk of bias was assessed using the MINORS criteria and Cochrane Risk of Bias 2 tool. RESULTS: The search yielded 1272 studies, 50 underwent full-text review and 23 met inclusion criteria. Non-randomized studies were of moderate to good quality, while randomized trials had a high risk of bias. Age ranged from 6 months to 15 years. Race and socioeconomic factors were inconsistently reported. There were 11 HRQoL outcome measure instruments of which four were disease-specific. Eleven studies used OM-6 and nine were included in the meta-analysis. Pooled analysis of five studies showed a mean OM-6 change of 1.79 (95% CI: 1.53-2.06; 95% PI: 0.92-2.67; I2 = 68%) 4-6 weeks after surgery; a mean change of 1.87 (95% CI: 1.15-2.58; 98%) after 6 months across two studies; and a mean change of 1.64 (1.02 to 2.27; -6.35 to 9.64; 98%) after 9-13 months across three studies. CONCLUSIONS: There is no consistency in HRQoL instruments used to evaluate pediatric OM surgery outcomes in current literature with few RCTs. Meta-analysis showed a clinically significant large improvement in HRQoL 4-6 weeks after tympanostomy tube placement. LEVEL OF EVIDENCE: N/A Laryngoscope, 2024.

Intracapsular Versus Total Tonsillectomy in Patients with Trisomy 21.

OBJECTIVES: Intracapsular tonsillectomy and adenoidectomy (iTA) has become a popular alternative to extracapsular tonsillectomy and adenoidectomy (TT) for the treatment of pediatric obstructive sleep apnea (OSA) due to improved recovery and fewer complications. The objective of this study was to compare surgical recovery and impact on OSA of iTA versus TT in patients with Trisomy 21 (T21). METHODS: This is a case series with chart review of all T21 patients who underwent iTA or TT at our institution between July 1, 2015 and August 15, 2022. Data collected included demographics, comorbidities, preoperative sleep studies, intraoperative data, complications and recovery, postoperative sleep studies, and follow-up data. RESULTS: There were 62 (21.7%) patients who underwent iTA and 224 (78.3%) patients who underwent TT. The iTA group had significantly lower pain scores (p < 0.001), decreased use of narcotics (p < 0.001), shorter length of stay (p = 0.003), and faster return to oral intake (p = 0.01) during their postoperative hospital admission, and fewer 30-day complications (p = 0.009) compared to the TA group. Both groups showed significant improvements in their sleep studies. For 41 (66.1%) of iTA patients who had follow-up, median follow-up was 1.8 years and for 169 (75.4%) TT patients, median follow-up was 2.6 years. At follow-up, 21 of 41 (51.2%) iTA patients and 83 of 169 (49.1%) TT patients exhibited OSA symptoms (p = 0.084) and tonsillar regrowth was not significantly different between the two groups (p = 0.12). CONCLUSION: Patients with T21 experience less pain and fewer postoperative respiratory complications from iTA than from TT. The short-term impact of iTA versus TT on OSA, as measured by poysomnography, does not differ between the two techniques. LEVEL OF EVIDENCE: 3 Laryngoscope, 134:2430-2437, 2024.

Intravascular Large B-cell Lymphoma Diagnosed by Nasal Biopsy in a Patient Presenting with Bilateral Ptosis and Ophthalmoplegia.

Intravascular large B-cell lymphoma (IVLBCL) is a rare type of lymphoma, involving the lumen of predominantly small blood vessels, especially capillaries. The orbit is an uncommon site of involvement for IVLBCL, and diagnosis before autopsy is even more rare as most cases are established post-mortem. Herein, the authors describe a 73-year-old male who presented with 3 weeks of progressive bilateral ptosis and ophthalmoplegia. Computed tomography (CT) and subsequent magnetic resonance imaging (MRI) revealed diffuse abnormal thickening and enhancement of bilateral orbital apices, superior orbital fissures, and cavernous sinus, along with persistent focal opacification of the left frontal and ethmoid sinuses. Infectious and inflammatory workup of serum and cerebrospinal fluid was negative. Ethmoidal sinus and middle turbinate biopsy confirmed intravascular large B-cell lymphoma and the patient was started on R-CHOP chemotherapy regimen.

Postoperative respiratory complications after adenotonsillectomy in children with obstructive sleep apnea.

OBJECTIVE: Children with obstructive sleep apnea are considered high risk for postoperative respiratory complications, but opinions differ regarding the polysomnography (PSG) criteria that suggest the need for postoperative admission. Our objective was to determine if otherwise healthy children age ≥3 years with an apnea-hypopnea index (AHI) < 24 on overnight PSG can be safely discharged on the same day of surgery. METHODS: Case series with chart review of children age <18 years with positive PSG (AHI > 2) who underwent adenotonsillectomy (T&A) between January 2013 and August 2019. Data collected included patient demographics, medical history, comorbidities, PSG results, operative details, length of stay, intraoperative and postoperative respiratory complications and management. Potential predictors of respiratory complications were evaluated using chi-square/Fisher's exact test and 2-tailed unpaired t tests with the Bonferroni adjustment for multiple comparison artifact. The percentages of healthy children age ≥3 years who were discharged on the day of surgery at various PSG cutoffs were calculated. RESULTS: Of the 560 children, mean (SD) age was 6.4 (3.7) years, 318 (56.8%) were male, 438 (78.2%) were African American, 243 (43.4%) were obese, 16 (2.9%) had Down Syndrome and 12 (2.1%) had sickle cell disease. Median (range) AHI was 12.3 (2-145). Fifteen children (2.7% [95% CI 1.3, 4.0]) had an intraoperative or postoperative respiratory complication. Minor complications including mild desaturation, stridor, croupy cough, and laryngospasm occurred in 9 patients and did not prolong the planned ambulatory or hospital stay. Of the 6 children with more severe complications including prolonged desaturation, tachypnea, atelectasis, intercostal retraction and obstructive apnea requiring continuous positive airway pressure, all were planned admissions based on age, severe sleep study indices (AHI ≥ 24 or oxygen saturation nadir < 80%) or underlying medical condition. Of the 165 children age ≥3 without medical comorbidities known to be predictive of postoperative complications with an AHI ≥10 but <24, 113 (68.5%) were discharged home on the same day of surgery without additional respiratory sequelae. CONCLUSIONS: This study demonstrates a low risk of respiratory complications after T&A. Otherwise healthy children age ≥3 years with AHI <24 may be considered for ambulatory discharge.

Surgical Management of Sialorrhea: A Systematic Review and Meta-analysis.

OBJECTIVE: Chronic sialorrhea commonly occurs in patients with neurodevelopmental disorders. While conservative management can provide sufficient symptom control, surgical intervention is often required. One of the most common procedures utilized is submandibular gland excision (SMGE), with or without parotid duct ligation or rerouting (PDL or PDR). This study aims to compare these surgical approaches and their outcomes. DATA SOURCES: PubMed, Web of Science, and Embase. REVIEW METHODS: This systematic review includes studies of patients with chronic sialorrhea treated with SMGE alone or SMGE plus PDR or PDL and reports on postintervention outcomes and complications. Two independent investigators assessed study eligibility, rated quality, and extracted data for analysis. A random effects model was used for meta-analysis of pooled data. RESULTS: Of 3186 studies identified, 21 met inclusion criteria, with 708 patients: 103 underwent SMGE alone (15%); 299 (42%), SMGE and PDL; and 306 (43%), SMGE plus PDR. Overall, a majority of patients had significant improvement, with very good to excellent control of symptoms after surgery: SMGE, 82% (95% CI, 73%-89%); SMGE and PDL, 79% (95% CI, 73%-85%); and SMGE and PDR, 85% (95% CI, 75%-92%). Importantly, there was no significant difference in outcomes with the addition of PDL or PDR. Reported complications included sialocele, parotitis, dental caries, and dry mouth. CONCLUSION: Our systematic review identified consistent positive outcomes with SMGE for patients with chronic sialorrhea but no additional benefit when PDR or PDL was performed as a concurrent procedure.

Management of Type 1 Laryngeal Clefts: A Systematic Review and Meta-analysis.

OBJECTIVE: Endoscopic surgical management or injection laryngoplasty of type 1 laryngeal clefts in pediatric patients is used in those who do not respond to conservative treatment. This study compares conservative treatment, endoscopic surgical repair, and injection laryngoplasty for the management of type 1 laryngeal clefts. DATA SOURCES: PubMed, Web of Science, and Embase. REVIEW METHODS: This systematic review included studies of patients with type 1 laryngeal clefts who were managed with conservative treatment, injection laryngoplasty, or endoscopic repair, and all studies reported postintervention outcomes. Two independent investigators assessed study eligibility, rated the quality, and extracted data for analysis. A random effects model was used for meta-analysis of pooled data. RESULTS: Of the 1209 studies identified, 27 met inclusion criteria. There were 543 patients with type 1 laryngeal clefts represented in the studies, with outcomes reported for 537. Conservative therapy had a 52% (95% CI, 37%-66%; I2 = 63%) success rate at improving symptoms, while endoscopic repair had a significantly higher percentage resolution of symptoms (70%; 95% CI, 59%-79%; I2 = 62%, P < .001) as compared with conservative treatment (51%; 95% CI, 36%-65%; I2 = 62%) or injection laryngoplasty (36%; 95% CI, 20%-57%; I2 = 70%). The quality scores of the studies ranged from 7 to 12 out of 16. CONCLUSION: Our systematic review demonstrated significant improvement and resolution of symptoms for patients with type 1 laryngeal clefts treated with endoscopic repair as compared with other modalities. More prospective and controlled studies comparing treatment strategies with validated instruments to measure outcomes are necessary to determine their efficacy in the management of type 1 laryngeal clefts.

Systematic Review of Supraclavicular Artery Island Flap vs Free Flap in Head and Neck Reconstruction.

OBJECTIVE: The aim of this systematic review is to compare the surgical outcomes of supraclavicular artery island flap (SCAIF) and free tissue transfer (FTT) in head and neck reconstruction. DATA SOURCES: PubMed, Web of Science, and EMBASE databases. REVIEW METHODS: Independent screening and data extraction were performed by 2 authors. Only studies that directly compared SCAIF and FTT were included. Data were pooled with random-effects meta-analysis to determine the standardized mean differences (SMDs), risk differences, and 95% confidence intervals (CIs). Heterogeneity was assessed using the I2 statistics. The Methodological Index for Non-Randomized Studies tool was used to evaluate extent of bias in studies. RESULTS: The initial query yielded 661 results, of which 4 comparative studies remained for final analysis. The pooled sample sizes for the SCAIF and FTT cohorts were 100 and 84, respectively. SCAIF was associated with reduction of operative time by a large effect size (SMD, 1.65; 95% confidence interval, 0.78-2.52). The harvested flap areas and perioperative complications, including rates of total flap loss, partial flap necrosis, and recipient/donor site dehiscences, were comparable between the 2 procedures with low to high heterogeneity among studies. CONCLUSION: SCAIF requires less operative time and has comparable short-term perioperative results to FTT. The findings of this study support the viability of SCAIF as an alternative to FTT and provide evidence for its inclusion in the reconstructive armamentarium of major head and neck ablation and trauma.

Quality-of-Life Outcomes following Surgical Treatment of Ménière's Disease: A Systematic Review and Meta-analysis.

OBJECTIVE: Several surgical interventions are offered to patients with Ménière's disease (MD) who fail medical management. Although outcomes have historically been reported according to American Academy of Otolaryngology-Head and Neck Surgery guidelines, patient-reported outcome measures (PROMs) are increasingly used to evaluate treatments. This study reviews PROMs used to assess surgical treatments for MD and compares the effect of each intervention based on PROM scores. DATA SOURCES: PubMed, EMBASE, CINAHL, and Web of Science. REVIEW METHODS: This is a systematic review and meta-analysis of English-language studies that reported PROMs for surgical treatments of MD. Two independent investigators assessed study eligibility, rated the quality using Methodological Index for Non-Randomized Studies (MINORS), and abstracted data for comparative analysis. A random-effects model was used for meta-analysis of pooled data. RESULTS: Of 148 unique studies identified, 11 satisfied inclusion criteria. The Ménière's Disease Outcome Questionnaire (MDOQ) was the most commonly used survey. Interventions included intratympanic gentamicin, vestibular nerve section, endolymphatic sac surgery, and labyrinthectomy. Pooled analysis of 8 studies that used the MDOQ instrument demonstrated statistically significant improvements in quality of life but did not identify a difference between destructive and nondestructive procedures. CONCLUSION: Although our review shows significant improvements in PROM scores for both destructive and nondestructive interventions, there was no significant difference noted between treatment types. We cannot draw conclusions regarding the comparative effectiveness of specific interventions, and the results do not account for placebo effects or the natural history of the disease. Further investigation with randomized controlled trials should be considered in future studies.

DNA Methylation Profiling of Human Prefrontal Cortex Neurons in Heroin Users Shows Significant Difference between Genomic Contexts of Hyper- and Hypomethylation and a Younger Epigenetic Age.

We employed Illumina 450 K Infinium microarrays to profile DNA methylation (DNAm) in neuronal nuclei separated by fluorescence-activated sorting from the postmortem orbitofrontal cortex (OFC) of heroin users who died from heroin overdose (N = 37), suicide completers (N = 22) with no evidence of heroin use and from control subjects who did not abuse illicit drugs and died of non-suicide causes (N = 28). We identified 1298 differentially methylated CpG sites (DMSs) between heroin users and controls, and 454 DMSs between suicide completers and controls (p < 0.001). DMSs and corresponding genes (DMGs) in heroin users showed significant differences in the preferential context of hyper and hypo DM. HyperDMSs were enriched in gene bodies and exons but depleted in promoters, whereas hypoDMSs were enriched in promoters and enhancers. In addition, hyperDMGs showed preference for genes expressed specifically by glutamatergic as opposed to GABAergic neurons and enrichment for axonogenesis- and synaptic-related gene ontology categories, whereas hypoDMGs were enriched for transcription factor activity- and gene expression regulation-related terms. Finally, we found that the DNAm-based "epigenetic age" of neurons from heroin users was younger than that in controls. Suicide-related results were more difficult to interpret. Collectively, these findings suggest that the observed DNAm differences could represent functionally significant marks of heroin-associated plasticity in the OFC.

A prospective analysis of physical examination findings in the diagnosis of facial fractures: Determining predictive value.

BACKGROUND: There are >150,000 patient visits per year to emergency rooms for facial trauma. The reliability of a computed tomography (CT) scan has made it the primary modality for diagnosing facial skeletal injury, with the physical examination playing more a cursory role. Knowing the predictive value of physical findings in facial skeletal injuries may enable more appropriate use of imaging and health care resources. OBJECTIVE: A blinded prospective study was undertaken to assess the predictive value of physical examination findings in detecting maxillofacial fracture in trauma patients, and in determining whether a patient will require surgical intervention. METHODS: Over a four-month period, the authors' team examined patients admitted with facial trauma to the emergency department of their hospital. The evaluating physician completed a standardized physical examination evaluation form indicating the physical findings. Corresponding CT scans and surgical records were then reviewed, and the results recorded by a plastic surgeon who was blinded to the results of the physical examination. RESULTS: A total of 57 patients met the inclusion criteria; there were 44 male and 13 female patients. The sensitivity, specificity, positive predictive value and negative predictive value of grouped physical examination findings were determined in major areas. In further analysis, specific examination findings with n≥9 (15%) were also reported. CONCLUSIONS: The data demonstrated a high negative predictive value of at least 90% for orbital floor, zygomatic, mandibular and nasal bone fractures compared with CT scan. Furthermore, none of the patients who did not have a physical examination finding for a particular facial fracture required surgery for that fracture. Thus, the instrument performed well at ruling out fractures in these areas when there were none. Ultimately, these results may help reduce unnecessary radiation and costly imaging in patients with facial trauma without facial fractures.

HISTORIQUE: Plus de 150 000 patients se rendent à la salle d'urgence chaque année à cause d'un traumatisme facial. En raison de sa fiabilité, la tomodensitométrie est la modalité primaire pour diagnostiquer les lésions squelettiques de la face, tandis que l'examen physique joue un rôle plus superficiel. Le fait de connaître la valeur prédictive des observations physiques en cas de lésions squelettiques de la face pourrait favoriser une utilisation plus appropriée de l'imagerie et des effectifs en matière de santé. OBJECTIF: Les chercheurs ont réalisé une étude prospective à l'aveugle afin d'évaluer la valeur prédictive de l'examen physique pour déceler une fracture maxillo-faciale chez les patients traumatisés et pour déterminer si le patient devra subir une intervention chirurgicale. MÉTHODOLOGIE: Sur une période de quatre mois, l'équipe des auteurs a examiné les patients admis à l'urgence de leur hôpital à cause d'un traumatisme facial. Le médecin a rempli un formulaire d'évaluation de l'examen physique standardisé pour consigner ses observations physiques. Les tomodensitométries correspondantes et les dossiers chirurgicaux ont ensuite été examinés, et un plasticien a consigné les résultats sans connaître ceux de l'examen physique. RÉSULTATS: Au total, 57 patients respectaient les critères d'inclusion, soit 44 hommes et 13 femmes. Les chercheurs ont déterminé la sensibilité, la spécificité, la valeur prédictive positive et la valeur prédictive négative des observations groupées des examens physiques dans les principaux secteurs. À l'analyse plus approfondie, ils ont également signalé les observations tirées de de l'examen physique, où n≥9 (15 %). CONCLUSIONS: Les données ont démontré une valeur prédictive négative élevée d'au moins 90 % pour les fractures du plancher orbital, des zygomatiques, des mandibules et du nez par rapport à la tomodensitométrie. De plus, aucun des patients qui n'avait pas de fracture faciale selon l'examen physique n'a dû être opéré en raison d'une telle fracture. Ainsi, l'instrument donnait des bons résultats pour écarter ce type de fractures lorsqu'il n'y en avait pas. Au bout du compte, ces résultats peuvent contribuer à réduire des radiations inutiles et une imagerie coûteuse chez les patients ayant un traumatisme facial sans fractures.

Differences in DNA methylation between human neuronal and glial cells are concentrated in enhancers and non-CpG sites.

We applied Illumina Human Methylation450K array to perform a genomic-scale single-site resolution DNA methylation analysis in neuronal and nonneuronal (primarily glial) nuclei separated from the orbitofrontal cortex of postmortem human brain. The findings were validated using enhanced reduced representation bisulfite sequencing. We identified thousands of sites differentially methylated (DM) between neuronal and nonneuronal cells. The DM sites were depleted within CpG-island-containing promoters but enriched in predicted enhancers. Classification of the DM sites into those undermethylated in neurons (neuronal type) and those undermethylated in nonneuronal cells (glial type), combined with findings of others that methylation within control elements typically negatively correlates with gene expression, yielded large sets of predicted neuron-specific and non-neuron-specific genes. These sets of predicted genes were in excellent agreement with the available direct measurements of gene expression in human and mouse. We also found a distinct set of DNA methylation patterns that were unique for neuronal cells. In particular, neuronal-type differential methylation was overrepresented in CpG island shores, enriched within gene bodies but not in intergenic regions, and preferentially harbored binding motifs for a distinct set of transcription factors, including neuron-specific activity-dependent factors. Finally, non-CpG methylation was substantially more prevalent in neurons than in nonneuronal cells.